Thursday, September 17, 2020

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,

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 34 states (including DC) that had enacted the expansion as of June 2019, the last month for which CMS has recorded expansion enrollment data. 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.
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Medicaid Group VIII (ACA expansion) enrollment (June 2019**) vs. ACA marketplace enrollment (Feb. 2020)

State                       ACA Medicaid         ACA                      Marketplace
                                expansion                 marketplace           as % of 
                                enrollees                   enrollees                expansion 

Alaska 51,172 10,675 21%
Arizona 423,482 142,635 34%
Arkansas 250,431 58,615 23%
California 3,696,925 1,477,329 40%
Colorado 380,442 150,416 40%
Connecticut 267,885 103,955 39%
Delaware 62,488 22,497 36%
Dist. Of Col. 106,551 16,245 15%
Hawaii 107,314 18,373 17%
Illinois 655,276 273,180 42%
Indiana 309,510 52,542 17%
Iowa 172,180 52,542 31%
Kentucky 450,707 78,241 17%
Louisiana 460,757 80,471 17%
Maine* 28,462 58,487 205%
Maryland 310,031 135,474 44%
Massachusetts 336,735 293,075 87%
Michigan 671,648 247,075 37%
Minnesota 185,011 105,677 57%
Montana 95,805 41,540 43%
Nevada 209,695 73,101 35%
N. Hampshire 52,421 42,013 80%
New Jersey 518,216 224,649 43%
New Mexico 256,424 39,762 16%
New York 1,881,383 235,526 13%
North Dakota 19,692 20,662 105%
Ohio 526,131 183,608 35%
Oregon 461,989 135,313 29%
Pennsylvania 765,577 307,100 40%
Rhode Island 66,686 34,050 51%
Vermont 54,770 25,834 47%
Virginia 284,466 245,670 86%
Washington 549,684 202,150 37%
West Virginia 161,429 18,448 11%
Totals 15,269,635 5,206,930 34%

* In Maine, Medicaid expansion enrollment has taken off during the pandemic and now stands at 61,222. 

In the pandemic months, Medicaid enrollment is expanding rapidly -- likely in the neighborhood of 10% from February through August. Growth is even more dramatic among those rendered eligible by the ACA expansion -- 12.7% as of July in 17 states that broke it out. Medicaid enrollment would be still higher if states did more to advertise it and streamline enrollment. (They would be more likely to to do so if Congress would boost the federal match rate for states' Medicaid bills to a level commensurate with the crisis.) Signposting on the state ACA exchanges and on, the federal exchange, is one largely unused tool in this regard.

The impact of Medicaid expansion vs. the marketplace -- and Medicaid expansion in its own right -- is most extreme in those of the nation's poorest states that have enacted the ACA expansion (rendered optional to states by the Supreme Court in 2012).  To illustrate the point, below I've charted Medicaid expansion enrollment, marketplace enrollment, and pre- and post-ACA uninsured rates in the 10 states with lowest median household income.

Five of those states have expanded Medicaid and five have not. The five expansion states had all cut the uninsured rate in their nonelderly adult populations by half or more than half by 2018 (pre-pandemic, rates had upticked by about a percentage point by 2020). The nonexpansion states cut their uninsured rates age 19-64 by about a quarter.

ACA Medicaid and marketplace enrollment and uninsured rates, 10 poorest states 

     *Median HH income and uninsured rates are averaged. Enrollment and population totals are summed.

In the poorest expansion states, ACA Medicaid enrollment is six times the size of marketplace enrollment.

Marketplace enrollment is higher in nonexpansion states because in those states, eligibility for marketplace subsidies begins at 100% FPL, as opposed to 138% FPL in expansion states (below that level, expansion state residents are eligible for Medicaid). At 100-138% FPL, the premium a benchmark silver plan with comparatively low out-of-pocket costs is just 2% of income. About a third of enrollees in nonexpansion states have incomes below the 138% FPL threshold.  But that increased marketplace enrollment is nowhere near the foregone potential Medicaid enrollment, which begins at zero income.

Medicaid is the country's chief defense against a massive upsurge in the uninsured population during the current pandemic-driven economic crisis. The federal government should not only expand its financing of state programs, it should expand eligibility for the duration. State officials who care about the health of their constituents should do everything in their power to encourage enrollment, following the lead of Kentucky under Governor Andy Beshear.


1. A bit more than a quarter of enrollment in ACA-compliant private plans is effected off-exchange, and so not reflected in the totals above. Off-exchange enrollment is unsubsidized, as is 14.5% of on-exchange enrollment.

2. CMS has two ACA enrollment categories (labeled "Group VIII"): those rendered newly eligible under ACA criteria, and those eligible under ACA criteria in states that had already expanded eligibility for childless adults up to at least 100% of the Federal Poverty Level (the ACA expansion provides coverage up to 138% FPL).  Enrollees in both categories received the enhanced federal match rate of 90% mandated by the ACA. As of June2019, there were 12.0 million enrollees rendered newly eligible by the ACA, and 15.3 million in the broader category, rendered eligible by ACA criteria but including those who were already rendered eligible pre-ACA by expansions in select states. About half of the enrollees in the broader category are in New York, and another 337,000 in Massachusetts. Other states that have significant numbers of Group VIII enrollees not rendered newly eligible include Vermont, Illinois, Hawaii, Washington, D.C. Arizona, Maine, and Iowa. I've used the broader enrollment category here because the point is to spotlight the effect of broad Medicaid eligibility, not the legislative source of it.

Update, 9/19/20, from the Census' annual report on health insurance in the U.S.: In 2019, the uninsured rate among adults aged 19-64 was 9.8% in expansion states - and 18.4% in nonexpansion states.

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* The Maryland Health Connection, my poster child for Medicaid submergence in the post linked to at top, has since strongly improved its Medicaid signposting. And this week, New Jersey unveiled its new state-based marketplace, which will go live in mid-October and start enrolling marketplace applicants on November 1. The new site does a credible job steering visitors to NJFamilyCare, the state Medicaid program. It's two clicks from the lead message on the home page to here. I wish the text were larger, that there were more indication that there's strong odds a visitor will qualify, and that it was clearer that the info about special enrollment periods that precedes the NJFamilyCare info does not apply to the Medicaid program, but it's better than most.

** Corrected I originally dated the Medicaid enrollment figures to February 2020, when the numbers were updated.

Population: U.S. Census via Wikipedia
Median HH income: American Community Survey via Wikipedia
Effectuated enrollment, ACA marketplace, Feb. 2020: CMS
Medicaid Group VIII enrollment, Feb. 2020: CMS


  1. Thanks for one of many useful blog posts.

    Note that the under-informing about Medicaid and expanded Medicaid can be looked at as a symptom of the complexity of our byzantine health insurance system. (Compare to Canada single-payer for a simple model.)

    The complexity includes the ACA, which splits coverage into CHIPs, Medicaids and expanded Medicaid and the on-exchange plans.

    Myself, in MA, my early-retiree income status has put me around the 138% FPL dividing line between expanded Medicaid and subsidized on-exchange plans. Thus, 5 times the MA agencies have caused gaps without coverage or with unusable coverage due to this. (E.g. once, mid year, the state decided to re-classify me as getting expanded Medicaid, due to its update to new FPL cutpoints--they switched me to expanded Medicaid and stopped my on-exchange on 6 days notice. This would have bankrupted me, had I been in the hospital at the time with in-network providers and approved procedures.)

    Our system is just too complicated for the states to manage. (Remember, in many states, the state agencies operate somewhat as an employer of last resort.)

    Further, as you have pointed out here: , and I have pointed out in the the Wikipedia article on Medicaid estate recovery (which I wrote), here:,

    in 10-14 states, expanded Medicaid expenses are still estate recoverable. This can be all medical expenses paid out -- the person has no insurance, actually. Just a loan for raw medical expenses until death!

    We're not going to get single-payer anytime soon. The problems you point out in this blog post, as well in the one on Medicaid estate recovery, can be looked at as a symptom of our complex system, too complex for not-that-capable state agencies to manage.

    Or, in the words of someone I saw speaking on Amanpour the other day, we've gone, as the US often does, with bad, incompetent government. We need good, competent government. (And gosh, I can't see how we can possibly get to that with the current political situation.)

  2. Oops: In the prior comment, I believe I have failed to indicate that in the 10-14 states, the estate recovery on expanded Medicaid (and other non-long-term-care Medicaids) is for people 55 and older only.

    I should add that on that, when the person is eligible for any Medicaid, including ACA expanded Medicaid, they can't get a subsidized on-exchange plan. But they can still get, if they can afford it, and know about the estate recovery, an on-exchange plan without subsidy.

    However, even if they can afford it, one problem is they often don't know about the estate recovery. Some states have notice very obscure, such as MA, being this:

    where the notice is buried as items (9) and (10) on adobe p. 22, and requires consulting an estate lawyer to figure out what it means when it says "to the extent permitted by law".) (The same notice appears in the on the on-line application, after you have already entered all of your financial information.)

    On the Federal application (applying to states using the Federal exchange) there is no estate recovery notice at all. ( See p. 8, where the estate recovery warning is missing from the warnings for people getting Medicaid.) Possibly, the state Medicaid agency itself, after issuing the Medicaid, and exposing the person to estate recovery risk of all medical expenses, will tell the person. Who knows?

    Complex government beyond the technical capacity of its employees. Bad government!