Wednesday, September 30, 2020

Estimate: ACA Medicaid expansion enrollment has increased by more than 2 million in the pandemic

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Ever since I was a child -- okay, ever since the ACA was a child -- I've been reading that 12 million Medicaid enrollees were rendered newly eligible by the ACA Medicaid expansion, which extended eligibility to adults with incomes up to 138% of the Federal Poverty Level (e.g., $1468 per month for an individual, $1303/month for a family of four). That's been the case since July 2016, rounding up from 11.6 million at that point. In June 2019, the last month tallied by CMS, enrollment of the "newly eligible" stood at 12.0 million.

A larger number -- 15.3 million in June 2019 -- are rendered eligible by ACA criteria and not by standard pre-ACA criteria. But 3.3 million of them are in states that had expanded adult eligibility to at least 100% FPL pre-ACA*. The federal government pays the ACA's enhanced "match rate" of 90% of costs for this larger group, classified as Group VIII.

Nationally, total Medicaid enrollment shrank by about 5% from early 2017 to early 2020.  Then came the pandemic.  As the economy crashed, Medicaid enrollment surged. It has probably increased by more than 6 million from the end of February through August. Here I'd like to venture an estimate, based on the enrollment data below: about 2.2 million of the new enrollees are ACA expansion enrollees. That would put current Group VIII enrollment at about 17.5 million.

If we assume that 78% of the new Group VIII enrollees are "newly eligible," that comes to about 1.7 million, raising current "newly eligible" enrollment to about 13.7 million. These enrollees stand to lose their coverage if the Supreme Court voids the ACA in its entirely.  And new enrollment triggered by the ACA expansion is far from over. In my 28-state tally (second chart here), the increase from July to August, 1.5%, is the same as from June to July.

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Of the 35 states (including D.C.) that have enacted the ACA Medicaid expansion to date, about half have broken out Group VIII (ACA expansion) enrollment through August. The tally is below. In two states that have reported only through July, I have estimated August totals, by means explained below.

Pandemic Medicaid "expansion" enrollment in 18 states
February through August, 2020

     August totals marked in green are estimates based on June-July growth.

These states represent 36% of total Group VIII (ACA expansion) enrollment as of February. The increase recorded February through August is 951,278, an increase of 17.2%.   If  that rate of increase extended to the entire Group VIII population, that would suggest more than 2.64 million new enrollees. But enrollment in the pandemic months has been near-flat in California, up just 1.7% in July. California had 3.7 million Group VIII enrollees in mid-2019. Pegging Group VIII enrollment growth in California at 4% (an educated guess) suggests that the national estimate should be reduced by a bit less than 500,000. That's why I've pegged Group VIII enrollment growth at 2.2 million since February. That could of course be wrong, as the enrollment story in the expansion states that have not broken out Group VIII enrollment month-by-month could be different.

Other notes:

1. Illinois and New Hampshire have not yet reported through August. As the one-month rate of growth in all other states from July to August was 78% of the June-July rate, I added 78% of June-July growth to each of those states for an August estimate.

2. For states that report each month's tally early in that month (e.g., "September" enrollment as of Sept. 1), I have ascribed each month's tally to the month prior. That's to get an apples-to-apples comparison with states that report as of the end of each month. I did this so that the February total will reflect the last tally unaffected (or barely affected) by the pandemic.

3. I am indebted to Chris Frenier, Sayeh S. Nikpay and Ezra Golberstein for their previous analysis of pandemic Medicaid enrollment through June. In a most useful appendix,  Frenier et al. not only published URLs for monthly state Medicaid enrollment tallies, but specified the categories designating Group VIII enrollment in each state.


*  About half of the Group VIII enrollees who are not "newly eligible" are in New York, and another 400,000 or so in Massachusetts and Vermont, which had extended eligibility to 138% FPL pre-ACA. Other states that have significant numbers of Group VIII enrollees not rendered newly eligible include Illinois, Hawaii, Washington, D.C. Arizona, Maine, and Iowa.

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