Tuesday, August 18, 2020

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

August 18 post

Below is a snapshot of Medicaid enrollment growth since February in 15 states that have reported monthly enrollment through July. These 15 states account for slightly less than one third of total U.S. Medicaid enrollment.

From February through July, enrollment increased 9.1% in these states. February marked the final month in a three-year, 5 percent slide in total Medicaid/CHIP enrollment nationally. Not coincidentally, it was the last month in which enrollment was unaffected by job losses and fear of being uninsured triggered by the pandemic, though there was scant time in March for enrollment to reflect these factors.

The first twelve states listed below have enacted the ACA Medicaid expansion; the last three have not. Wisconsin is a de facto quasi-expansion state, as Medicaid eligibility is extended to adults with incomes up to 100% of the Federal Poverty Level instead of the 138% FPL threshold in expansion states.  The color code below reflects expansion status.

Pandemic Medicaid Enrollment in 15 States 
February through July 2020 (see updated chart at bottom)

Pandemic Medicaid enrollment through July 2020

Medicaid enrollment is up 2.1 million since February in these fifteen states. If the 9.1% increase extends through all 50 states, that would suggest total Medicaid enrollment of 77,450,000 in June, up from 71,055,314 in February. That would be in line with a May 2020 Urban Institute analysis, which forecast that if 15% unemployment lasted "several months," an increase in Medicaid enrollment ranging from 8.2 million to 14.3 million. Unemployment is currently a bit over 10%.

These fifteen states may not be representative. A somewhat larger sampling of tallies through June, provided below, is in line with this sampling, though.  So is enrollment in Texas, up 7% February through May, from 3.86 million to 4.13 million. Early tallies show weak growth in California, however, where 11.6 million were enrolled in February -- 16% of all U.S. enrollment, or the equivalent of about 8 states.

Pandemic Medicaid Enrollment in 19 States 
February through June 2020 (see updated chart at bottom)

Pandemic Medicaid enrollment through June 2020

Some housekeeping notes:

1. To get a cleaner snapshot than in past posts, I have created monthly categories, "through February" and "through July" (or June) meant to align state reports that appear at different times of the month. When reports appear early in the month and bear the name of the month they appear in, I have put them in the prior month. That is, if a report appears on August 7 and labels the most recent total "August," I put that total in the "through July" column. A reported total dated "through July 31" is also in the July column, as is a total that appears later than July 31 and is labeled "July." ( There must be a simpler way to explain this...)

2. Most of these state reports include all Medicaid enrollment. Those market "MCO" are limited to enrollment in managed Medicaid plans. In NY, the MCO total reflects about 70% of total enrollment as recorded (with a several-month lag) by CMS; the Minnesota and Illinois MCO totals represent about 80% of total enrollment. State reports don't align 100% with CMS tallies (provided in convenient table form by the Kaiser Family Foundation here); some state reports provide larger totals. North Carolina's reported total for February is about 25% higher than the CMS total. The differences stem in part from limited Medicaid programs that don't provide comprehensive coverage.

3. The Oregon "July" total is as of August 17. The most recent prior is dated July 6. Perhaps about 5,000 should be shaved from the "July" total for Oregon.

As noted in previous posts, a substantial portion of the enrollment gains come from not throwing people off.  The Families First Act, passed in late March, provided a 6 percentage point boost in the federal government's "match rate" for state Medicaid costs, conditioned on suspending "redeterminations" and disenrollments based on income increases or failure to provide required information for the duration of the national emergency.

For more discussion of enrollment trends, and links to state monthly Medicaid enrollment reports, please see this post.

UPDATE, 8/23/20: CMS has released the national Medicaid enrollment tally for May. Enrollment was up 3.4% to 73,469,597 from February 2020, the last month before job losses stemming from the pandemic started to register, and also the last month of a roughly three-year slide in enrollment. Meanwhile I have enlarged my sample of states reporting through June and July, which now shows enrollment up 7.0% in 28 states reporting through June, and up 8.8% in 23 states reporting through July. I've added Connecticut and Virginia among expansion states, and Kansas, Missouri, Oklahoma, South Dakota and Tennessee among nonexpansion states. Updated charts are attop.

An 8.8% increase nationally from February through July would put total enrollment at about 77.3 million. As of May, however, enrollment was nearly flat in California, which accounts for 16% of nation enrollment. Subtracting about 700,000 in apparently missing growth in CA suggests current national enrollment of about 76.7 million. Perhaps that's a bit high -- it may be that states that don't report enrollment on a timely basis are also not particularly committed to getting the newly uninsured enrolled during a crisis. OTOH, enrollment growth is high in several nonexpansion states, including the two largest, Florida and Texas (the latter is up 7% through May and not included in charts below).

See posts below for conditions and policies  contributing to enrollment in:
New York
Maine (also NY, KY, MN)

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