‘A huge red flag’? Medicaid, CHIP enrollment dropped 3% in 2018

Enrollment in Medicaid and the Children's Health Insurance Program (CHIP) dropped by 2.2 million people between January 2018 and January 2019, according to CMS data released last week.

Map: Where the states stand on Medicaid expansion

The data showed that enrollment in the programs declined from 74.6 million at the beginning of 2018 to 72.4 million at the beginning of 2019, indicating a 3% decline in overall enrollment.

Georgetown University's Center for Children and Families, which analyzed the data, determined 861,000 fewer children were covered by Medicaid and CHIP in 2018 when compared with 2017. The analysis revealed that child enrollment in the programs declined in 40 states, with the largest drops by percentage occurring in Mississippi, Missouri, and Tennessee.

What's behind the enrollment decline?

CMS Administrator Seema Verma said the agency's preliminary analysis of the seven states with the largest enrollment declines revealed that "[t]he improving economy seems to be a consistent factor" in enrollment declines. "It's always been clear that as the economy improves, unemployment drops and incomes grow, (and) people move off of public assistance programs like Medicaid," she said.

However, Verma said further analysis of the enrollment decline is "warranted." 

Some health policy experts have argued that the enrollment decline can be attributed to some states adopting stricter eligibility redetermination processes, Modern Healthcare reports. For instance, a report by Families USA found that Medicaid enrollment declined most in states that established tougher eligibility redetermination processes, like Arkansas, Missouri, and Tennessee.

Health care providers and insurers also have argued that families of mixed immigration status might be afraid to sign up for coverage because of a rule proposed by the Trump administration that would count legal immigrants' use of public health insurance as a negative factor when reviewing applications for permanent residency. That fear also might have contributed to the enrollment decline, they argued.

Decline in children's enrollment 'a red flag'

Joan Alker, executive director of Georgetown's Center for Children and Families, said the enrollment decline among children is a "huge red flag." According to Alker, the number of uninsured U.S. children in 2018 increased nationwide for the first time in ten years.

"We don't know how many of these kids got private insurance, but we know from what happened last year that the good economy was not enough to account for the decline in public coverage," Alker said. She added, "I'm absolutely confident that many of these children who lost Medicaid and CHIP last year don't have employer-sponsored insurance."

Advocates have noted that federal data show child enrollment in Affordable Care Act exchange plans also has declined over the past two years, which suggests that children are not moving from CHIP to exchange plans, Inside Health Policy reports (Meyer, Modern Healthcare, 4/25; Romoser, Inside Health Policy, 4/26 [subscription required]).

Where the states stand on Medicaid expansion

The Supreme Court ruling on the Affordable Care Act (ACA) allowed states to opt of the law's Medicaid expansion, leaving each state's decision to participate in the hands of the nation's governors and state leaders.

The Daily Briefing editorial teams have been tracking where each state stands on the issue since the ruling, combing through lawmakers' statements, press releases, and media coverage. In this latest iteration of our Medicaid map, we've determined each state's position based on legislative or executive actions to expand coverage to low-income residents using ACA funding.

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