Thursday, May 07, 2020

Enrollment in Medicaid surges in Minnesota

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An Urban Institute analysis released this week, How the COVID-19 Recession Could Affect Health Insurance Coverage, estimates, in the more conservative of two models deployed, that if the unemployment rate reaches 15%, Medicaid enrollment will increase by 8.2 million  nationally. That would constitute a 16% increase in total Medicaid enrollment for the under-65 population.

Minnesota appears to be halfway there already. The state tracks enrollment in managed* Medicaid and MinnesotaCare, a Basic Health Program that provides Medicaid-like coverage to people in households with income up to 200% of the Federal Poverty Level, on a monthly basis.

From February to May this year, managed Medicaid enrollment in Minnesota for adults age 21-64 is up 10.4%. For pregnant women, it's up 16%. Enrollment of children is up 6%. Enrollment in MinnesotaCare, the BHP, is up 24% -- though enrollment in that particular program was up almost as much in Feb-May 2019.

In total, managed Medicaid/MinnesotaCare enrollment has increased by 77,142 (8%) since February, more than five times last's year's increase in the same period of 14,547 (2%).  Since mid-March, 590,000 Minnesotans have applied for unemployment benefits, according to the state Management and Budget office's May budget projection.

Here are the Minnesota DHS's January-May managed Medicaid/MinnesotaCare Monthly enrollment tallies through May 2020 and 2019. I have added percentage and absolute increases from February to May. "MA" refers to Medical Assistance, the state name for Medicaid.

Source: MN Dept of Human Services
* I have imported the "MnCare Total" from a different sheet in the same report; it's very slightly different from the          summed totals of the categories listed here.
To some extent the increase is seasonal. Yearly, looking back as far as 2017, enrollment totals drop off in December and January,  then tend to rise at least through June and sometimes into the fall. In 2018, total enrollment increased 3.6% from February to May.  This year's increase is more than twice as sharp, however, as well as 5.3 times larger than last year's.

During the current emergency, the state has obtained a waiver to ensure that no one enrolled in Medicaid loses coverage during the pandemic -- a requirement for states that seek the enhanced federal payment share provided in the Families First Coronavirus Response Act. For the duration, "The department is not sending notices on the need to renew coverage or closure notices to Minnesotans on Medical Assistance and MinnesotaCare" -- which will probably forestall the annual winter enrollment drop.

With respect to coming increases, the Minnesota Dept. of Human Services sent this statement:
Because enrollment in public health care programs lags changes in the economy, such as growth in the unemployment rate, we anticipate Medical Assistance enrollment to increase this fiscal year (through June 30, 2020) by less than 2 percent compared to the February forecast. However, we expect the average monthly enrollment in Fiscal Year 2021, which begins July 1, to increase by 107,800 individuals or 10.1 percent, including both the impact of changes made under the executive orders to ensure ongoing coverage and access to care during the emergency and the anticipated economic recession.
Average monthly enrollment in the ten months of FY 2020 logged to date is 933,321. Enrollment in May 2020 is 989,065  -- 6% higher. The Minnesota DHS thus assumes continued growth, without the usual attrition triggered by re-enrollment. The 10% forecast growth for FY 2021 (or 12%* over about 16 months, when growth from late FY 2020 is factored in) is lower than Urban Institute's national estimate --though it would be somewhat higher if seniors were excluded, as in the Urban estimate. The state's updated May budget forecast cites (with some skepticism) optimistic economic projections (5.4% GDP decline in 2020; 6.3% growth in 2021) that may account for the difference.

Here are the specific enrollment projections included in the May forecast. The Medicaid projections include enrollment in Medicaid fee-for-service, which accounts for about 20% of enrollment, whereas the monthly tallies cited above are for managed care programs only, accounting for 80% of Medicaid enrollment as well as MinnesotaCare.

Medical Assistance (MA)
Overall, average monthly MA enrollment increased by 20,700 enrollees in FY2020 (+1.9%).
Overall, average monthly MA enrollment increased by 107,800 enrollees in FY2021 (+10.1%).
The FY2021 overall increase breaks down into:  13,000 (+1.2%) due to executive orders/waivers and 94,800 (+8.9%) due to recession.
This FY2021 recession impact breaks down into:  38,000 adults without children enrollees (+20.0%) and 56,800 families with children enrollees (+8.2%).

MinnesotaCare (MnCare)
Overall, average monthly MnCare enrollment increased by 750 enrollees in FY2020 (+1.0%).
Overall, average monthly MnCare enrollment increased by 22,500 enrollees in FY2021 (+30.0%).
All of the FY2021 enrollment increase in MnCare is due to the recession.

The projected steep increase in MinnesotaCare enrollment is noteworthy, and more or less mirrors the increase in the last few months. Enrollment in MinnesotaCare is available through MNSure, the state ACA exchange. Normally enrollment is closed outside of the ACA marketplace's Open Enrollment period in the fall.  Those who lose job-based coverage or experience other "life changes" at other times can apply for a Special Enrollment Period (SEP).  In response to the tsunami of job losses beginning in March, MNSure opened an emergency SEP in which anyone who was uninsured and ineligible for Medical Assistance (Medicaid, for which enrollment is year-round) could enroll in MinnesotaCare or the marketplace. The emergency SEP, running March 23-April 21, stimulated enrollment somewhat. Continuing job losses should continue to boost enrollment. MinnesotaCare is more affordable than marketplace coverage for people in the same income bracket (138-200% FPL) in most states.

P.S. The Urban Institute estimate for increase in Medicaid enrollment in Minnesota, at 15% unemployment via the more conservative model, is 181,000, as opposed to the state estimate of 128,500. Urban's more conservative model matches ten years of American Community Survey data regarding health insurance coverage with state-level unemployment data. The less conservative model uses 20 years of national time series data, which tracks the unemployment-uninsured ratio across two recessions but is less fine-grained. The 20-year model estimates Medicaid enrollment increase in Minnesota at 313,000, more than twice the state estimate.

* Total average monthly Medicaid enrollment in FY 2019 was 1,087,908, according to the DHS February 2020 forecast. It's now forecast to be 128,500 (11.8%) higher in FY 2021

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