Medicaid Expansion Could Have Covered an Additional 4M People in 2020

Uninsured numbers in “holdout states” would have dropped by 28% under “typical circumstances,” an Urban Institute analysis found.

If 15 states had expanded Medicaid under the Affordable Care Act (ACA), an additional 3.9 million people would have been insured in 2020, according to a report released by the Urban Institute Monday.

The study, supported by the Robert Wood Johnson Foundation, made estimations using the Health Insurance Policy Simulation Model (HIPSM), a model of the health insurance system “designed to estimate the cost and coverage effects of proposed health care policy options."

The most significant declines in the uninsured population would have been in southern states that have not expanded Medicaid under the ACA: Alabama at 43.1%, Mississippi at 39%, Missouri at 36.4%, and South Carolina 36.3%. Meanwhile, Wisconsin would experience the smallest percentage decrease, (16%), in its uninsured population.

"In addition to reducing the number of uninsured, expanding Medicaid under the ACA to low-income people improves health and reduces mortality in the enrolled population," the report says. "Two recent studies provide strong evidence that expansions of coverage under the ACA have reduced mortality rates in older adults by meaningful amounts."

It is noted that the estimates in this study are different from a  2018 analysis done by the Urban Institute, and differ from a January 2020 analysis on coverage gaps conducted by the Kaiser Family Foundation.

Under the ACA, states can choose to expand Medicaid eligibility for nonelderly people and as of January, 35 states and the District of Columbia have expanded the program while 15 states have not. This analysis found that had those 15 "holdout" states expanded under “typical circumstances,” there would have been an "overall 28% reduction in the number of uninsured people in those states combined."

Using a "pre-COVID-19 current-law baseline" the analysis also found:

• An additional 185,000 people "would gain more comprehensive insurance" by switching out of their current plan and enrolling in Medicaid.
• 4.1 million people would have ACA standard insurance coverage.
• There would be an increase of $30.4 billion federal spending on nonelderly healthcare.
• There would be an increase of $4.7 billion on Medicaid in the 15 "holdout" states.
• An increase in state spending would yield to "savings in other areas," as "several comprehensive analyses of current expansion states have found that Medicaid expansion had a net positive impact on state budgets."