Wednesday, May 27, 2020

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."

The state has also established emergency presumptive eligibility for Medicaid. Virtually any state resident under age 65 can enroll by filling out "the simplest one-page application I've ever seen," says Pugel. This enrollment ends after two months, or on July 31 if it's not extended; it is presented as a stepping stone to full Medicaid enrollment. A banner on the state Health and Family Services home page links to the emergency enrollment form.

A long way to go

Use of that easy form has been limited so far. As of the end of April, according to an analysis by Pugel, while about half of new enrollment* since February was via presumptive eligibility, only a third of that was through the emergency enrollment channel established for the pandemic. Enrollment via presumptive eligibility is available on a standing basis to uninsured pregnant women and uninsured low income adults.

Enrollment through this channel totaled 13,000 in March and April. "Honestly, I would have expected more," says Pugel.

Cara Stewart, director of policy advocacy at Kentucky Voices for Health and a veteran ACA enrollment assister, sees a need for more effective outreach. She infers that the information about coverage options that state agencies are sending out to state residents, for example when they apply for unemployment benefits, "can't be great -- people must not be understanding."

In light of the subsidized coverage available to most people who lose job-based coverage, Stewart says. "I'm shocked at the number of people who have contacted me about COBRA" -- the federally mandated option for those who lose employer-sponsored coverage to continue that coverage at full cost to themselves, usually for up to 18 months. Referring to the stimulus checks allotted to every American adult by the CARES Act, the largest Covid-19 relief bill to date, Stewart says, "People tell me they've spent the whole $1,200, all the money they had, on COBRA." Stewart senses a lack of collective memory about ACA coverage options -- the marketplace and Medicaid -- among those accustomed to employer-sponsored coverage.

Governor Beshear's messaging needs to be more specific, in Stewart's view. It's important not to assume that people know the extent to which the ACA expanded Medicaid eligibility, or that most people who lose employer-based coverage but earn too much to qualify for Medicaid will qualify for subsidized private plans in the ACA marketplace. "Say 'the rules have changed. Check your eligibility. Start with Medicaid.'"

The messaging problem is exacerbated because Republican Governor Matt Bevin, who lost his re-election bid to Beshear in 2019, dismantled Kentucky's successful state-based marketplace, Kynect, moving the state to the federal marketplace,, in advance of open enrollment for 2017. Kynect effectively integrated application for the ACA marketplace or Medicaid, depending on income and eligibility.  While the federal marketplace theoretically does this as well, a state website, Benefind, is a more direct and surer enrollment path for Medicaid that cross-checks eligibility for other state benefits. A search for health insurance is thus potentially split: Benefind (or the short presumptive eligibility form) for Medicaid, for marketplace enrollment if the applicant is not eligible for Medicaid.

As state budgets reel, Beshear still pushes enrollment

Cutting against the drive to cover the newly uninsured in many states is the collapse of state budgets under the pandemic's shock to the economy. On average, the federal government pays 60% of Medicaid costs, the rate varying according to state per capita income (it's 72% in Kentucky). For those rendered eligible specifically by the ACA Medicaid expansion, the match rate is 90%.  Politico reports that states are on the brink of slashing benefits and payment rates as fiscal year budget deadlines loom.

The second Covid-19 relief bill, the Families First Act, raised federal the match rate by 6%, on condition that states not throw anyone off the rolls for the duration of the emergency. That boost is not nearly enough to cover states' rising Medicaid expenses and huge deficits; in the much milder 2009 recession, Congress boosted the rate by 12 percentage points. The Heroes Act passed by the House would boost the match rate by a total of 14 percentage points as part of a trillion-dollar state aid package. Senate Majority leader Mitch McConnell declared the bill dead on arrival. The National Governors Association has called for $500 billion in new state aid.  Whether the bipartisan plea and constituent need move Republican senatrs remains to be seen.

Beshear is singing in the governors' SOS chorus, but so far he has not let fiscal pressure inhibit the "get covered" message.  "The governor has really taken a strong tack on that," notes Pugel. "In his press conferences he keeps saying "we're going to figure out a way to pay for it, but in the meantime we can't let people go without coverage, or go without unemployment benefits or go without food."

An ACA success story, revisited

Commitment to expanding healthcare access is a Beshear legacy. Under the leadership of Andy Beshear's father, Steve Beshear, who served as governor from December 2007 through December 2015, Kentucky embraced the ACA Medicaid expansion, implementing a successful state-based exchange and vigorously promoting the new coverage options. By 2016, Medicaid enrollment in the state had nearly doubled from its pre-ACA level, from 607,000 to 1.18 million, according to the Kaiser Family Foundation,** and the state uninsurance rate had been cut by nearly two thirds, from 14% in 2013 to 5%.

That progress was threatened and modestly rolled back by Beshear's successor, Republican Matt Bevin, who was elected in November 2015. Bevin initially ran on ending the state's enactment of the ACA Medicaid expansion and decommissioning the state's successful ACA exchange, Kynect. Bevin ultimately balked at ending the expansion, but he took other measures to curb enrollment -- most notably a plan to introduce work requirements for "able-bodied" adults. While that plan was struck down twice by the courts and then rescinded by Andy Beshear last December, the Bevin administration introduced subtler impediments to enrollment.

Total Medicaid enrollment in Kentucky fell 6%*** from January 2018 to January 2020. This month, enrollment passed the 2018 peak for the first time. With unemployment in the state at 15.4% in April, compared to 3.9% in April 2018, there are legions of newly uninsured who still need to be connected to benefits. The state is fortunate to have an administration that's trying to get the job done.

Update, 6/9 - as noted in this post. The new information about outreach is from Cara Stewart, cited above.
Kentucky also recorded a 2% increase from May to June and is up 10% since February, from 1.32 million to 1.45 million. Governor Andy Beshear's administration may be doing the most energetic outreach in the country. The state unemployment insurance agency is sending UI enrollment information to the Dept. for Medicaid Services, which is emailing and snail-mailing the newly unemployed to encourage them to enroll in health coverage. If a  recipient opens the email and does not complete an application as prompted, a second email promises that an HFS employee will phone with an offer of help. 
* Pugel's report cites a total enrollment increase of 67,216 in March and April. The state's monthly Medicaid log for May 1-31 shows an increase of 106,611 since February.

** Kaiser cites monthly CMS tallies consistently lower than those reported by the state. The Kentucky Health and Family Services website provides historical data only back as far as January 2018.

*** Nationally, Medicaid enrollment fell by 4% over the same period. The drop is probably due in part to a real increase in wealth: From 2014-2018, the number of Americans with incomes below the federal poverty level shrank 18.4%, from 46,657 to 38,056, according to the Census bureau, a trend that likely continued in 2019.

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