Medicaid
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Increasing Medicaid caseloads during the pandemic, what can we learn?

October 26, 2020
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Since February of this year, national Medicaid caseloads have increased by more than 7 percent with millions of Americans relying on the program as their primary source of coverage during the COVID-19 pandemic. This reverses a trend in recent years which saw many beneficiaries disenroll as the economy improved and federal administration imposed more stringent eligibility conditions for states. Fortunately, Ohio regularly publishes program enrollment data, which provides us with the opportunity to dig into the numbers that show Medicaid serves as a safety-net.

 When the Trump administration declared a public health emergency at the beginning of the pandemic, states were given more flexibility to respond to COVID-19.

When the Trump administration declared a public health emergency at the beginning of the pandemic, states were given more flexibility to respond to COVID-19. Flexibilities included the scale-up of telehealth; emergency approvals for new treatments; the availability of federally funded personnel to free local public health department resources; and Medicaid programs were given new flexibilities through waivers and emergency state plan amendments to address critical needs. Specifically, the emergency declaration enabled states to use temporary eligibility policies to streamline access to coverage and the Coronavirus Aid, Relief, and Economic Security (CARES) Act mandated states suspend eligibility renewals during the emergency as a condition of enhanced federal funding.

 Caseload increases suggest that Medicaid is doing what it was designed to do as a first responder in public health

Like the federal government, Ohio deployed its own policies and public health measures, including the closure of schools, bars, gymnasiums and government offices. Given the impact the orders had in increasing unemployment, access to Medicaid coverage became critical as people lost insurance typically provided through their employers. Importantly, closures included county Departments of Job and Family Services, which process eligibility applications for the Medicaid program. Given the need for social distancing, county Job and Family Services Departments could no longer safely accommodate the demands of processing eligibility applications in person. To ensure individuals were able to access coverage through Medicaid, especially as demand grew, Ohio leveraged the newly enabled federal flexibilities, suspended renewals for eligibility and a created a streamlined application process. In looking at the data, the trends in Ohio seem to indicate the policy was successful, with significant enrollment in the Covered Families and Children (CFC) and Group VIII (Medicaid expansion) categories.

 In looking at the age-related data of the program, what’s notable is the stark increase in the number of children who enrolled in Medicaid.

Between April and September, Ohio saw an average caseload growth of 42,588 per month and a total increase of 255,526 people. Interestingly, the majority of this increase comes from the CFC category (greater than 57 percent of the total), meaning that the enrollment increase is driven by coverage for parents and children. And while these numbers are much less than what was originally projected, in looking at the age-related data of the program, what’s notable is the stark increase in the number of children who enrolled in Medicaid. Between March and September, 71,476 children enrolled, which is an increase of 6.07 percent. Remarkably, this nearly wipes out coverage losses for children in Ohio, which saw nearly 27 thousand children lose coverage between 2016 and 2019. And while this is certainly good news in regards to reducing the number of uninsured children in Ohio, it underscores the fact that many families are facing significant economic hardship as a result of the pandemic and, what’s more, there may have been a deeper need for children’s coverage in Medicaid than what was possible in the pre-pandemic eligibility machinery of the state. It also does not account for the remainder of children who may still be uninsured, which is a significant concern given the potential of a second national health crisis as many children remain untreated.  

Beyond coverage by eligibility type and age, the Medicaid program seems to have had a proportional effect both on rural counties and by race. In looking at rural counties in Ohio compared to metropolitan and urban counties, as defined by the Health Resources and Services Administration, rural counties saw an enrollment increase of 8.81 percent compared to 9.21 percent for all other counties. This would suggest that the effects of the pandemic, and the economic conditions between counties, are roughly similar and, thus, benefit similarly. Second, in regards to race, enrollment by white Ohioans increased by 8.82 percent, Black/African-American Ohioans increased by 8.8 percent and other categories as listed by the state increased 11.72 percent. More than 94 percent of Ohio’s population is white or Black/African-American, which explains why the variance for other racial categories may be higher.

 Since February of this year, national Medicaid caseloads have increased by more than 7 percent

These trends suggest a few things. Primarily, caseload increases suggest that Medicaid is doing what it was designed to do as a first responder in public health, providing a source of coverage when it is most needed. Second, the significant increases in enrollment for parents and children suggest that there are potential operational lessons to be learned from the changes afforded through the public emergency that can be continued after its conclusion. Given the fact children represent 1 in 3 of the newly covered individuals during the pandemic, the data suggests that historical causes for the declines in children’s enrollment are more complex than an improving economy, singularly. Last, the enrollment increases, and the parity between geographies and racial categories therein, demonstrate the ways in which Medicaid is maintaining equal access to coverage even while other disparities remain.  

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