Monday, October 12, 2020

Job losses and the uninsured rate in the pandemic: A one-state snapshot

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Let's try a somewhat ambiguous one-state snapshot -- in New Jersey, my home state --  of the extent to which ACA programs may have blunted an increase in the uninsured population during the months when Covid-19 triggered huge increases in unemployment. 

According to the New Jersey Department of Labor, job losses due to the pandemic peaked at about 835,500 and stood at 426,110 as of August. Estimates of the ratio between the number of people losing jobs and the number losing insurance vary quite a bit, and the ratio probably varies quite a bit by state, depending on the types of jobs lost. The pandemic created novel conditions, in which a fair number of workers were furloughed and were able to keep their job-based insurance, at least for a while. 

In New Jersey, as in most states that enacted the ACA Medicaid expansion, Medicaid is the primary safety net for the newly uninsured.  Enrollees rendered eligible by the expansion -- adults with incomes up to 138% of the Federal Poverty Level -- are driving rapid growth in Medicaid enrollment in the state. Here's the story since February: 

Medicaid Enrollment Growth in New Jersey in the Pandemic

Coverage group

Feb 2020

Sept 2020

Increase Feb-Sept

% increase Feb-Sep

ACA expansion adults





Non-ABD children





All Medicaid





Source: NJ FamilyCare Monthly Enrollment Statistics

What about the ACA marketplace? From the first quarter to the second, total individual market enrollment in the state is down 1.76%, to 311,022. That's not a bad performance: attrition in the marketplace is usually continuous throughout the year. (Nationally, if enrollment stays flat from February through December, enrollment in December 2020 would be up by about 1.5 million over  December 2019.)  From 2016 through 2018, attrition from the first to second quarter in New Jersey averaged 6%.  

Somewhat complicating the picture is even more minimal second quarter attrition in 2019 than in 2020: last year, the second quarter drop in New Jersey was just 0.74%.  That may be due in part to a premium drop in 2019 effected by the enactment of a reinsurance program: off-exchange enrollment, which is unsubsidized, rose 1.22% in the second quarter of 2019 (quarterly reports are available here). 

In any case, the individual market can hardly be considered a major factor in picking up those who lost job-based coverage -- at least outside of the Open Enrollment Period, which begins on November 1. With the launch of supplemental state-based subsidies in 2021, as well as a new state-based marketplace with its own funding source for advertising and enrollment assistance, New Jersey is pinning some hopes on an enrollment boost in the coming OE period.

One more equivocal bit of data. The Census Bureau's experimental Pulse Survey, conducted online, is posting weekly or biweekly uninsurance estimates by state. The results are quite volatile. In New Jersey, the average uninsured rate for the population aged 18-64 in the last three periods, running from August 19 to September 28, is 10.8%. The Kaiser Family Foundation's estimate for New Jersey adults aged 19-64 in 2018, based on the Census' American Community Survey, is 11%.

I doubt that the uninsured rate in New Jersey has stayed flat in the pandemic. But Medicaid is pretty clearly doing yeoman's work to reduce the spike.


  1. Since you're talking New Jersey (one of the 10-14 states that estate recovers the costs paid out under ACA expanded Medicaid and other stabdard medical, i.e.non-long-term-care, Medicaids for people 55 and older), it's a great example to illustrate the pernicious effect of that in a crisis.

    You have 171,307 in New Jersey being moved to Medicaid or expanded Medicaid during the crisis, due to job loss, reduced hours, etc. Probably, the state is congratulating itself, and talking about what a great job they are doing, saying "we've got your back".

    Well, perhaps 30,000 of those 171,307 are 55 or older. If they get sick, may owe the state all of their medical bills paid out. (They have no insurance. Only a loan until death for medical expenses. A bomb.)

    Detail: the state can go after whatever it wants, depending on how it accounts for the Medicaid and expanded Medicaid expenses. It can take a mere annual capitation (in which case it would be a loan for insurance premium) or it could take all bills paid out. (MN, for instance, before it changed and stopped the estate recovery on expanded Medicaid, gave itself both options, and in fact still makes people sign that the state has either option on its ACA application. (On adobe p. 14, here:

    Of course, many of the 30,000 people who have just been given Medicaid have little in assets, perhaps no financial discipline, and no hope of ever passing on any assets to their kids.

    But some do. And they've been given a bomb. (There may indeed be many people with a lot of assets to lose, whose incomes dropped to below 138% of FPL due to the crisis (there is no asset test on expanded Medicaid, and eligibility for expanded Medicaid blocks one from eligibility for a subsidized on-exchange plan, and notification in the states is often obscure. It is missing on the Federal ACA application, actually.)

    I know the author of the blog knows about the issue, and was rather shocked to find out about it. (As posted here: )

    People looking for more information on this issue, which is NOT one of the issues Biden proposes to fix, see the Wikipedia article on Medicaid estate recovery. (I added the info of its affect on ACA-type ordinary medical coverage some time ago. You may want to check details, which are available from on-line references in the article.)

  2. Except for the Medicaid estate recovery, the Medicaid expansion is a good thing, of course. It actually removes a classical poverty trap, where people who earn more lose their benefits, keeping them locked into poverty.

    The Republicans, of course, are leaving (not expanding Medicaid), and attempting to reinstate (whole ACA repeal including expanded Medicaid), a poverty trap.

    Expanded Medicaid effectively changes the eligibility criterion for Medicaid from dirt poor in both income and assets to 138% of the Fed. Poverty Level in income, and also removes the dirt-poor-in-assets asset cap. (It has no asset cap.)

    Prior to the ACA expansion of Medicaid, (and without it in states that have chosen not to expand), low income people can exert effort to work and produce for the economy, and be slapped in the face for doing so. Losing their health coverage.

    On occasion, Republicans claim they want to remove that type of poverty trap.

    In fact, CATO's Conservative Swedish Johan Norberg, in a PBS Special "Work and Happiness" from 2017,

    ( at 10:50-16:20)

    tells us that the problem is, in the American system, if you work, you lose your benefits. Medicaid specifically is referenced. Poverty trap. Charles Murray and others appear, in agreement.

    But, the Republicans failed to expand Medicaid still in 12 states, and are trying to kill it in every state by taking away the whole ACA.

    Certainly Norberg could have placed that contradiction in his documentary. But he didn't.

    (I actually questioned him about this on his facebook page, here:¬if_id=1602538647678469¬if_t=feed_comment_reply&ref=notif

    where he did actually respond. By saying the timing of events, with the special planned in Jan 2015, made addressing the issue impossible. But I don't understand. The non-expansion of Medicaid in about 20 states by Republicans was in place a year prior to that, at ACA main provision time: Jan 2014.

    (I posted a further inquiry. Perhaps he will get back.)