Analysis of Recent National Trends in Medicaid and CHIP Enrollment
This data note looks at national and state-by-state Medicaid and CHIP enrollment data through November 2020, as states were still experiencing the health and economic effects of the coronavirus pandemic. After declines in enrollment from 2017 through 2019, preliminary data show that total enrollment grew to 78.9 million in November, an increase of 7.7 million from actual enrollment in February 2020 (10.8%), right before the pandemic and when enrollment began to steadily increase (Figure 1). Changes are somewhat larger if growth is compared to preliminary data for February 2020 (8.3 million or 11.7%). Increases in enrollment reflect changes in the economy (as more people experience income and job loss and become eligible and enroll in Medicaid and CHIP coverage) and provisions in the Families First Coronavirus Response Act (FFCRA) that require states to ensure continuous coverage to current Medicaid and CHIP enrollees to access a temporary increase in the Medicaid/CHIP match rates.
The information in this data note is based on Kaiser Family Foundation analysis of the Centers for Medicare and Medicaid Services (CMS) Performance Indicator Project Data. Medicaid/CHIP enrollment data are submitted monthly by state Medicaid agencies and, with each monthly update, states often revise the previous months’ enrollment to include retroactive enrollment and to better align with reporting criteria. Unless otherwise indicated, this report uses the enrollment data from the updated enrollment reports to reflect the most current enrollment data possible.
Medicaid/CHIP enrollment increased following the implementation of the Affordable Care Act (ACA) but was declining in the two years prior to the pandemic. Following the implementation of the ACA Medicaid expansion to low-income adults in 2014, there were large increases in Medicaid and CHIP enrollment across states that followed steady growth in coverage of children over the past decade. These increases reflected enrollment among newly eligible adults in states that implemented the expansion as well as enrollment among previously eligible adults and children due to enhanced outreach and enrollment efforts and updated enrollment procedures tied to the ACA. This trend began reversing when enrollment started to decline in 2018 and continued to decline in 2019. Total enrollment fell from 73.4 million in December 2017 to 71.1 million in December 2019, a decline of 2.3 million people or 3.1 percent. Month to month enrollment declines slowed but continued until February 2020. The declines in enrollment, in part, reflected a robust economy, but experiences in some states suggested that they may have also reflected enrollment losses among people who were still eligible for coverage due challenges completing enrollment or renewal processes.
Data show that Medicaid/CHIP enrollment is increasing amid the coronavirus pandemic as actual adjusted data from February 2020 to preliminary data in November 2020 show that enrollment increased by 7.7 million or 10.8%. Recent increases could reflect new enrollment related to changes in the economy and job loss, as well as eligibility and enrollment requirements included in the Families First Coronavirus Response Act (FFCRA), also known as maintenance of eligibility (MOE) requirements. Under the FFCRA, to be eligible for enhanced federal Medicaid matching funds, states must ensure continuous coverage for those enrolled in Medicaid as of March 18, 2020 and cannot make eligibility and enrollment more restrictive than policies in place as of January 2020. Over this period, all states experienced Medicaid/CHIP enrollment growth ranging from 6% to 22% (Figure 2).
Virtually all growth was concentrated in Medicaid, which grew by 11.8% (7.6 million enrollees) from actual adjusted February to preliminary November data. Conversely, CHIP has seen very little enrollment growth since February (1.5%, or 102,000 enrollees), and several states (21) have seen declines in CHIP enrollment from actual adjusted February through preliminary November reports.1 These declines in CHIP enrollment for some states could reflect changes in family income, causing children to move from CHIP to Medicaid coverage. As discussed below, all states reported increases in child enrollment for Medicaid/CHIP overall during this time period.
Reflecting economic changes and provision in FFCRA, adult enrollment in Medicaid/CHIP has increased rapidly during the pandemic, growing by 14.1% from actual adjusted February 2020 through preliminary November 2020 enrollment reports. This growth amounts to an additional 4.9 million adults in the 49 states and DC that report adult/child monthly enrollment (Arizona does not report children or adults separately). Additionally, three states began newly enrolling expansion adults in 2020 (Utah and Idaho in January, Nebraska in October), which may also be contributing to increased adult enrollment. Child enrollment grew as well, but at a slower pace: 7.4% or 2.6 million enrollees in the same period.2 Still, every state reporting these data saw an increase in child Medicaid/CHIP enrollment during this time period, despite declines in CHIP enrollment in some states (as discussed above).
Enrollment may continue to grow even as the economy begins to recover from the effects of the pandemic, as the MOE remains in place for Medicaid and due to the effects of ACA open enrollment. There is usually a lag between unemployment and Medicaid enrollment growth, so even if unemployment starts to decline, there may continue to be Medicaid enrollment growth. Current enrollees will not be disenrolled due to the MOE that will remain in place during the public health emergency period. Additionally, the ACA open enrollment period could also increase Medicaid/CHIP enrollment in future enrollment reports. The ACA Marketplace provides a single application for Medicaid, CHIP, and Marketplace coverage, and many people visiting the Marketplace during open enrollment will qualify for Medicaid or CHIP coverage. The regular ACA open enrollment period began November 1 and President Biden implemented the special enrollment period for the federal ACA Marketplace from February 15 through May 15, 2021. Medicaid/CHIP enrollment reports are lagged by approximately four months, but future data will provide better insight into how national and state-by-state Medicaid enrollment is responding to the pandemic, economic recovery efforts as well as the ACA open enrollment period.