Thursday, May 21, 2020

C'mon, states: take the wraps off Medicaid

Subscribe to xpostfactoid via box at top right. You'll get 2-3 posts per week, mostly re ACA.

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:

This app is available on, the federal exchange serving 38 states. You will likely find it quickly from the home page --   if  you recognize that you may be eligible for Medicaid. But millions of newly unemployed people used to being covered through their employers may not recognize that. Medicaid, many think, is "for poor people" -- and "a few months of unemployment doesn't make me poor."

True, sometimes. But the key word in the screen above is monthly. Medicaid eligibility is based on current monthly income, and enrollment is available year-round. Further, the $600/wk supplementary unemployment benefit provided through July 31 (and maybe beyond, if renewed) by the CARES Act does not count toward Medicaid eligibility (it does count toward marketplace subsidies).

Millions will qualify -- between 8 and 27 million according to Urban's estimates. In Medicaid expansion states, the thresholds are $1,468/month for an individual, $1,983 for a couple, $2,498 for a family of three and $3,013 for a family of four. The average unemployment check is $378/week, and much lower in many states.

If you are eligible for Medicaid, there's a good chance that a visit to an ACA exchange or any other government website won't make that clear to you.

Covered California, the golden state's exchange, gets visitors quickly to an income screening tool. But like most such tools on ACA exchanges (including the main one on, it's oriented primarily toward showing marketplace subsidies. It therefore prompts for annual income, not monthly. If the user's estimated annual income is below the Medicaid threshold, the tool will recognize that. But if the user  has earned substantial income year-to-date while current monthly income (e.g., provided by unemployment insurance) is below the monthly threshold, the app will show private marketplace plans at premiums that reflect the annual income.  The home page does have a tab for Medicaid ("Medi-cal") information. But clicking through yields no information about eligibility thresholds.

What's true on Covered California is generally true in the 13 state-based exchanges: If you use a screening tool, you will be prompted for annual income (it's also true on the plan preview app you'll find if you don't ask specifically for Medicaid screening). The Connecticut and Washington exchanges do give you a choice of entering annual, monthly, weekly income. But they don't tell you why you might want to pick "monthly."  The screening tools generally don't even mention Medicaid until/unless your income estimate appears to qualify you.

The orientation on all the ACA exchanges is toward marketplace coverage. If there's Medicaid information -- say, a prompt to check whether you're eligible -- it's decontextualized: there's no indication who may be eligible, or what the core criterion (current monthly income) is.

In a way that's understandable. The exchanges were conceived primarily as a vehicle for selling plans in the private marketplace -- notwithstanding that from the very beginning, the Medicaid expansion was forecast to reduce the uninsured population by as much as the marketplace was. And in the event, Medicaid accounted for far more of the reduction in the uninsured population enabled by the ACA than the private plan marketplace did.

The government-subsidized health insurance options for those who lose job-based coverage are a crazy quilt.  Navigating them can entail complexity, confusion, and sometimes tough decisions. Often, though, it's not so hard, or shouldn't be. Half the newly uninsured should be able to enroll in Medicaid or CHIP in short order. Some states, such as Kentucky, are making it really easy and opening the door even wider via emergency presumptive eligibility.

State websites -- the governor's, the departments of health, labor, banking/insurance, really all state sites in this emergency -- should prominently feature a CHECK IF YOU'RE ELIGIBLE FOR MEDICAID** box.  Enter you zip code, monthly income, household members and their ages -- bingo, you're likely eligible. Click here and apply.

That's the fly trap that will catch the largest portion of the newly uninsured. A lot of states may not want to maximize enrollment, as their budgets are being crushed by the pandemic. That's where more federal aid comes in. But for those who, like Kentucky Governor Andy Beshear, say let's get people what they need now and figure out how to pay for it later, the imperative is clear. Prompt people to check whether they're eligible for Medicaid.

A single screening app could effectively work for Medicaid and the marketplace together. But such an app would start by prompting for monthly income, and if the income provided is below the Medicaid threshold, stop there. If the income is above 138% FPL, then the app would prompt for annual income, i.e. ask whether the monthly income times twelve is an accurate estimate of annual, and go on to estimate marketplace subsidies and prices. But none of the screening tools work that way.

As it now stands, state exchanges and other sites feature a welter of information about coverage, most of it pertaining to the marketplace, and most of it irrelevant to the Medicaid-eligible -- i.e., the majority of those who'll find affordable coverage. That needs to change.

UPDATE, 6/3/20: The Brookings Institute has a terrific report focused on state unemployment agencies as the most promising channel to help applicants focus on health insurance and find coverage. Brookings in turn cites a Families USA call to action showing that state UI agencies are doing next to nothing to inform applicants about Medicaid or the marketplace (some have information about COBRA, usually buried).

* In the 35 states that have enacted the ACA Medicaid expansion, Urban's forecast ratio of Medicaid to individual market enrollment exceeds 2-to-1.

** In many states the program isn't called Medicaid, which carries a poverty stigma. It's NJ Family Care, or MassHealth, or Medi-cal. Whatever the state moniker, the shingle should be hung out, ubiquitously. 

1 comment:

  1. The states are in a lot more fiscal trouble than just the recent boost in federal Medicaid matching rates can solve.

    In the past, eligible persons could be enrolled in Medicaid after they were admitted to a hospital, and the hospital bill would be covered. We need that to continue.

    The states that did not expand Medicaid will have to do something to protect their own hospitals.