Eye-popping Numbers on Fraudulent Duplication in Medicaid, the ACA

Washington is finally serious about combating waste, fraud, and abuse in our welfare system. 

New data shows that an astounding nearly 3 million people are fraudulently receiving coverage under the Affordable Care Act (ACA or Obamacare) and Medicaid benefits or benefits across multiple states. Individuals may qualify for one of the programs but not both, and some individuals are ineligible for either. 

The Trump administration is on a mission to fix this duplication problem for good.

The Numbers

According to new data released by the Center for Centers for Medicare & Medicaid Services (CMS), duplication between both programs is a serious problem to the tune of 2.8 million people.

In 2024, 

• An average of 1.2 million Americans each month were enrolled in Medicaid/CHIP in two or more states.
• An average of 1.6 million Americans each month were enrolled in both Medicaid/CHIP and a subsidized Exchange plan.

How did this happen?

Federal regulations require that federal agencies periodically conduct examinations of their data to find dual enrollments in taxpayer-subsidized ACA Exchanges and Medicaid, called Medicaid Periodic Data Matching (PDM). This effort is meant to guard against improper enrollments and should be a bipartisan priority across administrations. Unfortunately, combating fraud has been partisan. 

The Trump 1.0 Administration strengthened these examinations and increased them to twice a year. Conversely, the Biden Administration paused these examinations to ensure that coverage for individuals was continuous throughout the COVID-19 public health emergency. While that may be an understandable motive, it created the opportunity for fraud. Additionally, the Biden Administration never ramped up oversight of fraudulent activity after the pandemic emergency ended.

CMS Administrator Dr. Mehmet Oz explained:

The Biden Administration struggled to ensure that individuals were only enrolled in the single Medicaid or Exchange plan for which they were eligible, that ends today. CMS is restarting these important checks to follow federal law. We are going to work with states to identify individuals enrolled in multiple programs and fix the duplicate enrollment problem to save taxpayers billions of dollars, while minimizing inappropriate coverage loss. This is exactly why we fought for stronger tools in the One Big Beautiful Bill Act—to go after this type of waste and finally put a stop to paying twice for the same person’s health coverage.

CMS laid out a plan that includes working with states to check whether individuals enrolled in Medicaid in different states are truly eligible and limiting enrollment to just one state, but ensuring that they don’t lose coverage. The agency also directly contacted individuals enrolled in both Medicaid and an ACA Exchange plan to either disenroll in Medicaid, drop their Obamacare, or prove they aren’t enrolled in both. Additionally, CMS is working with states to check whether individuals are dually enrolled in a state exchange and Medicaid and to remove them from one of the programs.

As I explained at length in a recent policy focus, Rightsizing Medicaid for Those Who Need It Most:

We have an incomplete picture of the true size of Medicaid fraud because both the Obama and Biden administrations excluded eligibility checks in their audits of improper payments. The federal government should require that audits assess whether states are determining eligibility before providing care to avoid improper payments. States should also be required to prove eligibility based on income and assets more regularly, such as at least once every six months, for ablebodied enrollees and perhaps annually for the disabled or seniors. 

Bottom Line

Medicaid reforms that prioritize better data reviews and enrollment oversight are critical to ensuring that this welfare program only serves the vulnerable populations it was created for.