Access to Care Among Individuals Who Experienced Medicaid Lockouts After Premium Nonpayment

This survey study compares the demographic characteristics, access to care, and health status of recent Medicaid enrollees in Wisconsin with and without experience of Medicaid lockouts.


Introduction
As of September 2019, 5 states have received federal waivers to temporarily suspend Medicaid eligibility for individuals who fail to pay required premiums. 1These periods, ranging from 3 to 12 months, are called lockouts, noneligibility periods, or restrictive reenrollment periods.Discontinuous Medicaid coverage is linked to poor access, 2,3 but the effects of temporary, short-term lockouts are unknown.Wisconsin received a Section 1115 waiver allowing the application of premiums enforced by lockouts among adults receiving transitional medical assistance (TMA), 4

a federally required
Medicaid category that provides time-limited coverage to parents and/or caretakers when their incomes increase to exceed the Medicaid program maximum. 5 Wisconsin did not expand Medicaid under the Patient Protection and Affordable Care Act; TMA covers some individuals who would otherwise be eligible for the expansion.This survey study compared the demographic characteristics, access to care, and health status of recent Medicaid enrollees with and without lockout experience.

Methods
We conducted cross-sectional surveys in 2016 and 2018 among individuals who were currently or recently enrolled in TMA, stratified by lockout experience.Survey participants were informed that their participation was entirely voluntary and could not affect their program benefits.The study was a contracted program evaluation and thus was designated as not research by the University of Wisconsin-Madison institutional review board.This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline.
The lockout group included individuals in at least the second month of a lockout from TMA coverage when the sample was drawn.The comparison group comprised individuals enrolled in TMA at the time the sample was drawn.Questionnaires were mailed in April 2016 and April 2018, with follow-up phone calls to nonrespondents in July of each year.Participants did not explicitly provide consent but had the option to not mail in a response or break off the interview.We pooled data from 2016 and 2018 to increase sample size; results were broadly similar between the 2 years.The sample consisted of individuals who completed the survey.We reported American Association for Public Opinion Research response rate 3 (ie, complete interviews per number eligible).
We weighted respondents in each group to account for differential nonresponse.We examined unadjusted demographic differences between the groups, then adjusted for demographic characteristics to compare self-reported access to care, health status, and insurance status in the 2 groups.We used 2-sided t tests to determine differences between groups and set P < .05 as the level for statistical significance.Analyses were conducted using Stata version 15 (StataCorp).Additional demographic characteristics of the survey sample vs sampling frame appear in eTable 1 in the Supplement, and demographic characteristics of individuals receiving TMA vs other parents or caretakers are shown in eTable 2 of the Supplement.

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Discussion
To our knowledge, this is the first study to compare recent Medicaid enrollees with and without lockout experience.Limitations included a cross-sectional study design that prevented causal inference, small sample sizes, and use of a single state where lockouts were relatively short-term (ie, at most 3 months).Although weighting was used to account for low response rates, our TMA sample overrepresented older, white enrollees (eTable 1 in the Supplement).Lockouts may disrupt access to care, which could account for some of the barriers identified in this study.Further research is needed to prospectively identify the effects of lockouts on access and long-term health outcomes.

Table 2 .
Access to Care and Health Status of Recent Medicaid Enrollees With Lockout Experience vs Those Without Lockout Experience a In 2016, there were 119 individuals surveyed in the

Table 2 )
. The 2 samples showed no significant differences in self-reports of having a usual source of care.However, those who experienced a lockout were less likely to report receiving needed medical care in the prior year (111 [64.9%] vs 561