Two Million Fewer Americans Have Health Insurance as States Tighten Medicaid Rules

Nearly 2 million more people in the United States went without health insurance coverage in 2018 compared with the previous year, largely as a result of a decline in public coverage under Medicaid and the Children’s Health Insurance Program (CHIP), according to a recent Census Bureau report.

The Census Bureau reported that overall, 8.5% of individuals (27.5 million), did not have health insurance at any point in 2018, up from 7.9% (25.6 million) the previous year. In fact, data from the Centers for Medicare and Medicaid Services (CMS) show that total Medicaid and CHIP enrollment dropped by 2.4 million, from December 2017 to June 2019, reversing a trend of increasing coverage since the implementation of the Affordable Care Act (ACA) under the Obama administration.

A survey report by the Kaiser Family Foundation (KFF) noted that some states’ use of Medicaid renewal process requirements and growing use of periodic eligibility checks are resulting in increased churn in the program and disenrollment of people who are still eligible for coverage. The Trump administration issued guidance in June encouraging states to ramp up periodic eligibility checks for Medicaid enrollees and indicated it planned to boost requirements related to eligibility verification, monitoring of changes in enrollee circumstances, and eligibility redeterminations, KFF noted.

The Trump administration has taken other actions that may hinder enrollment in public health insurance programs, such as allowing states to require that Medicaid enrollees work, pay premiums or copayments, and adhere to dollar limits or lifetime restrictions on benefits. In addition, Trump’s new “public charge” rule deems immigrants who have used public benefits such as Medicaid, food stamps, or housing assistance “public charges,” rendering them ineligible for green cards. The changes are likely to discourage such individuals from applying for public health benefits ( Psychiatric News).

APA has filed formal comments denouncing new work requirements in the Medicaid program, which provides coverage for nearly a quarter of the nation’s mental health services provided.

“At a time when suicide and opioid overdoses have reached epidemic levels, we are especially concerned about losses in health coverage that affect our most vulnerable populations,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “New work requirements and eligibility checks in Medicaid will disproportionately affect individuals with mental and substance use disorders, who may not wish to disclose their conditions and who often face barriers to employment. Even if such individuals meet the work requirements, they may still lose their coverage due to miscommunication, their inability to navigate the complex administrative processes, or lack of internet access.”

Eighteen states so far have either received approval from CMS to initiate work requirements in their Medicaid plans or have applications pending to do so. Advocates are fighting the rules in court, and three of the 18 states have had their work requirements overturned by the courts (Arkansas, Kentucky, and New Hampshire). In the meantime, thousands of individuals have lost their Medicaid coverage, some of whom were “locked out” of reapplying for coverage for a set number of months.

Other Census Bureau report findings—drawn from its Current Population Survey Annual Social and Economic Supplement and from its American Community Survey—are as follows:

• Employer-based coverage remained steady between 2017 and 2018, insuring about 55% of the population. About 18% were covered by Medicare, and 18% were covered by Medicaid. Of the three types of coverage, the percentage of people with Medicaid saw the largest decline, dropping 0.7 percentage points in 2018.

• An additional 425,000 children did not have any health insurance in 2018, an increase of 0.6 percentage points from the previous year. In total about 5.5% of children under age 19 were uninsured, largely because of a decline in public coverage as Medicaid and the Children’s Health Insurance Program covered fewer children.

• When it comes to the lowest-income Americans, the situation is more dire: In 2018, 14% of people in households with an annual income of less than $25,000 were uninsured, compared with 3% of people in households with an income of $150,000 or more.

• The percentage of people without health insurance at the time of 2018 interview ranged widely by state, from 2.8% in Massachusetts to 17.7% in Texas. These six states had the nation’s highest rates of uninsured individuals: Alaska (12%), Mississippi (12.1%), Florida (13%), Georgia (13.7%), Oklahoma (14.2%), and Texas (17.7%). ■