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An ad campaign in Alameda County, Calif., is working to attract people who are eligible to sign up for Medi-Cal, the state's version of Medicaid. The ads focus on the diversity of the population, with different ads featuring families of different races and different languages. This ad is in an Oakland, Calif., shopping district. Photo courtesy of Better World Advertising / www.socialmarketing.com

Medicaid-eligible but not enrolled? ACA a likely stimulus

The Affordable Care Act's coverage expansions and individual mandate might persuade millions who already are eligible to sign up for the first time.

By Jennifer Lubell — Posted Feb. 18, 2013

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Near-nudity may not be an obvious strategy to get people insured, but one county agency in California has employed this very approach to grab the attention of people eligible for Medi-Cal, the state's Medicaid program.

The ad campaign shows families minimally dressed and holding up signs urging people to get health insurance. “Our message is that you wouldn't let your family go without clothes — why let them go without health coverage?” said Lori A. Cox, director of the Alameda County Social Services Agency.

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Ads inviting California residents to sign up for Medicaid are running in multiple languages, including Spanish. Photo courtesy of Better World Advertising / www.socialmarketing.com

County officials estimate that there are thousands of residents eligible for the state's Medicaid program but not enrolled, including about 15,000 children. The agency also has set up a phone number to provide information about Medi-Cal eligibility, and those interested in applying may do so online.

Alameda's “Cover Your Family” strategy caught the attention of Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured. At a January briefing in Washington, Rowland cited the campaign as an innovative approach that highlights struggles states face in enrolling people eligible for public health insurance.

The provocative ads also underscore the fact that state officials, physicians and other health professionals need to think about more people than just the millions who will become newly eligible for coverage under the Affordable Care Act's Medicaid expansion starting in 2014 — or the millions who will buy private coverage through insurance exchanges. They also need to consider the population that Alameda County is targeting: Medicaid's currently eligible.

The “woodwork” population

With the ACA focusing so much attention on its authorized coverage expansions — and implementing a mandate on individuals to obtain health coverage starting in 2014 or pay a tax penalty — there is an expectation that current eligibles will be swept up in the mix as well. Some portion of these individuals will enroll in Medicaid for the first time in 2014 despite being eligible for the program earlier, a phenomenon that researchers and enrollment advocates have termed “coming out of the woodwork.” Some will sign up because the coverage mandate will apply to them, but others just might be discovering for the first time that public health assistance is available.

The amount of woodwork population a state can expect to enroll depends on several factors, said Melinda Dutton. She's a partner at Manatt Health Solutions, a law and consulting firm working with states, health professionals and others on health system reform implementation.

States that offer the least generous Medicaid assistance “are likely to have the least amount of woodwork, because there just aren't as many people who are eligible for the program,” she said. Another factor is the size of a state's overall population, and how successfully it has reached out to eligible people to get them signed up.

The possible woodwork effect does have some limits. One is that many current eligibles don't make enough money to be penalized under the ACA starting in 2014 for not having insurance, said Lorez Meinhold, deputy executive director and director of community partnerships with the State of Colorado Dept. of Health Care Policy and Financing. If the cost of buying an insurance policy is expected to exceed a certain percentage of a person's income, the tax penalty will not apply. Exemptions also will apply to people who are too poor to file any federal tax forms in the first place.

States also won't get as much federal support for covering those already eligible for the program, possibly affecting how aggressively officials act to get them enrolled. States that expand Medicaid in 2014 get an enhanced federal match rate of 100% over the first three years, eventually phasing down to no less than 90%, to cover new eligibles up to an effective rate of 138%. Covering those already eligible gets states regular federal matching rates, which are significantly less generous.

But whether or not states expand Medicaid, they still will be responsible in some way for the health costs of those currently eligible, Meinhold said.

Dutton said many are realizing that covering these current eligibles — who in general are poorer and sicker than those who would be covered under the expansion — will be advantageous to their budgets in the long run.

“People are going to get sick and show up in public hospitals and clinics and emergency departments,” which means significant amounts of uncompensated care dollars will come from state coffers, Dutton said. That's why expansion is an attractive option for states, as is greater enrollment of those who are currently eligible.

Current eligibles have been reluctant

Several historical barriers have stood in the way of getting eligible people to enroll in Medicaid — pervasive factors that could limit the size of the woodwork effect starting in 2014.

The program arose from the foundation of the welfare program, and its application processes are structured “to ensure that ineligible people can't mistakenly get in, as opposed to ensuring that eligible people can get in. So there's been more of a defensive posture in the program's roots than an offensive posture in terms of outreach,” Dutton said.

Another problem is that many people simply don't know they're eligible or assume that they don't qualify for Medicaid, she continued. “Even in states that have more of a commitment to bringing new populations in, they don't have the budget to do outreach and take out ads.”

Many Medicaid-eligibles live in remote rural areas with limited knowledge of public health insurance, said Pete Wertheim, vice president for strategic communications with the Arizona Hospital and Healthcare Assn. “For others, they are not incentivized to sign up for Medicaid until they have a need for treatment for a medical condition.” Other studies have suggested that some people resist public assistance because they are uncomfortable being seen as accepting a government handout.

For those who do want to sign up, Medicaid's enrollment system has been difficult to navigate. Ron Pollack, executive director of consumer group Families USA, said signing up for Medicaid often means having to take a day off from work. Potential applicants may have to bring in “a shoebox of verification for a variety of different eligibility factors. Those things are hassles, and it results in a good number of eligible people never getting coverage.”

Families USA is one of the founders of Enroll America, a nonprofit organization whose goal is to facilitate health insurance coverage for the uninsured. The ACA attempts to minimize such burdens by ending asset tests and face-to-face interviews for Medicaid sign-ups that observers have cited as inhibitors of enrollment.

In California, the system of qualifying for coverage has been very confusing, said Victoria Sorlie-Aguilar, MD, a family physician who practices in Ventura County. “There's literally buildings at different sides of town for different programs, the county indigent program, the charity clinic, Medicaid,” she said.

The ACA has been working toward establishing a “no wrong door” concept of signing up for coverage, “that no matter where you go to apply, you'll be moved into whatever you qualify for, without being sent to another agency or person. You'll have one application for everything,” Dr. Sorlie-Aguilar said.

What states are doing now

Dutton said the tension surrounding Medicaid's culture and the initial effort to weed out ineligible people has lessened somewhat, as more states recognize the benefits of public coverage for the sickest and poorest. “As we're shifting over to a post-2014 ACA world, we've got lots of changes in infrastructure in terms of electronic enrollment. There are funds for outreach and education through Medicaid and the exchanges. So there are opportunities to chip away at those barriers,” she said.

Oklahoma has used health information technology to bring more people into the program. It used to be that people who qualified for Medicaid wouldn't sign up because they worked all day and couldn't get to Medicaid offices during normal business hours. Or they struggled with paying for the care of a child in a bike crash without finding out they qualified for SoonerCare, the state's Medicaid program. “The good news is these [stories] are all history,” said Nico Gomez, deputy chief executive officer of the Oklahoma Health Care Authority, speaking at the Kaiser event in Washington.

Supported by a federal Medicaid transformation grant, the state has reconfigured its Medicaid system and removed access barriers with an online enrollment process, which has strengthened outreach, Gomez said. Eighty percent of the state's managed care population now can access Medicaid through online enrollment. In the past fiscal year, Oklahoma processed 440,000 online applications. Seventy percent were approved, “and we expect that number to go up,” he said.

Gomez said kiosks or computers also have been installed in physicians' offices and other care locations, enabling children and adults to apply for Medicaid online, “right at the point of service,” he said.

Some states, such as California and Maryland, have hired consulting firms to help them develop public education and outreach campaigns, Dutton said. “Most have not gotten to the point where they have … narrowed down who their target audiences will be. They're doing market research to determine what will be successful. And in the dialogue I've been a part of, the providers are the top-polling trusted sources” to help develop these campaigns.

Physicians can play an important role in helping people understand what they're eligible for, Pollack said.

“Whether it's Medicaid or the exchanges, I think the mission of doctors is to keep people healthy, and physicians know that a lot of people are unlikely to seek care if they feel they can't afford it because they are uninsured,” he said.

“If a physician serves somebody who is uninsured, it's in the interest of physicians to get them insured, because it's a source of revenue, so they can do well by doing good,” he said.

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ADDITIONAL INFORMATION

State tactics to boost Medicaid enrollment

The Kaiser Commission on Medicaid and the Uninsured recently reported that states are simplifying enrollment through online processes, as well as incorporating outreach and enrollment assistance efforts to sign up more people in Medicaid and the Children's Health Insurance Program.

Outreach effort States
In-person assistance in eligibility offices 48
Toll-free assistance hotlines 47
Ability to apply online 37
Ability to create online accounts 36
Out-stationed state eligibility workers 35
Ability to renew online 28
State-funded, community-based application assistance 23
Ability to upload scanned documents 15
Ability to receive paperless notices 4

Source: “Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013,” Kaiser Commission on Medicaid and the Uninsured, Jan. 23 (link)

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External links

“Individual Shared Responsibility for Health Insurance Coverage and Minimum Essential Coverage Proposed Rules,” Centers for Medicare & Medicaid Services, fact sheet, Jan. 30 (link)

“Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013,” Kaiser Commission on Medicaid and the Uninsured, Jan. 23 (link)

“The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis,” Kaiser Commission on Medicaid and the Uninsured, Nov. 26, 2012 (link)

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