Enrollment under the ACA: examples and best practices

1. Enrollment under the ACA: examples and best practices HLC Policy Committee April 6, 2011 Stan Dorn, Senior Fellow The Urban Institute Washington, DC 202.261.5561 sdorn@urban.org

2. Topics • Enrollment: not necessarily a slam dunk • Some examples of success • Other best practices

3. Part I. Enrollment: Not necessarily a slam dunk

4. Why enrollment matters • Access to care • Enforcement of the individual mandate • Stability of insurance markets

5. CHIP and Food Stamps: Early history Effective 10/1/97 Food stamps, after 2 years: 31% take-up Source: Selden, et al., 2004 (MEPS data).

6. More history • Medicare Savings Programs (MSP) reach < 33 percent of eligibles • In 2002, Social Security outreach to 16.4 million eligible people led to 74,000 enrollees • After much effort, Food Stamps reached an all-time high participation rate of 67 percent in FY 2006 • CHIP and Medicaid reached 82 percent of eligible children in 2008

7. Percentage of eligible children enrolled in Medicaid or CHIP, highest and lowest states: 2008 Source: Kenney, et al., 2010.

8. It’s not just low-income people! Source: Laibson 2005.

9. Part II. Examples of success

10. Medicare Part D Low-Income Subsidies (LIS) Total enrollment: 74% Source: CMS enrollment data. Calculations by Urban Institute.

11. Coverage expansion in Massachusetts • Extraordinary results • Only 2.6 percent of state residents were uninsured in 2008 • Most new coverage was highly subsidized • Well-known policy changes • Subsidies up to 300% FPL, through Medicaid and the new “Commonwealth Care” (CommCare) • All adults mandated to purchase coverage • Health insurance exchange (the “Connector”)

12. Massachusetts: less well-known policies • Massive PR campaign • Public-private partnership • Consumer-friendly application process • One application form for multiple subsidy programs • “No wrong door” • Automatically qualified people for subsidies based on data from prior free care pool • After 15 months, this accounted for roughly 1 in 4 newly insured • Application assistance • 60% of all successful applications completed, not by consumers, but by application assisters

13. Renewals in Louisiana • In many states, 30-50% of Medicaid/CHIP children lose coverage at renewal • Failure to complete and return the renewal form ends coverage, even if children continue to qualify • In LA, <5% lose coverage at renewal • When data matches show a reasonable certain of continued eligibility, automatic renewal • If more information needed, families encouraged to provide it by phone • <15% of families are asked to complete paperwork

14. Part III. Some Best practices

15. How do we know? • Lots of work around child health • Many experts, including: • Center on Budget and Policy Priorities • Families USA • First Focus • Georgetown Center for Children and Families • National Academy for State Health Policy • State Coverage Initiatives program of AcademyHealth • The Children’s Partnership • Urban Institute

16. Examples of best practices • Use authoritative data to qualify people for benefits • Simple applications in multiple languages • Diverse modalities for submitting applications • “No wrong door” • Consumer assistance • Streamlined renewals

17. ACA implementation • New federal resources and guidance to support IT development • Early innovator grants • Examples: Wisconsin and Oklahoma • Other exciting innovation • Louisiana rides again

18. Conclusion • High enrollment under ACA is possible • The legislation has many good elements • HHS is committed to effective implementation • But ACA is vast, and implementation duties will outstrip available resources, at both federal and state levels. • Nitty-gritty enrollment issues can easily fall through the cracks • Significant obstacles in many states • An outside coalition of stakeholder groups can keep the focus on enrollment best practices and make a significant difference, at the federal and state levels