Medicaid expansion enrollment far outstrips marketplace enrollment and is the chief bulwark against huge spikes in uninsured population

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As millions lose jobs and health insurance during the pandemic, I have railed against ACA marketplaces for submerging information about Medicaid* and focusing their messaging almost exclusively on the private plan marketplace.

In expansion states, at least twice as many of the newly uninsured will be eligible for Medicaid as for subsidized marketplace coverage, according to estimates by the Urban Institute and Kaiser Family Foundation. You'd never know it to look at most state-based marketplaces, and to a lesser extent, HealthCare.gov.

The exchanges were conceived primarily as private-plan marketplaces and still view routing people to the ACA's Qualified Health Plans as their primary -- almost sole -- mission. But in expansion states, they also qualify or enroll applicants into Medicaid where appropriate, and it's high time they recognized Medicaid enrollment (or routing) as a core mission.

The Medicaid expansion has been the primary engine for ACA-triggered reductions in the nation's uninsured population. To illustrate the point, I've set ACA Medicaid expansion enrollment next to marketplace enrollment in the 35 states (including DC) that have enacted the expansion so far. Nationally, Medicaid enrollees who fit the ACA's expansion enrollment criteria outnumber marketplace enrollees by a 3-to-1 margin, subject to a couple of caveats at bottom. Links to data sources are in the headings.

What's the matter with California? The mystery of flat Medi-Cal enrollment, revisited

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As part of a May budget revision in California, the state Department of Health Care Services (DHCS) projected that in response to job losses triggered by the Covid-19 pandemic, enrollment in Medi-Cal, the state Medicaid program, would increase  to 14.5 million by July -- roughly a 16% increase.

According to the state's current tally, from February to July enrollment in fact increased by just .02%, from 12.48 million to 12.50 million. Twenty-five other states that have reported enrollment through July show an 8.6% increase since February.  The Center for Medicare and Medicaid Service's most recent 50-state tally shows a 3.4% increase from February through May.

What gives? Why has Medicaid enrollment in California so far been essentially flat in the months since Covid-19 triggered mass unemployment?*

The DHCS cites several potential factors potentially inhibiting enrollment:

Pandemic Medicaid enrollment powers into August

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Update, 9/17: Total Medicaid enrollment in Utah is up 16.9% since February. See this post for backstory.

Update, 9/16: Kentucky today posted its tally for September: Medicaid enrollment is up 19.7% since early March. That's tops in the nation, perhaps due in substantial part to Kentucky's unique outreach efforts, e.g., contacting everyone who applies for unemployment benefits about their insurance situation. Please note that Kentucky is one of several states that report early each month, and that I place such reports in the prior month -- that is, the September report is categorized as "thru August" in the chart below.  In the 18 states for which I have totals through August, enrollment is now up 10.8% since February.

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A handful of states have posted Medicaid enrollment totals as of the end August (or, in the case of New York, as of mid-August or beyond*). The main takeaway is that growth in Medicaid enrollment triggered by the pandemic does not appear to be slowing down.  In the states charted below, enrollment grew by 1.5% from June to July. In the four states that have reported through all or most of August below, enrollment also increased 1.5% over the prior month. [Update 9/4: Minnesota up 1.2%; 5 states up 1.4% July-August.]

The sustained Medicaid enrollment growth five months after the first pandemic-induced lockdowns  should not be a surprise. As I've noted before, Medicaid enrollment is a lagging indicator. A United Hospital Fund study found that in the Great Recession of 2007-2009, Medicaid enrollment in New York peaked seven months after unemployment peaked. Robin Rudowitz of the Kaiser Family Foundation tells me that Medicaid enrollment continued to climb nationwide after the Great Recession officially ended, and that state Medicaid directors whom Kaiser surveyed at the end of April anticipated increases extending throughout the year.

Pandemic Medicaid Enrollment in 28 States 
February through July or August 2020
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple
Totals as of the end of each month

On Aaron Carroll's Coronavirus cap-and-trade

It feels odd for me to take issue with recommendations from Aaron Carroll on how to deal with the risk of coronavirus infection, individually and collectively. In March, Carroll was prescient on what we as a country needed to do (and, with Trump in charge, inevitably failed to do) after we'd already let community transmission run rampant -- reduce infections via shelter-in-place, and use the breathing room to ramp up testing. He is a trusted source on nutrition, medicine and healthcare policy, able to sift through piles of published studies and assess the evidence, as he did on core nutritional questions in The Bad Food Bible.

But I feel there's something off about Carroll's approach in today's column to risk balancing in response to the pandemic. No one should have any beef with the main point: when you give up one major form of risk mitigation (e.g, when you go back to school), don't give up all others (e.g., by congregating in basements). But how, then, to balance risks? Envisioning our individual conduct as "piles" of risk-mitigating and risk-enlarging decisions, Carroll writes:

Obama's montage of American history darkens

Hey America, ICYMI:

Addressed to the summer's young protesters:

You can give our democracy new meaning. You can take it to a better place. You're the missing ingredient -- the ones who will decide whether or not America becomes the country that fully lives up to its creed.

That work will continue long after this election. But any chance of success depends entirely on the outcome of this election. This administration has shown it will tear our democracy down if that's what it takes to win. So we have to get busy building it up -- by pouring all our effort into these 76 days, and by voting like never before -- for Joe and Kamala, and candidates up and down the ticket, so that we leave no doubt about what this country we love stands for -- today and for all our days to come.

Stay safe. God bless.

That's the 44th president of the United States warning that the 45th president will end democracy in America if we let him.

That warning represents quite a journey for Obama. He rose to prominence and won election by telling us that we are not as divided as we seem, that we are forever in the process of making our union ever more perfect, that Americans at pivot points in our history bent the arc of the universe toward justice.

Has Medicaid enrollment reached 77 million? (updated)

Update, 9/2: Four states post reports in recent days that bring totals through August. Discusson in  this post. 

Update, 8/27: Texas has reported June enrollment, and it's up 9% since February.  June chart below is updated. Most recent July chart, last updated 8/23, is unchanged.

One note about the apparent flat enrollment in California: the percentage of Medi-Cal enrollment that is Latinx, 50% in 2018, is about double the national average. The Trump administration's changes to the public charge rule, suspended though the new rule is, are likely continuing to chill enrollment among legally present noncitizens, and the effect may be particularly strong in California.

8/24/20:  Today the big addition is California enrollment through June. The state is a major outlier among expansion states, in that enrollment is up just 1.1% since February (after a slight dip in March). Adding CA dropped the all-state enrollment increase from February through June from 7.0% to 5.6%. The weak growth is apparently a mystery to state officials and advocates. I'll have more to say about that later in the week. [Update, 9/1: California has now published a raw total for July that shows a drop of 74,000. I had noted the July drop in this database, but as California is notoriously slow to account for retroactive liability, the July total is likely to be adjusted up.]  

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Pandemic Medicaid Enrollment in 29 States 
February through June 2020 (as of 8/27)
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple

California totals include about 850,000 enrollees in programs not counted by CMS, e.g., enrollees funded without a federal match rate. (As noted in the 8/23 update below, CMS state tallies now run through May 2020. The monthly totals for California listed above may yet be published online; they were sent to me. They are roughly congruent with eligible individuals tracked in this database.

UPDATED  9/2/20
Pandemic Medicaid Enrollment in 23 States 
February through July or August 2020
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple

The ACA today: A mid-pandemic assessment

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High-CSR coverage in Nebraska (top) vs. unsubsidized coverage in Alaska (bottom)

Enrollment in ACA marketplace plans totaled 12.7 million at the end of Open Enrollment 2016 and 11.4 million at the end of OE 2020.  Enrollment as of the end of OE has shrunk in every year since the 2016 peak.

Those top-line fact tend to shape basic perceptions of how the marketplace has fared. But in itself the top line is almost meaningless. The marketplace, and the U.S. healthcare system more generally, have undergone an array of changes, some of which mitigate the impression of modest, steady erosion, and some of which reinforce or even intensify it. Among the OTOHs:

• Collapse in unsubsidized enrollment.  Enrollment in ACA-compliant health insurance plans by people who did not qualify for ACA premium subsidies stood at 6.7 million in the first quarter of 2016 and at 3.4 million in Q1 2019. * Huge premium increases in 2017 (triggered by a genuine market correction) and 2018 (in response to Republican attempts to repeal the ACA and sabotage the marketplace) appear to have driven half of unsubsidized enrollees out. The ACA's failure to provide affordable insurance to a large percentage of those who don't qualify for subsidies stands out as one of its core failures -- offset though it may be by the law's provision of subsidized insurance (mostly Medicaid) to some 20 million people who would otherwise have remained uninsured.

Medicaid enrollment in Utah could use a state push

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Last week I noted that Utah's launch of full ACA Medicaid expansion in January of this year was fortunately timed to catch tens of thousands of Utah residents who have lost access to employer-sponsored health insurance during the pandemic.

Yesterday I spoke to Stacy Stanford and Sarah Leetham of the Utah Health Policy Project about Utah's Medicaid enrollment gains during the pandemic -- which might fairly be deemed moderate when the full context is considered. UHPP was in the thick of the successful fight to pass a referendum to enact the ACA Medicaid expansion in 2018 and works with a network of partners to provide enrollment assistance to Utahns seeking coverage.

To review the back story briefly: After the referendum passed, Utah's Republican legislature and governor enacted a partial expansion, offering Medicaid to state residents with income up to 100% of the Federal Poverty Level instead of to the ACA's stipulated  threshold of 138% FPL. The partial expansion launched in April 2019, while the state filed a federal waiver request seeking to apply the ACA's 90% federal match rate to the limited expansion population. When CMS rejected the waiver, the state went to Plan B -- full expansion -- effective Jan 1, 2020. A work requirement went into effect on Jan. 1 but was suspended in April 2020 -- before anyone who failed to comply with its reporting and job-seeking demands could be disenrolled -- in response to the pandemic.

Medicaid enrollment in a pandemic: 26-state snapshot

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Update through 9/2 here

Update, 8/19: See this post for a somewhat cleaner comparison through July, reconciling states' different schedules for tallying and methods of labeling a given month.

Update, 8/15: Illinois Medicaid enrollment surged 6.4% from June to July and is up almost 10% since May. Enrollment in Indiana is up 11.8% since February. Of the twelve expansion states below that have reported enrollment in all or most Medicaid programs through July (excluding tallies for expansion population only), the average increase since February is 9.2%. 
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It's time for a fresh post on pandemic Medicaid enrollment, instead of piling updates on my prior snapshot. While I'm focused primarily on states that enacted the ACA Medicaid expansion, I've started to also track nonexpansion states and will keep adding them as I find data.  I have a bunch of URLs to pick through, thanks to a very helpful overview of enrollment in 33 states through May and June  by Chris Frenier, Sayeh S. Nikpay, and Ezra Golberstein.

To review some basic context: the Urban Institute forecast that nationally just shy of half* of those who lose access to employer-sponsored insurance will enroll in Medicaid if severe unemployment lasts for "several months to a year." At 15% unemployment, Urban projects that between 8.2 million and 14.3 million people will enroll in Medicaid, an increase of 11%--20% over total enrollment in early 2020, or 16%--28% over the total of enrollees under age 65.   While the current national unemployment rate has dipped officially to 10%, it's likely to spike again as our public health failures lead to renewed shutdowns and our legislative failures result in cutoffs or sharp reductions in relief benefits.

Note that some of the the tallies below are for the ACA Medicaid expansion only -- that is, adults with incomes under 138% of the Federal Poverty Level. The federal government pays 90% of the cost for enrollees rendered eligible by the expansion. It's not surprising that the expansion population tallies reflect faster growth, since a large percentage of the nation's children were enrolled in Medicaid or CHIP pre-pandemic, enrollees over age 65 are in Medicare and usually not reliant on employer-sponsored insurance, and those eligible for disability Medicaid are also likelier to have been enrolled pre-pandemic.

       Medicaid enrollment in 26 states, February - August 2020

In a devilish pandemic, Medicaid expansion is Utah's cave up in the hills

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In 2018, voters in Utah passed a referendum to enact the ACA Medicaid expansion, which would make Medicaid available to adults with incomes up to 138% of the Federal Poverty Level. Utah's Republican legislature and governor writhed, twisted, and enacted a partial expansion, to 100% FPL, effective in April 2019. When the federal government rejected a waiver to apply the ACA's 90% federal match rate to that limited expansion population, the state went to Plan B -- full expansion -- effective Jan 1, 2020. A work requirement was suspended in April 2020 in response to the pandemic.

Good timing. As the pandemic struck, jobless claims in Utah rose from 40,500 in February to 166,300 in April before falling back to 85,700 in June. The unemployment rate went from 2.5% to a peak of 10.4% in April to 5.1% in June. Medicaid enrollment responded: