Thursday, June 04, 2020

Wasting asset for insuring the newly uninsured: State unemployment insurance agencies

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I want to use my small megaphone to help call attention to a vital unused resource in the drive to connect millions of newly unemployed Americans to available subsidized health insurance: state unemployment insurance agencies.

The Brookings Institution put out an admirably clear briefing identifying the size of the target population and the steps state unemployment insurance (UI) agencies should take to inform those seeking unemployment benefits of their insurance options -- and ideally, to help them enroll. That report builds on a Families USA call to action spotlighting the almost total abdication of UI agencies on this front.

Just prior to the pandemic,  a pathetically small proportion of the unemployed (under 30%) accessed unemployment insurance. Historically, a similarly inadequate percentage of the newly unemployed found their way to health insurance within a few months. The ACA appreciably boosted the latter percentage, from 30% to 44%, according to Brookings. Transition from employer-sponsored insurance to Medicaid or marketplace is still missed by the majority.

In the current crisis, the Kaiser Family Foundation estimates that 79% of tens of millions of newly uninsured people will be eligible for either Medicaid (47%) or subsidized marketplace coverage (31%).  We have to do better than we've done historically to connect people to benefits for which they're eligible.

The complexity of application for Medicaid or marketplace is part of the problem (partly because of flaws in the ACA exchanges' initial screening tools, which de-emphasize and can miss Medicaid eligibility).  But the larger problem is ignorance. People don't know that when their income drops off a cliff they're very likely eligible for Medicaid -- immediately (and if they aren't, their children probably are). If their income remains middle class, they don't know that they very may well be eligible for subsidized marketplace coverage.  Brookings cites a Hart Research survey finding that just 12% of the uninsured know about the availability of ACA tax credits. Experienced ACA enrollment assisters constantly report pervasive ignorance of the subsidized options available to them.

As tens of millions of Americans file unemployment claims, the office they interact with is a major but unused resource for cluing them in to health insurance options. As Brookings points out:
the process of applying for and receiving UI lends itself to efforts to facilitate health coverage enrollment. People generally obtain UI benefits by submitting an online application that is similar to the type of online application used for Marketplace and Medicaid coverage, so consumers are already accustomed to the process and have assembled relevant information. In addition, UI beneficiaries interact with the online UI system several times per month to recertify their eligibility, creating multiple opportunities to encourage health care enrollment. Finally, much of the information needed to apply for health coverage overlaps with information provided on the UI application, creating potential opportunities to streamline enrollment.
Brookings details four ways UI agencies can help, in ascending order of commitment and complexity:

  • Providing general enrollment related information within the UI application and at periodic UI recertification.
  • Providing personalized and interactive information regarding likely eligibility at application and recertification.
  • Partnering with nonprofit insurance assisters, other state agencies, or web-brokers to refer UI consumers for enrollment support.
  • Building an integrated UI and health coverage application in partnership with a state-based Marketplace or web-broker.
As UI departments are currently overwhelmed, perhaps the best to hope for in the short-term is the first step listed above - providing basic information. At a minimum, this would entail a message that most qualify for assistance accompanied by a link to an ACA exchange -- for 38 states, state-based exchanges for the rest.  Since the exchanges tend to under-emphasize Medicaid, and the majority of those eligible for benefits will be eligible for Medicaid, referrals to state Medicaid websites or departments would also be advisable. 

In the 35 states that have enacted the ACA Medicaid expansion, notification that current monthly income is the only criterion for Medicaid eligibility, and information about the income eligibility thresholds, should also be provided. It's not brain surgery, as Maine's Medicaid agency illustrates:

Bonus points for replicating a screening tool I keep coming back to:

State UI websites do none of this. According to the Families USA report, exactly one state, Washington, provides health insurance information on its home page; nine states provide links to other websites with information. Whether any state agencies provide information in subsequent communication with applicants I don't know; Brookings seems to present its proposals de novo.

[Update: in a Families USA webinar today (6/4), Betsy Plunkett, marketing director for the Maryland Health Connection, said that the state UI office is sending information to applicants about health insurance, directing them to the exchange. Cara Stewart of Kentucky Voices for Health (who I interviewed recently about a Kentucky Medicaid enrollment surge) described close partnership between the state's health/family services and UI agencies -- the UI agency is sharing applicants' information with HFS, which then emails or snail-mails the applicant  information about health insurance options. If the applicant opens an email but doesn't complete a Medicaid application, a followup email promises a phone call offering help.* Stan Dorn of Families USA said that Maryland and Kentucky are the only states he knows of that are taking action of this sort.]

Outreach from UI agencies is all the more urgent because the pandemic has likely inhibited a heavily trod path to Medicaid enrollment: enrollment assistance at Federally Qualified Health Centers. While the Trump administration has gutted enrollment assistance funding in the 38 states using the federal exchange for the navigator program established by the ACA, FQHCs have their own funding stream for enrollment assistance, which has not been reduced. Like all healthcare facilities, however, the health centers have radically reduced normal medical services during the pandemic. So that enrollment channel has been largely closed off.

Providing basic health insurance information to applicants for unemployment benefits is low-hanging fruit.  Healthcare advocates in all states should be pushing for it.

* Information about Kentucky enrollment outreach has been corrected. I originally wrote that the outreach email came from the UI dept.

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