Takeaway: Should be about 20M based on TANF and SNAP eligibility and historic patterns for the expansion populations


It is indeed a frustrating thing to figure out. Medicaid enrollment data has been confounded with poor record keeping and reporting. Policy changes such as expansion of the program to include able-bodied childless adults have further muddied the waters. Finding correlates is difficult and they come with some limitations. Those caveats aside and until the data mandated by Congress start to appear, we can make some educated guesses.

In the brief period between mid-2018 and Feb 2020, Medicaid enrollment drifted lower with the unemployment rate. Recipient counts in the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) tended to follow a similar pattern. Since passage of the CARES Act in early 2020, Medicaid enrollment has become disconnected from other U.S. poverty programs as eligibility determinations were suspended.

States are restarting the redeterminations and can begin disenrolling in April. It then becomes a question of how much and when. People receiving benefits through TANF and SNAP will almost always for declared eligible for Medicaid on their qualification for other programs, or about 44M people. The Medicaid expansion population has reliably accounted for about 15M people since about 2017 until April 2020. In other words, there are about 69M people that should remain enrolled in Medicaid once eligibility redeterminations begin.

That leaves about 20M adults and children subject to loss of eligibility. Assuming employment continues to hang in there, almost all of this excess enrollment is likely to have or be eligible for insurance elsewhere. Medicaid mix at the major hospital systems like Ascension barely moved from 2Q 2020 through 3Q 2021 when labor cost increases probably drove providers to more aggressively support patients' coverage applications. Even then, Ascension's Medicaid mix rose from 13.0% in 3Q 2021 to 14.8, close to the pre-pandemic watermark.

Disenrolling Medicaid is often framed as a "loss of coverage" and the specter of bad debt and charity care emerges. This time, however, it appears that will not be the case.

Emily Evans
Managing Director – Health Policy