This report examines the substantial growth in Medicaid enrollment that has taken place over the course of the COVID-19 pandemic. We show that this growth has been largely driven by the continuous coverage requirement of the Families First Coronavirus Response Act. We project continued enrollment growth through the end of 2021, followed by rapid disenrollment in 2022 after the public health emergency (PHE) declaration expires. Our key findings are as follows:
- We estimate that by the end of 2021, 17 million more nonelderly people will be enrolled in Medicaid than before the pandemic, reaching a total of 76.3 million Medicaid enrollees younger than 65. Our estimate assumes the PHE will expire at the end of 2021.
- We find that the continuous coverage provision significantly contributes to ongoing Medicaid enrollment growth. In a typical month before the pandemic, many people would lose Medicaid eligibility and fall off the rolls, while other people would gain eligibility and sign up because of changes in income or family composition. Over 21 months, eliminating the disenrollment caused by loss of eligibility translates into a substantial cumulative enrollment increase.
- A recent change in guidance from the Centers for Medicare & Medicaid Services (CMS) gives states up to 12 months to restore normal income eligibility redeterminations for Medicaid enrollees once the PHE expires, instead of just 6 months under previous rules (CMS 2021). More gradual processing of enrollment over 12 months could reduce unnecessary losses of coverage by allowing more time for planning and outreach. However, the expected loss of the enhanced federal medical assistance percentage (FMAP) in March 2022 gives states a financial incentive to process enrollment more quickly.
- We estimate that the number of Medicaid enrollees could decline by about 15 million people during 2022. This includes 8.7 million adults and 5.9 million children. We estimate that one third of adults losing Medicaid coverage after the PHE could qualify for subsidized private health coverage in the Marketplaces. Nearly all of the remainder would likely have access to an offer of employer coverage in their family deemed affordable under the Affordable Care Act.
- Many of those losing Medicaid coverage would be eligible for other sources of subsidized coverage. Of the adults who would lose Medicaid, we estimate about a third would be eligible for Marketplace premium tax credits (PTCs) if the enhanced tax credits in the American Rescue Plan Act (ARPA) were made permanent. Of the children losing Medicaid, 57 percent would be eligible for the Children’s Health Insurance Program (CHIP), and an additional 9 percent would be eligible for Marketplace coverage with tax credits. Thus, good coordination between state Marketplaces and Medicaid agencies is essential to reduce unnecessary losses of health coverage.
The report was published by the Urban Institute in September 2021. Following the extension of the PHE, we published a follow-up report with updated projections in March 2022. In December 2022, we published a third installment. Our findings have been cited by the New York Times, the Washington Post, the LA Times, CNN, NBC News, CBS News, the Associated Press, USA Today, POLITICO, Bloomberg Businessweek, NPR, HuffPost, Forbes, and Axios, among many other media outlets.