Friday, June 26, 2020

Loss of health insurance looks modest so far, but it's early days

The Covid-19 pandemic has delivered an unprecedented shock to the U.S. economy, though its duration remains to be seen. Of the 21 million unemployed as of the end of May, 15.3 million were on temporary layoff, according to the Bureau of Labor Statistics. As of the end of May, the BLS reported an unemployment rate of 13.3%, while acknowledging that the rate would be 3 points higher if those classified as employed but absent from work were counted as unemployed, as they should have been (see pg. 6 here).

How many of the newly unemployed will lose access to health insurance? The Urban Institute and the Kaiser Family Foundation both put out estimates in May. At 15% unemployment, Urban forecast that between 17.7 million and 30.1 million would lose access to employer-sponsored insurance, and that about 29% of these people would become uninsured, the rest (71%) enrolling in Medicaid or the ACA marketplace.  Kaiser estimated that the number of people losing access to employer-sponsored insurance (ESI) would be about 87% of total job losses*, and that 79% of those who lost ESI would be eligible for Medicaid or subsidized marketplace insurance. Urban pegged the rise in the uninsured population at 5.2-8.5 million; Kaiser, at about 5.5 million.

What do we know about the impact of job losses on the uninsured rate so far? We do have data. The CDC is reporting results weekly from a Census Bureau "demonstration project," the Household Pulse Survey, a quick-and-dirty web survey introduced with a host of caveats.  The Commonwealth Fund, meanwhile, interviewed 2,271 adults about their health insurance status between May 13 and June 2.
Click here to subscribe to xpostfactoid

The Household Pulse Survey can be quite volatile week-to-week on a state-by-state level, but overall shows little movement. In fact, in the week of June 11, the estimated national uninsured rate for adults aged 18-64, 13.2%, is up only modestly from the week of April 23 12.6% -- and lower than the rate recorded in the long-established National Health Insurance Survey for January-June 2019, 13.7%.

The Commonwealth Fund survey indicates relatively modest losses of health insurance to date. Of the 21% who said they or their spouse had been laid off or furloughed, just 41% had coverage through a lost or furloughed job. Of those, 21% said that either they, their spouse or both were now uninsured. That would appear to point toward a bit less than 2% of the population becoming newly uninsured. While many of those who lost job-based coverage may find their way to Medicaid or marketplace coverage, relatively few have done so thus far, according to the Commonwealth Fund results:

Caveats, caveats:

1. Many who have been furloughed may find themselves unemployed longer term, and subsequently uninsured. The recent surges in Covid-19 cases in multiple states including the nation's most populous -- California, Texas, Florida -- do not bode well.

2. The Commonwealth Fund indicates that the newly uninsured have had more recourse to COBRA than to Medicaid or the marketplace. That could change. Cara Stewart, an experienced ACA enrollment counselor in Kentucky, told me that COBRA is often people's first impulse upon layoff. But COBRA can also be a placeholder. After losing job-based insurance, you have 60 days to opt in to COBRA, and another 45 days to pay the first premium. If you do opt in, coverage is retroactive. Also, employers sometimes cover the premium for a limited period.

3. It often takes time for the unemployed to find their way to Medicaid or the marketplace. Shelli Quenga, an ACA enrollment counselor in South Carolina who's been at it since the ACA marketplace launched in fall 2013, told me that people take care of more immediate needs -- food and rent -- first.  A United Hospital Fund analysis of Medicaid enrollment in New York during the Great Recession found that Medicaid enrollment, which increased by 400,000 in the state from December 2007 to December 2009, peaked seven months after jobless claims peaked.  State government agencies, most notably the unemployment insurance divisions of labor departments, generally do little or nothing to spur enrollment. As for the ACA marketplace, awareness of its offerings and the subsidies available remains extremely low -- and the Trump administration is doing basically zero outreach.

4. That said, Medicaid enrollment appears to be increasing fast in what's still relatively early days. In mid-May, Georgetown University's Joan Aiker checked in on 13 states that report monthly Medicaid enrollment with little lag and reported that all but one were showing notable enrollment increases from February (i.e., pre-pandemic-related shutdowns) to April or May, including Missouri (6.5%) Wisconsin (5.1%), Minnesota (4.6%), Maine (4.3%), Kentucky (4.2%) and New Hampshire (3.2%).  In early June I noted that enrollment growth in Minnesota and Kentucky had topped 10%, along with surges in New York, Arizona and Maine. Nationwide, Medicaid enrollment has probably increased by about 5%. The Urban Institute forecasts point toward growth in total Medicaid enrollment in the 11-20% range if 15% unemployment persists for "several months to a year."

5. Off-season marketplace enrollment is also elevated by about 300,000-400,000, or 3-4%, enabled by emergency Special Enrollment Periods (SEPs) in twelve state-based exchanges, allowing anyone who's uninsured to apply for coverage, and by individual SEPs, mainly for loss of job-based coverage, in the 38 states using (where Trump's CMS refused to open an emergency SEP). That increase is in comparison to where enrollment would be had the pandemic not struck; it does not take into account normal enrollment attrition, usually about 10% by mid-year.

Underfunded, under-publicized and uneven as our health insurance safety net may be, it would be far worse had the ACA been repealed -- or if the lawsuit by Republican attorneys general and governors seeking its judicial nullification were to succeed, as the Trump administration urged the Supreme Court this week. By Urban's estimate, 53% of the newly uninsured will be eligible for Medicaid in the 35 states (plus D.C.) that have thus far enacted the ACA Medicaid expansion, versus just 33% in nonexpansion states. About 13 million Medicaid enrollees have been rendered eligible by the ACA expansion, and that number will grow during this crisis if the ACA is not voided. Another 9 million are subsidized in the ACA marketplace. The Center for American Progress estimates that 23 million people will lose health insurance if the ACA is struck down -- in the midst of a pandemic. That's not going to happen (unless perhaps a liberal justice dies or is incapacitated prior to ruling). But it would if the Trump administration had its way.

Subscribe to xpostfactoid
* Kaiser's estimate accounts for family members of the laid off person on one hand, and for the many who were not insured through their employer or who had access to a family member's insurance on the other hand. The Urban Institute estimates that 1 percentage point increase in unemployment leads to a 0.61 percentage point decrease in the rate of adults with employer-sponsored insurance (ESI) and a 0.52 percentage point decrease in children insured through ESI.

No comments:

Post a Comment