Trying to count Obamacare’s Medicaid enrollment? Good luck.

January 23

1. Health and Human Services says that 6.3 million people signed up for Medicaid in the last three months of 2013, from October through December. These are, not coincidentally, the three months of 2013 when people could start signing up for the Affordable Care Act's Medicaid expansion. That's the part of the law that expands Medicaid to those who earn less than 133 percent of the poverty line - about $15,000 for an individual - if they live in one of the blue states below expanding the program.


2. We don't know how many of those people gaining Medicaid because of the Affordable Care Act. There are lots of people who were eligible for Medicaid prior to the Affordable Care Act but didn't take action to enroll in the program. Maybe they never got around to signing up or found the paperwork too difficult. Maybe they hadn't heard about the Medicaid program--but did start hearing about it this past fall, when there was lots of focus on the health law's insurance expansion. When states send the federal government information about the number of people signing up for coverage, they don't specify whether it's "Obamacare Medicaid" or "normal Medicaid." They just tell the federal government that somebody signed up for Medicaid.

This explains why you see over 1 million people gaining coverage this past December in states that did not expand Medicaid--states where literally nothing changed about the type of coverage they offer.

3. To make matters even more confusing, these numbers don't represent the people who go to HealthCare.gov, type in their income and find out they're eligible for Medicaid. This particular report represents people who went directly to their state Medicaid office. In that way, this report misses some of the people who are coming in a different front door. However, in the 14 states that are running their own exchange, the numbers do include those who came in through the online marketplace.

And, lastly (because you weren't confused enough already) 14 states also include in their figures people who already have Medicaid and are renewing that coverage. You can find a list of those states on page 3 of this report.

4. The question on health wonks' minds is: How many people got Medicaid under Obamacare? We don't have that answer until the early spring. Each quarter, states submit reimbursement requests to the federal government. The end of the first quarter of the year is March 31. That's when states will tell the federal government how much they should be paid for each person they cover on Medicaid. That's where states will have to specify who gained coverage under the health-care law, because the federal government will pay 100 percent of those enrollees' costs. Typically the federal government only splits the bill with the state.

5. A handful of states do report this specific number. Washington, for example, counts a total of  381,000 people who have signed up for Medicaid in since October. Of those, about one third - 134,000 people - are newly eligible for the program. An additional 63,000 were eligible already but are now signing up for the first time. And, last, 183,000 people were previously covered under Medicaid and were re-determined eligible to stay on the program. Similarly, in Maryland, Charles Gaba's analysis suggests that about one-third of Medicaid sign-ups were people renewing policies.

Using Arkansas numbers, Sean Trende has estimated that about 45 percent of those signing up for Medicaid are newly eligible under the health-care law. Taken together, these numbers seem to suggest about one-third to half of the Medicaid sign-ups are among those newly-eligible under Obamacare. But again, we won't know the actual number until April at the earliest.

6. Another way to think about the numbers is the impact that the Medicaid expansion is having. The Obama administration crunched the numbers and finds that states expanding Medicaid have had a 73 percent increase in enrollment as compared to a baseline period from July through September. States that did not expand, meanwhile, had a 3 percent increase.

7. Medicaid enrollees renewing their coverage are, pretty clearly, not gaining coverage because of the Affordable Care Act. As to whether those who were eligible previously but just now signing up count as Obamacare enrollees is more a matter of punditry than policy. No, these people did not gain coverage because the Affordable Care Act expanded Medicaid. But yes, it's possible that without the Affordable Care Act's heavy publicity and enrollment push, they would be without coverage.

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