Medicaid enrollment likely reaches 81 million in January

Subscribe to xpostfactoid 

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.*]

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

On educating voters

The Times' Robert Pear reports that labor leaders are backing away from the pre-Scott Brown compromise forged between House and Senate Democrats over the excise tax in the health care reform bill, on grounds that "the proposal is too high a price to pay for the limited health care package they expect to emerge from Congress."

If that's true, it would seem that labor leaders don't expect the House to pass the Senate bill with a "reconciliation sidecar," which is very bad news.   Also striking, though, is the article's snapshot of the extent to which attacks on the bill from all sides have penetrated voters' perceptions, whereas its virtues have not. The attacks cross-fertilize: 

At meetings of the House Democratic Caucus, lawmakers from Massachusetts, including Representatives Edward J. Markey and Richard E. Neal, said they were struck by the vehemence of opposition to the tax in their districts.

Mr. Markey recalled that a constituent had poked him in the chest and said: “Eddie, I’ve voted for you my whole life. But if you think you will tax my benefits and give the money to Ben Nelson in Nebraska, you’re crazy.” Senator Nelson, Democrat of Nebraska, voted for the bill after it was rewritten to provide extra Medicaid money to his state.

To which there's an obvious response: if the excise bill is in there, the Nelson giveaway won't be. Even Nelson has asked that the special deal for Nebraska be removed from the bill. So any deal that House Democrats cut that allows a portion of the Senate bill's excise tax to remain in place would entail getting rid of the Nelson deal.

Markey does not say that he did not make that point to the voter. But so many Democrats seem so cowed by every line of attack, no matter how partial, trivial, misleading, disingenuous  -- it's agonizing to watch them cringe.