Utahns with Medicaid Insurance

Authors: Radhika Bhakta and Allison Witman
Publication Date: November, 2024.

Established in 1965, Medicaid is a joint federal and state-funded health insurance program designed to assist individuals and families with limited financial resources in accessing healthcare services, including doctor visits, hospitalizations, and prescription drugs. Medicaid plays a crucial role in providing health insurance coverage to children, the disabled, and low-income adults. Approximately 1 in 5 Americans is covered through Medicaid and the program is the second-largest source of insurance coverage in the United States after employment-based insurance.

States set eligibility rules, thus eligibility and access to Medicaid varies dramatically across states. For example, a non-disabled, childless adult in Washington, D.C. with income up to 215 percent of the federal poverty line can obtain Medicaid insurance. That same adult would only be eligible in Utah if their income was below 138 percent of the federal poverty line. In nine states, a non-disabled, childless adult is never eligible for Medicaid coverage – Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming.

Medicaid eligibility has also changed dramatically over time. Previously, the program mostly enrolled low-income children and disabled adults, but in the past 10 years, 40 states and Washington, D.C., have opted to expand Medicaid eligibility to include low-income adults. During and after the COVID pandemic public health emergency, the federal government prevented states from disenrolling Medicaid recipients to ensure that patients had access to health insurance during a time of uncertainty, job loss, and health risk. After years of enrollment growth, the number of beneficiaries is shrinking as states redetermine the eligibility of beneficiaries (leading to disenrollment of ineligible individuals) now that the public health emergency has ended, a process termed “unwinding.”

In Utah, Medicaid plays a much smaller role in providing health insurance coverage than in other states. About 10 percent of Utahns have Medicaid, which is the lowest rate in the nation. Utah was also a late adopter of Medicaid expansion in 2019 and has more recently been unwinding its Medicaid enrollment in the post-COVID era, resulting in huge swings in the number of enrolled beneficiaries in the past five years. Between April 2020 and April 2023, the number of people enrolled in Medicaid increased by 191,492, which was a 58% increase in three years. Since April 2023 as the state redetermined Medicaid eligibility after the enrollment freeze, enrollment has fallen by 183,824 people, nearly reversing the previous increase. This brief discusses the changes in Medicaid policy and enrollment during this period of great flux in the program.

Medicaid Eligibility in Utah

Access to Utah’s Medicaid program varies depending upon a person’s eligibility category. Figure 1 shows Utah’s Medicaid eligibility thresholds as a percentage of the federal poverty line for several groups. The Medicaid eligibility cutoff for children between the ages of 0 and 5 is 144 percent and children ages 6 to 18 is 138 percent. (The federal poverty line for a family of four is $31,200 in 2024, making the 144 percent threshold about $44,928.) Children above those cutoffs are eligible to receive Children’s Health Insurance Program (CHIP) coverage in families with income up to 205% of the federal poverty line, effectively meaning that all children below this income threshold in Utah are eligible for government-subsidized health insurance. Pregnant women with incomes up to 144 percent of the federal poverty line are eligible for Medicaid coverage and about 17 percent of all births in the state are financed by Medicaid. Childless adults and parents are eligible up to 138 percent of the federal poverty line. In addition to these eligibility categories, Utah has special programs that create pathways for Medicaid eligibility for other groups such as the aged, blind, and disabled, refugees, cancer patients, children in foster care, and former foster care youth.

Figure 1. Medicaid/CHIP Eligibility Thresholds for Select Groups, 2024

Note: The figure shows the maximum income eligibility cutoff as a percentage of the federal poverty line for selected groups. All figures include disregarded income for eligibility determination. Eligibility thresholds were obtained from the Kaiser Family Foundation.

Medicaid expansion drastically affected eligibility thresholds for parents and childless adults in Utah. Prior to 2019, childless adults were not eligible for Medicaid and parents with incomes up to 60 percent of the federal poverty line could obtain Medicaid coverage (Figure 2). In November 2018, voters approved full expansion of Medicaid to all adults up to 138 percent of the federal poverty line. However, the full expansion was not implemented as planned in April 2019 because the state legislature enacted an amended plan that included only partial expansion to 100 percent of the federal poverty line. This partial expansion lasted through 2019 while the state applied for federal waivers to continue the partial expansion; however, the Centers for Medicare and Medicaid services declined Utah’s waiver requests and full expansion was adopted in January 2020.

Figure 2. Utah Adult Medicaid Eligibility Thresholds Over Time

Note: The figure shows Medicaid income eligibility thresholds as a percent of the federal poverty line between January 2018 and December 2020 for parents and childless adults in Utah. Eligibility thresholds were obtained from the Kaiser Family Foundation.

Thus, the 9 months between March 2019 and January 2020 represented a transition in access to public health insurance for low-income adults. More parents became eligible for Medicaid while low-income adults without children gained access for the first time.

In March 2020, the Families First Coronavirus Response Act prohibited states from disenrolling Medicaid beneficiaries, ushering in a period of massive increases in Medicaid enrollment. After three years of disenrollment freezes, the public health emergency ended, and states began the process of redetermining eligibility for Medicaid beneficiaries. Starting in March 2023, removal of 23 million people nationwide who had received Medicaid benefits but no longer qualified or could not demonstrate qualification for the program began. Utah began its unwinding in March 2023 and completed it in April 2024.

Enrollment Expansion and Contraction in Utah

Between 2018 and 2024, Utah experienced a massive expansion and contraction in the number of Medicaid beneficiaries (Figure 3). When voters approved Medicaid expansion in November 2019, there were 310,151 beneficiaries enrolled. Partial expansion in 2019 resulted in a small increase in enrollment of only about 4,000 people, resulting in 314,177 total Medicaid beneficiaries as of December. Enrollment changed minimally during the full expansion period between January and March 2020, but exploded starting in April 2020. The number of people enrolled in Utah’s Medicaid program grew from 330,995 in April 2020 to 522,487 in April 2023, a 58% increase.

It was estimated that full expansion could increase Utah’s Medicaid enrollment by up to 120,000, so it is clear that a significant portion of the increase in enrollment was due to the unique circumstances of the pandemic, which caused reductions in income that resulted in more people falling under the income eligibility thresholds.

Figure 3. Number of Persons Enrolled in Medicaid in Utah, 2018 – 2024

Note: The figure shows the number of people enrolled in Medicaid in Utah between January 2019 and June 2024. The vertical lines indicate the date that voters passed Medicaid expansion, the date that Medicaid was partially expanded, and the date of full expansion. Enrollment data was obtained from the Utah Department of Health and Human Services.

The 191,492 person increase in enrollment between April 2020 and April 2023 was comprised of growth across several eligibility categories. The largest source of new Medicaid enrollees was 63,802 non-parents that were newly eligible for Medicaid due to the expansion (Figure 4). The next largest group was children, with 58,416 enrolled during the pandemic period. Expansion parents with incomes between 60 and 138 percent of the federal poverty line comprised 25,286 of the enrollment increase.

Nearly all the growth in enrollment during the pandemic period has been reversed since April 2023 when the unwinding process began. Since then, 183,824 people have been disenrolled from Utah’s Medicaid program. Children were the largest group to lose Medicaid/CHIP benefits by far, with a reduction of 76,075 beneficiaries under the age of 18. Non-parents eligible under the Medicaid expansion criteria declined by 42,315 and parents eligible under the expansion criteria declined by 24,391.

Figure 4. Change in Enrollment by Group, Expansion and Contraction Periods

Note: Figure shows growth in enrollment by category between April 2020 and April 2023 and decline in enrollment by category between April 2023 and June 2024. Enrollment data is obtained from the Utah Department of Health and Human Services.

What has happened to the nearly 200,000 people who were disenrolled from Medicaid during the unwinding process? In order to find out, the Utah Department of Health and Human Services conducted a survey of 1,000 disenrolled beneficiaries. Key results of the survey are presented in Figures 5 and 6. Among those who were disenrolled, thirty-nine percent of respondents received health insurance through an employer, 15 percent through the marketplace, and 7 percent through Medicare. The remaining 30% were uninsured, meaning approximately 55,000 Utahns had no health insurance coverage after disenrollment.

Figure 5. Current Insurance Status of Disenrolled Medicaid Beneficiaries

Note: Figure shows the insurance status of disenrolled Medicaid beneficiaries. Data is from a survey funded by the Utah Department of Health and Human Services.

Although the majority of respondents found coverage outside of the Medicaid program, most respondents also said they would reenroll if they could. When asked, “If you could re-enroll yourself or your household member(s) in Medicaid today, would you?” 58% of respondents said definitely, 21% of respondents said probably, and 21% said undecided, probably not, or definitely not (Figure 6). With 79% of respondents willing to definitely or probably reenroll in Medicaid if they were eligible, it is clear that beneficiaries viewed the program positively. Indeed, when asked to rate Medicaid insurance on a scale from 1 to 10 with 10 being the best insurance possible, 33% of respondents to the survey gave the program a 9 or a 10 rating.

Figure 6. Interest in Reenrolling in Medicaid by Disenrolled Medicaid Beneficiaries

Note: Figure shows the interest in re-enrolling in Medicaid among disenrolled Medicaid beneficiaries. Data is from a survey funded by the Utah Department of Health and Human Services.

The Impacts of Medicaid

Despite the dramatic changes in state Medicaid policy and enrollment through the expansion, COVID pandemic, and public health emergency unwinding, Utah’s Medicaid enrollment has ended up close to where it started. The number of people with Medicaid has only increased by 29,000 since Utah voters approved Medicaid expansion in November 2018. Medicaid policy remains a contentious issue in the state, with recent bills from both sides of the aisle failing to pass, including proposed cuts in the event there is a funding shortfall and expansion to cover more pregnant people. Under newly passed legislation, Medicaid will begin covering eligible incarcerated individuals prior to release from detention and will cover traditional healing services for American Indian/Alaska Native people.

With Medicaid continuing to be an area of great legislative interest in Utah, it is worth understanding the impacts of Medicaid on patients and state budgets. The rollout of Medicaid expansion across states over time created an ideal natural experiment for studying the causal impacts of Medicaid. So what does the research say? The majority of studies find that Medicaid expansion benefits patients in terms of increased insurance coverage, improved access to care, and increased health outcomes. Medicaid expansion improved mortality rates overall and for certain conditions. Expansion is associated with increased use of primary, preventive, and mental health care and improved self-reported health. In sum, Medicaid increased access to health care and contributed to better health.

Broader Medicaid eligibility also means more budgetary costs. As a joint federal-state program, Medicaid is funded using both federal and local funds. In 2023, Utah’s total Medicaid spending was $5.0 billion, of which $3.6 billion (73%) was paid by the federal government, and $1.4 billion (27%) by the state of Utah.  However, the federal government pays for 90% of expansion beneficiaries’ expenditures—so of the $1.3 billion in total health spending of beneficiaries of Medicaid expansion, Utah paid $135 million, or about $1,500 per expansion beneficiary—making expansion benefits a relative bargain for health insurance coverage.