Which states are underenrolled in Medicaid?- 5 mins
At Nava we’ve started working on a cool idea: integrated benefits. Integrated benefits is the idea that any given individual or household may be eligible for one or more social services programs and in order to enroll in those programs, they shouldn’t have to provide the same information multiple times.
Many of the social services are administered at the state level. How do we prioritize where to develop integrated services?
One simplistic approach I’m trying is quantifying where there is the greatest need: where are there the greatest numbers missing out on these services?
Using poverty, population and medicaid data, I estimated a “Medicaid enrollment gap”: The difference between the percentage of the population enrolled in Medicaid and the percentage of the population eligible for Medicaid under the ACA.
The ACA was designed to expand Medicaid. The ACA included a provision on Medicaid which was intended to be uniform across states: everyone with income below 133% of the federal poverty line (FPL) would be considered eligible for Medicaid.
Sidebar: If you work in government, you’ll find policies can be a treasure trove of gotchas. The Wikipedia page for Medicaid states the new Medicaid eligibility threshold as 133%, however other sources state the new threshold is 138%. Both are correct! The ACA also detailed a new way to calculate income level that made the nominal rate of 133% effectively 138%.
One thing I was surprised to find was for most states, the “gap” is positive: more individuals are enrolled in Medicaid than are living under the new income eligibility threshold. This is easily explained: Each state is given freedom to enforce it’s own Medicaid eligibility rules, so some states have implemented even higher eligibility thresholds.
Yet a few states are still significantly underolled. Note Virginia and North Carolina in the map below.
It turns out, the provision for the new threshold in the ACA was overruled in the Supreme Court:
However, the Supreme Court ruled in NFIB v. Sebelius that this provision of the ACA was coercive, and that the federal government must allow states to continue at pre-ACA levels of funding and eligibility if they chose.
So, while most states have more Medicaid enrollees than population living under the poverty line, a few states do not. And those states really appear as outliers. In the plots below you see those states with small and negative Medicaid enrollment gaps (as determined by the original ACA) clearly match those states who have chosen not to expand Medicaid under the ACA.
Difference between Medicaid Enrollment and Medicaid-Eligible
Medicaid Enrollment population has been calculated using medicaid enrollment and population data from each state from medicaid.gov and census.gov, respectively.
The Medicaid-Eligible population has been estimated using the percentage of the population at different income levels.
See the Data section at the bottom of this post for more detail on and links to data sources.
From the Kaiser Family Foundation
- Poverty at different levels of the FPL from kff.org: web page. From my wild google searching, I haven’t found state-level data on percentage of the population at 133 or 138% of the FPL. So percentage of the population at 138% of the FPL has been interpolated from the percentage of the population living at 100%, 100-199% and 200-399% (source code).
- Population data from census.gov: web page, csv file
- Medicaid enrollment from medicaid.gov: web page, pdf file. PDF data was copy / pasted to create CSV. Data not available for South Dakota.