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Reflections on Medicaid Enrollment for the Next Decade
by Kelly Ellis and Fanny Tashia, EMRTS
What is the Difference Between Medicare and Medicaid?
Many people confuse the terms Medicare and Medicaid. While they are both government-administered health insurance programs, they were created to help two different groups of people. Medicare is health insurance for people 65 years or older or people under 65 with a qualifying disability or end-stage renal disease.3 Medicare is administered at the federal level. Medicaid is a joint federal and state program that helps pay medical costs for people with limited income and it is administered at the state level. States are responsible for designing and executing their individual Medicaid programs using federal guidelines.4 The Children’s Health Insurance Program (CHIP) provides healthcare to children from families that make too much money to qualify for Medicaid, but cannot afford private insurance. CHIP is also administered at the state level.5
The onset of COVID-19, coupled with increases in unemployment across the country, led to a 13.1% surge in Medicaid enrollments
Current Medicaid Enrollment and Spending
The COVID-19 pandemic has vastly impacted individuals across the nation and the systems built to protect them. Before the pandemic, enrollment in Medicaid decreased between the calendar years 2017 and 2019 from 73 million to 71 million.6 The onset of COVID-19, coupled with unemployment increases across the country, led to a significant surge in Medicaid enrollment to 80.5 million people in January 2021, an increase of 13.1% since the start of the coronavirus pandemic.7 With such large numbers of individuals enrolled in Medicaid and such a large portion of taxpayer dollars being spent to treat them, integrity in allocation and service of Medicaid is imperative. In the fiscal year 2020, the total Medicaid expenditures for the federal government and each state combined amounted to nearly $679 billion, $447 billion being the federal share of outlays.8 During the state fiscal year 2019 Medicaid comprised the second largest portion of state expenditures after education.9 In Virginia alone over $14 billion was spent on Medicaid during the state fiscal year 2020- nearly $9.4 billion was from federal funding and nearly $4.9 billion was from state funding.10 Pennsylvania, one of the top 5 most populous U.S. states, spent $32 billion on Medicaid during the state fiscal year 2019- $18 billion from federal funding and nearly $14 billion from state funding.11
Medicaid Enrollment and Spending Projections
To ensure individuals and families enrolled in Medicaid receive the care they need, state and federal governments must use the nearly 700 billion tax dollars allocated to Medicaid funding responsibly.12 The number of individuals receiving Medicaid, and the cost to deliver care to them, is projected to keep increasing for the next ten years. By December 2030, it is estimated that nearly 120 million people will be receiving assistance from Medicaid/CHIP (Figure 1), and over a trillion dollars will be spent to provide their care (Figure 2). Enrollment in Virginia is estimated to reach over 3.2 million (Figure 3) and cost just over $30 billion (Figure 4). In Pennsylvania, Medicaid/CHIP enrollment is estimated to be over 4 million recipients by December 2030 (Figure 5) and cost taxpayers nearly $50 billion (Figure 6).
Note: All graphs can be viewed on our Interactive Dashboard. (The link will open a new window.)
Figure 3: Projection for child and total Medicaid enrollment in Virginia 2021-2030. Light teal represents child enrollment in CHIP and Medicaid; dark teal represents adult Virginia enrollment.
Medicaid Program Integrity
With these increased enrollment and cost figures comes increased responsibility for healthcare providers and the state and federal governments. Surges in Medicaid enrollment and spending are likely to increase improper payments and fraudulent claims by healthcare providers and beneficiaries. In state fiscal year 2020, the Medicaid improper payment rate was estimated to be over 10%.13According to the Government Accountability Office, improper payments include payments that should not have been made or were made for an incorrect amount.14 Medicaid fraud and abuse, however, can take on many forms. The Centers for Medicare and Medicaid Services (CMS) define Medicaid fraud as the intentional provision of false information to obtain medical care or services from Medicaid. For example, providers may intentionally bill for services that were unnecessary or never performed at all. Another common form of Medicaid fraud that healthcare providers commit is ‘upcoding’, billing for more complex services than what was provided to beneficiaries.15Beneficiaries, in turn, may commit fraud by sharing Medicaid ID cards with someone not enrolled in Medicaid or by providing false information to qualify for Medicaid enrollment. Medicaid abuse occurs when a beneficiary or provider participates in activities that lead to unnecessary costs on behalf of Medicaid.16
In the federal FY 2020, 19,720 total investigations were reported to the Office of Inspector General (OIG-HHS) to examine potential Medicaid fraud and abuse cases, leading to 1,325 indictments.17A North Carolina couple is facing 14 years in prison for billing Medicaid $17 million for services provided for patients who were already deceased.18In San Antonio, Texas, a physician’s assistant faces 20 years in prison after admitting in 2021 to fraudulently billing over a billion dollars to Medicaid and TRICARE and receiving kickbacks for writing prescriptions and performing unnecessary tests on patients.19A woman running an LLC designed to ensure Medicaid recipients are given the help they need was charged with stealing $2.8 million from the Virginia Medicaid system and using it to fund a lavish lifestyle of travel, cosmetic surgery, and gambling. “We must hold fraudulent healthcare providers accountable, not only because they are stealing from our healthcare system but they are also stealing from Virginia taxpayers in the process” says Virginia’s Attorney General, Mark R. Herring.20These abuses are unfortunately rampant in a system that was designed to serve some of the most vulnerable populations in the United States.
Closing Remarks
Medicaid is the primary source of long-term healthcare in the United States. Medicare provides health insurance for the nation’s fastest growing population, those who are 65 and older.21These two very important social programs are government-administered and funded by taxpayers. Although the CMS is the country’s single largest provider of healthcare, many Americans are unaware of the scope of Medicaid and Medicare enrollment or their costs. If you have ideas for how these systems could be improved to be more efficient or innovative please share with us at ask@emrts.us
The authors developed projections using the Prophet model, a forecasting procedure implemented in R, and Kats, a library for generic time series analysis in Python. Projections are developed based on data gathered from Medicaid and other sources such as the Kaiser Family Foundation. Once the projections were completed, the authors developed visualizations using Instadeq, a user-friendly data analysis and visualization ‘software as a service’ tool that allows for instantaneous data manipulation and does not require coding.
References
1 10 Things to Know about Medicaid: Setting the Facts Straight
2 Medicaid Financing: The Basics
3 What’s Medicare? (this link triggers a pdf download)
4 FY 2021 Budget in Brief (this link triggers a pdf download)
5 Children’s Health Insurance Program (CHIP)
6 Monthly Child Enrollment in Medicaid and CHIP
7 Analysis of Recent National Trends in Medicaid and CHIP Enrollment
8 FY 2021 Budget in Brief (this link triggers a pdf download)
9 Distribution of State Expenditures (in millions)
10 2020 Virginia Medicaid & CHIP Data Book (this link triggers a pdf download)
11 Federal and State Share of Medicaid Spending
12 MFCU Statistical Data for FY 2020 (this link triggers a pdf download)
13 2020 Estimated Improper Payment Rates for Centers for Medicare & Medicaid Services (CMS) Programs
14 Improper Payments
15 There Are Many Types of Medicaid Fraud (this link triggers a pdf download)
16 Reporting Medicaid Fraud and Abuse
17 MFCU Statistical Data for FY 2020 (this link triggers a pdf download)
18 Cashing in on the dead: Former NC couple lived lavishly on Medicaid fraud money
19 San Antonio Physician’s Assistant Admits to Defrauding Medicaid and Medicare
20 Owner of Virginia company sentenced for $2.8M Medicaid fraud
21 65 and Older Population Grows Rapidly as Baby Boomers Age
Kelly Ellis is a Biostatistics M.S. student attending George Mason University (GMU), a public research university located in Fairfax, Virginia. GMU was founded in 1957 as the Northern Virginia branch of the University of Virginia. In 1972 GMU became an independent university and is now Virginia’s largest four-year public university. Kelly obtained her B.S. in Biology from GMU in 2018 and will graduate with her Biostatistics M.S. in December 2021. Kelly has experience solving real-data problems in the biological and health areas.
Fanny Tashia is a Information System Management M.S. student attending Carnegie Mellon University. The university was founded in 1900 in Pittsburgh, Pennsylvania and is known for its computer science and engineering programs. Before pursuing a master’s degree, Fanny worked for three years as a consultant in Indonesia and is experienced in working within a variety of industries, including the healthcare industry.