Friday, August 14, 2020

Medicaid enrollment in Utah could use a state push

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Last week I noted that Utah's launch of full ACA Medicaid expansion in January of this year was fortunately timed to catch tens of thousands of Utah residents who have lost access to employer-sponsored health insurance during the pandemic.

Yesterday I spoke to Stacy Stanford and Sarah Leetham of the Utah Health Policy Project about Utah's Medicaid enrollment gains during the pandemic -- which might fairly be deemed moderate when the full context is considered. UHPP was in the thick of the successful fight to pass a referendum to enact the ACA Medicaid expansion in 2018 and works with a network of partners to provide enrollment assistance to Utahns seeking coverage.

To review the back story briefly: After the referendum passed, Utah's Republican legislature and governor enacted a partial expansion, offering Medicaid to state residents with income up to 100% of the Federal Poverty Level instead of to the ACA's stipulated  threshold of 138% FPL. The partial expansion launched in April 2019, while the state filed a federal waiver request seeking to apply the ACA's 90% federal match rate to the limited expansion population. When CMS rejected the waiver, the state went to Plan B -- full expansion -- effective Jan 1, 2020. A work requirement went into effect on Jan. 1 but was suspended in April 2020 -- before anyone who failed to comply with its reporting and job-seeking demands could be disenrolled -- in response to the pandemic.

As of December 2019, 42,991 Utahns rendered eligible by the partial expansion (adults with incomes below 100% FPL) had enrolled. From February to June this year, enrollment in the expansion population grew by 24.3%, from 47,948 to 59,589. From March 2019, the month prior to partial expansion, total Utah Medicaid enrollment increased 21.5% through June 2020, to 343,375. That increase of 60,826 includes some 16,000 people who were transferred from a limited state-subsidized Primary Care Network program into full Medicaid when the partial expansion launched. 

Looking back at the pre-pandemic period, Stanford says that enrollment "really was slower than we hoped. The boots-on-the-ground people were all a little disappointed in the uptake rate."

State officials, according to Stanford, "are not really keen on promoting it. They haven't put money behind outreach and any kind of promotion. They hired I think three outreach workers. The state is relying on nonprofit and groups that do outreach with low income folks."

Leetham adds: "We had to do a lot of educating and outreach --  the messaging has been pretty confusing for a long time" -- as the state went through years of battle over expansion and changing plans. "The people who needed expansion didn't really know what was going on with it.  Clients will say, 'Oh, I applied [pre-expansion] and didn't qualify,' or 'the expansion didn't happen.'"

What about during the pandemic months? Now, too, "It's really falling on us get the word out there," Stanford says. "The governor [Republican Gary Herbert] was doing press conferences every single day during the early Covid period. Now he's doing them weekly. I've watched everyone one of them, and he's not once said the word 'Medicaid.' He'll promote other benefits, like unemployment, but he has not once mentioned Medicaid." (Contrast Kentucky, where Democratic Governor Andy Beshear encourages Medicaid enrollment in every briefing.)

"We see how important insurance coverage is, and especially Medicaid in getting a handle on the pandemic," Leetham adds. "Especially in Utah, with the disparities we see -- our minority communities are getting hit the hardest, and Medicaid is one of the best tools for fighting that."  But the state isn't helping much. As a state using the federal exchange,, Utah is exposed to the Trump administration's gutting of federal funding for enrollment assistance (reduced 84% from 2017-2018) and advertising (down 90%). UHHP has coped with the funding cut by becoming a nonprofit brokerage.

All that said, overall growth in Utah Medicaid enrollment during the pandemic months has been substantial. A total enrollment increase of 10.8% from February through June puts Utah in the top tier of states. One would expect a newly minted full Medicaid expansion to drive enrollment growth, and that's true to a degree, with 24.3% growth in the expansion population -- though Utah is unique in its two-phase expansion, and growth in phase 1 (partial expansion, April-December 2019) was below expectations.

Stanford and Leetham see pandemic-era growth as moderate. January, says Stanford, is usually the highest-enrollment month. During the pandemic, "every month has been a January-type level." 

Utah, like all states, has met the requirement in the Family First Act, the second federal Covid-19 relief bill, to refrain from disenrolling any Medicaid enrollees for the duration of the national emergency, and that has boosted enrollment totals. Leetham notes that a moratorium on CHIP premiums and the suspension of work requirements have also boosted numbers. With UHPP and other enrollment assisters working remotely, however -- serving clients via screen-share or phone -- applications are taking longer, slowing the work flow.

Stanford notes that the state has taken one measure that may be having a mildly stimulative effect. In compliance with Trump administration policy, a special enrollment category has been added for Covid-19 testing for the uninsured.  The application for that coverage is extremely short, with presumptive eligibility granted, and state officials "are using it as an on-ramp" to full Medicaid enrollment.  While the state recorded just 558 Covid-uninsured enrollees in June, the first month of operation, it's possible that more enrollees in full Medicaid have since entered through this channel.

On the other side of the equation, during open enrollment for 2020, which ran from November 1 through December 15 last fall, approximately 50,000 Utahns with incomes in the 100-138% FPL range enrolled in private subsidized marketplace plans. While those enrollees became eligible for Medicaid on January 1, the state is enabling a "passive" transition, as Stanford puts it. That is, they're not encouraging transfer until 2021, when those with incomes below 138% FPL will no longer qualify for marketplace subsidies. "The state isn't super-eager to take on the 10% match" -- its share of the Medicaid bill for expansion enrollees, Stanford says. The federal government pays 100% of marketplace subsidies.

To step back, the 21.5% growth in Utah Medicaid enrollment in the 14 months following partial expansion is somewhat low by national standards.  It's true that Utah is a wealthy state, with a median household income of $71,414 in 2018 -- almost $10,000 above the national median. In next door Colorado, however, with a near-identical median household income of $71,953, Medicaid enrollment is 64% above the pre-ACA-expansion total -- albeit six years after Colorado enacted its expansion. 

A closer "comparable" might be Virginia, with a median household income of $72,577, which enacted the expansion in January 2019. From December 2018 to April 2020, Virginia Medicaid enrollment increased 37.8%, from 1,053,309 to 1,450,785. By June 2019, six months after the expansion launch, enrollment had increased by 25.7%. 

These comparisons don't take into account the distribution of income within the population, or myriad other factors. But they do suggest a range of expectation.

When the Utah legislature was considering Medicaid expansion, they worked consistently with an estimate of 150,000 new enrollees. Stanford said that all along "the 150,000 estimate felt high, but that's the number the legislature agreed on" and advocates had no motive to pick a fight on that front. At present, "we try to recognize 60,000 new enrollees as a victory" -- particularly, one might think, as more than half the increase has occurred during the pandemic. But plainly there are many uninsured in the state who are eligible for coverage, and the state government could be doing far more to enroll them.

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