October 2016 CMS Medicaid Report: Net increase of 17 million (actually 17.9 million)

Every month I post an entry about the official CMS Medicaid enrollment report, documenting the increase in Medicaid enrollment since ACA expansion went into effect. The numbers were increasing dramatically every month for nearly two years, but started slowing down last fall as most of the expansion states started maxing out on their eligible enrollees. I wrote about the August 2016 report back on 11/20, and normally would be writing about the September report today. Instead, however, I'm skipping right past September, because the preliminary report for October was just released today:

Some of the data contained in this table is designated as "preliminary" because it is reported soon after the close of the reporting month and contains few, if any, individuals who become eligible in current month after the close of the month due to retroactive eligibility under Medicaid or similar reasons. When applicable, states report “updated” data one month after the close of the reporting period to account for retroactive enrollment.

It looks like a few of the final numbers may shift around slightly after the final report comes out, but this should be pretty close to where things stood as of 10/31/16.

The key points:

Medicaid and CHIP Total Enrollment

• 74,369,888 individuals were enrolled in Medicaid and CHIP in the 51 states reporting October 2016 data. 68,858,877 individuals were enrolled in Medicaid and 5,511,011 individuals were enrolled in CHIP (please see contextual information below regarding CHIP enrollment).
• Nearly 17 million additional individuals were enrolled in Medicaid and CHIP in October 2016 as compared to the period prior to the start of the first Marketplace open enrollment period (July - Sept. 2013), in the 49 states that reported relevant data for both periods, representing nearly a 30.1 percent increase over the baseline period. (Connecticut and Maine aren't included because they did not report data for both periods).

Medicaid Child and CHIP Total Enrollment

• Nearly 35.8 million individuals are enrolled in CHIP or are children enrolled in the Medicaid program in the 48 states that reported child enrollment data for October 2016. Children enrolled in the Medicaid program and individuals enrolled in CHIP make up approximately 50.6 percent of total Medicaid and CHIP program enrollment.

The 5.5 million in CHIP figure confused me until I read this clarification:

Other sources of enrollment data, including data from the Statistical Enrollment Data System (SEDS) and Medicaid Budget and Expenditure System (MBES), may not align with the enrollment data included in this report because of methodological differences. For example, in the most recent published SEDS annual enrollment report, CHIP enrollment was reported as approximately 8.4 million. Unlike the point-in-time, monthly enrollment counts included in this report, the SEDS CHIP enrollment figure represents the number of individuals ever enrolled in CHIP throughout the year.  SEDS total and state-specific annual enrollment data.

In other words, at this exact moment there are only 5.5 million children enrolled in CHIP, but at various points throughout the year a total of 8.4 million unique individual children have been for at least part of the year.

It also looks like it's just as well that I skipped over the September report because there appear to have been some data mismatch issues which had to be cleared up anyway:

49 states reported both October 2016 enrollment data and data from July-September 2013. These 49 states reported total enrollment in October 2016 of nearly 73.4 million individuals, and July-September 2013 average enrollment of approximately 56.4 million. For October 2016, CMS is reporting growth of 16,954,576 compared to July-September 2013. This figure is greater than the 15,714,326 in net enrollment growth that was included in the Medicaid and CHIP: September 2016 Applications, Eligibility Determinations, and Enrollment Report by more than 1.24 million.  This difference does not match the 45,279 increase in the full report for the September to October 2016 period because the 45,279 figure is based on 51 states, while the 1.24 million figure is based on only 49 states.  Also, Florida and California updated their data this month to better align with CMS’s data specifications, which means that the summary statistics in the September 2016 report are not perfectly comparable to the figures in this report. Please note, the July-September 2013 data may contain individuals with retroactive Medicaid coverage, and the October 2016 data included in this report is preliminary, the difference reported here between October 2016 and July-September 2013 period is likely understated.

Florida revised its enrollment methodology in October 2016 to incorporate its SSI population that is enrolled in Medicaid and to more closely report to CMS’s data specifications. The state subsequently revised total enrollment counts from prior months to reflect the updated methodology and ensure comparability across months.  However, Florida was not able to revise its baseline enrollment to account for its entire SSI population that is enrolled in Medicaid so its October enrollment and baseline enrollment figures are not perfectly comparable.

California updated its September enrollment figure to ensure comparability across months.

Similar to the last four months (June, July, August, and September 2016), 48 states submitted child enrollment data in October 2016, as compared to the 47 states that submitted data in the months prior to June 2016.  Because more states submitted child enrollment data in June -- October 2016, these figures are not comparable to child enrollment statistics from other months’ reports. New Mexico submitted child enrollment data starting in June 2016.

This figure (16,954,476 more people enrolled than September 2013) is actually a stunning increase compared to August's 15.7 million net growth figure, and actually dovetails perfectly with my own correction from a few weeks ago, in which I determined that ACA-specific Medicaid enrollment is over a million people higher than I had previously thought.

But it's even higher yet compared to the pre-ACA enrollment tally, because neither of those numbers includes the 950,000 people who were quietly added to Medicaid via other ACA provisions before the expansion program officially launched:

These enrollment counts are in addition to the enrollment increases from the nearly 950,000 individuals who gained coverage as a result of the Affordable Care Act before open enrollment began. Seven states implemented an “early option” to expand Medicaid coverage to adults with incomes up to 133 percent of the Federal Poverty Line (FPL) between April 1, 2010 and January 1, 2014, using new state plan authority provided by the Affordable Care Act or a demonstration under section 1115 of the Social Security Act building upon that authority.

When you add those people to the mix, Medicaid/CHIP enrollment is actually 17,904,476 people higher than it was the day that the Affordable Care Act was signed into law in March 2010...of which 12.3 million is due specifically to the ACA expansion provision.

The breakout of the 17.9 million is roughly:

• 12.3 million: ACA expansion specifically (across 31 states + DC)
• 1.0 million: Other ACA provisions (across 7 states)
• 3.6 million (?): "Woodworkers" who were already eligible for traditional Medicaid/CHIP prior to the ACA but didn't enroll until after the expansion started
• 1.0 million (?): Newly eligible for traditional Medicaid/CHIP regardless of the ACA

Here's a simplified table from the October report breaking down the net gain since Sept. 2013 by state (the additional 950K prior to this isn't included here). There are two states (Connecticut and Maine) for which the CMS report doesn't include the September 2013 enrollment numbers. I've included a column which shows just how much of that net increase is due specifically to the ACA's Medicaid expansion provision.

I've also listed which U.S. Senators are up for re-election in each state in 2018. As you can see, Republicans Jeff Flake (Arizona) and Dean Heller (Nevada) will be under tremendous pressure not to repeal the Affordable Care Act; nearly 6% of Arizona's entire population and 7% of Nevada's are enrolled in Medicaid specifically due to the ACA.