A record number of New Yorkers relied on Medicaid for health care in 2021, with monthly enrollment exceeding seven million for the first time, according to a new report by state Comptroller Thomas P. DiNapoli.

While enrollment has grown by about 5% per year over the last 15 years, increasing from about one in seven New Yorkers in 1998 to one in three in 2021, state budget projections rely on expectations for significant enrollment declines that may not materialize.

“Federal and state Medicaid policy changes over the past decade have contributed to a steep decline in the number of New Yorkers without health care coverage, ranking New York eighth lowest in the United States for uninsured residents. This is good news,” DiNapoli said. “However, if current enrollment trends continue, the state could face billions of dollars in unbudgeted costs. State policymakers should closely monitor program enrollment and spending trends and take steps to ensure that New Yorkers continue to have access to the health care they need.”

Medicaid is a federal, state and local government-funded program that provides a wide range of medical services to economically disadvantaged populations, including low-income children and their families, low-income seniors, and low-income people with disabilities. The state Division of the Budget estimates the state share of Medicaid will be $27.8 billion in state fiscal year 2021-22, representing the second largest category of state spending, exceeded only by education.

ENROLLMENT TRENDS

The share of New Yorkers without health care coverage has fallen from 11.4% in 2008 to 5.2% in 2019, thanks in part to the expansion of Medicaid. The pandemic and resulting economic recession swelled Medicaid enrollment in New York to record levels in 2021, with the monthly number of individuals covered by the program reaching seven million for the first time in February 2021. Adults accounted for two-thirds of enrollment growth, rising by 356,677 to a monthly average of more than three million enrollees for the first three months of 2021. The mid-year update to the 2021-22 enacted budget financial plan, expects monthly enrollment to remain above seven million at least through March 2022, but decline by nearly 17% by March 2023 and return to pre-pandemic levels of just over six million by March 2024 as the economy recovers, unemployment rates decrease, and individuals temporarily enrolled begin to decline.

SPENDING TRENDS

The federal share for most Medicaid services is determined by the Federal Medical Assistance Percentage (FMAP), which is based on a formula that provides higher reimbursement to states with lower per capita incomes relative to the national average. New York’s FMAP is the statutory minimum of 50%, reflecting the state’s relatively high per capita income. As part of its response to the pandemic, the federal government increased its share of funding for most Medicaid services, including a 6.2 percentage point increase for New York for each calendar quarter during the public health emergency.

Specific Medicaid spending trends include:

¯ Prior to the pandemic, from 2007-08 through 2019-20, total Medicaid spending (including the federal, state and local shares) grew by 5.4% per year, increasing by nearly $30 billion to reach $75.9 billion.

¯ During the pandemic, in SFY 2020-21, total Medicaid spending in New York declined by about $650 million or less than 1% compared to the previous year, reflecting what may have been a decrease in utilization of non-COVID medical care, particularly early in the pandemic. State spending decreased by more than $4 billion, reflecting the 6.2 percentage point FMAP increase.

¯ DOB expects total Medicaid spending will rise to $83.8 billion in SFY 2021-22, remain relatively flat through March 2024 and increase to $85.8 billion in SFY 2024-25.