Wednesday, September 02, 2020

Pandemic Medicaid enrollment powers into August

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Update, 10/4: see this post for 32-state enrollment through August (California included).

Update, 9/27: I'd like to venture a top-line estimate for Medicaid enrollment through August.  In the 25 states I can track through August (I've added Mississippi), enrollment is up 10.5% Aug-Feb. In tracking through July, California's near-flat enrollment drops total growth Feb-July by 1.9% percentage points. Assuming continued weak growth in CA in August, let's assume 8.6% enrollment growth since February. According to CMS's February tally, that would peg total enrollment through August at 77,293,798 -- call it 77.3 million, up about 6 million from February. (Preliminary August numbers for California are in, and they show a drop, which will probably be adjusted up to a very modest increase, based on recent history.)
      Of course, enrollment growth in the twenty states not tracked below could be different from the that of the tracked states. It's just occurred to me that I can tally the growth in those states through May, the last month tallied by CMS, and compare it to growth through May in the states tracked below. Then again, growth in many states surged after May -- but by definition this near-real-time tracking is tentative. Stay tuned. [Update: increase through May for the 20 states not included in my July chart is essentially identical to the 50-state increase excluding California -- 3.6% vs 3.7%. As of May, California pulled down the national average to 3.2%, from 3.7% excluding California. That's a 13.5% decrease in the increase, to put it awkwardly. Shaving the same percentage off the 10.5% August increase recorded for 25 states below suggests a 9.1% national increase since February and a national total upwards of 77.6 million enrolled in Medicaid.

Update, 9/22: California wrecks the average for July. Minus California, states below are up 8.8% through July; CA knocks that down to 6.9%. California has also posted a raw total for August that's below July's, but that total will doubtless be adjusted up, as July's has been. Also, South Dakota is up 1.3% July to August.
      The California monthly totals below were supplied by the state Dept. of Health Care Services. Raw totals recorded in two public state databases (1, 2) are slightly different from these totals. California deems the data preliminary for a full 12 months, and the state's monthly totals have changed considerably in the period in which I've been tracking. Growth remains surprisingly low, however.

Earlier updates at bottom.

Original post: (9/2/20): A handful of states have posted Medicaid enrollment totals as of the end August (or, in the case of New York, as of mid-August or beyond*). The main takeaway is that growth in Medicaid enrollment triggered by the pandemic does not appear to be slowing down.  In the states charted below, enrollment grew by 1.5% from June to July. In the four states that have reported through all or most of August below, enrollment also increased 1.5% over the prior month. [Update 9/4: Minnesota up 1.2%; 5 states up 1.4% July-August.]

The sustained Medicaid enrollment growth five months after the first pandemic-induced lockdowns  should not be a surprise. As I've noted before, Medicaid enrollment is a lagging indicator. A United Hospital Fund study found that in the Great Recession of 2007-2009, Medicaid enrollment in New York peaked seven months after unemployment peaked. Robin Rudowitz of the Kaiser Family Foundation tells me that Medicaid enrollment continued to climb nationwide after the Great Recession officially ended, and that state Medicaid directors whom Kaiser surveyed at the end of April anticipated increases extending throughout the year.

Pandemic Medicaid Enrollment in 31 States (updated 9/30)
February through July or August 2020
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple
Totals as of the end of each month

Pandemic Medicaid Enrollment in 28 States (updated 9/30)
February through August 2020
Expansion states in blue; nonexpansion states in red; Medicaid to 100% FPL in purple
Totals as of the end of each month

A report released yesterday by Families USA's Joe Weissfeld on Medicaid enrollment during the pandemic tracks growth since February in 38 states that report on a monthly basis. The report finds a net national increase of 4.3 million enrollees as of the last month each state reported, which ranges from May to July. That's consistent with my tracking, which suggests enrollment growth of about 5.3 million nationally from February through July (California, where enrollment has been flat, would drag down the July percentage recorded above by about a percentage point).  The Families USA total runs only through May or June in many states. Current enrollment is probably 76-77 million nationally.

The difference between monthly totals I've recorded and some of Families USA's stems mainly from my effort to reconcile states that report at different times of the month. Because I wanted a start point just prior to the first effects of the pandemic, I put totals reported in early March in the "through February" category and follow that practice in later months: a total recorded as of Sept. 1 (e.g., Arizona's) appears in the "through August" column above. Thus Families USA classes Virginia's Aug. 1 report as "August";  I have it as "through July."  For states that report after a substantial lag, I take the month designated at face value.

The Families USA report emphasizes that states will not be able to handle the massive influx of Medicaid enrollees without a further boost to the federal "match rate" paid to each state. The Families First Act boosted the FMAP by six percentage on condition that states pause disenrollments for the duration of the national emergency, which all states have done. As the economic cardiac arrest induced by the pandemic has decimated state revenue, states are in dire need of both direct federal aid and a further FMAP boost. Otherwise they will have to make savage cuts to services, including Medicaid; since they cannot disenroll people, they will have to cut services offered to enrollees and/or payments to providers (which effectively cuts service by reducing the ranks of participating providers).

About half of those who have lost or will lose job-based coverage as a result of the pandemic are probably eligible for Medicaid. Enrollment would be still greater if states publicized the benefit and streamlined enrollment more than they do, which would require a system and culture in which 1) further enrollment didn't entail acute fiscal pain for states, 2) all states had a culture that embraced publicly funded insurance as an essential alternative for those who lack access to job-based insurance, and 3) state processing systems and technology for all benefits, including unemployment insurance and food stamps, weren't groaning archaic miseries. For an on-the-ground view of how a state committed to insuring the uninsured could maximize Medicaid (and marketplace) enrollment, see Cara Stewart's account of how the state that's doing it best could do better. 

Update: The Center for Budget and Policy Priorities' Matt Broaddus posts estimates similar to those above. Like Families USA, CBPP ascribes to August some tallies posted early in the month. That makes sense in that people enrolled as of August 1 are unlikely to disenroll, thanks to the national stay on state-initiated disenrollments. But "August" tallies posted in early September reflect growth through the end of the month, so I'll stick to my through-end-of-month categorization. CBPP's overall estimate -- 6 million new enrollments, which would bring national enrollment to 77 million -- is congruent with mine.

Update, 9/21: Medicaid enrollment in New Jersey is up 8.5%, February through August 2020.

Update, 9/17: Total Medicaid enrollment in Utah is up 16.9% since February. See this post for backstory.

Update, 9/16: Kentucky today posted its tally for September: Medicaid enrollment is up 19.7% since early March. That's tops in the nation, perhaps due in substantial part to Kentucky's unique outreach efforts, e.g., contacting everyone who applies for unemployment benefits about their insurance situation. Please note that Kentucky is one of several states that report early each month, and that I place such reports in the prior month -- that is, the September report is categorized as "thru August" in the chart below.  In the 18 states for which I have totals through August, enrollment is now up 10.8% since February.

Update, 9/15: August totals added for Indiana, Iowa, Virginia, West Virginia, Florida, and Missouri. Increases from July range from 1.1% (Iowa) to 1.8% (Florida and Missouri). Update 2: Michigan added; it's up 11.1% February-August. In 17 states that have reported through August, enrollment is up 1.4% over July and 10.3% since February.  I've added a new chart with totals for states that have reported through August.

Update, 9/10: August totals added for Alaska, North Carolina, Tennessee and Wisconsin. All but Alaska are up at least 1% from July to August.

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

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* The NY Dept. of Health website states, "Posting of the monthly Medicaid Managed Care Enrollment Report will generally occur during the third week of the enrollment month." The August report was posted later than than that, but presumably reflects August enrollment. During the pandemic emergency, states have refrained from actively disenrolling beneficiaries.


  1. I see the Medicaid enrollment is up due to COVID, as you report. (These would be traditional Medicaid, and, in the rough 36 states that have expanded, expanded Medicaid as well.)

    I live in Massachusetts, and have noted that the MA government is boasting how good a job it's doing getting people onto Medicaid who have lost their job-related insurance, or whose income has dropped to below 138% of the Federal Poverty Level (regardless of assets), moving them from on-exchange plans to expanded Medicaid.

    If you know about Medicaid estate recovery rules across the states you will know that in 10-14 states the recovery is being done even on non-long-term-care Medicaids for people 55 and over. You will then take note of a pernicious goofiness of our complicated, still-inadequate health insurance system.

    In those 10-14 states (of which my MA is one), the state is, due to COVID job losses, switching people to Medicaid, saying "don't worry--we've got your back". However, in the case of people 55 or older, it's actually passing them a financial bomb. If they get expensively sick while they have the Medicaid or expanded Medicaid, their estates are on the line for all medical expenses paid out. (They actually have no insurance at all!)

    The issue of this Medicaid estate recovery being done on ordinary (non-long-term-care) Medicaids was actually pointed out in this blog last year, where shock was expressed, because the problem is truly shocking when the ACA is presumably supposed to be giving everyone affordable health insurance. (Not just a loan until death for medical expenses.)

    (This link: )

    In more detail than you had, about 8 states, which used to do Medicaid estate recovery on non-long-term-care stopped starting in 2014, the year the main ACA provisions went into effect, or later. (They stopped the recovery on either all non-long-term-care Medicaids, or sometimes just ACA expanded Medicaid.)

    (These states include NY, CT, OR, WA, CA, MN, and CO. A number of other states that expanded Medicaid never did the non-LTC recovery, such as PA. Leaving about 10-14 with the problem. It's hard to tell exactly how many states still have the problem, since some states are not specific in their on-line postings about estate recovery.)

    For people not familiar with the issue, a good general reference is the Wikipedia article on Medicaid estate recovery.

    Wikipedia is not, in itself, reliable, so you can click on the references to verify.

    (This is the link: Or, it case it gets diluted by some editor in the future, this is the backup: )

    I have some other references to the (rare) press coverage of the issue. Let me post them.

    Seattle Times article (late 2013):

    Which actually led, in just a few days, to Washington State stopping estate recovery on at least expanded Medicaid, as here:

    And here is a case of some activism in MN getting the recovery stopped in 2017

    2014 Washington Post Article (early 2014) on the general issue:

  2. Let me toss on a real-world example, to make the Medicaid estate recovery on ACA expanded Medicaid real rather than abstract.

    It was caught a few weeks ago by Michelle Singletary in the Washington Post.

    ( )

    If you scroll down to “Q: Medicaid estate recovery”, you will see that Dad, living in Maryland, ages 62 to 64, got ACA’s expanded Medicaid after he lost his job, and Maryland Medicaid paid the bills for his illnesses.

    Dad thought he had real insurance.

    But, alas, when he died, at age 64, his 3 children, who also had though he had had real insurance, discovered that although Dad was among the 91% of people counted as “insured” by the U.S. Census Bureau, he actually had just a loan until death for medical expenses, and actually, had no insurance at all.

    (All bills paid out had to be paid back to the Maryland Medicaid Department by Dad’s 3 kids–that’s not insurance in any sense of the term.)

    This example should also help straighten out many the common misconception that Medicaid estate recovery is only done for long-term-care and nursing home expenses. In maybe 10-14 states, including MD as in the example, it is done for all Medicaid medical expenses for people 55 and over.