Medicaid enrollment in a pandemic: The case of Kentucky

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Update (6/9/20) at bottom, with June enrollment numbers and more information re enrollment outreach in KY.

Of the tens of millions of Americans likely to lose access to health insurance as a result of job losses triggered by the Covid-19 pandemic, the Urban Institute estimates that about half -- 8.2 million in the most conservative of several scenarios -- will enroll in Medicaid. Kentucky appears to have gotten off to a comparatively fast start, though state healthcare advocates see a need for more intense outreach.

Medicaid enrollment in the state has increased by more than 100,000 (8%) since February, from 1.32 million to 1.42 million, according to the state's monthly membership tally.  In 2019, enrollment from March to May was flat, down less than 1%. At 20% unemployment, which we're likely to reach in the next jobs report, between 336,000 and 397,000 Kentuckians are likely to have lost access to job-based insurance, according to the Urban Institute estimate. Urban foresees Medicaid enrollment in Kentucky increasing by between 208,000 and 228,000 thousand if that unemployment rate holds for some months.

Dustin Pugel, a senior policy analyst at the Kentucky Center for Economic Policy, credits Governor Andy Beshear, elected just last November, with stimulating and facilitating crisis Medicaid enrollment.  During his daily televised, widely watched Covid-19 briefings, Beshear regularly starts with ten steps for fighting the virus, and, Pugel says, "One of them is signing up for benefits. Medicaid is mentioned every single time."

C'mon, states: take the wraps off Medicaid

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On the eve of the pandemic, about 13 million Americans were enrolled in ACA-compliant individual market health insurance plans. About 71 million were enrolled in Medicaid.

As job losses triggered by the pandemic exceeded 30 million, the Urban Institute forecast that at a 15% unemployment rate, among 17.7-30.0 million people losing access to employer-sponsored insurance, just under half would enroll in Medicaid and just under a quarter in marketplace or other private insurance.* Analyses by the Kaiser Family Foundation and Health Management Associates also show Medicaid to be the main vehicle for insuring those who lose access to employer-sponsored insurance.

Every ACA exchange, every state Medicaid agency, and arguably every state government website should be foregrounding an app that looks (and works) like this:

New Jersey's "Get Covered" message submerges Medicaid

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New Jersey, a very blue state with a liberal governor and large Democratic majorities in both houses of the legislature, is committed to helping hundreds of thousands of residents newly uninsured in the Covid-19 pandemic to find subsidized coverage. The state has launched an information campaign to help people get covered.

But New Jersey's ACA marketplace is stuck in limbo during a tough time. The state is in the process of creating its own state-based exchange (SBE), scheduled to launch on November 1. In the meantime, it's technically an SBE, but still using the federal exchange, HealthCare.gov, for enrollment.

That creates a messaging problem. The state has created a website, Get Covered New Jersey, to help people find coverage. But it has to be a complex switching station. Those eligible for subsidized marketplace coverage need to enroll through HealthCare.gov. Those eligible for Medicaid -- probably the majority of the newly uninsured -- can also apply via HealthCare.gov but, for reasons explained below, are probably better off applying directly through the state's Medicaid program, New Jersey Family Care. Finally, those who earn too much to qualify for aid need to be aware of ACA-compliant plans offered off-exchange only, especially since these include the cheapest silver plan available.

Get Covered New Jersey tries, but in my view fails to help people figure out quickly what kind of help they're eligible for, and act accordingly.

The main problem is that the site doesn't foreground Medicaid or, most vitally, a Medicaid eligibility screener. According to an Urban Institute estimate, almost half of New Jersey's  newly uninsured residents (224,000 out of 489,000 by the study's more conservative of two estimates) should end up in Medicaid, while just under a quarter may enroll in marketplace coverage.

Obama's bid to bend the arc back toward justice

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In 2013, I marveled as pundits expressed surprise when Obama said what he'd always said about the economic case for a fairer distribution of wealth. It seemed that the connection Obama constantly asserted between fairness and prosperity hadn't registered. I wondered, Will we hear Obama in retrospect?

The answer now appears to be yes, evident in the outpouring of love and longing in reaction to his virtual commencement speeches for graduates of historical black colleges and universities and all high school graduates. But not in the way I'd anticipated.

Obama's core pitch, as candidate and president, was for a recommitment to shared prosperity -- public investment, income redistribution -- after decades of steadily encroaching plutocracy. He encased this pitch in a seductive narrative of American history in which this commitment to the common good was renewed and extended at intervals: the nation might err, but its long-term course was to approach ever nearer to fulfilling its founding principles of equal rights and shared opportunity. Democracy, embodied in bottom-up demand for justice, enabled periodic course correction: American history followed the arc that bends toward justice.

Hey America, let's go through the Obamagate

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Trump, displeased by U.S. law enforcement and intelligence agencies' investigations of the criminals and traitors who staffed his 2016 campaign and early administration, is deploying Barr (and his own deranged rhetoric) to smear and criminalize those efforts and tie them to the past administration under the rubric of "Obamagate."

In Trump parlance, "Obamagate" is a mass of trumped-up charges and projections advancing the fiction that Obama, like Trump himself, deployed law enforcement and intelligence to pursue his personal enemies and protect his personal friends. Obamagate is a moral looking glass through which Trump's face is imposed on Obama's.

I'll give Trump this: The term does have a certain resonance. Would that this country could pass through an equally fantastic Obamagate to various norms and benefits we took for granted when Obama was president.

If only we could..

• Pass through an Obamagate to a time when the president put the national interest above his personal interests, and worked as hard to advance prosperity and opportunity in states run by his political rivals as in states run by his political allies.

Getting insured after job loss: Just how complicated?

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About 27 million of the newly unemployed and their family members have likely lost health insurance, according to a new Kaiser Family Foundation estimate.

The ACA offers a leaky but not entirely unseaworthy lifeboat. According to Kaiser estimates, 79% of the newly uninsured are at present likely eligible for ACA-subsidized coverage -- 12.7 million for Medicaid and CHIP and 8.4 million for subsidized private plans in the ACA marketplace.

The basic buckets that those seeking insurance should find themselves sorted into shouldn't in principle be that complicated. Here's the breakdown:

The ACA as it should have been: Massachusetts' ConnectorCare in a crisis

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On March 11, the Massachusetts Health Connector became the first ACA marketplace to respond to the flood of job losses triggered by the Covid-19 pandemic by opening an emergency Special Enrollment Period (SEP) in which any uninsured resident could enroll in private market coverage. Eventually, 12 of the 13 state-based exchanges opened emergency SEPs, whereas HealthCare.gov, the federal exchange serving 38 states, declined to do so, though HealthCare.gov has taken steps to ease the normal SEP-for-cause application process. 

On  May 1, Massachusetts reported that in the SEP's first 40 days, 8,300 state residents had gained coverage specifically through the emergency SEP, while 20,200 in total had enrolled in coverage in March and April -- the bulk of them via ordinary SEPs, in which an applicant reports a life change, usually loss of other insurance, that qualifies her to enroll outside of the annual fall Open Enrollment period.

It's hard to assess the success or impact of the emergency SEPs based on these kinds of data snippets, which several state marketplaces have put out. On the whole, March/April enrollment in Massachusetts represents 6.3% of enrollment as of the end of Open Enrollment in January. That does seem a somewhat elevated off-season pace.* In any case, it's likely that Medicaid will pick up the lion's share of the newly uninsured, and the enrollment report did not include Medicaid numbers.

Enrollment in Medicaid surges in Minnesota

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An Urban Institute analysis released this week, How the COVID-19 Recession Could Affect Health Insurance Coverage, estimates, in the more conservative of two models deployed, that if the unemployment rate reaches 15%, Medicaid enrollment will increase by 8.2 million  nationally. That would constitute a 16% increase in total Medicaid enrollment for the under-65 population.

Minnesota appears to be halfway there already. The state tracks enrollment in managed* Medicaid and MinnesotaCare, a Basic Health Program that provides Medicaid-like coverage to people in households with income up to 200% of the Federal Poverty Level, on a monthly basis.

From February to May this year, managed Medicaid enrollment in Minnesota for adults age 21-64 is up 10.4%. For pregnant women, it's up 16%. Enrollment of children is up 6%. Enrollment in MinnesotaCare, the BHP, is up 24% -- though enrollment in that particular program was up almost as much in Feb-May 2019.

In total, managed Medicaid/MinnesotaCare enrollment has increased by 77,142 (8%) since February, more than five times last's year's increase in the same period of 14,547 (2%).  Since mid-March, 590,000 Minnesotans have applied for unemployment benefits, according to the state Management and Budget office's May budget projection.

ACA enrollment in a pandemic: What we know so far

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Roughly 30 million Americans have filed jobless claims in the last six weeks. Slightly fewer than half that number may have also lost health insurance, according to an analysis by the Economic Policy Institute.*

The Urban Institute estimates that 59% of those in industries most vulnerable to job loss who lose job-based coverage will have access to government-supported insurance -- Medicaid, CHIP, or the ACA marketplace. How many accept the help is a different question.

The SEP imperative

The answer may depend in part on how wide the ACA online exchanges open the door. Normally, the uninsured can seek coverage only during a limited Open Enrollment Period (Nov. 1 - Dec. 15 in the federal exchange, longer in the 13 state-based exchanges), unless a change in life circumstances during the off-season renders them newly eligible. In that case they are granted a Special Enrollment Period (SEP). Applying for a SEP adds steps to the already complicated ACA enrollment process. Under normal circumstances, an applicant has to upload or mail in proof of loss of coverage, or proof of another SEP trigger, such as marriage.