CMS Report: ~680K of those kicked off of Medicaid enrolled in #ACA exchange plans or BHPs thru July (updated)

Originally posted 10/31/23; updated 11/08/23

Back in September, Amy Lotven of Inside Health Policy found an excellent scoop from a new CMS report hiding in plain sight:

New CMS data, quietly released in late August, show about 178,000 consumers chose a qualified health plan (QHP) through a state or federal exchanges after losing Medicaid and CHIP coverage in the first two months of the Medicaid unwinding. Those sign-ups through the end of May are more than three times the 54,000 enrollments that CMS reported in July, which reflected only the April numbers.

As a reminder: Normally, states will review (or "redetermine") whether people enrolled in Medicaid or the CHIP program are still eligible to be covered by it on a monthly (or in some cases, quarterly, I believe) basis. However, the federal Families First Coronavirus Response Act (FFCRA), passed by Congress at the start of the COVID-19 pandemic in March 2020, included a provision requiring state Medicaid programs to keep people enrolled through the end of the Public Health Emergency (PHE). In return, states received higher federal funding to the tune of billions of dollars.

As a result, there are tens of millions of Medicaid/CHIP enrollees who didn't have their eligibility status redetermined for as long as three years.

With the end of this continuous coverage as of March 31st, 2023, healthcare advocates have been warning that millions of people would lose coverage, including many who are still actually eligible...and sure enough, as of this week, at least 9.5 million Medicaid enrollees have lost coverage so far, of whom a stunning 72% (6.86 million) were kicked off the program for purely procedural reasons--that is, failure to return a form or, in some cases, state administrations either mistakenly or deliberately sweeping entire families off the programs if a single member is no longer eligible.

The 178K figure only ran through the end of May, however. The Centers for Medicare & Medicaid Services (CMS) have been posting updated reports monthly; the newest one includes data through the end of July:

  • Across the 33 states hosted via HealthCare.Gov, ~731K people who were kicked off of Medicaid/CHIP applied for ACA exchange coverage
  • Of those, ~84.3K (12%) were determined by to still be eligible for Medicaid/CHIP and presumably have been re-enrolled
  • The remaining ~643.2K (88%) were determined by to be eligible for an ACA exchange Qualified Health Plan (QHP), with or without subsidies
    • 558.4K were eligible for subsidies; 84.8K weren't
  • Of those, 468,630 (64.1% of the total who applied) actually enrolled in a QHP

The state-based exchange report is laid out little differently:

  • Across the 18 states which operate their own state-based ACA exchange, ~904K people who were kicked off of Medicaid/CHIP applied for ACA exchange coverage.
  • Of those, ~95.1K (11%) were determined eligible for a Basic Health Plan program in Minnesota or New York; 87.5K (9.7%) enrolled in a BHP plan
  • Another ~618K (68%) were determined eligible for an ACA exchange Qualified Health Plan (QHP), with or without subsidies
    • 383.5K were eligible for subsidies; 244.6K weren't
  • Of those, 123,661 (13.7% of the total who applied) actually enrolled in a QHP

Across all 50 states +DC, that's 592,291 who actually enrolled in a QHP through the end of July, plus the BHP enrollees for a total of 679,825 total.

Overall, that's 41.6% of the 1,635,404 people who applied for ACA marketplace coverage through June. Another 84.3K were determined to still be Medicaid/CHIP eligible, leaving ~871.3K (~53.3%) who had to find some other type of coverage.

It's also important to note that this obviously does not mean that only ~1.64 million Americans had lost Medicaid/CHIP coverage through the end of July. Remember, this only includes those who actually applied for coverage to begin with.

The KFF Medicaid Unwinding Tracker put the total number of Americans who had lost Medicaid/CHIP coverage as of July 19th at over 3.09 million. The dates don't match up, but it's also likely that the actual figure as of July 19th was higher than that; assuming those cancel each other out, this suggests that perhaps 22% of those who had lost Medicaid/CHIP through the end of July enrolled in ACA exchange plans or QHPs.

If you further extrapolate that out to the 9.53 million who have lost Medicaid/CHIP coverage as of October 26th, it would mean perhaps 2.1 million have enrolled in QHPs/BHPs, although this is still speculative.

UPDATE 11/08/23: Thanks to Andrew Sprung for pointing me towards a different CMS report found at the same page! The Medicaid and CHIP National Summary of Renewal Outcomes – March through July 2023 report specifies that a total of 5,521,024 Medicaid/CHIP enrollees were terminated from their coverage from March - July 2023, considerably higher than KFF's minimum estimate above. This means that through the end of July, 10.7% of the Unwinding population enrolled in ACA exchange coverage and another 1.6% enrolled in BHP coverage, or 12.3% total.

If you further extrapolate that out to the more than 10 million people who have been disenrolled as of Nov. 1st, it means the number who have moved to exchange QHPs is up to perhaps 1.1 million as of today, plus another 160K BHP enrollees.

It may seem surprising at first that there are more people in state-based exchange states who lost coverage given that only 40% of the total U.S. population lives in those states, but keep in mind that all of the state-based exchange states have expanded Medicaid under the ACA, while 10 of the states haven't done so (including huge states like Texas and Florida), meaning they generally had a higher portion of their residents in Medicaid/CHIP in the first place.

There's also still a strange disconnect between the ratios of and SBM states here: 64.1% of applicants enrolled in QHPs, while only 23.4% of SBM applicants enrolled in either QHPs or BHPs. Huh.

I've reformatted most of the relevant data into a simplified, easier-to-follow spreadsheet with all 50 states +DC. Some key takeaways:

  • 19,400 people in 4 states (CA, MD, MA & RI) which have this capability have been automatically transferred from Medicaid/CHIP over to ACA exchange plans.
  • Nationally, around 36.2% of the Unwinding population who applied for coverage via their ACA exchange have actually enrolled in a QHP, plus another 5.8% in MN/NY who enrolled in BHP plans
  • The percentage ranges widely, from as little as 3.0% in Kentucky to as much as 73.6% in South Carolina.
  • Only 73.9% of those determined eligible for QHPs were also deemed eligible for APTC subsidies. This is noteworthy because it's significantly lower than the 90.5% of all ACA exchange enrollees who are receiving subsidies. It suggests that either a disproportionately high portion of the Unwinding population is higher income (which makes sense) or that those most likely to actually apply in the first place are higher income, which is rather counterintuitive. Unfortunately the report doesn't break out the APTC/no APTC numbers of those who actually enrolled in QHPs, however.

UPDATE 11/08/23: As noted above, thanks to the Medicaid/CHIP Nat'l Summary of Renewal Outcomes report, I've added two columns at the end: Total cumulative Medicaid/CHIP terminations and the percent of that total who had enrolled in an exchange QHP or BHP as of July.

This ranges from as little as less than 1% in DC, Colorado & Nevada to as high as 39% in my home state of Michigan. Huh.