Changes in Medication Use During Medicaid Continuous Enrollment and Unwinding

TL;DR

This study examines how Medicaid enrollment and prescription medication use changed during the pandemic and after coverage unwinding, showing that states with protective policies mitigated medication access declines.

Contribution

The study quantifies the impact of Medicaid enrollment changes on prescription medication use and highlights the role of state policies in mitigating these effects.

Findings

Medicaid enrollment increased by 2.42% per quarter during continuous enrollment and decreased by 4.92% during unwinding.

Prescription use increased by 1.85% per quarter during continuous enrollment and decreased by 3.94% during unwinding.

States with protective policies saw smaller decreases in chronic medication use during unwinding.

Abstract

How did the use of prescription medications change during periods of Medicaid continuous enrollment during the COVID-19 pandemic and the subsequent unwinding of coverage once the continuous enrollment provision ended in April 2023?

In this cross-sectional study including all Medicaid enrollees from 2018 through the first quarter of 2024, state Medicaid enrollment increased by 2.42% per quarter during continuous enrollment and decreased by 4.92% per quarter during unwinding; concurrently, the number of prescriptions increased by 1.85% per quarter and then decreased by 3.94% per quarter.

Expansion and unwinding of Medicaid coverage had measurable impacts on patient access to prescription medications, and these changes were affected by state policies.

This cross-sectional study analyzes how the unwinding of Medicaid enrollment is associated with changes in patients’ use of health services, such as prescription medications.

During the COVID-19 pandemic, Medicaid enrollment increased because states suspended routine eligibility determinations. After this continuous enrollment provision ended in April 2023, millions of US individuals lost Medicaid coverage.

To measure how the unwinding of Medicaid enrollment was associated with changes in patients’ use of health services, such as prescription medications.

A cross-sectional study was carried out using interrupted time series analysis to compare changes in quarterly Medicaid enrollment and prescription medication use from 2018, quarter (Q) 1 through 2024, Q1. Data were analyzed from November 2024 to February 2025.

The onset of continuous enrollment provision (2020, Q2) and unwinding (2023, Q2).

The outcomes were quarterly state Medicaid enrollment and estimated number of reimbursed prescriptions. Log-transformed linear regression models were used to compare changes in state enrollment and prescriptions after continuous enrollment and unwinding, overall and stratified by states with different net enrollment changes and policies to protect patients during unwinding. Subsets of medications for certain chronic conditions and formulations primarily used by children were analyzed.

In the quarter before the COVID-19 pandemic (2019, Q4), Medicaid enrollment was 71.4 million, and there were about 183.2 million prescriptions reimbursed by Medicaid programs. This included 59.1 million (32.3%) prescriptions treating chronic diseases, 30.3 million (16.5%) for acute conditions, and 15.0 million (8.2%) for other specified conditions. In 2023, Q2, enrollment peaked at 93.9 million (31.4% increase from baseline), and the number of prescriptions peaked at 212.6 million (16.1% increase from baseline). Enrollment increased by 2.42% (95% CI, 2.15%-2.70%) per quarter during continuous enrollment and decreased by 4.92% (95% CI, −6.12% to −3.70%) per quarter during unwinding. Concurrently, the number of prescriptions increased by 1.85% (95% CI, 1.21%-2.50%) per quarter and then decreased by 3.94% (95% CI, −5.73% to −2.11%) per quarter. Trends were similar for chronic disease medications and pediatric-specific formulations. States with the highest disenrollment during unwinding had the largest decreases in chronic disease medication use; states that implemented more protective policies had smaller decreases in enrollment and insignificant decreases in chronic medication use.

This cross-sectional study found that changes in Medicaid medication use during the COVID-19 pandemic continuous enrollment period and after unwinding were smaller than corresponding changes in enrollment. Unwinding had measurable impacts on patient access to prescription medications, but states that implemented protective policies were able to mitigate these changes.

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