Medicaid Enrollment Trends During the COVID-19 Pandemic

Manatt on Health: Medicaid Edition

Background

Medicaid has seen significant increases in enrollment across all states since the outbreak of the COVID-19 pandemic. According to the latest data from the Centers for Medicare and Medicaid Services (CMS), total Medicaid enrollment increased by nearly 10 million (or 15 percent) from February 2020 through January 2021.1

The causes of this enrollment surge are twofold. One, the pandemic led to significant economic disruptions, which have historically triggered growth in Medicaid enrollment as individuals lose income and access to employer-sponsored coverage.2 In April 2020—immediately following the outbreak of the pandemic—millions of Americans lost jobs and the unemployment rate jumped to nearly 15 percent, a rate not seen since the Great Depression.3 While the economy has made significant strides since then, unemployment remains elevated and continued recovery could be hampered by the continued spread of the COVID-19 Delta variant (or other, unanticipated pandemic-related disruptions and/or variants).

The second reason for the growth in Medicaid enrollment is federal legislation passed by Congress in March 2020 aimed at shoring up state finances while also protecting health insurance coverage during the pandemic. The Families First Coronavirus Response Act (FFCRA) temporarily increased the federal share of Medicaid funding for states. As a condition of accessing this enhanced funding, states were prohibited from disenrolling individuals from Medicaid for the duration of the federal Public Health Emergency (PHE). This so-called “continuous coverage” requirement extends from March 18, 2020, through the end of the month in which the PHE ends.4 Since a portion of Medicaid beneficiaries typically “churn” off of the program each month due to changes in circumstances (i.e., income levels, changes in household), paperwork requirements related to renewals, and other reasons, the continuous coverage requirement effectively eliminated churn, resulting in immediate increases in Medicaid enrollment.5, 6 In January 2021, the Biden Administration announced that the PHE will likely remain in place through the entirety of 2021; accordingly, the FFCRA continuous coverage requirement will likely remain in effect at least through the end of the year.7

Throughout the pandemic, Manatt has maintained a 50-state tracker providing a detailed look at Medicaid enrollment trends since the beginning of the pandemic. This tracker provides enrollment data that is both more recent and more detailed than the latest CMS enrollment data. In the following, we discuss key trends from the latest data available through our tracker, as recent as May 2021.8

Key Survey Findings

Our analysis finds that since the beginning of the pandemic, Medicaid enrollment growth has substantially outpaced recent, pre-COVID-19 rates of growth in the program, particularly among non-elderly, non-disabled adults who are most likely to be impacted by job losses.

Surging Enrollment Across Eligibility Groups. From February 2020 through May 2021, the median state among the 14 states with available data for that period saw total enrollment growth of 18.7 percent, with the average state seeing monthly growth well above previous levels.

  • From February to March 2020, overall enrollment growth was essentially flat in most states; however, growth began to spike in April 2020 following the outbreak of the pandemic, with the median state seeing a one-month growth rate of 2.1 percent from March to April 2020. Month-to-month enrollment growth slowed somewhat in subsequent months, but has remained significantly elevated in most states. Through May 2021, monthly enrollment growth rates have remained above one percent in many states.
  • These monthly enrollment growth rates are substantially higher than what many states had been experiencing prior to the pandemic; over the past several years, many states have seen flat or even negative month-to-month changes in enrollment (the median monthly enrollment growth rate in 2019 was -0.07 percent).9, 10
  • Taken together, total enrollment growth from February 2020 through May 2021 in the median state was 18.7 percent; growth was substantially faster in some states, including Utah (35.1 percent) and Indiana (28.3 percent).

ACA and Non-ACA Adults. Enrollment growth has been the fastest among non-elderly, non-disabled adults in nearly all states. This is likely driven by the fact that working-age adults are most likely to have faced employment disruptions as a result of the pandemic. Additionally, Medicaid participation rates are generally lowest among non-elderly, non-disabled adults, leaving more room for growth during the pandemic.11

  • Between February 2020 and May 2021, the median expansion state saw growth in the Affordable Care Act (ACA) adult expansion group of 40.3 percent.
     - This rate was substantially higher in some states, including Utah (83.0 percent through March 2021), Maine (76.2 percent through May 2021) and Indiana (57.6 percent through May 2021).
     - Monthly growth in expansion enrollment in the median expansion state has remained stable since the summer of 2020 and has exceeded two percent in nearly all months since the beginning of the pandemic.
  • Across all states with reported data, enrollment of non-expansion adults (i.e., parents and pregnant women eligible through pathways other than the ACA expansion) grew at a median rate of 40.8 percent from February 2020 through May 2021.
     - As of the most recent month of reported data, at least seven states—Florida, Illinois, Indiana, Missouri, North Carolina, Texas and Utah—experienced growth of over 60 percent.
     - While growth has slowed since the beginning of the pandemic, monthly growth in non-expansion adult enrollment in the median state has exceeded two percent in most months.

Children and ABD Eligibility Groups. Enrollment growth has been substantially slower among child and aged, blind and disabled (ABD) eligibility categories.

  • Between February 2020 and May 2021, child enrollment in the median state grew by 12.8 percent; monthly growth in the median state has fallen below one percent in recent months, though remains elevated relative to pre-pandemic enrollment.12
  • For ABD populations, enrollment grew by only six percent in the median state from February 2020 to May 2021, with monthly growth rates generally falling below 0.5 percent.

Conclusion

While the economy has recovered many of the jobs lost during the initial months of the pandemic, the economic picture remains uncertain for many states and certain types of workers, particularly as the Delta variant continues to spread.13 Our analysis indicates that states are still seeing robust growth in Medicaid enrollment relative to pre-pandemic times. Given persistently elevated levels of unemployment and the expected extension of the PHE (and the related FFCRA continuous coverage requirement) through the end of 2021, states are likely to see enrollment continue to grow for the foreseeable future. As states grapple with uncertain fiscal situations, the implications of continued Medicaid enrollment growth on state budgets and on access to coverage for millions of people will continue to be front and center issues for policymakers.


1 CMS. State Medicaid and the Children’s Health Insurance Program (CHIP) Applications, Eligibility Determinations, and Enrollment Data. February 2021. Available here: https://data.medicaid.gov/Enrollment/State-Medicaid-and-CHIP-Applications-Eligibility-D/n5ce-jxme/data.

2 Medicaid and CHIP Payment and Access Commission (MACPAC). Considerations for Countercyclical Financing Adjustments in Medicaid. June 2020. Available here: https://www.macpac.gov/wp-content/uploads/2020/06/Considerations-for-Countercyclical-Financing-Adjustments-in-Medicaid.pdf.

3 U.S. Department of Labor Bureau of Labor Statistics. News Release: Employment Situation – April 2020. May 2020. Available here: https://www.bls.gov/news.release/archives/empsit_05082020.pdf.

4 FFCRA § 6008.

5 Center on Budget and Policy Priorities. Continuous Coverage Protections in Families First Act Prevent Coverage Gaps by Reducing “Churn”. July 2020. Available here: https://www.cbpp.org/research/health/continuous-coverage-protections-in-families-first-act-prevent-coverage-gaps-by#:~:text=The%20continuous%20coverage%20provision%20does,experience%20fluctuations%20in%20their%20earnings.

6 Kaiser Family Foundation. Analysis of Recent National Trends in Medicaid and CHIP Enrollment. July 2021. Available here: https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/.

7 U.S. Department of Health and Human Services. Letter to Governors. January 2021. Available here: https://ccf.georgetown.edu/wp-content/uploads/2021/01/Public-Health-Emergency-Message-to-Governors.pdf.

8 The 50-state Medicaid enrollment tracker analysis is limited by the fact that it relies on state data reported at varying frequencies and levels of detail; additionally, states often rely on different reporting methodologies. As such, these variations mean that the enrollment numbers reported by states are not necessarily comparable across states. However, the data do allow us to track trends within and across over 40 states; accordingly, our analysis focuses on state growth rates rather than aggregate figures.

9 MACPAC. Changes and in Medicaid and CHIP Enrollment. November 2019. Available here: https://www.macpac.gov/wp-content/uploads/2019/11/Changes-in-Medicaid-and-CHIP-Enrollment.pdf.

10 CMS. State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data. February 2021. Available here: https://data.medicaid.gov/Enrollment/State-Medicaid-and-CHIP-Applications-Eligibility-D/n5ce-jxme/data.

11 Kaiser Family Foundation. Medicaid/CHIP Child Participation Rates. 2013 – 2016. Available here: https://www.kff.org/medicaid/state-indicator/medicaidchip-child-participation-rates/.

12 Including children enrolled in Medicaid and CHIP.

13 U.S. Department of Labor. News Release: Unemployment Insurance Weekly Claims. July 2021. Available here: https://www.dol.gov/ui/data.pdf.

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