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

Click here to subscribe to xpostfactoid

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.

Medicaid enrollment in a pandemic: 18-state snapshot (expansion only)

Subscribe to xpostfactoid

Update, 8/14: for all further updates please see the 26-state snapshot published August 12.

Update, 8/5/20:  Enrollment in Utah, which enacted full Medicaid expansion in Jan. 2020 following a partial expansion (for adults up to 100% FPL) launched in April 2019, increased 10.9% from February to June 2020. The population of enrollees rendered eligible by the expansion is up 25.5% in the same period. As the unemployed population in Utah was 45,000 higher in June than in February (largely recovered after a huge spike in April), the increase in Medicaid enrollees in the state since February (33,615) may exceed the increase in newly uninsured. 

Update, 8/4/20: Minnesota managed Medicaid/MinnesotaCare enrollment increased 1.5% July-August. It's now up 14.% since February. New York is up 9.5%, Feb-July; New Jersey is up 7.0% in the same period. Medicaid expansion population totals for Maine and Virginia are also update. 

Update, 8/2/20: I have updated the chart with July and/or June tallies for Illinois, Maryland, Oregon, and Washington. Noteworthy: a 3.1% surge in Illinois in June, and an Oregon update through July 27 that shows total enrollment up up 9.1% since February 3. Overall, enrollment in Medicaid programs charted by these 16 states (e.g., all Medicaid, managed Medicaid only, or ACA Medicaid expansion population only) was up 6.8% February through June. Colorado, newly added, was up 7.0%, Feb-June.

As mass unemployment appeared almost instantly in the wake of the pandemic-triggered shutdowns in March, and is likely to persist as the U.S. fails to contain the virus, I have focused almost all posts in recent weeks on increases in Medicaid enrollment in states that have enacted the ACA Medicaid expansion.

To repeat a baseline expectation, the Urban Institute 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.   While the current national unemployment rate has dipped officially to 11% (actually 12% when a categorization error acknowledged by BLS is added in), 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.

In Kentucky and Minnesota, Medicaid enrollment has already increased by double digits since February. In others, it's barely budged.  Myriad factors determine the rate of growth, including the extent of job losses in the state, the types of jobs lost, the mode/duration of layoff, and state per capita income.

I am more focused on factors within the states' control -- whether there is any effective outreach to inform the newly unemployed of their health insurance options and prompt them to apply -- for Medicaid (primarily) or marketplace insurance as appropriate.  Outreach can come via state-based ACA marketplaces (there are just 13; the federally administered HealthCare.gov serves the rest), advertising, governors' pandemic briefings, the state taxing authority (as in Maryland) or -- most promisingly, through the unemployment insurance division of state labor departments, as urged by Families USA and the Brookings Institute. As far as I know, Kentucky, where Medicaid enrollment is up 14%, is the only state that's fully exploiting this vital channel. Expanding presumptive eligibility (which Kentucky has also done) or accepting attestation of income can also have a strong impact.