State Estimates of the Low-Income Uninsured Not Eligible for the ACA Medicaid Expansion

The Patient Protection and Affordable Care Act (ACA) will expand access to affordable health insurance for millions of Americans. In states that choose to implement the Medicaid expansion for low-income adults, Medicaid will provide an important new pathway to coverage. Yet, even in states that choose to expand Medicaid a significant proportion of the low-income nonelderly adult population will be excluded from the Medicaid expansion due to their immigration status. Legal permanent residents, in most circumstances, are ineligible for Medicaid benefits for the first five years during which they reside legally in the U.S. and unauthorized immigrants are excluded from Medicaid coverage. SHADAC Issue Brief #35 provides the first state-specific estimates of the number of uninsured low-income adults that will potentially be excluded from the Medicaid expansion because of their immigration status.

Download a PDF of the brief.

Hest, Robert
Lanigan, Lindsey

Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

This update uses data from the September release of the Household Pulse Survey, collected from August 23 – September 4, 2023.

Introduction

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. Since February 2020, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has increased by 23 million enrollees and analysis indicates that as many as 15 million individuals will exit Medicaid to other coverage or become uninsured. This blog uses data from the U.S. Census Bureau’s Household Pulse Survey (HPS) to track trends in adult health insurance coverage rates as states “unwind” the Medicaid continuous coverage requirement and restart standard redetermination procedures.

Given the intense interest from policymakers and the media in monitoring coverage transitions during the unwinding, many states have released Medicaid administrative data showing their progress, with some State-based Marketplaces also reporting transition data. Though administrative data can show the number of successful Medicaid renewals and coverage terminations along with transitions to Marketplace coverage, they cannot provide information on transitions to other sources of coverage, such as employer-sponsored insurance or provide an estimate of changing rates of uninsured individuals. 

As states continue the process of redetermining beneficiaries’ Medicaid eligibility, this resource will help track transitions in coverage. Specifically, it will present rates of primary source of health insurance coverage by type (Employer/Military, Direct Purchase, Medicaid/CHIP) and rates of no insurance as they are observed in the HPS. Estimates will be presented at the state and national level by selected individual and geographic characteristics. The survey does not include children, so the analysis is limited to adults 18 and older.

This blog will be updated on a monthly basis as new HPS data are released and compare the latest monthly coverage estimates (reference above in the subtitle) to estimates from March 2023, the last month before the unwinding began.

Highlighted Findings

Limited to statistically significant changes at the 95% confidence level.

• There were no observed changes in coverage among all adults at the national level
• Though unchanged nationally, a small number of states saw changes in the share of adults who had employer-sponsored insurance as their primary source of coverage
• The share of adults with Direct Purchase coverage saw small but significant changes, such as declines in three states (Delaware, Illinois, and Kansas) and among those with previous year household incomes at or above $100,000 as well as increases in two states (Maryland and Wyoming)
• The share of adults with no coverage saw modest changes among subpopulations (non-Hispanic White individuals, those age 65+) and in a few states (Alaska, D.C., and Kansas)
• There were few significant state-level changes in the share of adults with Any Medicaid/CHIP, or Medicaid/CHIP as primary source of coverage

Select a coverage type from the orange box on the right in the dashboard below to filter the visualizations. 

Methods and Data

This analysis uses public use microdata from the Household Pulse Survey (HPS), a monthly, nationally representative, quick-turnaround survey that collects data on topics including household demographics, education, employment, food sufficiency, financial spending, housing security, and physical and mental health, in addition to current health insurance coverage.

The survey has a typical monthly sample size of 60,000 to 80,000 U.S. adults and is designed to produce state-level (and a select number of metropolitan-level) estimates of the civilian noninstitutionalized adult population. The survey does not include children (those age 17 or younger).

Data is collected for approximately two weeks each month from adults (age 18 or older) via a short, online survey and is released on a monthly basis. Readers should keep in mind that the HPS emphasis on producing near-real-time data comes with the tradeoff of lower levels of data quality compared with “gold standard” surveys such as the American Community Survey (ACS). These data quality issues include very low response rates (e.g., 6.7% response rate in the March 2023 survey), underrepresentation of harder-to-reach groups (e.g., adults with lower levels of education, young adults), a lack of editing and imputation for most variables, and likely some degree of nonresponse bias. For these reasons, HPS estimates should be treated with a greater degree of caution than estimates from other federal surveys.

Further, like other surveys, the HPS relies on respondents’ self-reporting their coverage, which is often associated with known biases such as the Medicaid Undercount and reflects respondents’ (sometimes imperfect) knowledge of their own coverage rather than the reality reflected in administrative data sources. 

The HPS’ health insurance coverage measure is similar to that used in the ACS and asks respondents: “Are you currently covered by any of the following types of health insurance or health coverage plans?” Respondents are allowed to select “Yes” or “No” from among the following coverage types:

1.  “Insurance through a current or former employer or union (through yourself or another family member)”; 
2.  “Insurance purchased directly from an insurance company, including marketplace coverage (through yourself or another family member)”;
3.  “Medicare, for people 65 and older, or people with certain disabilities”;
4.  “Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability”;
5.  “TRICARE or other military health care”;
6.  “VA (including those who have ever used or enrolled for VA health care)”;
7.  “Indian Health Service”; or 
8.  “Other”

The response options for employer coverage [1], TRICARE [5], and VA [6] were combined into one Employer/Military coverage category, and respondents were considered uninsured if they didn’t affirmatively report any coverage under options 1-6.

SHADAC’s primary source of coverage hierarchy was applied to determine which payer was likely primary when a respondent reported multiple sources of coverage (see SHADAC brief for more information).

For example, the hierarchy would classify a respondent reporting both Medicaid/CHIP coverage and Employer/Military coverage as having Employer/Military as a primary source of coverage, as Employer coverage typically acts as the primary payer for individuals with Employer and Medicaid coverage.

Estimates with a relative standard error (standard error divided by the percentage estimate) of 30% or greater, based on an unweighted denominator count of less than 50, based on an unweighted numerator count of less than five, or with a weighted estimate of exactly 0% or 100% were considered statistically unreliable and were suppressed.

Two-sided t-tests were used to assess statistically significant differences between the most recent data month and the baseline month (i.e., March). A lack of statistically significant difference does not affirmatively establish that there was no significant difference but rather that the data presented here are not sufficient to show a significant difference.

Hest, Robert
Lanigan, Lindsey
Stewart, Andrea

2022 ACS: Declining Uninsured Rates for the U.S. and States are Supported by Private and Public Coverage Increases

The U.S. Census Bureau released 2022 health insurance coverage estimates from the American Community Survey (ACS) today, which included state-level information about health insurance coverage by type as well by certain demographic categories. The Census Bureau also released an accompanying report and blog post highlighting many of the changes seen from 2021 to 2022.

Overall, the data showed a drop in uninsured rates, with an 8.0% rate of uninsurance in 2022 as compared to 8.6% in 2021. This echoes similar year-over-year decreases in uninsurance shown in data from the Current Population Survey (CPS), for which estimates were released on Tuesday, and in recent survey data from the National Health Interview Survey (NHIS). Eight percent represents the lowest-ever national rate of uninsurance measured in the ACS.

The national decline in uninsurance was supported by decreases in 27 states, with Maine the only state to see an increase in its uninsured rate, from 5.7% in 2021 to 6.6% in 2022, reversing the previous trend from 2019 to 2021.* Overall, uninsured rates ranged across states from a low of 2.4% in Massachusetts to a high of 16.6% in Texas, a continuing trend from past years. The largest drop in uninsured rates was found in Oklahoma, which fell by 2.1 percentage points (PP) to 11.7% in 2022 from 13.8% in 2021.

The drop in uninsured rates coincided with small yet significant increases in 2022 for both private coverage — 67.2% from 67.0% in 2021 — and public coverage — 37.2% from 36.8%. Alaska saw the largest increase in private coverage, rising 2.2 PP to 66.4%. Nine states saw increases in private coverage, while nine states saw decreases in private coverage. And unsurprisingly, Oklahoma saw the largest increase in public coverage, rising 2.3 PP to 39.6%: Oklahoma was one of two states, along with Missouri to have expanded Medicaid in 2022.

The rest of this blog post highlights some of the national and state-level changes that took place between 2021 and 2022 in the broadest categories of insurance (uninsurance, public coverage, and private coverage) for two key age groups, nonelderly adults (age 19-64) and children (age 0-18). Accompanying interactive maps allow readers to view and sort the different coverage types for each age group.

Key Findings from the 2022 ACS: Nonelderly Adults (19-64)

Figure 1. Changes in state-level coverage rates among nonelderly adults, 2021-2022

State-Level Uninsurance
Nonelderly adults also saw falling uninsurance rates, dropping by 0.9 PP from 12.2% in 2021 to 11.3% in 2022. Additionally, 31 states saw decreases in their uninsured rates for nonelderly adults while only Maine saw an increase, rising 1.4 PP to 9.6%. The largest decline in uninsurance was seen in Oklahoma, whose rate of uninsured nonelderly adults dropped a notable 3.4 PP to 16.8% in 2022.

State-Level Private Coverage
Private coverage increased significantly for nonelderly adults, rising 0.7 PP to 73.4% in 2022 from 72.7% in 2021. This increase was echoed across 21 states, with Mississippi seeing the largest increase at 2.2 PP, rising to 69.7% in 2022. Private coverage levels fell across just three states — Maine, Minnesota, and Virginia — with Maine seeing the most significant drop, falling 1.8 PP to 74.1% in 2022.

State-Level Public Coverage
Overall, nonelderly adults also experienced a significant increase in public coverage from 2021 to 2022. Rates of public coverage rose to 19.4% from 19.1% in 2021, driven by similar increases across 14 states. Individually, Oklahoma once again saw the largest increase — 19.9%, up from 16.3% in 2021. Of the eight states that saw decreases in 2022, public coverage for nonelderly adults declined the most in Rhode Island, dropping 2.1 PP to 21.7

Key Findings from the 2022 ACS: Children (0-18)

Figure 2. Changes in state-level coverage rates among children, 2021-2022

State-Level Uninsurance
For children, uninsured rates fell to 5.1% in 2022 from 5.4% in 2021. Fourteen states also saw drops in children’s uninsurance, Wyoming being the largest - falling 3.5 PP to 7.9%, followed by New Mexico, which saw a 2.6 PP decrease from 6.4% in 2021 to 3.8% in 2022. Three states (Connecticut, Pennsylvania, and Wisconsin) saw increased children’s uninsured rates for 2022.

State-Level Private Coverage
Unlike nonelderly adults, children did not experience an overall increase in private coverage for 2022. Private coverage remained statistically unchanged for children nationally at 60.6%. However, 13 states did see rising private coverage rates, with Rhode Island leading the way, jumping 4.8 PP to 69.4% in 2022. Six states saw declines in private coverage, led by a drop of 2.3 PP in Missouri, whose rate of private coverage for children in 2022 was 63.2%.

State-Level Public Coverage
Like private coverage rates, public coverage remained statistically unchanged for children from 2021 to 2022, sitting at 39.6%. Just eight states saw increased public coverage for kids in 2022, led by a 2.6 PP jump in North Dakota, from 21.3% in 2021 to 23.9% in 2022. And seven states saw declining public coverage rates, with children in Rhode Island experiencing a precipitous fall of 5.9 PP to 34.4% in 2022.

Future Data Releases and Products

Supplemental tables for the 2022 ACS 1-Year Estimates will be released from the U.S. Census Bureau on October 19, 2023, and 2018-2022 ACS 5-Year Estimates will be available on December 7, 2023.

Stay tuned for more granular details about insurance coverage changes in the states from 2021 to 2022 via customized SHADAC tables examining coverage at the state and county level, and for an announcement of updated health insurance coverage measures available on State Health Compare.

Notes

All changes described in this document are significant at the 90% level. Private coverage includes individually purchased, employer-sponsored coverage, and TRICARE military health coverage Public coverage includes Medicare, Medicaid/CHIP, and VA health care. Public and private coverage types are not exclusive and include individuals with those types of coverage alone or in combination with other coverage. Estimates represent the civilian noninstitutionalized population.

Overarching estimates of uninsurance and public and private coverage are for all ages, except where noted for children (age 0-18) and nonelderly adults (19-64).

COVID-19 Public Health Emergency Impacts

Continuous Coverage Requirement

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the pandemic ended on March 31, 2023. The resumption of Medicaid eligibility redeterminations and renewals (and potential disenrollments), a process commonly referred to as the “unwinding,” began on April 1, 2023, and each state has a year to navigate a return to normal operations while also meeting reporting requirements set by CMS for publicly sharing coverage transitions and outcomes data during this time. While the health insurance estimates released by the US Census Bureau for 2022 precede the beginning of the unwinding process, the data provide an essential baseline for understanding how health insurance coverage is distributed across the U.S. and among the states prior to the unwinding, as well as marker to measure the impacts of this seismic coverage transition as potentially millions of individuals, both adults and children, are poised to lose Medicaid and must either find another form of coverage (e.g., state-based marketplace or employer-sponsored insurance [ESI]), or risk becoming uninsured.

Several resources have been compiled by SHADAC to track the unwinding process in a variety of avenues, falling under several broader categories:

Guidance for States

• Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement
• Best Practices for Publicly Reporting State Unwinding Data

Health Insurance Coverage Data Tracking

• State-Based Marketplace Transition Data During the Unwinding
• State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement
• Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

*Data Collection and Dissemination
As has been extensively documented by both SHADAC and the Census Bureau, disruptions to data collection and dissemination efforts—as well as the presence of significant nonresponse bias—due to the COVID-19 pandemic heavily impacted estimates for 2020. As such, the Census Bureau released 2020 ACS 1-year data in an “experimental-only” format and cautioned against their use. Similarly, the Census Bureau recommends that data users do not compare 2020 ACS 1-year experimental estimates with any other data. Researchers therefore have compared 2019 to 2021 data. 

Hest, Robert
Lanigan, Lindsey
Stewart, Andrea

CPS ASEC: 2022 National Health Insurance Coverage Estimates Show Falling Rates of Uninsurance and Direct-Purchase Coverage (Infographic)

The U.S. Census Bureau has released an initial report detailing the state of health insurance coverage in the United States for 2022.

Drawing on data from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC), the report highlights good news overall as the percentage of the population without health insurance coverage at any point in 2022 fell to 7.9% from 8.3% in 2021—a decrease of 0.4 percentage points or approximately 1.3 million people (25.9 million in 2022 vs. 27.2 million in 2021). 

The following blog post explores changes in national-level coverage rates by demographic characteristics - such as age, employment, race and ethnicity, immigration status, poverty status, and Medicaid expansion status - for nonelderly adults (age 19-64) and for children (age 0-18). While neither group saw an overall significant change in uninsured rates, both experienced shifts across demographic subgroups.

Additionally of note, though not within the scope of this blog to explore further, elderly adults (age 65+) saw a significant increase in Medicare rates, which the Census Bureau notes is due to a larger elderly population overall, not a larger share of those adults having Medicare. The continued growth of an aging population will continue to have ramifications for a number of health-related measures, including health insurance coverage rates, and bears following in future research.

Changes in Uninsurance by Age (Nonelderly Adults age 19-64, and Children age 0-18) and Characteristics

Among nonelderly adults, the overall rate of uninsurance fell to 10.8% in 2022, a 0.8 percentage point (PP) decrease from 2021.

Comparatively, the uninsured rate among children remained statistically unchanged from 2021 (5.0%) at 5.4% in 2022.

Race and ethnicity
In 2022, rates of uninsurance fell among nonelderly Black, Hispanic, and White adults, declining to 11.4%, 23.4%, and 6.8% (versus 12.7%, 25.1%, and 7.5%), respectively. Rates of uninsurance among nonelderly Asian adults were unchanged at 7.4%.

Similarly, while uninsurance rates remained stable for children of several racial and ethnic groups in 2022 - 4.1% for Asian children, 4.7% for Black children, and 8.6% for Hispanic children - the rate of uninsurance rose significantly among White children, increasing to 4.1% in 2022 from 3.4% in 2021.

Immigration status
The rate of uninsurance among native-born nonelderly adults fell to 8.2% in 2022 from 9.1% in 2021, while the uninsurance rate among foreign-born adults remained statistically unchanged at 22.1% in 2022 compared to 22.8% in 2021.

Rates of uninsurance were unchanged among native-born children at 4.7% in 2022 and among foreign-born children at 20.6% in 2022.

Poverty level
When examining coverage by poverty level, rates of uninsurance were unchanged at 24.2% among nonelderly adults with incomes below 100% poverty, decreased to 15.2% from 16.8% for those between 100%-399% poverty, and decreased to 3.9% from 4.5% for those living at or above 400% poverty.

In 2022, rates of uninsurance were unchanged for children in the two lower poverty level categories—8.9% for those in families with incomes below 100% poverty and 6.1% for those living in families with incomes between 100%-399% poverty. However, uninsured rates rose to 2.6% among children in families with incomes at or above 400% of poverty, an increase of 0.9 PP from 2021.

Medicaid expansion status
As of January 1, 2022, 38 states and the District of Columbia have chosen to act on the option provided by the Affordable Care Act (ACA) and expand Medicaid eligibility requirements, with the additions of Missouri and Oklahoma last year. Comparing rates of uninsurance by expansion and nonexpansion states revealed divergent trends for nonelderly adults and children.

In 2022, the uninsured rate fell to 8.4% in 2022 from 9.2% in 2021 for nonelderly adults living in expansion states and fell to 16.2% in 2022 from 17.0% in 2021 for those in nonexpansion states.

However, children in expansion and nonexpansion states saw no significant change in uninsured rates for 2022 compared to 2021 at 4.1% and 8.1%, respectively.

Notable Public and Private Coverage Changes

Among nonelderly adults, rates of public coverage and private coverage were unchanged at 19.1% and 72.9%, respectively. Rates of employer-based coverage increased to 63.5% in 2022 among nonelderly adults, up 0.6 PP from 2021. Rates of Medicare coverage fell to 3.6% among nonelderly adults in 2022, down from 3.8% in 2021.

By Race and Ethnicity (Total Population)
Rates of private and public coverage were statistically unchanged among Asian (72.2% and 27.8%, respectively) and Hispanic individuals (49.4% and 37.7%, respectively).

Among Black persons, the percentage with private coverage rose to 56.6% in 2022, up from 55.1% in 2021, and the percentage with public coverage fell to 41.2% in 2022, down from 42.7% in 2021.

Among White individuals, the percentage with private coverage fell to 72.3% in 2022, down from 73.2% in 2021, and the percentage with public coverage rose to 35.4% in 2022, up from 34.6% in 2021.

Immigration Status (Total Population)
Rates of private and public coverage were unchanged among the native-born population at 67.6% and 36.7%, respectively. Among the foreign-born population, the percent with private coverage was unchanged at 54.4% while the percentage with public coverage rose to 32.8% in 2022 from 31.7% in 2021.

Medicaid Expansion Status (Total Population)
In expansion states, the share with private coverage fell to 66.6% in 2022 from 67.1% in 2021 while the share with public coverage rose to 37.6% in 2022 from 36.9% in 2021. In nonexpansion states, the share of the population with private coverage and public coverage were unchanged at 63.6% and 32.9%, respectively.

Employment Status (Nonelderly Adults)
Public coverage rose among working nonelderly adults in 2022 to 12.6% from 11.8% in 2021 while the share with private coverage was stable at 80.0%. Public coverage rose among those who worked full-time year round and those who worked less than full-time, year round, rising to 8.9% and 23.5%, respectively. Private coverage was unchanged among these groups at 84.8% and 66.0%, respectively. Private and public coverage were unchanged among those who did not work, at 47.5% and 42.6%, respectively.

More on the insurance coverage changes among working-age adults can be found in a topically focused blog released today by the Census Bureau.

Notes
All changes are tested at the 90% confidence level.
All estimates come from the 2022 and 2023 Current Population Survey Annual Social and Economic Supplements, which provide data for years 2021 and 2022, respectively.
Uninsured estimates represent individuals with no health insurance coverage for the entire calendar year.
Estimates of health insurance coverage type represent individuals with that type of coverage at any point during the calendar year. Types of health insurance coverage are not mutually exclusive.

COVID-19 Public Health Emergency Impacts

Continuous Coverage Requirement

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the pandemic ended on March 31, 2023. The resumption of Medicaid eligibility redeterminations and renewals (and potential disenrollments), a process commonly referred to as the “unwinding,” began on April 1, 2023, and each state has a year to navigate a return to normal operations while also meeting reporting requirements set by CMS for publicly sharing coverage transitions and outcomes data during this time. While the health insurance estimates released by the US Census Bureau for 2022 precede the beginning of the unwinding process, the data will provide an essential baseline for understanding how health insurance coverage is distributed across the U.S. and among the states prior to the unwinding, as well as marker to measure the impacts of this seismic coverage transition as potentially millions of individuals, both adults and children, are poised to lose Medicaid and must either find another form of coverage (e.g., state-based marketplace or employer-sponsored insurance [ESI]), or risk becoming uninsured.

Several resources have been compiled by SHADAC to track the unwinding process in a variety of avenues, falling under several broader categories:

Guidance for States

• Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement
• Best Practices for Publicly Reporting State Unwinding Data

Health Insurance Coverage Data Tracking

• State-Based Marketplace Transition Data During the Unwinding
• State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement
• Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

Data Collection and Dissemination - Nonresponse Bias

While Census Bureau researchers have not cited any concerns with CPS ASEC data collection or release processes, an ongoing issue of persistently lower response rates and resultant nonresponse bias has been documented for the past few years, coinciding with the beginning of the COVID-19 pandemic. In March 2023 (the point in time that the CPS is administered), the response rate fell to its lowest point yet, at 68.9%, compared to a pre-pandemic rate of 82% (March 2019). This lower response rate particularly affects the CPS measures of income, and since 2020, the Census Bureau has been working to address the bias in higher reported earnings using new weighting methods to create adjusted income and poverty estimates. More detail on this methodology can be found in a companion blog released today by Census Bureau researchers.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement (Cross-Post)

The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen, Emily Zylla, and Lindsey Theis, SHADAC

This expert perspective (EP) will be updated by SHADAC experts as additional dashboards/reports go live. Please visit the State Health & Values Strategies webpage for the most recent version of this EP.

Original publication date: March 16, 2023. Updated September 9, 2023.

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act, with significant health equity implications. As states restart eligibility redeterminations, millions of Medicaid enrollees will be at risk of losing their coverage with some portion exiting because they are no longer eligible, some losing coverage due to administrative challenges despite continued eligibility, and some transitioning to another source of coverage. As part of this process, the Centers for Medicare & Medicaid Services (CMS) requires states to closely track and monitor the impacts of the resumption of eligibility redeterminations and disenrollments, and on July 28, 2023, CMS released the first batch of these data. CMS’ commitment to transparency is mirrored by calls from advocates and researchers eager to see how progress is being made as people enrolled in Medicaid have their eligibility redetermined. 

Given the intense focus on coverage transitions during the unwinding and the delays and caveats of the CMS data, many states have published their own state data dashboards to monitor progress. Data dashboards are useful for publishing dynamic data that is in high demand. They allow states to make proactive decisions about what data to release and on what schedule and then organize that data in an easy-to-digest visual format that facilitates the interpretation of key trends and patterns at a glance. Given the intense interest in unwinding data to monitor the impact of coverage transitions, releasing data in this format also allows states to follow some specific best practices, including providing additional detail about definitions, timeframes, and state context that will be important for communicating the unique and specific circumstances that states are experiencing during unwinding. An SHVS expert perspective highlights best practices for states to follow when publicly reporting unwinding data.

States Publicly Posting Unwinding Data
 

To date, 42 states including the District of Columbia (D.C.) have publicly published unwinding data in some format (this does not include states with pre-existing enrollment dashboards that don’t specifically identify unwinding cohorts). In most cases, state Medicaid departments are releasing those data, although some State-Based Marketplaces (SBMs) are also publishing unwinding data (see the SHVS expert perspective on SBM Marketplace Transition Data During the Unwinding). Of the 42 states currently reporting data:

• 21 are releasing state unwinding data online in either an interactive dashboard or static pdf format.
• Two states have only released copies of their required CMS Monthly Unwinding Data.
• 19 states are releasing both state data and their CMS Monthly Unwinding Data reports.

In some cases states are publishing unwinding information in an ad-hoc way—such as in a report to a legislature. Because these data are not being systematically reported, they are not represented in the map above. 

SHADAC will continue to update this expert perspective as more states publish their unwinding data.

Variation in States’ Reporting of Indicators

There is a wide variation in the indicators that states are reporting on their state data dashboards and reports. Of the 42 states reporting publicly, most are now reporting renewal and termination data. Some states are also reporting other interesting indicators such as:

• Reasons for procedural denials 
• Number of cases terminated that are re-enrolled or reinstated in Medicaid 
• Number of Medicaid cases sent to the Marketplace 
• Enrollment in CHIP 

It’s important to note that states use different terminology, definitions, population denominators, and timeframes on their dashboards making it difficult to compare one state’s data to another. In some instances, the data displayed on state dashboards also varies from what states include in their monthly reports to CMS (see Georgetown’s State Unwinding Renewal Data Tracker for a summary of states’ monthly CMS reports). Another cause of variation in the types of indicators reported across states is that states began disenrolling people from Medicaid in different months; for example, five states began disenrollments in April and another 14 states began disenrollments in May. Also, CMS has allowed states to delay terminations for one month and conduct additional outreach.

Unwinding Indicators & Disaggregated Data Reported by States
 

Few states are reporting disaggregated data on their dashboards. The most common breakdowns that states are providing are by program and geography (typically by county). Although CMS only asks states to report data by modified adjusted gross income (MAGI) and non-disability applications, versus disability applications, additional data breakdowns by age, race, ethnicity, and program type can elucidate important trends about the disproportionate impact of unwinding on groups that have been economically or socially marginalized.

Visit the SHVS Expert perspective for a selection of state dashboard examples including: Arizona, Colorado, Massachusetts, Minnesota, New Hampshire, Ohio, Oregon, Utah, and Washington.