While enrollment in Obamacare’s exchanges has fallen below original projections, largely due to unaffordable premiums for health insurance coverage, enrollment in its Medicaid expansion has exploded. By the end of 2016, enrollment in 24 states that expanded Medicaid enrollment to able-bodied adults exceeded the states’ original projections by an average of 110 percent.
New studies and data suggest two related reasons why: Ineligible individuals getting on (or staying on) the Medicaid rolls, and people dropping private coverage to enroll in Medicaid expansion.
Last fall, Louisiana made big headlines regarding Medicaid expansion, but for the wrong reason: The state’s legislative auditor found that a large subset of enrollees had incomes far in excess of the thresholds to qualify for Medicaid expansion. The state eventually admitted that at least 1,672 individuals with six-figure incomes had received Medicaid benefits. (No, that’s not a typo.)
The study caused a political firestorm in Louisiana. Eventually, the state dropped approximately 30,000 individuals from the Medicaid expansion rolls. Ironically enough, the Medicaid program came in approximately $400 million under budget in the fiscal year ended June 30—due in large part to the enrollment purge. To put it another way, Louisiana taxpayers had spent $400 million in the prior fiscal year on ineligible Medicaid enrollees.
A study released this month provides new evidence that the phenomenon of ineligible enrollees may go far beyond Louisiana. The study examined Census data in states that expanded Medicaid when Obamacare’s expansion took effect in 2014 and compared it to states that have not expanded. Upon analyzing the data by income, the authors found that
There is strong evidence that Medicaid participation increased for groups for whom Medicaid was not intended to be the source of insurance coverage. Neither excluding those who might be categorically eligible [e.g., individuals with disabilities already eligible for Medicaid], nor focusing on those whose income was far from the threshold alters the fundamental results. The estimated program effect grows over time.
For instance, the authors found that for individuals making more than 250 percent of the federal poverty level—nearly double the eligibility threshold for Medicaid expansion—fully 65 percent of the gains in insurance coverage after Obamacare took effect came not from people enrolling in employer coverage or other insurance (e.g., exchange plans), but from increased Medicaid enrollment.
Liberals would argue that some of these “ineligible” people result from survey errors—i.e., people not accurately reporting their income or coverage sources. They might also blame this phenomenon on people “churning” on and off Medicaid—individuals with variable incomes qualifying for Medicaid in some months, but exceeding income limits in other months.
However, the scope of this phenomenon and the fact that it occurred comparatively high up the income scale suggests widespread problems with rooting out ineligible Medicaid enrollees. People could fail to report income increases to state authorities, improperly estimate their income when applying for coverage, or—as the authors suggest—friendly social workers could decide to cast potential enrollees’ circumstances in the best possible light when filling out application forms on their behalf.
Government Programs ‘Crowding Out’ Private Coverage
In other cases, Medicaid expansion appears to have accelerated the phenomenon of “crowd out,” whereby people drop their private coverage to enroll in government-funded benefits. Crowd out enrollees are not necessarily ineligible for benefits—that is, they meet income limits and other criteria for Medicaid—but every dollar spent on covering people who already had health insurance prior to expansion arguably represents a sub-optimal use of scarce taxpayer dollars.
As part of my work with the Pelican Institute, I recently reported that the Louisiana Department of Health compiled internal data showing that, once Medicaid expansion went into effect in the state in July 2016, several thousand individuals each month dropped their private coverage to go on Medicaid. The Department of Health, claiming the data inaccurate, stopped compiling it altogether late in 2017—even though their stated explanation for the inaccuracy meant their data arguably under-stated the number of individuals dropping coverage.
The Foundation for Government Accountability has compiled similar numbers on the crowd-out phenomenon for states that have yet to expand Medicaid. According to their research, the majority of potential Medicaid enrollees in non-expansion states either have private coverage—whether through an employer or purchased individually—or have access to federally subsidized coverage on the Obamacare Exchanges.
The data raise the obvious question of why states would want to follow Louisiana’s lead and spend hundreds of millions of dollars (at minimum) subsidizing individuals who previously had private insurance.
Will Congress Act?
The twin developments suggest a major role for Congress, to say nothing of the states, in combating these sizable expenditures on Medicaid waste, fraud, and abuse. More rigorous eligibility checks would help, for starters, as would the widespread adoption of a new Medicaid waiver program approved in Utah.
Beginning in January, the Utah waiver will require individuals with an offer of employer coverage to remain enrolled in that employer plan, with Medicaid reimbursing premiums—a change designed to avoid the crowd-out seen in Louisiana.
Overall, however, the findings suggest that a significant amount of the vast spending on Medicaid expansion has gone towards inefficient, wasteful, and outright fraudulent efforts—yet another example of a well-intentioned government program gone awry.