Racial Disparities and Personal Responsibility Incentives in Medicaid

To determine whether personal responsibility incentives in Medicaid differentially affect enrollment and the comprehensiveness of plan benefits among members who are non-Hispanic Black and non-Hispanic White.

We conducted an interrupted time series analysis to estimate trends in racial disparity ratios of enrollment across more comprehensive Healthy Indiana Plans (HIP) before and during the COVID-19 Public Health Emergency (PHE) when the state suspended personal responsibility incentives, including monthly premium contributions.

We analyzed restricted-access administrative data from the Indiana Family and Social Services Administration from 2018 through 2023. The analytic cohort comprised 939,667 non-Hispanic Black and non-Hispanic White adults (19-64 years) enrolled in one of four HIP tiers, including HIP Plus or HIP Basic, and HIP State Plan Plus or HIP State Plan Basic in which presence of a qualifying health condition is required for eligibility.

Before the PHE, members who are non-Hispanic Black were approximately 23 percentage points less likely to be in the more comprehensive HIP Plus plan relative to members who are non-Hispanic White. An increase in the disparity ratio of 0.076 points toward parity (95% CI, 0.054-0.097 points) for HIP Plus recipients was observed following suspension of personal responsibility incentives during the PHE. After an administrative upgrade of all HIP Basic recipients to HIP Plus plans during July 2021, this disparity ratio increased an additional 0.146 points from the start of the PHE (95% CI, 0.141-0.151 points) to 0.994 (95% CI, 0.993-0.994).

Personal responsibility incentives in Medicaid are associated with substantial and persistent racial disparities in enrollment and plan comprehensiveness. The study indicates that while the temporary removal of these incentives can reduce disparities, proactive policy interventions may be necessary to achieve and maintain equitable access to care.