Lacking Medicaid Supplemental Insurance Tied to Racial Care Disparities

Losing eligibility for Medicaid supplemental insurance was associated with racial care disparities among beneficiaries with incomes above 100 percent of the federal poverty level (FPL), a study published in JAMA Internal Medicine found.

Beneficiaries may seek supplemental insurance from Medicaid, employers, or Medigap to account for the gaps in Medicare coverage. However, supplemental insurance enrollment varies by income, race, and ethnicity.

Medicare beneficiaries must have incomes at or below 100 percent FPL to qualify for Medicaid supplemental insurance through the Qualified Medicare Beneficiary program. Many Black and Hispanic beneficiaries have incomes slightly above this threshold, which may lead to racial care disparities.

Researchers used data from the Health and Retirement Study (HRS) and Medicare administrative data from 2007 to 2018 to determine if the loss of Medicaid eligibility above 100 percent FPL was associated with racial and ethnic disparities in care access and utilization.

The study sample included 2,885 Black and Hispanic beneficiaries and 5,259 White beneficiaries.

Among Black and Hispanic beneficiaries, 62 percent with incomes below the 100 percent FPL threshold had Medicaid, compared to 18.2 percent with incomes above the threshold, resulting in a Medicaid enrollment cliff of 43.8 percentage points.

The Medicaid enrollment cliff among White beneficiaries was 12.9 percentage points lower at 31 percentage points.

Among Black and Hispanic beneficiaries, losing Medicaid eligibility was associated with a 5.7 percentage point increase in the probability of reporting difficulty accessing care due to costs. Additionally, loss of Medicaid eligibility was associated with 6.3 fewer outpatient services per person-year and 6.9 fewer medication fills per person-year for this population.

Black and Hispanic beneficiaries who exceeded the 100 percent FPL threshold had fewer outpatient evaluation and treatment visits (-2.9 visits per person-year) and filed fewer chronic disease medications (-2.7 fills per person-year).

Black and Hispanic beneficiaries tend to have higher rates of chronic diseases, including diabetes, hypertension, and heart disease. The findings raise concerns that low-income beneficiaries of color are less likely to receive adequate care for chronic conditions when they exceed the Medicaid eligibility threshold.

White beneficiaries were less likely to experience care barriers compared to Black and Hispanic beneficiaries, highlighting the racial care disparities stemming from Medicaid eligibility loss. Exceeding the income threshold was associated with greater reductions in outpatient use and medication fills for Black and Hispanic beneficiaries compared to their White counterparts, the study noted.

Additionally, not having Medicaid coverage was associated with 19.1 fewer prescription drug fills per person-year for Black and Hispanic beneficiaries compared with White beneficiaries.

“These findings suggest that low-income Black and Hispanic beneficiaries encounter greater difficulty obtaining care when they do not have Medicaid supplemental insurance to cover Medicare’s cost sharing,” researchers wrote.

Broadening Medicaid supplemental insurance eligibility would help mitigate these racial care disparities. Policymakers could increase the threshold to 200 percent FPL and reduce cost-sharing assistance gradually between 100 and 200 percent FPL. Policies to boost access to the Part D Low-Income Subsidy could also minimize cost-related barriers to medication use, the study suggested.