Digging Deeper into Medicaid Enrollment: Exploring States’ Experiences

By Molly Warren

Almost 7 million individuals enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) between October 2013 and May 2014, according to the most recent data from the Centers for Medicare and Medicaid Services (CMS). This represents an 11.4 percent increase in enrollment since the initial open enrollment period began. And, considering that Medicaid and CHIP enrollment continues year-round, and that 6.7 million are already enrolled, it looks like states are well on their way to reaching the Congressional Budget Office’s estimate that Medicaid will cover eight million more Americans in 2014!

Medicaid enrollment chart1

While the biggest driver for enrollment appears to be Medicaid expansion, interestingly, there is significant variation across both expansion and non-expansion states. Enrollment in Medicaid expansion states ranged from a (huge!) increase of 52 percent in Oregon to a four percent increase in Delaware, and non-expansion states ranged from a 14 percent increase in South Carolina to a five percent decrease in Wyoming.

There are a lot of reasons why some states are seeing higher Medicaid and CHIP enrollment than others. Some of these factors include:

  • Using auto-enrollment and fast-track enrollment strategies. Ten states that expanded Medicaid increased their enrollment by more than 20 percent, and half of these states used auto-enrollment from other state programs (including Vermont and Maryland) or the fast-tracked enrollment process (including Oregon, West Virginia, and Arkansas) to facilitate enrollment.
  • Characteristics of the uninsured. The number of uninsured consumers eligible for Medicaid varies considerably based on a few state-specific factors, including state eligibility levels (both whether or not a state expanded Medicaid and eligibility levels for specific populations) and participation rates. States with more generous eligibility and higher participation rates prior to the first open enrollment period had fewer new consumers to enroll than states that were making significant changes to eligibility and/or that had experienced low participation rates in the past.

For example, most states did not cover adults without dependent children prior to 2014, but a few did. One of them, Delaware, covered these adults up to 100 percent of the federal poverty level (FPL) (about $11,500 for an individual). This means that in Delaware, only a small slice of residents became newly eligible (adults with incomes between 100-138 percent FPL). It is not surprising, then, that Medicaid enrollment in Delaware increased less than in expansion states that began covering these adults for the very first time this year.

  • A smooth transition to new IT systems. The Affordable Care Act requires states to streamline and simplify their Medicaid and CHIP applications and to coordinate marketplace and Medicaid IT systems. Implementation of these changes has varied across the country — some states had a fairly smooth transition, while others have not. And a handful of states are still working with CMS to meet all application and coordination requirements. IT systems may not have the same striking effect on boosting enrollment rates as some other factors, but they can certainly hurt enrollment. If handoffs are not working efficiently or applications require additional manual processing, consumers are less likely to get enrolled in a timely manner.

Medicaid enrollment continues year round, so stay tuned for additional analysis as application backlogs are cleared, IT systems improve, and more states expand Medicaid!


Medicaid Enrollment Chart2

Note: Arizona, Arkansas, California, Colorado, Delaware, the District of Columbia, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia expanded their Medicaid programs to all individuals up to 138% FPL prior to May 2014. New Hampshire is expanding their Medicaid program August 15, 2015 and is considered a non-expansion state in this analysis. Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming have no immediate plans to expand their Medicaid programs. Connecticut, Maine, and North Dakota did not submit Medicaid/CHIP enrollment numbers to CMS and are not included in this analysis.

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