Medicaid Unwinding

Breaking via the Centers for Medicare & Medicaid Services (CMS):

Under the Biden-Harris Administration, Over 20 Million Selected Affordable Health Coverage in ACA Marketplace Since Start of Open Enrollment Period, a Record High

  • As January 16 coverage deadline approaches, Biden-Harris Administration continues to encourage Americans to sign up for quality, affordable health care coverage

Under the Biden-Harris Administration, the U.S. Department of Health and Human Services announced today that over 20 million people have selected an Affordable Care Act (ACA) Health Insurance Marketplace plan since the 2024 Marketplace Open Enrollment Period launched on November 1 — a record number of enrollments.

In mid-December, I posted an update to my 2024 ACA Open Enrollment Period projections in which I upgraded my prior estimate of 18.5 million QHPs + BHPs combined to more than 19 million total.

A few days later, based on a press release from the Centers for Medicare & Medicaid Services (CMS) announcing over 15.3 million QHPs via the federal exchange alone, I updated my projection significantly more, to around 20.7 million QHPs (Qualified Health Plans) and 1.3 million BHPs (Basic Health Plans), or roughly 22 million total.

CMS's press release states that they won't be posting the next detailed/state-by-state enrollment breakout until January 10th, so aside from a handful of minor SBM updates here and there, there hasn't been much to report on the enrollment front since then...until this:

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.

Just 3 days ago, I posted a revised 2024 ACA Open Enrollment Period projection, in which I upgraded my prior projection from 18.5 million Americans signing up for either Qualified Health Plans (QHPs) or Basic Health Plans (BHPs) combined nationally to over 19 million doing so. That 18.5M projection was itself a drop from my original projection of 19M QHPs + BHPs combined from a month earlier.

I delved into the various reasons for both my original and revised projections, but the bottom line is that I figured it would end up being somewhere in the neighborhood of 19 - 19.5 million, give or take, likely broken out something like ~18 million QHPs plus another ~1.3 million BHPs in New York & Minnesota only.

I even included 20 million as an outside possibility.

via the Centers for Medicare & Medicaid Services (CMS):

Biden-Harris Administration Releases New Medicaid and CHIP Renewal Data Showing the Role State Policy Choices Play in Keeping Kids Covered

  • Sec. Becerra Calls on Nine States with the Highest Child Disenrollments to Immediately Take Up Proven Federal Flexibilities to Protect Children and Families; Biden-Harris Administration Extends Federal Flexibilities to States Until End of 2024

Today, the U.S. Department of Health and Human Services (HHS) released new data on state Medicaid and Children’s Health Insurance Program (CHIP) enrollment changes among children and youth since full eligibility renewals for these programs restarted earlier this year. The data released today make it clear that state policy choices have real consequences for children and families during Medicaid and CHIP renewals. States that take up proven flexibilities and strategies from the Centers for Medicare & Medicaid Services (CMS) are better able to protect kids’ coverage – especially when the state has also expanded Medicaid.

Back on November 5th, just a few days into the 2024 Open Enrollment Period, I did some back-of-the-math number crunching and concluded that the odds were pretty good that total 2024 OEP ACA enrollment (including both exchange-based Qualified Health Plans, or QHPs, as well as enrollment in Basic Health Plans (BHPs) in New York & Minnesota only) would break 19 million people for the first time in the ACA's history.

This was based on some simple assumptions:

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.

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.

Last week I reported that at least 593,000 of the "Medicaid Unwinding" population (Americans who had their Medicaid or CHIP coverage terminated since the end of the COVID public health emergency's "Continuous Coverage" provision ended at the end of March) had shifted over to an ACA exchange plan as of the end of July (plus another 88K who enrolled in BHP plans).

As I noted at the time, perhaps 11% or so of the Unwinding population might move to ACA exchange policies instead when the dust settles on the ongoing unwinding process (12% or so if you include BHP enrollees).

Today, Amy Lotven of Inside Health Policy reports some additional data which indirectly supports this:

As long-time readers know, every year during the ACA Open Enrollment Period (OEP) I have a tradition of regularly updating a graph tracking how many Americans have enrolled in on-exchange Qualified Health Plan (QHP) policies nationally. The Graph®, as I've come to call it, is how this entire website got started; the logo for ACA Signups even consists of a stylized version of the original version from the 2013 - 2014 OEP.

That first year I attempted to track every conceivable population--on-exchange QHPs, off-exchange QHPs, Medicaid expansion enrollment, SHOP (ACA small business exchange) enrollees) and even the amorphous "sub-26er" populations of young adults enrolled in their parents employer plans thanks to ACA provisions. Some of these were nearly impossible to accurately estimate, but I really tried my best.

Over the next year or two, I not only dropped the categories which I wasn't able to track properly, my tracking of the remaining ones became much more streamlined and sophisticated. Eventually I decided to stick with just two categories: On-exchange QHPs and those enrolled in the Basic Health Plan (BHP) programs in Minnesota and New York.

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