Where is Medicaid enrollment surging? Notes from a few states

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Last month, the Urban Institute forecast that at 15% unemployment, between 8.2 million and 14.3 million people would enroll in Medicaid, an increase of 11-20%.* While the job rate officially now stands at 13.3%, it would be 3 points higher if those classified as employed but absent from work were counted as unemployed, as BLS says they should be (see pg. 6 here).

I have been tracking Medicaid enrollment in states that have accepted the ACA Medicaid expansion and that report timely monthly data. As of early May, enrollment in Kentucky and Minnesota was the highest I was able to track, having increased about 8% since February.  Nationally, the increase at that point was probably about half that. In both states, enrollment increased by another 2% from May to June.

Below, a few bulletins from states (including MN and KY) showing significant enrollment growth. A 2% jump in a given month seems like a frequent marker that enrollment is getting in gear.

New Medicaid expansion + increased silver loading should improve ACA marketplace risk pools

Over the next couple of years, two forces will be at work to make ACA marketplace risk pools somewhat wealthier and therefore healthier -- even as other factors pull the other way.

The factors working to improve the risk pool are Medicaid expansion, which pulls the lowest income  enrollees out of the marketplace, and silver loading*, which creates discounts in bronze and gold plans that mainly benefit (and draw in) enrollees at the upper income range of subsidy eligibility (201-400% of the Federal Poverty Level).

At incomes below 201% FPL, the bronze/gold discounts for the most part are not valuable enough to offset the free, strong Cost Sharing Reduction subsidy available at that income level, and available only with silver plans. At 200-400% FPL, the discounts were attractive enough to offset factors inhibiting enrollment for 2018, such as the huge advertising and outreach cuts implemented by the Trump administration and confusion about repeal and the individual mandate. As I've noted before, compared to 2017 enrollment levels, 2018 enrollment  at 201-400% FPL outperformed enrollment below 201% FPL by about 8 percentage points. That in turn shifted the income distribution of exchange enrollees upwards a couple of percentage points:

Income distribution of subsidized enrollees: HealthCare.gov, 2017-2018

Year	Number enrolled at 0-200% FPL*	Percent enrolled at 0-200% FPL	No. enrolled at 201-400% FPL	Percent enrolled at 201-400% FPL
2017	5,507,246	59.8%	2,851,601	31.0%
2018	5,092,349	58.2%	2,891,851	33.0%

Source: Public Use Files (2018, 2017) published by CMS