Look closely at this tweet by the @BarackObama account, maintained by the pro-Obama group Organizing for America. The 6 million figure comes from combining a figure of 2.1 million for people selecting a plan via state and federal exchanges, through December, and 3.9 million for Medicaid, through November. Thus the claim that “6 million Americans have already signed up for coverage thanks to health reform.”
There is much less to the Medicaid figure than meets the eye. (The exchange figure has been updated recently, to 2.2 million, but not the Medicaid figure.) Indeed, there has been vast confusion about what this figure means, especially in the news media. The Fact Checker cited the 3.9 million figure in a few recent columns, but prodded by a colleague as well as an interesting analysis by Sean Trende at Real Clear Politics, we decided to take a closer look.
Bottom line: This number tells you almost nothing about how the Affordable Care Act is affecting Medicaid enrollment. Reporters need to stop using it.
This all started with a dense report issued on December 20 by the Center for Medicare and Medicaid Services, a unit of the Department of Health and Human Services. A CMS official walked us carefully through the numbers, and we also consulted with experts on Medicaid.
Medicaid, of course, is the health care program for the poor, generally at or below the federal poverty level. The Affordable Care Act expanded it to individuals with incomes of up to 138 percent of the federal poverty level (about $15,850), though the Supreme Court gave states the option of whether to participate.
So far, 25 states and the District of Columbia have expanded Medicaid, while four more are considering it. Under the ACA, the government will initially pay 100 percent of the cost of expansion, though it eventually drops to 90 percent. (Under the current formula, the cost is split at least 50-50 between the states and the federal government.)
The Congressional Budget Office estimates that in 2014, the number of Americans on Medicaid will increase by 9 million. Most of those would be in the new pool of applicants but it could also include some people who were previously eligible for Medicaid but had never signed up before all the publicity about new health-care options.
Generally, reporters and administration officials have treated the 3.9 million as being entirely composed of people who ended up on Medicaid because of provisions in the law.
Here’s the Associated Press headline when the CMS report was released: “Nearly 3.9M qualify for Medicaid under health law.”
The beginning of the article said:
“The Obama administration says nearly 3.9 million people have qualified for coverage through the health care law’s Medicaid expansion. The numbers released Friday cover the period from Oct. 1 to Nov. 30 and underscore a pattern of Medicaid outpacing the law’s expansion of private insurance.”
A front-page article in The Washington Post on January 1 was a bit more detailed but essentially said the same thing:
“A far greater number — about 3.9 million — took steps in October and November to sign up for Medicaid, according to federal figures. That includes people who became eligible for the state-federal program under the expansion as well as those who could have enrolled previously but for one reason or another did not sign up until now.”
The Fact Checker noted some fuzziness about the figure, but used terminology such as this: “The law included a significant expansion of Medicaid, which in just two months has added as many as 3.9 million people to its rolls.” We didn’t quite say there was a connection to the Affordable Care Act, but readers certainly might have gotten that impression.
So where would reporters get these ideas? Look at how administration officials spoke about the number.
Here’s White House official David Simas in a conference call with reporters on Jan. 2:
“When we break down the numbers a little bit more, this includes more than 2.1 million people who’ve enrolled in private plans through the federal and state-based marketplaces since October 1st and 3.9 million Americans who learned that they’re eligible for coverage through Medicaid and the Children’s Health Insurance Program, also known as CHIP, in October and November.”
And here’s Marilyn Tavenner, CMS administrator, in a blog post titled “Nationwide Enrollment for Health Care Coverage Surged in December:”
“Additionally, 3.9 million Americans learned they’re eligible for coverage through Medicaid and the Children’s Health Insurance Program (CHIP) in October and November. These numbers include new eligibility determinations and some Medicaid and CHIP renewals.”
The word “some” should be a tip-off. Here’s what the number actually includes:
• Medicaid and CHIP eligibility determinations made directly through state Medicaid and CHIP offices in every state.
• Medicaid and CHIP eligibility determinations made directly through state-based marketplaces (where the state is running their own marketplace).
• New eligibility determinations as well as renewals–i.e., people previously enrolled in Medicaid who are deemed eligible for another year.
At first glance, one could deduce that this is essentially an accounting of everyone who signed up for Medicaid in October and November. But there is actually one piece missing:
• Any of the Medicaid or CHIP eligibility determinations made through healthcare.gov. (Through November, that figure was nearly 270,000
750,000. Note: this column was briefly posted with the figure for the December report but the numbers have now been corrected.)
In theory, if you wanted to know the universe of people who actually were deemed to be eligible for Medicaid in those two months, you would need to combine 3.9 million and 270,000, though CMS concedes that there is probably some duplication.
Eventually all those people who are deemed eligible for Medicaid through healthcare.gov will end up being reported by the states back to CMS, so that’s why CMS does not combine the two figures. (Meanwhile, as The Washington Post reported, more than 100,000 also failed to be reported to states because of software defects.) But, for the moment, you could say that about 4.2 million people were found to be eligible for Medicaid and CHIP in October and November.
But what these figures do not tell you is how many additional people have joined Medicaid because of the Affordable Care Act. No one really knows, though some have tried to tease out figures from the data that has been presented.
CMS says that information about the number of people added because of the Medicaid expansion will not be available until after the end of March, when states start sending their quarterly bills to the federal government for their 100 percent refund of people in the expansion pool. Determining how many people came out of the “woodwork”—the previously eligible who suddenly focused on health care options and thus joined Medicaid—will take even more analysis.
There may be so much confusion about the 3.9 million figure because the October and November reports were the first time CMS had ever released monthly numbers. In other words, there is no apples-to-apples comparison over the same period in the previous year. But over the course of the next year the figure is just going to get bigger and bigger, and then it will be clear it is describing the entire Medicaid universe.
The Pinocchio Test
Essentially, then, it is ridiculous to suggest, as the @BarackObama tweet does, that the people who have selected a health plan in the exchanges are in anyway equivalent to the 3.9 to 4.2 million who were deemed eligible for Medicaid.
Soon, CMS will release the Medicaid numbers for December. Presumably the new numbers will reveal as little about the impact of the Affordable Care Act as the 3.9 million figure. Reporters need to be very careful about using the new figure in any sentence that includes a reference to the new health-care law.
We’re awarding Three Pinocchios to everyone, including The Fact Checker, who improperly used this number or left the wrong impression about it.
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