Is the U.S. uninsured rate at an all-time low?
Enough states have reported Medicaid tallies through February to posit that the pandemic has increased enrollment by more than ten million nationally since February 2020. Adjusting for the usual difference* between CMS's official totals (now posted through November**) and my sample below (based on state monthly reports), year-over-year enrollment growth since February 2020 is likely about 14.8%, and total enrollment likely stands at about 81.7 million. A quarter of the U.S. population is enrolled in Medicaid.
I don't think we've fully fathomed the effect on access to health insurance of the pandemic, the battered and flawed but still functioning and funded ACA programs in place as the pandemic hit, and pandemic relief measures. Consider...
The Families First Act effectively required states to pause Medicaid disenrollments for the duration of the Covid-19 emergency, and enrollment will continue to grow until that moratorium ends.*** Enrollment growth among those rendered eligible by the ACA Medicaid expansion is close to 30%. In the ACA marketplace, average monthly enrollment in 2021 will probably exceed 2019 enrollment by at least a million, perhaps more, spurred by extended Special Enrollment Periods and subsidies enhanced by the American Rescue Plan Act. As the population ages, Medicare enrollment grows by about 1.5 million yearly. Meanwhile, the huge job losses triggered by the pandemic appear to have had only a modest effect on employer-sponsored insurance: enrollment through September was down by just 2-3 million, according to a KFF estimate.
Put it all together, and it would appear that somewhere near 10 million more Americans may be insured at present than on the eve of the pandemic. While the uninsured rate had ticked up from 2017 to 2019, it may well be at an all-time low at present (the NHIS survey shows a drop in uninsured in the second quarter of 2020).
Medicaid enrollment in 34 states, February 2020 to January/February 2021 (click to enlarge)
Totals in green are estimated; totals in blue are in states that have enacted the ACA Medicaid expansion; totals in red are for nonexpansion states. Wisconsin is in purple signifying partial expansion (Medicaid eligibility to 100% FPL).
For more context and explanation of my compilation practices, see this post and this post
Update: I forgot about the Census Bureau's Pulse Survey, an experimental online-only survey updated weekly during the pandemic. Health insurance tallies are recorded here. While volatile and to be regarded with caution, the Pulse Survey shows the uninsured rate trending down. As a benchmark, the survey's headnote highlights that in 2019, 14.7% of NHIS respondents age 18-64 were uninsured at the time of interview. In the most recent two week period recorded, March 3-15, the Pulse found 11.6% of adults in that age range uninsured at the time of interview. The average for the last three periods, from February 3 through March 15, is also 11.6%. Last July, across three one-week periods, the average was 14.0%.
Update 2, 4/7/21: Today CMS released enrollment numbers for the emergency Special Enrollment Period commenced on Feb. 15. Through March 31, it had generated 300,000 more enrollments than SEPs in the prior year in HealthCare.gov states alone. Marketplace enrollment is probably at an all-time high for this point in the year.
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* CMS has posted the preliminary November 2020 total, and as I estimated on back on Dec. 31, it shows an increase of 11.6% since February 2020. CMS's official tallies for all 50 states plus D.C. generally trail my compilations of states' monthly reports by about three months and consistently show about a half percentage point less enrollment growth than my 34-state tally. As the 24 states in my sample that have reported through February show .08% enrollment growth for the month, my sample will come in at about 15.3% year-over-year growth as of February 2021 when the month's tally is complete.
**CMS posts preliminary and then final tallies for each month. Since each month's final tally typically differs from the preliminary total by several hundred thousand (throughout the pandemic, final totals have been consistently higher), CMS compares preliminary-to-preliminary monthly totals. The preliminary total for February 2020 that CMS uses for comparison with the preliminary November total is lower than the final February total by 552,394. In the last month for which a final total is available, the preliminary total in October is lower than the month's final total by 315,894. As I noted in November, from January through June last year, CMS's updated monthly total exceeded the preliminary count by an average of 474,539 per month.
***Conversely, the end of the moratorium is likely to be disruptive, as many states will move aggressively to disenroll those whose incomes have risen above the eligibility threshold.)
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Postscript, 4/7/21: Norm Spier, commenting below, is right to keep bird-dogging a major blot on the Medicaid expansion: Medicaid Estate Recovery, to which enrollees over age 55 are potentially subject. That is, a majority of expansion states retain the right to recover the cost of Medicaid enrollment from the estates of all enrollees over age 55, as explained in this post (focus on New Jersey in this post). As pointed out by commenter Bob Hertz below, MACPAC's 2021 Report to Congress on Medicaid and CHIP was released in March, and Chapter 3 on Medicaid Estate Recovery. While the report is focused almost exclusively on recovery for long-term care services financed by Medicaid (the original target of estate recovery, and also highly inefficient and unequitable), it also relays that 20 states and D.C. currently pursue estate recovery for the over-55 Medicaid expansion population. The map of each state's policy below is from pdf page 47 (report pg. 117) of the MACPAC report. It reveals that estate recovery in all states yielded a grand total of $773 million in 2019. As Bob Hertz puts it, "This is barely a raised dimple in the overall Medicaid program and not worth the fear and torment that is caused."