Medicaid: 55% of potential "Woodworkers" have enrolled in NON-expansion states

2019 OPEN ENROLLMENT ENDS (most states)

Time: D H M S

Margot Sanger-Katz has a fascinating story today about the "woodworker" effect in non-expansion states. I've written about woodworkers many times before; the short version is, these are people who were already eligible for Medicaid even before/without the ACA expansion provisions, but who never actually enrolled in the program for any number of reasons. Their reasons could be personal (embarrassment/shame over taking a "handout"), it could be because they didn't know that they were eligible (the rules vary from state to state), it could be because the enrollment process is too confusing (again, not an easy process in some states).

In any event, figuring out which of the 10.65 million people who've been added to Medicaid due to ACA provisions through the end of October (closer to 12 million through this week) fit into the actual "expansion" category versus the "woodworker" category isn't easy...depending on which state you're talking about.

In the states which have expanded Medicaid via the ACA, it can be a royal pain, except in the rare cases such as Washington State where the exchange helpfully breaks it out for you; in the case of WA, it's been consistently around a 65/35 split between "expansion" and "woodworkers". In the other expansion states (+DC), it's trickier.

However, in the non-expansion states, it's quite easy...because anyone who's enrolled in Medicaid in those 23 states falls into the "woodworker" category by definition (except, of course, for those who just fell on hard times in the past year or so, but that's true in every state).

According to Sanger-Katz, the CMS report states that Medicaid enrollment in the 23 non-expansion states has gone up by around 1.5 million people since the beginning of the year.

Meanwhile, according to the Kaiser Family Foundation's updated estimates, as of last winter, around 2.73 million people were eligible for Medicaid/CHIP in those states at the time, thus defining them as "woodworkers" (I've confirmed with Larry Levitt of the KFF that this number refers to those who were eligible last fall, not currently).

That means that in non-expansion states, 55% of all potential "woodworkers" have enrolled in less than 1 year.

Now, that alone is huge, on both a human level (the more people getting enrolled, the better!) as well as on a state budgetary level. Remember, with "strict ACA expansion", the Federal government pays 100% of for the first few years, then gradually dropping down to 90%. That means that the expansion states are getting a hell of a deal, since they'll have gobs of federal funds coming into their state while only having to cover 10% of the cost at most.

However, with standard Medicaid (which includes "woodworkers"), the states have to put up a much larger portion of the cost--ranging from around 30-50% depending on the state in question. The more woodworkers enroll, the more the state budget has to account for. Of course, that also means that emergency rooms, hospitals, doctors/etc. save a ton on uncompensated medical treatment for people who can't afford to pay, but that's another discussion.

So, what about woodworkers in the expansion states? Well, my own estimate has it at around 3.13 million nationally.

The total net increase in Medicaid to date is around 12 million, and I'm pretty certain about the total...what I'm wondering here is whether my ratio between "strict" and "woodworkers" is accurate.

I estimate around 7.8 million of those are "strict expansion", plus another 1.07 million who were "bulk transferred" from some other existing state program (LIHP in CA, VHAP/Catamount in Vermont and so on). I'm assuming that if those folks were already eligible for pre-ACA Medicaid they would have been placed there, so they're really in the "strict expansion" category, not "woodworkers".

Therefore, if you subtract the confirmed 1.5 million woodworkers in non-expansion states an you have around 1.63 million remaining in the 27+DC which did expand the program. That would equate to around an 82% of the total being "strict expansion" in those states (7.80M / 1.63M).

As I noted above, in the case of Washington State alone, expansion has only been like 65% of the total. If every other expansion state is similar to WA, the numbers should be closer to 6.1M / 3.3M, which would bring the total WW number to around 4.8 million...or 40% of the 12 million total. However, there are so many variables between the demographics/etc of the states that I've reached my number-crunching limits here.

We'll know the answer eventually, but not until the full-year CBO/CMS reports come out showing how much each state had to pay towards their Medicaid costs were for the year, broken out between the different categories...and that report probably won't be out until next spring at the earliest, I'd imagine?