Estimate: ACA Medicaid expansion enrollment may have grown 25% from February to December 2020

Subscribe to xpostfactoid 

As Covid-19 burned its swath through the U.S. in December, Medicaid enrollment in the ACA expansion category (adults with monthly incomes up to 138% of the Federal Poverty Level) continued the rapid growth that started with the pandemic.

Enrolment increased 2.7% from November in the 17 states for which I've been able to locate monthly expansion-category enrollment reported through December. In those 17 states, enrollment increased 27.6% from February 2020 -- the last month in which the economy was unaffected by the pandemic -- through December.

Medicaid enrollment in a pandemic: The case of Kentucky

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

Update (6/9/20) at bottom, with June enrollment numbers and more information re enrollment outreach in KY.

Of the tens of millions of Americans likely to lose access to health insurance as a result of job losses triggered by the Covid-19 pandemic, the Urban Institute estimates that about half -- 8.2 million in the most conservative of several scenarios -- will enroll in Medicaid. Kentucky appears to have gotten off to a comparatively fast start, though state healthcare advocates see a need for more intense outreach.

Medicaid enrollment in the state has increased by more than 100,000 (8%) since February, from 1.32 million to 1.42 million, according to the state's monthly membership tally.  In 2019, enrollment from March to May was flat, down less than 1%. At 20% unemployment, which we're likely to reach in the next jobs report, between 336,000 and 397,000 Kentuckians are likely to have lost access to job-based insurance, according to the Urban Institute estimate. Urban foresees Medicaid enrollment in Kentucky increasing by between 208,000 and 228,000 thousand if that unemployment rate holds for some months.

Dustin Pugel, a senior policy analyst at the Kentucky Center for Economic Policy, credits Governor Andy Beshear, elected just last November, with stimulating and facilitating crisis Medicaid enrollment.  During his daily televised, widely watched Covid-19 briefings, Beshear regularly starts with ten steps for fighting the virus, and, Pugel says, "One of them is signing up for benefits. Medicaid is mentioned every single time."

C'mon, states: take the wraps off Medicaid

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

On the eve of the pandemic, about 13 million Americans were enrolled in ACA-compliant individual market health insurance plans. About 71 million were enrolled in Medicaid.

As job losses triggered by the pandemic exceeded 30 million, the Urban Institute forecast that at a 15% unemployment rate, among 17.7-30.0 million people losing access to employer-sponsored insurance, just under half would enroll in Medicaid and just under a quarter in marketplace or other private insurance.* Analyses by the Kaiser Family Foundation and Health Management Associates also show Medicaid to be the main vehicle for insuring those who lose access to employer-sponsored insurance.

Every ACA exchange, every state Medicaid agency, and arguably every state government website should be foregrounding an app that looks (and works) like this:

New Jersey's "Get Covered" message submerges Medicaid

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

New Jersey, a very blue state with a liberal governor and large Democratic majorities in both houses of the legislature, is committed to helping hundreds of thousands of residents newly uninsured in the Covid-19 pandemic to find subsidized coverage. The state has launched an information campaign to help people get covered.

But New Jersey's ACA marketplace is stuck in limbo during a tough time. The state is in the process of creating its own state-based exchange (SBE), scheduled to launch on November 1. In the meantime, it's technically an SBE, but still using the federal exchange, HealthCare.gov, for enrollment.

That creates a messaging problem. The state has created a website, Get Covered New Jersey, to help people find coverage. But it has to be a complex switching station. Those eligible for subsidized marketplace coverage need to enroll through HealthCare.gov. Those eligible for Medicaid -- probably the majority of the newly uninsured -- can also apply via HealthCare.gov but, for reasons explained below, are probably better off applying directly through the state's Medicaid program, New Jersey Family Care. Finally, those who earn too much to qualify for aid need to be aware of ACA-compliant plans offered off-exchange only, especially since these include the cheapest silver plan available.

Get Covered New Jersey tries, but in my view fails to help people figure out quickly what kind of help they're eligible for, and act accordingly.

The main problem is that the site doesn't foreground Medicaid or, most vitally, a Medicaid eligibility screener. According to an Urban Institute estimate, almost half of New Jersey's  newly uninsured residents (224,000 out of 489,000 by the study's more conservative of two estimates) should end up in Medicaid, while just under a quarter may enroll in marketplace coverage.

Enrollment in Medicaid surges in Minnesota

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

An Urban Institute analysis released this week, How the COVID-19 Recession Could Affect Health Insurance Coverage, estimates, in the more conservative of two models deployed, that if the unemployment rate reaches 15%, Medicaid enrollment will increase by 8.2 million  nationally. That would constitute a 16% increase in total Medicaid enrollment for the under-65 population.

Minnesota appears to be halfway there already. The state tracks enrollment in managed* Medicaid and MinnesotaCare, a Basic Health Program that provides Medicaid-like coverage to people in households with income up to 200% of the Federal Poverty Level, on a monthly basis.

From February to May this year, managed Medicaid enrollment in Minnesota for adults age 21-64 is up 10.4%. For pregnant women, it's up 16%. Enrollment of children is up 6%. Enrollment in MinnesotaCare, the BHP, is up 24% -- though enrollment in that particular program was up almost as much in Feb-May 2019.

In total, managed Medicaid/MinnesotaCare enrollment has increased by 77,142 (8%) since February, more than five times last's year's increase in the same period of 14,547 (2%).  Since mid-March, 590,000 Minnesotans have applied for unemployment benefits, according to the state Management and Budget office's May budget projection.

Smooth the path to Medicaid enrollment for the newly uninsured

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

As tens of millions of Americans lose job-based health insurance, the heavyweight in reducing the ranks of the newly uninsured is going to be Medicaid -- at least, in the 36 states that have enacted the Medicaid expansion  (and if Democrats don't push through a 100% COBRA subsidy). Medicaid will far outweigh the ACA marketplace for several reasons:

• Medicaid eligibility is based on monthly income, whereas marketplace subsidy eligibility is based on annual income. Mid-year, marketplace subsidies are therefore weakened by income earned year-to-date.
• The average normal unemployment benefit nationally is $378 per week* -- close to the Medicaid eligibility threshold in expansion states for a single person ($1468/month) and well below the threshold for any larger family. 
• The extra $600/week UI benefit provided for up to 4 months by the CARES Act does not count as income for Medicaid eligibility purposes, but it does count toward subsidy eligibility in the ACA marketplace. 

Reverse reinsurance for COVID-19 treatment

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

The case for the federal government picking up the cost of all COVID-19 treatment for everyone, not just the uninsured, is compelling.* Benefits include:

• Eliminating inhibitions about seeking treatment, thereby helping to contain contagion as well as saving lives. 
• Avoiding a major channel of financial harm at a time when tens of millions are likely to suffer extensive financial harm.
• Establishing a unified database of treatment/results.
• Paying providers swiftly while eliminating price-gouging via balance billing (which enacted COVID-19 legislation has so far enabled at providers' behest).

At the same time, as we pile on trillions in federal debt with abandon, there's no reason that private insurers and self-funded health plans shouldn't pay their fair share.

A mechanism already exists to calibrate what constitutes such a "fair share." It's the statutory Medical Loss Ratio (MLR) that health plans are required to maintain. MLR is the percentage of premiums a plan spends on medical care for enrollees. The ACA-mandated minimum MLR is 80% for individual and small group plans and 85% for large group plans. If a plan spends below those thresholds on claims, it's required to rebate the employer (in group plans) or the enrollees (in individual market plans).

The newly unemployed also need an emergency Special Enrollment Period

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

After a week or two of rumors that the Trump administration would open an emergency Special Enrollment Period (SEP) on HealthCare.gov, the federal ACA exchange used by 38 states, the administration announced on Tuesday that it would not do so. Twelve of the thirteen state-based exchanges have announced emergency SEPs since March 10, with only Republican-ruled Idaho demurring.

As Jeff Young put it, team Trump could not choke down "an admission that the law and its benefits help people." Their spite will likely cost some people their lives and others all their worldly wealth. As the Kaiser Family Foundation's Larry Levitt noted, some 9.2 million of the nation's uninsured were eligible for ACA marketplace subsidies at last count (i.e., as of 2018).

Normally, enrollment in ACA-compliant private plans is only possible during Open Enrollment, which runs Nov. 1 - Dec. 15 in HealthCare.gov states. A SEP is available at other times only to those who undergo a "life change," such as loss of employer coverage, marriage, divorce, death of a family member, etc.

Whether fear of COVID-19 and the huge costs of hospitalization (ranging from about $9,000-90,000 by Kaiser's estimate) would induce many of the uninsured to seek coverage is an open question.*  Poor takeup among the subsidy-eligible has persisted since the ACA marketplace launched. The 9 million subsidy-eligible uninsured estimated by Kaiser roughly match total on-exchange enrollment. Takeup is better among those rendered eligible for Medicaid by the ACA expansion, but Kaiser also estimates that about 7 million uninsured are eligible for Medicaid and CHIP. An emergency SEP, plus a concerted public information campaign, might shrink those ranks.

The main benefit of an emergency SEP opened unconditionally to all may lie elsewhere, however. ACA enrollment can be complicated at the best of times. An ordinary SEP, including one triggered by job loss and attendant insurance loss, adds friction.  An applicant has to attest to and verify the loss of insurance; the marketplace has to confirm it, grant the SEP, and then open the gate. In some states, accepting evidence of loss of coverage is up to the insurance company with which the applicant seeks to enroll.

Emergency Special Enrollment Periods in 12 state ACA marketplaces: How easy?

Subscribe to xpostfactoid via box at top right.

Update, 4/7/20: Early emergency SEP data collected by Charles Gaba indicates that states that require a phone call to begin the SEP application are seeing slower enrollment than states where an emergency SEP application can be completed online.

Twelve of the thirteen states (including D.C.) that run their own ACA marketplaces have announced emergency Special Enrollment Periods to help the uninsured get covered while the Coronavirus rages. Washington state was first to announce a SEP,  on March 10. CMS is "evaluating" following suit for the 38 states using the federal platform, HealthCare.gov. Idaho is the only holdout (and only red state) among the SBEs.

Kudos to the states that have taken the plunge. May it go smoothly operationally. Some began with some messaging confusion, e.g., info about the emergency SEP that seemed contradicted by older messaging about conventional SEPs, granted only to individuals for life changes such as job loss instead of to anyone seeking insurance. Most of those have been straightened out, but some mixed messaging lingers.  Below, a sampling of clear and not-so-clear home page messaging.

The card spells MOOP: Will Covid-19 expose Americans to financial risk?

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

The Miami Herald reports that a man who developed flu-like symptoms after a business trip to China did what he felt was the right thing and went to the hospital to get tested for the Coronavirus. Hospital officials wanted to give him a CT-scan, but since he knew his insurance was limited, he asked for a flu test first.  Smart move. He tested positive for flu, and that was that -- except for the $3,270 bill that came later, with more to come.

The hospital told him that his share of the bill was $1,400. The story then focused on the fact that this man was in a short-term, limited duration plan that demanded he supply three years of medical records to prove that he didn't have a "pre-existing condition," i.e., a recent prior bout of flu.

That's outrageous, but it misses a broader point about Americans' financial exposure when the Coronavirus spreads. If this individual's medically underwritten policy does pay out, he's not necessarily in a worse financial position than the average insured American who walks into a hospital with suspected Covid-19.