The rate decline was highest among those who had incomes between 100% and 200% of the federal poverty level. Those in traditionally uncovered demographies, such as people who are Latino, American Indian/Alaska native and those who don’t speak English, saw larger gains in coverage.
Half of the top 10 states for coverage gains expanded Medicaid under the Affordable Care Act between 2019 and 2021. The leading state, Maine, reached a 7.1% uninsured population in 2021, dropping from 10.2% in 2019. Officials shifted to a state-based exchange for the 2022 plan year.
“Many of the areas with the greatest coverage gains since 2019 had higher than average uninsured rates in 2021, suggesting progress in narrowing geographic disparities but still with substantial gaps remaining; the lack of Medicaid expansion in 11 states plays a key ongoing role in coverage disparities across states,” the report authors wrote.
The state with the largest increase in uninsured people was Alabama, which reached 12.5% in 2021 compared to 12.1% in 2019.
In addition to Medicaid expansion, other policies that helped those receive coverage include increased premium tax subsidies under the American Rescue Plan.
Also helping is the Medicaid continuous coverage provision, which has barred states from kicking people off rolls during the COVID-19 public health emergency.
That policy is set to end in April, however. Researchers have said that as many as 15 million to 18 million people could be affected.
States are taking some steps to help those eligible remain in the program. Most states plan to update enrollee mailing addresses and follow up with those people when action is recovered to maintain coverage, according to a recent Kaiser Family Foundation report.
Forty-one states said it will take up to 12 months to process renewals, KFF said.
Over 1.8 million more people enrolled in marketplace coverage compared to last year — a 13% increase, and the most amount of plan selections of any year since the launch of the ACA marketplace a decade ago, according to the CMS. The record-breaking enrollment numbers include 3.6 million first-time marketplace enrollees.
However, some coverage protections rely on the federal COVID-19 public health emergency status, which will expire without an extension in mid-April. Medicaid enrollment numbers are expected to drop at the end of the public health emergency, with as many as 18 million enrollees projected to lose Medicaid coverage, according to the Robert Wood Johnson Foundation.
And in Texas, an expansion could reduce the $7 billion in uncompensated care hospitals there have to absorb each year, according to the state’s hospital association.
Yes, but: Republican lawmakers in the holdout states continue to oppose enlarging their Medicaid rolls, citing higher state costs of covering a bigger population.
And hospital associations in North Carolina and Florida have opposed expansion plans, either out of concern about alienating key lawmakers or because the plans could bring other changes that disrupt dollars flowing to their members.
State of play: South Dakota voters approved a Medicaid expansion ballot measure this fall, leaving 11 non-expansion states.
Democratic governors in North Carolina and Kansas think they may be wearing down Republican opposition, Politico reports, but still face uphill battles when the new legislative sessions begin.
Zoom in: Medicaid expansion can bring dollars into a state’s health care system, even if the program pays only a fraction of the actual cost of care.
Numerous studies show that Medicaid expansion can have a positive financial impact on hospitals’ operating and profit margins, particularly smaller rural facilities, Robin Rudowitz, vice president at the Kaiser Family Foundation, told Axios.
The program could provide a reprieve for hospitals that were kept afloat in part by federal pandemic aid that’s now drying up.
“We have hospitals with 12 days cash on hand. We’ve lost a nursing home this year. We have seen decreased services. We’ve lost OB services in a few places, and we’ve seen over the years the decrease in mental health,” Wyoming Hospital Association vice president Josh Hannes told state lawmakers last month, per Politico.
Expanding Medicaid in other states has also led to a significant decline in uncompensated care costs, as well as improved states’ health outcomes, including overall mortality.
Yes, but: Medicaid expansion is not necessarily a silver bullet that will rescue every struggling facility.
Some state hospital associations are seeking other types of relief, from cuts in hospital bed taxes or higher reimbursements for existing Medicaid beneficiaries.
Of note: Rural, small hospitals have the most to gain from Medicaid expansion, because they serve a smaller patient populations with a larger pool of uninsured people.
Congress sweetened the deal for non-expansion states in the American Rescue Plan Act, with a 5% increase in the federal Medicaid Assistance Percentage for the state’s current Medicaid recipients, which lasts for two years.
In Texas, whose uninsured rate is the highest in the nation, hospital leaders think Medicaid expansion could help cover many in the working class whose jobs do not offer health plans.
“If you could get those folks coverage at a Medicaid rate it would obviously help the financial situations of (rural) hospitals, and if you could get them to a medical home you could deal with more acute medical conditions going forward,” John Hawkins, president of the Texas Hospital Association, told reporters last week.
The bottom line: While rural hospitals all over are facing headwinds, those in non-expansion states are bearing the brunt of the pain. And while there is a potential lever for those states, it doesn’t appear likely their elected officials are willing to pull it.
Of these 18 million people, 3.8 million people will become completely uninsured, according to the Urban Institute’s report. The estimate is higher than HHS’ August prediction of 15 million people losing coverage after the public health emergency.
If the Covid-19 public health emergency expires in April, about 18 million people could lose Medicaid coverage, a new report concludes.
The Urban Institute, which published the report, found that of these 18 million people, 3.8 million people will become completely uninsured. About 3.2 million children will likely move from Medicaid to separate Children’s Health Insurance Programs. Additionally, about 9.5 million people will receive employer-sponsored insurance. Lastly, more than 1 million people will enroll in a plan through the nongroup market.
The Urban Institute’s estimates, published Monday, is higher than the U.S. Department of Health & Human Services’ (HHS) prediction of 15 million people losing coverage after the public health emergency ends. HHS’ report was published in August and stated that 17.4% of Medicaid and Children’s Health Insurance Program enrollees would leave the program. The Urban Institute’s report did not provide a percentage.
To conduct the study, researchers from the Urban Institute relied on the most recent administrative data on Medicaid enrollment, as well as recent household survey data on health coverage. It used a simulation model to estimate how many Americans will lose Medicaid insurance.
In 2020, Congress passed the Families First Coronavirus Response Act due to the Covid-19 pandemic. It barred states from disenrolling people during the public health emergency, and in return, states received a temporary increase in the federal Medicaid match rates. From February 2020 to June 2022, Medicaid enrollment increased by 18 million people, an unprecedented number, according to the Urban Institute.
Currently, the public health emergency is set to end in January. But since the government has to provide a 60-day notice before the expiration —and did not do so in November — it is expected to be extended to April.
Because many of the affected enrollees who will lose Medicaid coverage will be eligible for coverage through federal or state Marketplaces, the Urban Institute recommends coordination between the Marketplaces and state Medicaid agencies
Researchers called on the government to take action so Americans are prepared for the end of the public health emergency.
“State Medicaid officials and policymakers must continue to ensure that individuals currently enrolled in Medicaid are aware of the approaching end of the public health emergency, and that they have a plan to maintain or find new health coverage through their employer, the federal healthcare Marketplace, or Medicaid,” the Urban Institute said.
Driven by the steady progress of Medicaid expansion and pandemic-era policies to ensure access to health insurance coverage, the US uninsured rate hit an all-time low of 8 percent in early 2022. Since the Affordable Care Act passed in 2010, the US uninsured rate has been cut in half, with the largest gains coming from Medicaid expansion.
However, using data from Commonwealth Fund, the graphic below illustrates how this noteworthy achievement is undermined by widespread underinsurance, defined as coverage that fails to protect enrollees from significant healthcare cost burdens. A recent survey of working-age adults found that eleven percent of Americans experienced a coverage gap during the year, and nearly a quarter had continuous insurance, but with inadequate coverage.
High deductibles are a key driver of underinsurance, with average deductibles for employer-sponsored plans around $2,000 for individuals and $4,000 for families.
Roughly half of Americans are unable to afford a $1,000 unexpected medical bill. Americans’ healthcare affordability challenges will surely worsen once the federal COVID public health emergency ends, because between 5M and 14M Medicaid recipients could lose coverage once the federal government ends the program that has guaranteed continuous Medicaid eligibility.
The process of eligibility redeterminations is sure to be messy—while some Medicaid recipients will be able to turn to other coverage options, the ranks of uninsured and underinsured are likely to swell.
In its Q3 earnings call, Oscar Health CEO Mario Schlosser revealed that the “insurtech” has pulled out of the MA market in Texas and New York, leaving it with only one Florida-based plan. Oscar entered the MA business with high hopes in 2020, but counted fewer than 5K MA members in Q3 2022.
Although its Affordable Care Act exchange enrollment has nearly doubled since last year, now covering more than 1M lives, Oscar is still struggling with high medical loss ratios, which have kept it from turning a profit. The company’s stock price is at an all-time low, having declined over 90 percent from its peak, shortly after its 2021 IPO.
The Gist: Like Bright HealthCare before them, Oscar pulling out of MA is another sign that the chance of meaningful disruption from “insurtechs” has nearly vanished. While still privately held, Oscar achieved fame in the early 2010s through catchy marketing that targeted a young, tech-savvy client base, and its move into MA before the pandemic signaled broader ambitions.
Oscar’s travails illustrate just how hard it is to start an insurance company from scratch, even with an intriguing and comprehensive technology platform. The company proved unable to overcome its lack of market power in negotiations with providers, and faced difficulty managing a small, unstable risk pool.
Now that more traditional insurers are improving their mobile tech interfaces and telehealth offerings, the differentiated value Oscar offers to its members has clearly diminished.
While the final balance of the House and Senate are still unknown after Tuesday’s midterm elections, both chambers are expected to be narrowly divided.
Ballot initiatives on reproductive health produced more unambiguous results, with three states—California, Michigan, and Vermont—amending their constitutions to affirm reproductive rights, and two states—Kentucky and Montana—voting down proposals that would have imposed greater legal barriers to abortion access. South Dakota became the seventh, and likely final, state to expand Medicaid via ballot initiative, making an additional 28K South Dakotans eligible for coverage, and reducing the number of states that have yet to expand Medicaid to 11.
The Gist: Democrats beat expectations, bucking historical trends in which midterm voters swing strongly against the President’s party. But healthcare did not feature prominently in voters’ choices, with this being the first election in over a decade where the state of the Affordable Care Act and protecting individuals’ access to care and coverage was not a significant choice driver.
The fallout from the Supreme Court’s decision in June to overturn Roe v. Wade had a clear impact on voter turnout, with abortion tying inflation for voters’ top concern in exit polls. At the state level, South Dakota voters approved Medicaid expansion, where over 40 percent of the state’s uninsured adults could now gain access to coverage—another clear sign that voters, regardless of party affiliation, are behind the ACA’s expanded vision for the safety net program.
Moving forward, a closely divided Congress is unlikely to take on significant healthcare legislation, regardless of who ultimately holds the House and Senate.
Earlier this month, the Biden administration officially extended the federal public health emergency (PHE) declaration it had set in place for COVID-19. That means the PHE provisions will stay in effect for another 90 days — until mid-January at least.
When the PHE does end, a number of rules developed in response to the pandemic will sunset. One of those is a provision that temporarily requires states to let all Medicaid beneficiaries remain enrolled in the program — even if they have become ineligible during the pandemic.
Estimates suggest that millions could lose Medicaid coverage when this emergency provision ends. Among those who would lose coverage because they are no longer eligible for the program, about one-third are expected to qualify for subsidized coverage on the Affordable Care Act (ACA) marketplaces. Most others are expected to get coverage through an employer. It remains an open question, though, how many people will successfully transition to these other plans.
A recent paper by health economics researcher Laura Dague and colleagues in the Journal of Health Politics, Policy, and Law sheds light on these dynamics. The authors used a prior change in eligibility in Wisconsin’s Medicaid program to estimate how many people successfully transitioned to a private plan when their Medicaid eligibility ended.
Wisconsin’s Medicaid program is unique. Back in 2008 — before the ACA passed — Wisconsin broadly expanded Medicaid eligibility for non-elderly adults. After the ACA came into effect, Wisconsin reworked its Medicaid program in a way that made about 44,000 adults (mostly parents) with incomes above the federal poverty line ineligible for the program. To remain insured, they would have to switch to private coverage (via Obamacare or an employer).
Only about one-third of those 44,000 people had definitely enrolled in private coverage within two months of exiting the Medicaid program.
The remaining two-thirds of people were uninsured or their insurance status couldn’t be determined.
Even using the most optimistic assumptions to fill in that missing insurance status data, the authors estimated only up to 42% of people might have had private coverage within three months.
Nearly 1 in 10 enrollees had re-entered Medicaid coverage within six months, possibly due to fluctuations in household income.
This paper has several limitations. Health insurers are not required to participate in Wisconsin’s APCD, so the authors may not be capturing all successful transitions from Medicaid to private insurance. The paper also does not distinguish between different types of private insurance: Some coverage gains may have resulted from employer-based insurance rather than the ACA marketplace.
Still, the findings suggest that when a large number of Wisconsin residents lost Medicaid eligibility in 2014, many were not able to transition from Medicaid to private coverage. Wisconsin’s experience can help us understand what might happen when the national public health emergency ends and Medicaid programs resume removing people from their rolls.
Using longitudinal survey data and 2021 enrollment information, HHS estimated that, based on historical patterns of coverage loss, this would translate to about 17.4% of Medicaid and Children’s Health Insurance Program (CHIP) enrollees leaving the program.
About 9.5% of Medicaid enrollees, or 8.2 million people, will leave Medicaid due to loss of eligibility and will need to transition to another source of coverage. Based on historical patterns, 7.9% (6.8 million) will lose Medicaid coverage despite still being eligible – a phenomenon known as “administrative churning” – although HHS said it’s taking steps to reduce this outcome.
Children and young adults will be impacted disproportionately, with 5.3 million children and 4.7 million adults ages 18-34 predicted to lose Medicaid/CHIP coverage. Nearly one-third of those predicted to lose coverage are Hispanic (4.6 million) and 15% (2.2 million) are Black.
Almost one-third (2.7 million) of those predicted to lose eligibility are expected to qualify for marketplace premium tax credits. Among these, more than 60% (1.7 million) are expected to be eligible for zero-premium marketplace plans under the provisions of the American Rescue Plan. Another 5 million would be expected to obtain other coverage, primarily employer-sponsored insurance.
An estimated 383,000 people projected to lose eligibility for Medicaid would fall in the coverage gap in the remaining 12 non-expansion states – with incomes too high for Medicaid, but too low to receive Marketplace tax credits. State adoption of Medicaid expansion in these states is a key tool to mitigate potential coverage loss at the end of the PHE, said HHS.
States are directly responsible for eligibility redeterminations, while the Centers for Medicare and Medicaid Services provides technical assistance and oversight of compliance with Medicaid regulations. Eligibility and renewal systems, staffing capacity, and investment in end-of-PHE preparedness vary across states.
HHS said it’s working with states to facilitate enrollment in alternative sources of health coverage and minimize administrative churning. These efforts could reduce the number of eligible people losing Medicaid, the agency said.
The Inflation Reduction Act of 2022extends the ARP’s enhanced and expanded Marketplace premium tax credit provisions until 2025, providing a key source of alternative coverage for those losing Medicaid eligibility, said HHS.
WHAT’S THE IMPACT?
While the model projects that as many as 15 million people could leave Medicaid after the PHE, about 5 million are likely to obtain other coverage outside the marketplace and nearly 3 million would have a subsidized Marketplace option. And some who lose eligibility at the end of the PHE may regain it during the unwinding period, while some who lose coverage despite being eligible may re-enroll.
The findings highlight the importance of administrative and legislative actions to reduce the risk of coverage losses after the continuous enrollment provision ends, said HHS. Successful policy approaches should address the different reasons for coverage loss.
Broadly speaking, one set of strategies is needed to increase the likelihood that those losing Medicaid eligibility acquire other coverage, and a second set of strategies is needed to minimize administrative churning among those still eligible for coverage.
Importantly, some administrative churning is expected under all scenarios, though reducing the typical churning rate by half would result in the retention of 3.4 million additional enrollees.
THE LARGER TREND
CMS has released a roadmap to ending the COVID-19 public health emergency as health officials are expecting the Biden administration to extend the PHE for another 90 days after mid-October.
The end of the PHE, last continued on July 15, is not known, but HHS Secretary Xavier Becerra has promised to give providers 60 days’ notice before announcing the end of the public health emergency.
A public health emergency has existed since January 27, 2020.
Republican-led states that have resisted expanding Medicaid for more than a decade are showing new openness to the idea.
Driving the news: In the decade-plus since the landmark Affordable Care Act was enacted, 12 states with GOP-led legislatures still have not expanded Medicaid coverage to people living below 138% of the poverty line (or nearly $19,000 annually for one person in 2022).
But there’s evidence that the political winds are changing in holdout states like North Carolina, Georgia, Wyoming, Alabama and Texas, as leaders court rural voters, assess new financial incentives and confront the bipartisan popularity of extending health care coverage.
Why it matters: Medicaid expansion, a key component of the Affordable Care Act, means increasing access to federal health insurance coverage for low-income residents, in exchange for a 10% state match of the federal spending.
Experts say it expands access to care, lowers uninsured rates and improves health outcomes for low-income populations.
More than 2 million Americans would gain coverage if the 12 states expand Medicaid, according to a 2021 estimate from the Kaiser Family Foundation.
The big picture: Some Republican states have already expanded Medicaid through executive authority or — in states where it’s legal to do so — citizen-led ballot initiatives.
Referendums on the issue passed in Nebraska, Utah and Idaho in 2018 and Missouri and Oklahoma in 2020.
Medicaid expansion is on this November’s ballot in Republican-controlled South Dakota. (Voters there in June rejected a GOP proposal to make it harder to pass.)
Be smart: In most of the remaining non-expansion states, neither ballot initiatives nor executive authority are options, leaving the legislature with the authority to make the decision.
“If there is a person that has spoken out more against Medicaid expansion than I have, I’d like to meet that person,” Republican Senate leader Phil Berger said at a May press conference after reversing his stance. “This is the right thing for us to do.”
Brian Robinson, former spokesman for the first Georgia governor to reject Medicaid expansion, argued in June it’s time to make the change. Politically, it would “steal an issue” from Democrats, he told Axios Atlanta.
Policy-wise, “this isn’t what we would do,” Robinson said of Medicaid’s much-criticized structure. “But Republicans can’t agree on what we would do. This is the policy and the law, and it’s not going away. It would bring home hundreds of millions from a program we’re paying into already.”
What they’re saying: “There is real momentum on Medicaid expansion in these conservative states that have been holding out,” said Melissa Burroughs of Families USA, a health care advocacy group working with partners in non-expansion states to push the policy.
Burroughs told Axios there are Republicans championing or discussing expansion in every non-expansion state, but often “political dynamics and leadership” stand in the way.
Former Alabama Gov. Robert Bentley,who had refused to expand Medicaid himself, is now urging his fellow Republicans to pass it for the benefit of rural parts of the state.
In Texas, the state with the highest percentage of uninsured residents per capita, some Republicans have co-sponsored Medicaid expansion bills. That indicates “cracks” in Republican opposition, Luis Figueroa, legislative and policy director at progressive think tank Every Texan, told Axios Austin’s Nicole Cobler and Asher Price.
Tennessee’s Republican lieutenant governorsuggested possible openness to the policy last year, though there’s been no meaningful legislative movement.
Details: The winds are shifting for several reasons, experts told Axios.
Money: The 2021 federal pandemic relief law sweetened the deal for non-expansion states, with a provision designed to offset states’ costs entirely for the first two years. Plus, Republicans’ initial fears that the federal government would pull its 90% matching funds haven’t come to pass.
COVID-19: Under the federal state of a public health emergency, Medicaid access was automatically extended. But those temporary allowances could lift next year and millions could lose coverage, putting additional pressure on leaders.
Politics: Medicaid expansion continues to be broadly popular, and the Republican campaign to “repeal and replace” the Affordable Care Act has failed in the courts and Congress — neutralizing what was once a key argument against expansion.
Health care access: As hospitals across the country close, deepening the rural health care crisis, the benefit of getting more reimbursement from additional Medicaid recipients is difficult to ignore for rural hospital revenues — though the policy is not a silver bullet to end the crisis.
The intrigue: Democrats in these states, including gubernatorial candidates like Georgia’s Stacey Abrams and Texas’ Beto O’Rourke, continue to campaign heavily on Medicaid expansion — banking on polling showing the policy to be consistently popular among the public.
“I think a lot of Republican members would like to extend Medicaid even more than they will say it,” Texas Democratic State Sen. Nathan Johnson, who has led the push for expansion there, told Axios Austin’s Cobler and Price.
He said Republicans “are handcuffed by the ideological and political constraints. They will try to do some things to help people, but they need to get over the reflexive opposition to Medicaid expansion.”
Between the lines: Even in non-expansion states, partial expansion proposals have gained traction.
Kaiser Health News found that nine of the 12 states have sought or plan to seek an extension of postpartum Medicaid coverage, including for up to one year in North Carolina, Tennessee, South Carolina and Georgia.