Monday, July 20, 2020

How to boost Medicaid enrollment in a pandemic: Kentucky's Cara Stewart has an idea or eight

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Let's zoom in once more on Kentucky, the state that appears to be having the most success enrolling the newly unemployed in Medicaid. From February to July, Medicaid enrollment in the state rose by 14.3%.  That's the sharpest increase in the nation, I believe, in the period of mass job loss triggered by the pandemic. [Update, 9/17: Medicaid enrollment in Kentucky is now up 19.7% since early March.]

That's not an accident. Kentucky has probably been the most proactive state in reaching out to the uninsured and helping them find subsidized coverage if eligible. Yet American standards are low: ignorance about Medicaid and the ACA marketplace is rife throughout the land. Cara Stewart, a longstanding advocate for increased healthcare access in Kentucky, and currently director of policy advocacy at Kentucky Voices for Health, believes the state could be doing more to reach out to the uninsured. We'll get to those ideas shortly. First, some benchmarks.

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In a widely cited analysis published in May, the Urban Institute estimated that in states that have enacted the ACA Medicaid expansion (as Kentucky has), about 53% of those who lose access to employer-sponsored insurance would be eligible for Medicaid (the monthly income threshold for childless adults in expansion states is $1,468/month for an individual, $3,013 for a family of four). In Kentucky, a low-income state, Urban estimates that about 62% of those who lose ESI will be eligible. Under its more conservative of two models*, Urban forecast that if 15% unemployment lasts for "several months to a year," 233,000 Kentuckians would lose access to ESI, and 144,000 would (or should?) enroll in Medicaid. Under a "high scenario," 397,000 state residents would lose ESI, and 249,000 would enroll in Medicaid.

Since February, Medicaid enrollment in Kentucky increased by 187,000 -- exceeding the Urban Institute's more conservative forecast at 15% unemployment. Strikingly, the state unemployment rate has tumbled from 15.4% in April to 10.9% in May and a pre-pandemic-y 4.3% in June. If that's not statistical noise -- or a blip soon to be reversed by resurgent Covid-19 and the expiration of federal relief --  the uninsured rate could conceivably be lower than before the pandemic triggered mass job losses.

In the pandemic months, Kentucky has taken the following action to encourage the newly unemployed to get covered by Medicaid or subsidized marketplace insurance:
  • In his televised briefings, which until recently were offered daily, Governor Andy Beshear regularly encourages Kentuckians to seek coverage.

  • The state established an emergency category of temporary presumptive eligibility (PE) for Medicaid and created a half-page online enrollment form that basically takes all comers.

  • Perhaps most importantly, the state unemployment insurance department sends applicant contact info on a weekly basis to the Department for Medicaid Services, which contacts UI applicants by email or snail mail and follows up by phone.
Cara Stewart acknowledges that this effort is probably best in the nation -- but that is not saying much. Between unemployment and enrollment in publicly financed insurance yawns a chasm of ignorance and stigma. In red states like Kentucky in particular, Medicaid is looked down on as poor people's insurance, though more than half of those who lose employer-based insurance will qualify. 

For starters, Stewart would like to see the Medicaid Department -- and Governor Beshear -- replicate a strategy used by the unemployment insurance department to increase the response rate to phone outreach. Currently, she estimates, about 40-50% return phone calls about Medicaid, and the enrollment rate is about 20%.  Americans tend not to pick up the phone unless the call is from a known source. To prime people for calls regarding unemployment insurance, the state broadcast the number on social media, in newspapers, and in the governor's daily briefings, with a message: if this number is calling you, pick up.  "They fixed that in the first week for unemployment insurance," Stewart says. "Do the same for Medicaid."

Stewart's other ideas:
  • Deploy contact tracers.  Kentucky's health department currently has about 700 people calling state residents who have tested positive for Covid-19 and those with whom they report having recent contact.  Some tracers have protested that they're not enrollment assisters. "Fine," Stewart says, "hand them off to Kynectors" -- her favored term for state-funded enrollment assisters (more on that below). "You're giving people upsetting news that their health is at risk -- so make sure they have health coverage."

  • Use hold time.  "We could be asking everyone when they are on hold for unemployment insurance to interview for all other benefits including Medicaid," Stewart says.

  • Deploy school principals. To enable remote learning during the pandemic, Kentucky public schools have distributed laptops and Chromebooks to students who need them. Administrators reach out to recipients at regular intervals to confirm that the student still has the device and that it's still working. "We could require school administrators to check on health insurance when they check in on the tech," Stewart proposes.

  • Establish auto-enrollment. When someone applies for unemployment insurance, Stewart asserts, "we have everything we need for a PE Medicaid application.  Use that and apply for them and send a letter saying you now have Medicaid presumptive eligibility in addition to any other coverage (if any)." An opt-out would be provided (or an opt-in, if the state prefers to be more conservative).  

  • Establish auto-enrollment, Part 2.  As of the end of April, about half of new Medicaid enrollments in Kentucky were through presumptive eligibility -- both the emergency PE program noted above and a pre-crisis PE program for uninsured pregnant women and low income adults. Enrollment through PE lasts just 60 days, and Stewart  wants to smooth the path to full coverage. She suggests handing off PE enrollees who don't actively seek permanent enrollment but appear eligible to the state's six Medicaid managed care organizations (MCOs), who could conditionally enroll the handed-off candidates, with an opt-out. 

  • Smooth re-entry for the incarcerated. Stewart proposes providing those released from prison with an ID to make it easier for them to enroll in Medicaid. "They shouldn’t have to wait and pay and pay for a Social Security card or birth certificate. We took their fingerprints and scanned their eyeballs. We know who they are. Print their docs for them so that’s not an enrollment barrier." 

  • Rebrand Kynect. By happy accident, ruby-red Kentucky had a Democratic governor, Steve Beshear, when the ACA's core programs became operative on January 1, 2014. Beshear had prepped the ground by opting Kentucky into the ACA Medicaid expansion and establishing a state-based exchange, Kynect, that integrated Medicaid and marketplace enrollment, and by deploying state-funded "Kynectors" to fairs and other public venues to introduce people to the system and enroll them. The Kynect branding was essential in a state ideologically hostile the ACA, a.k.a. "Obamacare," and Kynect earned a sterling reputation in the state. Republican governor Matt Bevin, who succeeded Beshear in late 2015, dis-Kynected the state exchange in advance of Open Enrollment for 2017. Current Governor Andy Beshear (Steve's son) plans to reopen Kynect in time for the 2022. In Stewart's view, re-branding the state funded enrollment assisters as "Kynectors," as they were dubbed pre-Bevin, would make Kentuckians likelier to seek and accept their help, reducing the stigma attached with seeking "Obamacare." The rebranding now would also make it harder for a veto-proof Republican legislature to kill the Kynect revival, Stewart believes. 
Kentucky State Fair
Kentucky State Fair, a Kynect outreach site
In a country with a functional universal healthcare coverage system, including one that relies largely on employers to provide coverage, the procedure for a newly laid-off person to transition to  public health insurance would be straightforward: notify the local health department of loss of employer coverage and enroll in a program open to all who need it, provided on a sliding income scale. That's more or less how things work in Japan. In the U.S., roughly a quarter of those who lose job-based coverage are not eligible for any subsidized coverage at all. In the fourteen states that have refused to enact the ACA Medicaid expansion, the subsidy-ineligible percentage of the newly uninsured rises to half.  Many who are eligible for marketplace subsidies find the coverage on offer prohibitively expensive.** Many more have no idea what's on offer, particularly in red states, where "Obamacare" was vilified for years by ruling Republicans. Many if no Americans have no idea where to look for insurance when they're laid off -- and if they google "health insurance" they're likely to connect with purveyors of the ACA-noncompliant junk insurance promoted by the Trump administration. Application on the ACA exchanges, which in expansion states can enroll or qualify applicants for Medicaid as well as marketplace coverage, is in many cases fraught with complexity and requires assistance.

State government action to overcome these hurdles can have a major impact, as Kentucky's current enrollment performance indicates.  Given the complexity of the process, the fragmented nature of the programs available, the hypersensitivity of eligibility standards to changes in income or life circumstance, and the general ignorance, actively fostered in more than half the states by Republican hostility, there is always more to be done to connect people with the benefits they're entitled to. Committed healthcare advocates and enrollment assisters can help governments that have the will to enroll people find a multitude of channels.

[Update, 9/17: The state has been running an ad campaign targeted at minority communities encouraging Medicaid enrollment, according to Cara Stewart.]


*  Urban's more conservative model matches ten years of American Community Survey data regarding health insurance coverage with state-level unemployment data. The less conservative model uses 20 years of national time series data, which tracks the unemployment-uninsured ratio across two recessions but is less fine-grained.

** For a single person with an income of $32,000/year, a benchmark silver plan costs $226/month , with an average deductible in excess of $4,000. Out-of-pocket costs are much lower for those with incomes below 200% of the Federal Poverty Level (about $25k/year for a single person)

Photo by Amanda Cottrell from Pexels

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