Is the uninsured rate flat since 2019, or down a bit?

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See 8/31 update from NHIS survey at bottom

The Urban Institute, in an analysis of results from its own ongoing Heath Reform Monitoring Survey, found that the uninsured rate among adults aged 19-64 did not change significantly from March 2019 to April 2021. 

That's at least a backhanded tribute to the U.S.'s kludgy health insurance safety net as bolstered by the Affordable Care Act. Big picture: in Urban's estimate, as a result of the pandemic, employer-sponsored insurance  fell by 3 percentage points (from 65% to 62.3%) in the survey period, while insurance through public programs (mainly Medicaid) increased by 4 percentage points (from 13.6% to 17.5%). 

You could read these results as a paean to the ACA Medicaid expansion (which Republicans almost repealed in 2017). In states that have expanded Medicaid, Urban found that the uninsured rate actually dropped two percentage points for people with incomes below 138% FPL, the Medicaid eligibility threshold. According to CMS, total Medicaid enrollment (including children) increased by 11 million -- 15.6% -- from February 2020 to March 2021.  Enrollment among adults rendered eligible by the expansion increased by about double that rate.

Urban recorded a much more modest and ambiguous impact for the ACA marketplace -- though the huge enrollment surge during the emergency Special Enrollment Period open from February 15 through August 15 of this year, turbo-charged by subsidy increases enacted in the American Rescue Plan, which appeared on HealthCare.gov on April, was mainly missed by Urban's study period. I'll return to that in a bit.

I speculated in May that the U.S. uninsurance rate might be at an all-time low, powered by huge gains in Medicaid enrollment, significant gains in marketplace enrollment, and relatively modest losses in employer-sponsored insurance during the pandemic. My methods (and math) are far less sophisticated than Urban's, and this is not to question their results (no source ever has a really complete picture of insurance in the U.S.).  That said, a few comments and caveats below.

Is the U.S. uninsured rate at an all-time low?

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Enough states have reported Medicaid tallies through February to posit that the pandemic has increased enrollment by more than ten million nationally since February 2020. Adjusting for the usual difference* between CMS's official totals (now posted through November**) and my sample below (based on state monthly reports), year-over-year enrollment growth since February 2020 is likely about 14.8%, and total enrollment likely stands at about 81.7 million. A quarter of the U.S. population is enrolled in Medicaid.

I don't think we've fully fathomed the effect on access to health insurance of the pandemic, the battered and flawed but still functioning and funded ACA programs in place as the pandemic hit, and pandemic relief measures.  Consider...

The Families First Act effectively required states to pause Medicaid disenrollments for the duration of the Covid-19 emergency, and enrollment will continue to grow until that moratorium ends.***  Enrollment growth among those rendered eligible by the ACA Medicaid expansion is close to 30%. In the ACA marketplace, average monthly enrollment in 2021 will probably exceed 2019 enrollment by at least a million, perhaps more, spurred by extended Special Enrollment Periods and subsidies enhanced by the American Rescue Plan Act. As the population ages, Medicare enrollment grows by about 1.5 million yearly. Meanwhile, the huge job losses triggered by the pandemic appear to have had only a modest effect on employer-sponsored insurance: enrollment through September was down by just 2-3 million, according to a KFF estimate.

Medicaid enrollment likely reaches 81 million in January

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Chart updated 3/3/21

This is an update to my recent post estimating total national Medicaid enrollment at upwards of 80 million through December, up from 71.2 million in February 2020, the last month before the pandemic struck the economy.

I've added December updates from four states -- including the big one, California -- to the sample, as well as adding Nebraska, which enacted the ACA Medicaid expansion beginning in October. As I forecast, continued relatively slow growth in California drops the full-sample rate of increase by about two and a half percentage points.  

As always, the official CMS tally for all states, currently stuck in September, is likely to show a somewhat smaller increase than my sample. For September, my sample showed an increase of 9.7% over February, while CMS currently shows a 9.4% increase in the same period.  Conservatively, then, I'll posit that CMS will show a 12.5% increase from February through December 2020, which would put national enrollment at 80.1 million.  (The sample consists of states for which I can find monthly enrollment reports.)[Update, 4/5/21: CMS's preliminary November total shows an increase of 11.6% since February, as I forecast on New  Year's Eve, compared to the 12.0% increase for the same period charted in my sample below.*]

The ACA as pandemic safety net

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In the New York Times Upshot, Margot Sanger-Katz, Sarah Kliff and Quocktrung Bui report that the health insurance safety net as bolstered by the ACA, patchy though it is, appears to have held the uninsured rate close to steady during the pandemic months. In brief: Medicaid enrollment in the ACA expansion category is up more than 20% since February; ACA marketplace enrollment in 36 HealthCare.gov states is up 6.6% for 2021, and losses of employer-sponsored health insurance appear relatively modest.

I have been tracking these developments as they unfold. Some of the posts below corroborate the core findings cited in Upshot, and some supplement those findings. In reverse chronological order:

• ACA marketplace enrollment was already up by more than 6% year-over-year by June 2020. 

• Medicaid enrollment among those rendered eligible by the ACA Medicaid expansion is up more than 20% since February and likely exceeds 18 million.

• In states that have so far refused to enact the ACA Medicaid expansion, the ACA marketplace has picked up some slack: in nonexpansion states, marketplace enrollment is up 10% in 2021.

As long as no one is thrown off Medicaid, will enrollment keep growing by 1% per month?

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I am beginning to wonder. I gather that no one has a precise idea what percentage of Medicaid enrollees are disenrolled every month by state income checks and eligibility redeterminations. The Families First Act paused those disenrollments for the duration of the national emergency -- as of now, through the end of March -- though a new interim final rule issued by Seema Verma's CMS appears to give states a green light to deem some past enrollments "invalid" and void them.

Of course, people continue to disenroll from Medicaid -- when they get a job with affordable insurance, or marry someone with insurance, or move, or age into Medicare (at which point the income thresholds for Medicaid drop in most states), or age out of CHIP, or die...etc. etc. It also seems clear that with 5 million more unemployed in November than in February, despite a snap-back from 14 million newly unemployed at the May peak, demand for Medicaid has grown.

At the same time, the Kaiser Family Foundation recently found that the ranks of those insured through employers have decreased only modestly (-1.5%) in the pandemic. Medicaid enrollment, meanwhile, has continued to grow by 1% per month or more in recent months -- at least by my compilation of state monthly enrollment reports, which shows somewhat more growth that CMS's time-lagged official monthly tally.* Certainly a significant portion, and possibly a very large portion of the enrollment growth is a result of the pause in disenrollments.

Estimate: Total Medicaid enrollment stands at 78 million

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Update, 10/24/20: September totals added for IN, MD, ME, MI, MO, NV and UT. I also had to correct misallocated months in Kansas.
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Enough Medicaid enrollment data is in for September to venture an estimate that total Medicaid enrollment now stands at 78 million, up by about 7 million or 10% since February. 

In 13 states with total enrollment of about 24 million, enrollment rose 1.3% from August to September, roughly in line with recent month-to-month increases.  As in previous months, California will probably drag down the total, perhaps to 1%.

Please see this post for the assumptions behind my August estimate of 77.3--77.6 million, further updated here. Note that the August total for Illinois is still estimated, based on increases in prior months. Any error there would have a negligible effect on the total.

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.

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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

Medicaid enrollment in a pandemic: 26-state snapshot

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Update through 9/2 here

Update, 8/19: See this post for a somewhat cleaner comparison through July, reconciling states' different schedules for tallying and methods of labeling a given month.

Update, 8/15: Illinois Medicaid enrollment surged 6.4% from June to July and is up almost 10% since May. Enrollment in Indiana is up 11.8% since February. Of the twelve expansion states below that have reported enrollment in all or most Medicaid programs through July (excluding tallies for expansion population only), the average increase since February is 9.2%. 
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It's time for a fresh post on pandemic Medicaid enrollment, instead of piling updates on my prior snapshot. While I'm focused primarily on states that enacted the ACA Medicaid expansion, I've started to also track nonexpansion states and will keep adding them as I find data.  I have a bunch of URLs to pick through, thanks to a very helpful overview of enrollment in 33 states through May and June  by Chris Frenier, Sayeh S. Nikpay, and Ezra Golberstein.

To review some basic context: the Urban Institute forecast that nationally just shy of half* of those who lose access to employer-sponsored insurance will enroll in Medicaid if severe unemployment lasts for "several months to a year." At 15% unemployment, Urban projects that between 8.2 million and 14.3 million people will enroll in Medicaid, an increase of 11%--20% over total enrollment in early 2020, or 16%--28% over the total of enrollees under age 65.   While the current national unemployment rate has dipped officially to 10%, it's likely to spike again as our public health failures lead to renewed shutdowns and our legislative failures result in cutoffs or sharp reductions in relief benefits.

Note that some of the the tallies below are for the ACA Medicaid expansion only -- that is, adults with incomes under 138% of the Federal Poverty Level. The federal government pays 90% of the cost for enrollees rendered eligible by the expansion. It's not surprising that the expansion population tallies reflect faster growth, since a large percentage of the nation's children were enrolled in Medicaid or CHIP pre-pandemic, enrollees over age 65 are in Medicare and usually not reliant on employer-sponsored insurance, and those eligible for disability Medicaid are also likelier to have been enrolled pre-pandemic.

       Medicaid enrollment in 26 states, February - August 2020

How to boost Medicaid enrollment in a pandemic: Kentucky's Cara Stewart has an idea or eight

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Let's zoom in once more on Kentucky, the state that appears to be having the most success enrolling the newly unemployed in Medicaid. From February to July, Medicaid enrollment in the state rose by 14.3%.  That's the sharpest increase in the nation, I believe, in the period of mass job loss triggered by the pandemic. [Update, 9/17: Medicaid enrollment in Kentucky is now up 19.7% since early March.]

That's not an accident. Kentucky has probably been the most proactive state in reaching out to the uninsured and helping them find subsidized coverage if eligible. Yet American standards are low: ignorance about Medicaid and the ACA marketplace is rife throughout the land. Cara Stewart, a longstanding advocate for increased healthcare access in Kentucky, and currently director of policy advocacy at Kentucky Voices for Health, believes the state could be doing more to reach out to the uninsured. We'll get to those ideas shortly. First, some benchmarks.

Where is Medicaid enrollment surging? A June update

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7/9/20 -- see updates at bottom re strong July enrollment growth in Minnesota and Kentucky

A month ago, I spotlit a handful of states in which Medicaid enrollment was surging in response to the mass job losses triggered by the Covid-19 pandemic. Here, an update.

To review the context for enrollment growth recorded so far: the Urban Institute has forecast that if 15%* unemployment lasts for "several months to a year," between 8.2 million and 14.3 million people would enroll in Medicaid, an increase of 11%--20% over total enrollment in early 2020, or 16%--28% over the total of enrollees under age 65.  Joan Aiker and Tricia Brooks of Georgetown have tracked enrollment in 22 states that have reported through May and found an average increase of 5% over February.

Notes below track enrollment logged in June or as of July 1.  While the Georgetown scholars are tracking both expansion and nonexpansion states, I've limited myself to expansion states where growth is particularly strong.

As of the end of May, both Kentucky and Minnesota had reported increases exceeding 10% since February. I don't have an update yet for either. Among states with new data:

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.

ACA enrollment in a pandemic: What we know so far

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Roughly 30 million Americans have filed jobless claims in the last six weeks. Slightly fewer than half that number may have also lost health insurance, according to an analysis by the Economic Policy Institute.*

The Urban Institute estimates that 59% of those in industries most vulnerable to job loss who lose job-based coverage will have access to government-supported insurance -- Medicaid, CHIP, or the ACA marketplace. How many accept the help is a different question.

The SEP imperative

The answer may depend in part on how wide the ACA online exchanges open the door. Normally, the uninsured can seek coverage only during a limited Open Enrollment Period (Nov. 1 - Dec. 15 in the federal exchange, longer in the 13 state-based exchanges), unless a change in life circumstances during the off-season renders them newly eligible. In that case they are granted a Special Enrollment Period (SEP). Applying for a SEP adds steps to the already complicated ACA enrollment process. Under normal circumstances, an applicant has to upload or mail in proof of loss of coverage, or proof of another SEP trigger, such as marriage.

In 2016, CBO started counting Medicaid enrollment differently

CORRECTION, 6/6/17: Somehow, I missed an email response to my query from CBO (and asked them again twice after receiving the email). In 2016, they did not count partial benefit enrollees in their Medicaid totals; rather, the difference was that they counted people with multiple sources of coverage, including Medicaid, as Medicaid enrolled, whereas in past years they counted only the coverage source deemed primary. I was correct that in 2016 they started counting dual eligibles in both Medicaid and Medicare.

In a US News article by Kimberly Leonard about why the ACA private plan marketplace is not meeting enrollment expectations, while the ACA as a whole is reducing the ranks of the uninsured more or less on schedule, this claim did not compute:

Under Obamacare, states were allowed to expand the program to many more people, but many states have opted not to. Despite that, 16 million people more than expected enrolled in Medicaid and the Children's Health Insurance Plan, including in states that did not expand the program. Many people, it turns out, realized that they could have qualified for Medicaid even before the passage of the health care law.

Similarly, last March, when the Congressional Budget Office published its latest forecast of the ACA's effects, The New York Times' Robert Pear reported: