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Ensuring Continuous Eligibility for Medicaid and CHIP: Coverage and Cost Impacts for Adults

Photo, Doctor examines patients throat with her gloved hands.

Dr. Sarah Nadia Ali works with a patient at Mary’s Center on March 17, 2023, in Washington, D.C. If all states were to ensure 12 months of continuous Medicaid eligibility for adults, more would be enrolled in Medicaid programs, fewer would be uninsured, and households and employers would each save $1 billion a year in health spending. Photo: Bonnie Jo Mount/Washington Post via Getty Images  

Dr. Sarah Nadia Ali works with a patient at Mary’s Center on March 17, 2023, in Washington, D.C. If all states were to ensure 12 months of continuous Medicaid eligibility for adults, more would be enrolled in Medicaid programs, fewer would be uninsured, and households and employers would each save $1 billion a year in health spending. Photo: Bonnie Jo Mount/Washington Post via Getty Images  

Toplines
  • Lack of continuous Medicaid coverage leads to breaks in health care and higher state administrative costs. By adopting policies similar to those for children, Congress could allow states to provide continuous eligibility to all adults in Medicaid.

  • If all states were to ensure 12 months of continuous Medicaid eligibility for adults, more people would be enrolled in the Medicaid program, fewer would be uninsured, and households and employers would each save $1 billion a year in health spending

Toplines
  • Lack of continuous Medicaid coverage leads to breaks in health care and higher state administrative costs. By adopting policies similar to those for children, Congress could allow states to provide continuous eligibility to all adults in Medicaid.

  • If all states were to ensure 12 months of continuous Medicaid eligibility for adults, more people would be enrolled in the Medicaid program, fewer would be uninsured, and households and employers would each save $1 billion a year in health spending

Abstract

  • Issue: Disruptions in health coverage may delay care for beneficiaries and create higher administrative costs. To address these disruptions, Congress recently mandated 12-month continuous eligibility for children with Medicaid coverage starting in 2024. One state currently has continuous eligibility for adults, and two more will by 2024.
  • Goal: To estimate the impact of extending universal 12-month and 24-month continuous eligibility to all adult Medicaid enrollees on health care coverage and costs.
  • Methods: Simulation of changes in health coverage and government spending impact, using the Urban Institute’s Health Insurance Policy Simulation Model.
  • Key Findings and Conclusions: If all states adopted 12-month continuous eligibility for adults, 451,000 more adults would be enrolled in Medicaid in an average month in 2024, a 1.3 percent increase. There would be 267,000 fewer uninsured people in an average month, and the reduction in the number of people uninsured at any time would be greater. Federal and state spending in 2024 would increase by $479 million and $158 million, respectively. Both are increases of only 0.1 percent in spending on acute care for the nonelderly. Households and employers would each save about $1 billion a year in health care spending, and total health care spending would decline by $1.8 billion in 2024. Continuous eligibility for 24 months would further expand coverage and reduce costs.

Introduction

Every year, millions of adults are enrolled in Medicaid for less than 12 months, and many reenroll within a year.1 Although some who leave the program after less than a year do so because they have obtained other health insurance (such as coverage through a new employer), others simply become uninsured. Disruptions in health coverage can lead to people delaying needed care and to higher costs for Medicaid.2

To improve continuity of coverage, many policymakers have proposed giving Medicaid enrollees a fixed term of continuous eligibility. Under the Affordable Care Act (ACA), states cannot make most Medicaid enrollees go through the renewal process more than once every 12 months.3 However, beneficiaries are required to report changes in circumstances that could affect eligibility, and states can require individuals to provide income verification in as little as 10 days or face disenrollment. But under a policy that guaranteed a fixed term of continuous eligibility (12 months in most proposals), coverage would remain. Yet some beneficiaries could still lose coverage during the year if they move out of state, age out of a program for children, or fail to pay premiums.

States have long had the option of extending 12-month continuous eligibility to children through Medicaid or the Children’s Health Insurance Program (CHIP). Congress made this mandatory in the Consolidated Appropriations Act of 2022. However, states need to apply for a Section 1115 waiver to extend continuous eligibility to adults. New York is the only state that currently has 12-month continuous Medicaid eligibility for adults. The Centers for Medicare and Medicaid Services (CMS) recently approved continuous eligibility waivers that will cover adults in Oregon and Illinois, and other states are seeking similar waivers.

In this brief, we use the Urban Institute’s Health Insurance Policy Simulation Model to estimate the impact of all states adopting 12-month and 24-month continuous eligibility for adults in Medicaid in 2024. By this time, all states will have implemented 12-month continuous eligibility for children. We consider the impact of similar policies on children in a companion issue brief.4

Our estimates do not include the temporary impact of the unwinding of the COVID-19 public health emergency (PHE), which will affect health coverage for the first half of 2024.5

Key Findings

Impact on coverage with 12-month continuous eligibility. If all states adopted 12-month continuous Medicaid eligibility for adults, we estimate that 451,000 more adults would be enrolled in an average month of 2024, an increase of 1.3 percent (Exhibit 1 and Appendix 1). There would be 315,000 more Medicaid expansion beneficiaries (a 2.2% increase) and 136,000 more nondisabled adults enrolled (a 1.2% increase).

Buettgens_ensuring_continuous_eligibility_medicaid_chip_impacts_adults_Exhibit_01

With this increase in Medicaid coverage, 267,000 fewer adults would be uninsured in an average month, a decrease of 1.1 percent (Exhibit 2 and Appendix 1). Many people are uninsured for only part of the year, so the reduction in the number of adults ever uninsured during the year 2024 would be higher. There would be 145,000 fewer adults with employer-sponsored insurance, 30,000 fewer adults with nongroup coverage, and 9,000 fewer adults with coverage that doesn’t comply with ACA standards.

Buettgens_ensuring_continuous_eligibility_medicaid_chip_impacts_adults_Exhibit_02

Impact on coverage with 24-month continuous eligibility. With 24-month continuous eligibility in all states, we estimate that 823,000 more adults would be enrolled in an average month of 2024, a 2.4 percent increase. There would be 487,000 fewer adults lacking insurance in an average month, a 2.1 percent decrease (data not shown).

In Appendix 2, we show nonelderly Medicaid enrollment in each state with universal 12-month and 24-month continuous eligibility. States that have expanded Medicaid generally see much larger increases than nonexpansion states because many more adults are eligible for the program.

Impact on spending and savings with 12-month continuous eligibility. With 12-month continuous eligibility in all states, federal Medicaid and CHIP spending would increase by $889 million in 2024 (Exhibit 3 and Appendix 3). Medicaid administrative costs would be $87 million lower because the state incurs a cost each time a person is disenrolled and reenrolled. (See “Potentially Higher Savings on the Costs of New Medicaid/CHIP Enrollees.”) Fewer people would get marketplace coverage, so federal spending on marketplace premium tax credits would be lower by $134 million. The federal government would also save $189 million on uncompensated care for the uninsured, mainly through reduced Medicare Disproportionate Share Hospital (DSH) payments. In all, the federal government would spend $479 million more on acute care for the nonelderly in 2024, a 0.1 percent increase in spending on such care.

Buettgens_ensuring_continuous_eligibility_medicaid_chip_impacts_adults_Exhibit_03

State and local governments would spend $328 million more on Medicaid and CHIP with universal 12-month continuous eligibility for adults (Exhibit 4 and Appendix 3). This is much lower than the federal increase because many of the new beneficiaries would qualify as newly eligible under the ACA’s Medicaid expansion, and the federal government would pay 90 percent of their costs.

Buettgens_ensuring_continuous_eligibility_medicaid_chip_impacts_adults_Exhibit_04

States would realize administrative savings of $51 million. State and local governments would save $118 million on uncompensated care. In all, state and local governments would spend $158 million more in 2024, an increase of 0.1 percent in spending on acute care for the nonelderly.

Households would save $1.0 billion in 2024 as more adults stay enrolled in Medicaid (Exhibit 5 and Appendix 3). Employers would spend $1.1 billion less in premium contributions. In all, total health care spending on the nonelderly would decline by $1.8, because health care spending is generally less in Medicaid than private health coverage because of the program’s lower provider payment rates.

Buettgens_ensuring_continuous_eligibility_medicaid_chip_impacts_adults_Exhibit_05

Impact on spending and savings with 24-month continuous eligibility. With 24-month continuous eligibility in all states, we estimate that net federal spending on health care would increase by $1.5 billion and state spending would increase by $597 million, increases of 0.3 percent. Households would save $2.5 billion in premiums and other out-of-pocket health care costs.

Discussion

Until 2022, there was little interest in extending Medicaid continuous eligibility to adults. New York was the only state with such a waiver. In 2022, CMS approved an Illinois waiver authorizing 12-month continuous eligibility for adults and an Oregon waiver extending 24-month continuous eligibility to all Medicaid enrollees, with continuous eligibility up to age 6 for young children. New Jersey has also submitted a waiver extending 12-month continuous eligibility to most nondisabled adults. Although states currently must submit a Section 1115 waiver to extend continuous eligibility to adults, Congress could pass legislation making it a state option that does not require a waiver.6

One reason for this increased interest in continuous eligibility for adults is the Families First Coronavirus Response Act of 2020, which barred states from disenrolling Medicaid beneficiaries during the COVID-19 public health emergency. This led to record-high Medicaid enrollment and record-low numbers of uninsured people.7 Medicaid enrollment continued to grow during the three years in which the PHE was in effect, highlighting that tens of millions of Americans become Medicaid-eligible at some point as their incomes fluctuate.

There are several important limitations in these estimates. First, the Medicaid and CHIP Payment and Access Commission (MACPAC) notes differences in continuity of enrollment between states, but only gives a few examples at the extremes.8 We do not have data to support simulating state-specific differences.

Second, we do not simulate health coverage in each individual month. The number of people uninsured at any point during 2024 will be higher than the average monthly number of people lacking health insurance because many people are uninsured for only part of the year.

Third, our estimates do not reflect permanent changes that states could make to their eligibility systems to enhance continuity of coverage after the public health emergency unwinds. These changes could increase enrollment both in the baseline and under a policy of continuous eligibility.

Other potential changes underway in some states include extending postpartum Medicaid coverage beyond 60 days9 and greater use of ex parte (automated) renewals. At the time of writing, specific state plans were evolving, and comprehensive public information on state plans was lacking.

Conclusion

We find that extending 12-month continuous eligibility to adults in all states would meaningfully increase Medicaid enrollment and reduce the number of people without health insurance. Federal and state health care spending on acute care for the nonelderly would increase as a result, but only by 0.1 percent. Households and employers would each save about $1 billion per year in health insurance premiums and health care spending. Total health care spending also would decline modestly because Medicaid provider reimbursement rates are lower than those paid by commercial insurance.

Some recent state waivers extend continuous eligibility to 24 months; we find that this would have a little less than twice the impact of 12-month continuous eligibility on coverage and government spending.

HOW WE CONDUCTED THIS STUDY

We produce our estimates of health coverage and costs for 2024 using the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM), a detailed microsimulation model of the health care system.10 Starting with HIPSM’s simulation of current law, we identify people in HIPSM who, although not currently eligible for Medicaid, were eligible within the past year or two years (for 12-month and 24-month continuous eligibility, respectively). We used the same methodology for estimating the health coverage impact of the federal COVID-19 public health emergency (PHE).11 Those gaining Medicaid or Children’s Health Insurance Program (CHIP) coverage because of continuous eligibility are taken from this population.

MACPAC reported the percentages of child Medicaid and CHIP beneficiaries who had fewer than 12 months of coverage in states with and without 12-month continuous eligibility, finding that the share was lower in states with continuous eligibility.12 The increase in enrollment that this implies for universal 12-month continuous eligibility is lower than in some studies conducted before the Affordable Care Act (ACA).13 The ACA made important changes in Medicaid and CHIP eligibility determination that limited the frequency of the renewal process; it is likely that the impact of extending 12-month continuous eligibility is lower under the ACA than it would have been before the ACA.

No state has implemented 24-month continuous eligibility, but the PHE has been in effect for more than two years, so it gives insight into the impact of disenrollment restrictions over time. We compared child Medicaid and CHIP enrollment growth in states that had 12-month continuous eligibility in 2021 and 2022, finding that monthly growth in 2022 was 71 percent of monthly growth in 2021.14 We estimate that 24-month continuous eligibility would have 1.71 times the impact of 12-month continuous eligibility.

Potentially Higher Savings on the Costs of New Medicaid/CHIP Enrollees

Several factors moderate the cost to states of extending continuous eligibility. Nationally, we find that most new enrollees would qualify as newly eligible under the Affordable Care Act’s (ACA’s) Medicaid expansion. The federal government would pay 90 percent of the costs of these people. Studies have found that beneficiaries enrolled less than 12 months have higher average costs because of delayed care or pent-up demand. Enrollment and disenrollment are significant costs to Medicaid and the Children’s Health Insurance Program (CHIP), so 12-month continuous eligibility could save administrative costs.

We provide a sensitivity analysis of health care costs considering the savings in health care and administrative costs for beneficiaries of continuous eligibility. Research finds that those enrolled in Medicaid for a fraction of a year tend to have higher monthly costs than those continuously enrolled.15 These results cannot be used to set exact targets for differences in spending, so we assume a discount of 5 percent in Appendix 3 and 10 percent in Appendix 4.

Continuous eligibility for adults also would reduce spending on Medicaid administrative costs. A study from 2015 estimates the cost of combined disenrollment and reenrollment to have been between $400 and $600.16 However, not every new enrollee under 12-month continuous eligibility would have been both disenrolled and reenrolled during that year. We assume administrative savings of $306 per new enrollee in Appendix 3 and $575 per new enrollee in Appendix 4. This is divided into federal and state shares using the standard federal medical assistance percentage (FMAP).

With higher savings (Appendix 4), the federal government would spend $356 million more in 2024, compared with $479 million in Appendix 3. State and local governments would spend $96 million more in 2024, compared with $158 million in Appendix 3.

NOTES
  1. Medicaid and CHIP Payment and Access Commission, An Updated Look at Rates of Churn and Continuous Coverage in Medicaid and CHIP (MACPAC, Oct. 2021).
  2. Sarah Sugar et al., Medicaid Churning and Continuity of Care: Evidence and Policy Considerations Before and After the COVID-19 Pandemic (Assistant Secretary for Planning and Evaluation, Office of Health Policy, Apr. 12, 2021); Benjamin D. Sommers et al., “Insurance Churning Rates for Low-Income Adults Under Health Reform: Lower Than Expected but Still Harmful for Many,” Health Affairs 35, no. 10 (Oct. 2016): 1816–24; and Katherine Swartz et al., “Reducing Medicaid Churning: Extending Eligibility for Twelve Months or to End of Calendar Year Is Most Effective,” Health Affairs 34, no. 7 (July 2015): 1180–87.
  3. The exceptions are people whose eligibility is not based on modified adjusted gross income (AGI), such as the disabled and elderly.
  4. Matthew Buettgens, Ensuring Continuous Eligibility for Medicaid and CHIP: Coverage and Cost Impacts for Children (Commonwealth Fund, Sept. 2023).
  5. Matthew Buettgens and Jessica Banthin, Estimating Health Coverage in 2023: An Update to the Health Insurance Policy Simulation Model Methodology (Urban Institute, May 2022).
  6. Sara R. Collins and Lauren A. Haynes, “Congress Can Give States the Option to Keep Adults Covered in Medicaid,” Commonwealth Fund (blog), Nov. 14, 2022.
  7. Matthew Buettgens and Andrew Green, The Impact of the HHS Public Health Emergency Expiration on All Types of Health Coverage (Urban Institute, Dec. 2022).
  8. Data for several states, including large states like Florida, were excluded from their analysis because of data issues. More generally, administrative data has always had an issue with different states reporting in different ways, so their national results will be more consistent than individual state estimates.
  9. Medicaid Postpartum Coverage Extension Tracker,” Henry J. Kaiser Family Foundation, Aug. 2023.
  10. Matthew Buettgens and Jessica Banthin, The Health Insurance Policy Simulation Model for 2020: Current-Law Baseline and Methodology (Urban Institute, Dec. 2020); and Buettgens and Banthin, Estimating Health Coverage in 2023, 2022.
  11. Buettgens and Banthin, Estimating Health Coverage in 2023, 2022.
  12. MACPAC, Updated Look at Rates of Churn, 2021.
  13. Benjamin D. Sommers, “From Medicaid to Uninsured: Drop-Out Among Children in Public Insurance Programs,” Health Services Research 40, no. 1 (Feb. 2005): 59–78; Rosemary Borck, Valerie Cheh, and Lucy Lu, Recent Patterns in Children’s Medicaid Enrollment: A National View (Mathematica Policy Research, May 2011); and Victoria Wachino and Alice M. Weiss, Maximizing Kids’ Enrollment in Medicaid and SCHIP: What Works in Reaching, Enrolling, and Retaining Eligible Children (National Academy for State Health Policy, Feb. 2009).
  14. Enrollment data for 2020 include the effects of pandemic-related job losses. Employment has since recovered to prepandemic levels nationally.
  15. Sommers et al., Insurance Churning Rates, 2016; and Allyson G. Hall, Jeffrey S. Harman, and Jianyi Zhang, “Lapses in Medicaid Coverage: Impact on Cost and Utilization Among Individuals with Diabetes Enrolled in Medicaid,” Medical Care 46, no. 12 (Dec. 2008): 1219–25.
  16. Swartz et al., “Reducing Medicaid Churning,” 2015.

Publication Details

Date

Contact

Matthew Buettgens, Senior Fellow, Urban Institute Health Policy Center

[email protected]

Citation

Matthew Buettgens, Ensuring Continuous Eligibility for Medicaid and CHIP: Coverage and Cost Impacts for Adults (Commonwealth Fund, Sept. 2023). https://doi.org/10.26099/7tvw-hr31