Wednesday, September 09, 2020

What's the matter with California? The mystery of flat Medi-Cal enrollment, revisited

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As part of a May budget revision in California, the state Department of Health Care Services (DHCS) projected that in response to job losses triggered by the Covid-19 pandemic, enrollment in Medi-Cal, the state Medicaid program, would increase  to 14.5 million by July -- roughly a 16% increase.

According to the state's current tally, from February to July enrollment in fact increased by just .02%, from 12.48 million to 12.50 million. Twenty-five other states that have reported enrollment through July show an 8.6% increase since February.  The Center for Medicare and Medicaid Service's most recent 50-state tally shows a 3.4% increase from February through May.

What gives? Why has Medicaid enrollment in California so far been essentially flat in the months since Covid-19 triggered mass unemployment?*

The DHCS cites several potential factors potentially inhibiting enrollment:
  • When people are laid off, their first concerns are food, rent, and other immediate necessities. In economic downturns, Medicaid enrollment tends to be a lagging indicator.
  • In the current crisis, many people who filed for unemployment may have been furloughed and maintained their employer-sponsored health insurance. 
  • Many of those who lost their jobs in this crisis, such as restaurant and hotel employees, are low income and may already have been enrolled in Medicaid. 
  • Hospitals and clinics are major sources of Medicaid enrollment, assessing the uninsured who come in through treatment and enrolling them via presumptive eligibility, available in California as in many states. During the pandemic, says Adam Weintraub, a DHCS spokesperson, "Nobody was really using medical services for any but the most critical needs. And that behavior seems to be continuing."
All of these factors are at play in all states, though variations in state economies and ethnic composition may make some more salient in California.  Again, then: why has Medicaid enrollment in California appeared to have barely increased at all during the pandemic months?

Problems with the enrollment process

One factor that may be particularly acute in California is a lag in Medicaid application processing and record-keeping. Weintraub explains: "In many states, all the eligibility decisions are handled at the state level. Because California is so spread out, we have federated our eligibility reviews down to the county level. And many of those county offices were shut down and were working remotely during the pandemic. We may have people who have come into the system and are being processed more slowly than they normally would. We do expect to see those numbers come up in the months ahead."

Jen Flory, a policy advocate at the Western Center on Law and Poverty, says that during the pandemic, when county offices were closed, more applications were coming in through the CalHEERS system, the application processing engine used by Covered California, the state ACA exchange. As volume built up, "We heard from the counties that new applications were taking longer than 45 days to process." She adds that the backlog is not likely to be in the tens of thousands, or 100,000 at most.

Flory further notes that when people enroll in person for CalFresh, the state food stamps program, county workers often ask them whether they're enrolled in Medicaid and encourage them to enroll if they're not. During the pandemic, "A lot of the surge in CalFresh enrollment happened when county workers had moved to remote work. A lot of people may have been missed."  Flory adds, however, that potential enrollments missed this way "might amount to thousands, or maybe tens of thousands" -- one more contributing factor to apparent low enrollment, but not likely a dominant one.

Problems with the enrollment process went beyond slow processing and missed opportunities. After Governor Newsom issued an executive order on March 17 suspending income redeterminations that lead to disenrollment,** the state's automated systems chugged on, erroneously disenrolling an estimated 200,000 people in April and May. The state has worked first to contact and re-enroll these people, and eventually to simply auto-re-enroll the remainder. DHCS claims that all but 21,000 -- those who were determined to have been disenrolled appropriately -- are once again covered.

Those re-enrollments will eventually be added back to monthly totals going back to April, Weintraub said. Accounting for enrollees who opt for retroactive coverage, which extends back 90 days in California, may also boost totals. Even so, California enrollment gains through July at least will remain far behind national averages. Marissa Kraynak, director of health policy research at the California-based Insure the Uninsured Project (ITUP), notes that retroactive adjustments to monthly enrollment figures are usually in the range of 8,000-12,000, or less than .01%. The re-enrollment of the disenrolled could add as much as 1.5% in total.

Katie Heidorn, ITUP's executive director, flags a further problem with CalHEERS processing, one that may have kept some prospective enrollees out of Medi-Cal, possibly diverting some into the private-plan ACA marketplace. The CARES Act, the massive Covid-19 relief bill signed into law on March 27, provided supplemental unemployment insurance payments of $600 per week for up to four months to an expanded range of laid off workers, including the self-employed. The law stipulated that those payments not be considered income for the purpose of determining Medicaid eligibility. Yet, early on, "we heard from at least one county that they were counting [the extra UI income] in Medi-Cal."

California has established presumptive eligibility in Medi-Cal for uninsured people who seeking Covid-19 testing or treatment. The state has established a 24/7 Medi-nurse line for the uninsured as well as for Medi-Cal enrollees who don't have a primary care doctor.  In addition to providing guidance on Covid-19 symptoms and treatment, the hotline will connect callers with a provider who can get them enrolled via presumptive eligibility into Covid-19 coverage, which can be a bridge to full Medi-Cal coverage for those who qualify. A bit shy of 18,000 people have been enrolled through this channel, according to Weintraub.

The Latin x-factor

Nationwide, 25% of Medicaid enrollees identified as Latinx as of 2013, the last year tracked by the Kaiser Family Foundation. In California, Medicaid enrollment was 50% Latinx as of 2018.

California's large immigrant community may be a factor in the apparent slow growth in Medicaid enrollment in the state during the pandemic. The Trump administration's rewrite of the so-called public charge rule, potentially penalizing the immigration status of legally present noncitizens who enroll in benefit programs including Medicaid, has loomed since October 2018, when the rule change was first proposed.  The rule may be inhibiting enrollment in the Latinx and other immigrant communities.

Weintraub notes that when the ramped-up public charge rule was finalized in February of this year, there was "no noticeable spike in voluntary disenrollments --  people saying, in effect, 'get me out of your database.'"***  Flory notes, however, that "new enrollment is skewing more white than we had seen." That may not be due primarily to the public charge rule:  "Maybe the message is not getting out to Spanish language media," she adds.

Flory also speculates that the inability for navigators to do in-person enrollment events because of the pandemic "might have more of an effect in some of our hard-to-reach communities, like the Latinx community. Normally, enrollments events might happen at a Catholic church, or another community space where you get people who might not know how to sign up for health insurance."

The long pause in non-critical medical care at hospitals and federally qualified clinics may also disproportionately affect immigrant communities, as on-site Medicaid enrollment is also a major channel for in-person assistance. Katie Heidorn notes that claims in federally qualified health clinics and county-run public hospitals, both major sources for Medicaid enrollment, are down 25-50%.

In short, immigrant communities tend to rely heavily on in-person enrollment, whether through non-profit enrollment assisters, county offices, or in-house assisters at hospitals and health clinics. These channels are all curtailed or shut down entirely.  Heidorn notes that much non-critical care is being delivered via telehealth, and that she's heard anecdotally that a lot of clinics are not serving new patients.

Weintraub stresses that new funding for the state's county-based navigator project, which targets enrollment assistance to hard-to-reach MediCal populations, was allocated in the budget year beginning July 1. An outreach push will start in October.

Getting the message out

In countries such as Japan and Germany that rely heavily on employers to provide health insurance but still manage to provide universal coverage, the transition to public insurance programs for people who lose access to employer-sponsored plans is fairly straightforward. Not so in the U.S., where government-subsidized insurance is available to at best 70-80% of those currently losing their insurance with their jobs, according to estimates by the Urban Institute and Kaiser Family Foundation.    Ignorance of the available programs -- Medicaid and the ACA marketplace -- is rife; enrollment is complex; eligibility and the degree of federal aid available is highly sensitive to income fluctuations; and immigration status affects eligibility even for legally present noncitizens.****

State departments of labor, health and human services, struggling to process huge demand for benefits with often antiquated computer systems and understaffed departments, compounded by the current necessity of staff working from home, are hard-pressed to focus on aggressively getting word out about available benefits.  In Kentucky, 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. But Kentucky -- where Medicaid enrollment increased 14% from February through July -- is an outlier.  To my knowledge, no other state has established such an active collaboration.

California does send recipients of unemployment insurance a notice with their first check encouraging them to explore their health insurance options on Covered California, the state ACA marketplace. CoveredCA, like most state-based marketplaces, has a "one door" enrollment system: applicants will be routed either to the private plan marketplace or to Medi-Cal, depending on income and other eligibility factors. And Covered California has been advertising, notes Anthony Wright, , executive director of Health Access California. a coalition of healthcare consumer advocacy groups. It has publicized emergency Special Enrollment Periods for the ACA marketplace, where enrollment during pandemic months, March 20 through August 20, has been more than twice enrollment in the same period last year, suggesting about 140,000-150,000 additional marketplace enrollees.

But information about Medicaid is hard to come by on CoveredCA. Like all the online marketplaces established by the ACA, its emphasis is on the private plan marketplace, where coverage is subsidized for those who earn too much to qualify for Medicaid but less than 400% of the Federal Poverty Level (effective in 2020, California added limited state-funded subsidies up to 600% FPL). This has not changed during the pandemic, notwithstanding that about twice as many of those who lose job-based coverage will qualify for Medicaid as for subsidized marketplace coverage -- which is often quite expensive, even if subsidized.

The CoveredCA home page features a screening tool that prompts for income and quickly indicates which program the visitor likely qualifies for (and the subsidy level if they qualify for subsidized marketplace coverage). But that tool prompts for annual income. Medi-Cal eligibility is determined by current monthly income. The screening tool won't recognize Medi-Cal eligibility if the applicant has earned substantial income prior to layoff. The more detailed actual enrollment process does determine current monthly income and route applicationsaccordingly, but that depends on a person electing to complete an application.

More broadly, CoveredCA messaging is oriented toward the private plan marketplace, where coverage can be quite expensive even when subsidized. Medi-Cal, available to more of the uninsured than marketplace coverage, costs enrollees nothing. "We've tried to tell the department [of health care services]: 'affordable' is not good enough. People need to hear 'free,' says Jen Flory.  "For a lot of people, the word hasn't gotten out."

Like most of the enrollment factors cited here, more emphasis on Medi-Cal on Covered California would likely have a marginal effect on total enrollment.  But the broader fact is that there is no broadcast mechanism to get across the message that about half of those who lose health insurance along with their jobs will qualify for Medi-Cal -- i.e., free, comprehensive health insurance.

One channel unique to the pandemic is governors' televised briefings. In Kentucky, Governor Andy Beshear touts Medicaid enrollment in every briefing -- which were held daily until recently. In California, "Newsom doesn't mention Medicaid," notes Anthony Wright of Health Access California.

For all the contributing factors cited above, the apparent lack of Medi-Cal enrollment growth in California since February remains a mystery. " Generally the advocacy groups that we've talked to are all scratching their heads," says Heidorn.  "We did all expect a pretty major increase in enrollment. I don't think that 2 million number that the Department set out is way off base. We've had over four million people file for unemployment in California."

*          *          *

Part of the apparent enrollment shortfall may be an illusion born of slow record-keeping. Part may be delayed reaction: the extent and timing of loss of insurance among those who are laid off or furloughed during the pandemic doubtless varies among states.  The heavy Latinx concentration in the Medi-Cal population may be a factor, as much because of that community's reliance on in-person enrollment channels as because of any chill imposed by the Trump administration. "Get covered" messaging and targeting could be more focused on Medi-Cal. The full picture will likely take months or years to come into focus.

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* The California DHCS sent the following raw monthly tallies for 2020:

Medi-Cal Certified Eligibles, January 2020 – July 2020 
Month of Eligibility
Certified Medi-Cal Eligibles

** The second pandemic relief bill, the Families First Act signed into law on March 18, required states to refrain from Medicaid disenrollments for the duration of the emergency as a condition of receiving an increase in the federal "match rate" for their Medicaid costs. All states complied with this condition.

***On July 29, the U.S. District Court for the Southern District of New York issued an injunction blocking enforcement of the rule, but on August 12, the U.S. Second Circuit Court of Appeals limited the reach of the injunction to New York, Connecticut and Vermont.

**** Federal law stipulates that legally present adult noncitizens are ineligible for federally funded Medicaid until they have been in the country for five years. Some states require even longer waiting periods, such as 40 quarters of employment. Those subject to the bar are eligible for subsidized marketplace coverage, even if their income is below the Medicaid eligibility threshold (138% FPL in expansion states; 100% FPL in nonexpansion states). Those with incomes below 138% FPL pay 2% of income for a benchmark silver plan, enhanced with Cost Sharing Reduction that raises the plan's actuarial value to 94%. While such plans have relatively low costs (deductibles average about $200), those costs are still a hardship for many low income enrollees and prospective enrollees. In households with mixed immigration status, some members may be on Medicaid and others eligible for marketplace coverage. Whereas Medicaid enrollment may be penalized under the public charge rule, marketplace coverage is not.

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