Medicaid, ACA Enrollment Growth Attended Level Uninsurance in 2020

During 2020, a stable uninsurance rate attended enrollment growth in Medicaid and the Affordable Care Act marketplace, according to a report from the Assistant Secretary for Planning and Evaluation (ASPE) Office of Health Policy.

Despite the raging pandemic, uninsurance rates remained fairly stable in 2020. Less than 10 percent of the overall population was uninsured, according to researchers’ estimates.

Meanwhile, both Medicaid and the Affordable Care Act marketplace saw major gains in enrollment, a trend that continued into the first couple of months of 2021. 

“These results can inform Open Enrollment efforts and strategies being taken to expand coverage further in 2022,” the researchers wrote.

The researchers looked at three different types of surveys to assess group health insurance enrollment fluctuations, but all marked a decline in group health insurance enrollment from 2019 to 2021.

Mark Farrah Associates found a 1.8 percent decline in group health insurance coverage, whereas Interstudy reported a 1.0 percent drop. The 2020 Insurance Component of the Medical Expenditure Panel Survey (MEPS-IC) identified a 2.7 percent decline, considered not significant.

The study also evaluated the 10-K filings from the top five largest insurers.

According to the 10-K filings, Humana lost the largest share of its employer-sponsored health plans membership. Humana’s fully-insured plans lost 14.4 percent of their membership from 2019 to 2020. However, UnitedHealth Group’s self-insured plans saw the greatest decline in actual enrollment, losing 900,000 members within the same timeframe.

Declines in employment among small businesses led to declines in coverage in that population, but large employers maintained fairly consistent enrollment levels.

In non-group health insurance—both on- and off-exchange—, enrollment has continued to grow with each passing year from 2019 through 2021. More than eight out of ten enrollees used advanced premium tax credits to make plans more affordable in 2019, 2020, and 2021.

Medicaid enrollment grew by 11.6 million lives from February 2020 to April 2021, with the latter month’s enrollment estimate hovering around 82 million.

“The growth in Medicaid enrollment was largely driven by a requirement for states to suspend eligibility redeterminations in order to receive a 6.2 percentage point increase in their FMAP per the FFCRA provision,” the researchers stated.

“Although Medicaid enrollment increased during 2020, the increase was smaller than the industry expected. Possible explanations for the lower increase include that those who lost their jobs at the beginning of the pandemic were more likely to be uninsured already, coverage provisions in the ACA played a critical role helping people maintain and gain coverage, economic support from FFCRA and the CARES Act helped stimulate economic recovery, and many employers opted to furlough rather than terminate their employees to maintain their benefits (e.g., health insurance).”

In the non-elderly adult uninsured population, researchers found that coverage disparities persisted in 2020. Uninsurance was more common among Latino and Black communities when compared to White and Asian populations, and low-income individuals or residents in states that have not expanded Medicaid.

The report warned that federal surveys may have been impacted by the coronavirus pandemic, making their data not entirely accurate.

During the first few months of the pandemic, researchers tried to predict the impact that the coronavirus pandemic would have on enrollment. They arrived at varying conclusions. The four most well-known studies predicted a range of employer-sponsored health plan enrollment losses, from 10.1 million to 30 million, or that 5.4 million individuals would be uninsured.

As 2021 progresses, researchers have been able to revisit the numbers with more clarity and context.