"Where There's a Will There's a Way": The Impact of State Variations in the Implementation of Continuous Coverage on...

To explore how the Medicaid continuous coverage requirement and unwinding process was implemented in three states with diverse existing policy environments and implications for the implementation of post-emergency 12-month postpartum extensions.

State data on unwinding performance and qualitative in-depth interviews with 48 stakeholders and patient-facing healthcare workers in Texas, New York and New Jersey.

State Medicaid stakeholders and patient-facing healthcare workers in each state were interviewed with the goal of gaining insights into: (1) How the continuous coverage requirement was implemented; (2) What effects continuous coverage had on access to care for postpartum mothers; (3) How states are implementing the pandemic unwinding and postpartum extensions.

Interviews were recorded and took place over Zoom between September 2022 and March 2024. Interview transcripts were analyzed thematically using an open coding approach.

The study found that low awareness of the continuous coverage requirement blunted potential benefits: little changed in practice in recommended patient care or follow-up procedures. Differences in state unwinding approaches reflected differential state capacity to minimize procedural disenrollment and political incentives to either rapidly reduce or maintain Medicaid rolls. Based on these findings, we describe how political will, state capacity and policy legacies interact to either increase or decrease administrative burdens associated with program enrollment/re-enrollment.

While the continuous coverage requirement in theory applies equally across US states, its implementation was inconsistent and influenced by state capacity and political objectives creating differential experiences across states. To ensure that postpartum Medicaid coverage extensions have maximal impact on improving maternal health, states should develop improved communication strategies to ensure that providers and community-based organizations are aware of coverage changes and leverage available flexibilities to increase use of administrative renewal and ensure smooth coverage transitions.