MinnesotaCare and the Mystery of the CMS State-Level Projections

A regular site visitor has sent me some in-depth information about the public healthcare program situation in Minnesota, which is evidently quite a bit more complicated than most other states. I've put together this information into what I hope is a cohesive whole, with my response below. Anyone who's more familiar with the Minnesota situation can feel free to correct or clarify any of this if you'd like.

Regarding your blog post entitled Minnesota Update: Nominal private increase; Medicaid up 10% In it, you quote the Minnesota StarTribune, which states, in part, that:

"Of those nearly 72,000 enrollees, slightly more than 26,000 signed up for private insurance while the rest are on public plans."

Several thousand more than 26,000 should be counted as exchange sign-ups rather than Medicaid signups. Minnesota has a sort of in-between basic health plan called MinnesotaCare. It covers people between 133% and 200% (I think?) of poverty. It is not Medicaid (which is called Medical Assistance in Minnesota) and therefore not part of the ACA Medicaid expansion, but it is a public plan. So, when the StarTribune refers to "public plans," they are lumping Medicaid and MinnesotaCare together. The state has cleared this up before in reporting on Minnesota's enrollment numbers in the New York Times. MinnPost reported on this correction back in November.

The most recent breakout of the private plan / Minnesota Care / Medical Assistance numbers is 25,860 / 15,997 / 25,948 respectively. If you combine the private plan and MinnesotaCare numbers from the MPR post - you get 41,857 exchange plan enrollments (a mix of public and private) and 25948 Medicaid (Medical Assistance) enrollments as of Dec. 27th. I get that you're separating enrollments into private insurance and government funded insurance, and by that measure, MinnesotaCare clearly fits in the latter category.

But when you shift from questions of funding to looking at enrollment projections, you hit a snag.  The CBO [Ed: Actually, CMS] 3/31/14 Enrollment Projection for Minnesota from the spreadsheet is 67,000.  The snag is that it appears that the CBO CMS based this projection for Minnesota on a combination of private plan and MinnesotaCare enrollments.  

The money quote from page 12 of the Health Insurance Marketplace November Enrollment Report (emphasis mine):

(14) Minnesota's cumulative data for “Individuals Determined Eligible to Enroll in a Marketplace plan,” “Individuals Determined Eligible to Enroll in a Marketplace plan with Financial Assistance,” and “Individuals Who Have Selected a Marketplace plan” do not include adults between 133% and 200% of the Federal Poverty Level (FPL) because these individuals are enrolled in the MinnesotaCare program. In addition, children up to 275% FPL are covered through the Medicaid program. Please note that when comparing Minnesota's cumulative data for these indicators with other State-Based Marketplaces, the number of individuals (2,505) determined eligible for MinnesotaCare should be included in the calculation.

I'm not that familiar with the Arkansas plan, but my understanding is that, unlike MinnesotaCare, it covers the Medicaid population, people up to 133% of poverty, but it does that by putting them in private managed care plans rather than traditional Medicaid. [Ed: I've been informed that in Arkansas, newly eligible people aren't put into private managed care plans; instead, the expansion population shops on the exchange and gets premium assistance on a private plan.] As far as I know, the handful of other states that are considering this option are also considering it for people under 133% of poverty.  

The Basic Health Plan (or Program as it's sometimes called), which is what MinnesotaCare is, is an ACA option that covers people in the 133%-200% of poverty range.  Here's a brief description from the Kaiser Family Foundation:

Basic Health Program

States will have the option to implement a Basic Health Program (BHP) under health reform that gives states 95% of what the federal government would have spent on subsidies for adults between 133% and 200% of the federal poverty level and legal resident immigrants with incomes below 133% who have been in the U.S. for fewer than five years (and therefore do not qualify for Medicaid).

A January 2013 policy brief on the subject from New York (which is quite helpful) mentions that several states have indicated an interest in implementing a Basic Health Plan, including California, the District of Columbia, Massachusetts, Minnesota, New York, Rhode Island, Utah, and Washington State.  However, I've yet to find another state besides Minnesota that has officially implemented a Basic Health Plan.

OK. As I explained to the person who sent all of the above, this is some pretty deep-in-the-weeds stuff, and it does help to put some of the Minnesota numbers in context (which is why I asked for the OK to repost here, with their approval). However, in terms of "recategorizing" the MinnesotaCare enrollments under the "exchange" enrollments, that's something I simply can't do because the chief distinction between the "Private" and "Medicaid/CHIP" tallies is how they're paid for, not whether one was included in the original CBO/CMS/HHS projection figures under a certain category or not. MinnesotaCare is almost fully funded via a combination of federal and state taxpayer dollars, and therefore belongs under the "Medicaid/CHIP" column (although perhaps I should consider changing that to something more all-encompassing).

As for the "problem" which categorizing it as such would pose with regards to the 67,000 "Private QHP" projection, the simple answer there is that, as far as I can tell, while the national "7 million" private enrollment projection figure issued by the CBO was based on solid analysis of the demographic situation at the time, the state-level CMS projection breakdown is, in many cases, based on little more than educated guesswork.

As the CMS put it in their own report: 

 In general, the enrollment targets provided by state- based Marketplaces are more ambitious than the initial Department enrollment targets for those specific states. As a result, using the publicly available SBM targets without adjusting other states would have raised the projected number of 2014 Marketplace enrollees by 1.4 million; therefore, the Marketplace ramp-up rates for other states were revised downward accordingly to maintain the 7 million total. 

Basically, they lowered the estimates for states that didn't provide their own estimates in order to shoehorn all the state target numbers into that overall 7 million target. As a result, you get some pretty strange projections: Connecticut's CMS target was only 33,000, while Kentucky, whose uninsured population is only 1.8x as high, has a target 6.6x higher. Vermont and Utah, with a 4.5x difference in population and wildly different socioeconomic conditions, have IDENTICAL projection numbers, not just for the final tally but for every individual month in between.

in other words, while the CMS projection numbers may have been baked into the public consciousness to the point that they're touting their success when hitting them, I also wouldn't get too concerned about states which don't meet these "targets" either, since the target numbers don't necessarily bear a whole lot of connection to the population or demographics of that particular state anyway.