Just ahead of Unwinding, ACA Medicaid expansion likely peaked at ~24.4M people

Tue, 05/02/2023 - 4:51pm

Back in January, I noted that total enrollment in healthcare policies either specifically created by or expanded to more people by the Affordable Care Act had broken 40 million Americans:

With last week's report from the Centers for Medicare & Medicaid Services (CMS) touting the record-breaking 16.3 million Qualified Health Plan (QHP) selections during the 2023 Open Enrollment Period (OEP), it's time to take another look at the grand total.

For this, I'm assuming a similar 94% average effectuation rate as of February 1st (2 days from now) to the ASPE report from last year for QHP enrollees. Taken literally, that would mean 15,328,061 effectuated on-exchange ACA enrollees.

However, this data only includes OEP enrollment through January 15th (or the 14th in a few states). While 2023 OEP ended on the 15th in most states, the deadline was/is later in CA, DC, MA, NJ NY & RI...which means it's very likely that another 50,000 - 100,000 people will be added to the final QHP tally when the dust settles tomorrow (Tuesday, January 31st) evening. Even assuming the same 94% effectuation rate, that will still bring the effectuated QHP total to roughly 15.4 million.

In fact, a report from the HHS Dept's Assistant Secretary for Planning & Evaluation later confirmed that the actual number of effectuated QHP enrollees was more like 15.64 million.

When you threw in the 1.22 million BHP enrollees in NY & MN, this came to 16.86 million QHPs + BHPs combined, although QHP enrollment has likely dropped off a bit more since then...perhaps down to 16.5 million or so.

And then I added in Medicaid expansion enrollees:

The most recent official Medicaid/CHIP enrollment data available for all states comes from the monthly Medicaid & CHIP Enrollment Trend Snapshot reports via CMS. The most recent of these is from September 2022, which isn't too out of date...but these reports (as well as the raw determinations / enrollment data which they're based on) don't separate out "Group VIII" (ACA Medicaid Expansion) enrollees, making them useless for my purpose today.

For that, the most comprehensive data comes from the quarterly Medicaid & Budget Expenditure System (MBES) reports, which separate out VIII Group enrollees, and even breaks those out between those newly eligible for Medicaid specifically due to ACA expansion as well as those who would have already been eligible for Medicaid prior to the ACA but who enrolled thanks to the ACA dramatically streamlining the enrollment process. The only problem here is that the MBES reports only run through March 2022, at which point the national ACA expansion total stood at 22,275,433.

Since that time, the monthly "Enrollment Trend" reports have been updated through January 2023, while the MBES reports have been updated through September 2022...adding another six months of ACA expansion data.

According to the September 2022 MBES report, total ACA Medicaid expansion had grown to 23,413,954 Americans...up nearly 1.14 million since March 2022...exactly as I had projected:

Assuming these states are representative, it's safe to assume that Medicaid expansion is up at least 4.3% nationally since March 2022, or around an additional 960,000 people. If you go with the higher end estimate (+5.4%), it would be up over 1.2 million nationally.

However, even that is still missing another six months of data. How much has Medicaid expansion grown since last September? The data isn't available for every state (or at least isn't easy to separate out from total enrollment in some), but I was able to find it for 15 of them:

Across these 15 states alone, ACA Medicaid expansion enrollment is up 461,295 people since last September, or 4.4% overall.

Assuming these states are representative, it's safe to assume that Medicaid expansion is up at least 4.4% nationally since September 2022, or around an additional million people.

That would put the grand total at right around the same 41 million I had it at in March, with QHPs being a few hundred thousand lower and Medicaid expansion being a few hundred thousand higher.

I should also note that there's likely another 2 - 3 million people enrolled in OFF-exchange individual market Qualified Health Plans, all of which are unsubsidized. You can argue as to whether or not these should "count" as being "ACA-enabled coverage" since the individual market already existed prior to the ACA, but the ACA required that these medical policies be significantly improved in terms of comprehensiveness and to have the same regulations as exchange-based policies including guaranteed issue, community rating, removal of annual/lifetime limits, maximum out-of-pocket cost caps and so forth.

If you count these, that puts the grand total of "ACA healthcare coverage" at somewhere between 43 - 44 million people.

It's important to keep in mind that this was likely a high water mark given the start of the "Medicaid Unwinding" process in April...that is, people being disenrolled from Medicaid/CHIP who normally would have been kicked off the program at some point over the past three years but who were kept enrolled due to COVID-19 pandemic legislation which required states to maintain continuous coverage of all enrollees unless they voluntarily chose to drop their Medicaid coverage.

According to Joan Alker and Louise Norris, over 9,400 Virginians and 27,000 Idahoans have already been disenrolled via the "unwinding" process, and that's just the beginning. The Kaiser Family Foundation estimates that perhaps 17 million Americans will ultimately be disenrolled from Medicaid or CHIP by the time the unwinding process ends.

ACA
Medicaid
Medicaid Expansion
Medicaid Unwinding

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