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 July 2021, as the COVID-19 vaccine was widely available to people ages 12 and older and the number of COVID-19 cases and deaths were nearing a low point in 2021. After declines in enrollment from 2017 through 2019, total Medicaid / CHIP enrollment grew to 83.6 million in July 2021, an increase of 12.4 million from enrollment in February 2020 (17.4%), right before the pandemic and when enrollment began to steadily increase (Figure 1). 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 enrollment to current Medicaid enrollees to access a temporary increase in Medicaid match rates. The continuous enrollment requirement under the FFCRA has all but halted the problem of churning in Medicaid – the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time – in addition to preventing Medicaid coverage loss during public health emergency. While enrollment has increased for 17 consecutive months, the monthly increases appear to be slowing compared to April through August 2020, when monthly increases were the largest. However, the fallout from the Delta and Omicron variants – as well as ongoing economic uncertainty – could impact Medicaid enrollment trends as new data become available.

The information in this data note is based on KFF 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. Except for the latest month’s enrollment (July 2021), this brief reports data from the updated enrollment reports for all other months to reflect the most current enrollment data possible. However, the data presented in this brief will differ from those presented in monthly Medicaid and CHIP Enrollment Snapshots published by CMS, which use exclusively preliminary enrollment reports for all months.

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 71.2 million in December 2019, a decline of 2.2 million people or 3.0%. 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 also have reflected enrollment losses among people who were still eligible for coverage due to challenges completing enrollment or renewal processes.

Data show that Medicaid / CHIP enrollment is increasing amid the coronavirus pandemic as data from February 2020 to July 2021 show that enrollment increased by 12.4 million or 17.4%. 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 11.7% to 42.3% (Figure 2). The state with the largest growth since February 2020, Oklahoma, implemented the Medicaid expansion on July 1, 2021 and saw total Medicaid / CHIP enrollment grow by 123,000 in the month of July 2021 alone (a 13.7% increase from June 2021 enrollment), which contributed to the large cumulative enrollment increase. Three other states have implemented expansion since 2020 – Utah and Idaho in January 2020 and then Nebraska in October 2020 – contributing to higher than average rates of enrollment growth in these states as well.

Virtually all growth was concentrated in Medicaid, which grew by 18.8% (12.1 million enrollees) from February 2020 to July 2021 data (Figure 3). Conversely, CHIP has seen very little enrollment growth since February 2020 (3.5%, or 232,000 enrollees), and several states (14) have seen declines in CHIP enrollment from February 2020 through July 2021 reports. 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 23.6% from February 2020 through July 2021 enrollment reports (Figure 4). This growth amounts to an additional 8.1 million adults in the 49 states and DC that report adult / child monthly enrollment (Arizona does not report children or adults separately). As mentioned above, four states began newly enrolling expansion adults since January 2020 (Idaho, Nebraska, Oklahoma, and Utah), contributing to increased adult enrollment. Child enrollment grew as well, but at a slower pace: 11.1% or 3.9 million enrollees in the same period. Still, virtually 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).

Future enrollment reports may continue to capture growth since July 2021 as the MOE remains in place for Medicaid and because of other factors, including the effects of ACA open enrollment and the Delta and Omicron variants. Current enrollees will not be disenrolled due to the MOE that will remain in place during the public health emergency period, which is currently set to expire in April 2022 but may be renewed due to challenges created by the Omicron variant. Medicaid / CHIP enrollment reports are lagged by approximately six months, so future Medicaid / CHIP enrollment reports may also show further increases stemming from the Biden administration’s implementation of a special enrollment period for the federal ACA Marketplace that was in place from February 15 through August 15 , 2021 as well as the regular open enrollment period for the ACA Marketplace beginning November 1, 2021. 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 return to in-person schooling in the fall may also increase Medicaid / CHIP enrollment through school-based outreach and enrollment programs. Subsequent enrollment reports will also include Missouri’s Medicaid expansion implementation, which occurred in October 2021 and could add to enrollment in forthcoming reports. Forthcoming enrollment reports may also show if Medicaid / CHIP enrollment was affected by the Delta and Omicron variants and ongoing economic changes. Looking ahead, CMS recently announced new grant funding for organizations that conduct outreach and enrollment assistance for children, families, and pregnant people, such as schools, safety net organizations, and state and local governments to help reduce the number of uninsured children by increasing Medicaid / CHIP enrollment and retention.

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