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Reform Update: Slow start predicted for expanded Medicaid enrollment

By Rich Daly
Posted: June 18, 2013 - 2:45 pm ET

Officials hoping to enroll millions more beneficiaries into Medicaid programs this fall are signaling the possibility of a slow start. Ultimately, they hope to use some past success to overcome obstacles that have long left uncovered millions of Medicaid-eligible enrollees.

Cindy Mann, Medicaid director for the CMS, said at a recent Washington ACO Summit that she is confident that states will be ready by October to enroll millions who will gain access to the safety net insurer under healthcare reform.

The Patient Protection and Affordable Care Act allowed states to expand Medicaid access to all residents with incomes of up to 138% of the federal poverty level, and about half of them have done so.

But more time and work will be needed to improve the Medicaid enrollment process, Mann said at the gathering of health policy experts. Such problems would mean states won't be ready for "plan A" during the first year, but will instead rely on "plan B," she said.

The Medicaid expansion is expected to grow enrollment in the program by 7 million in 2014 and rise to 12 million new enrollees by 2020, according to February projections by the Congressional Budget office.

But enrollment in Medicaid is complicated by several factors, according to health policy experts, including its interlocking eligibility determinations with the health insurance exchanges also authorized by the 2010 healthcare overhaul. Eligibility for the exchanges or Medicaid will vary by state, depending on whether state officials chose to expand Medicaid eligibility. A July 2012 Urban Institute analysis concluded 15.1 million additional people would have gained Medicaid coverage if all states had expanded eligibility, but up to 3.6 million of them will instead gain subsidized exchange coverage since their state is not expanding eligibility.

Other complicating factors include the logistical challenges of simultaneously enrolling the millions who were eligible for either the Medicaid or the State Children's Health Insurance Program before the health law's eligibility expansions but never signed up. Many of those 7.2 million previously eligible people, according to the Urban analysis, are expected to also be driven to enroll by coverage campaigns launched by the Obama administration and allied organization—a phenomenon known as the woodwork effect.

It remains unclear whether the enrollment effort for Medicaid and the exchanges that began to roll out this week will outperform earlier Medicaid enrollment efforts, which left so many without coverage.

Anne Filipic, the president of Enroll America, a not-for-profit group aiming to drive enrollment in Medicaid and the exchanges, told reporters Tuesday that her group aims to learn from previous successful enrollment drives and to try new tactics.

“We will be doing testing to see what works,” she said about tactics that will include political campaign-style cold calls from volunteers.

Recent experiences in Medicaid enrollment were chronicled by a series of interviews with Medicaid officials previewed in a Health Affairs blog last week by Dr. Benjamin Sommers, an assistant professor in the Harvard School of Public Health, and colleagues.

The interviews revealed that five early adopting Medicaid expansion states and the District of Columbia had generally good results in enrolling newly eligible beneficiaries. Although few state officials saw evidence of the woodwork effect, they expect the enrollment campaign to change that.

They “pointed out that this was different because this was just the Medicaid piece of this; we didn't have the mandate, didn't have the exchanges, didn't have all of the PR that's going to go along with the national expansion in 2014,” Sommers said in an interview. “So their expectation is that the woodwork effect is going to come next year.”

Also, Sommers and his colleagues found that enrollment challenges will continue even after new beneficiaries are signed up. Officials in several of the states interviewed said they had difficulties enrolling very low-income adults and keeping them enrolled, in part because some of them had “transient housing and other unstable social circumstances.” Among the tools that overcame such obstacles to continuing enrollment was the use of “culturally and linguistically competent outreach conducted through community-based providers.”

Maine governor vetoes Medicaid expansion

On Monday, Maine Gov. Paul LePage vetoed a bill to expand Medicaid in the state by 70,000 enrollees, the Associated Press reported.

The Republican said he feared the state would ultimately bear the financial burden for the new enrollees.

The Democratic-controlled Legislature was left scrambling to override the second LePage veto of a Medicaid expansion. In an effort to make the Medicaid expansion more palatable to Republican legislators, Democrats had retooled the Medicaid expansion from the previous vetoed version by cutting off the state's participation in the program after three years.

LePage told lawmakers Monday that Maine's welfare system has already grown too fast and too large and he is concerned that the state would remain locked into the expanded services despite the sunset provision.

Ariz. governor inks Medicaid expansion

Also on Monday, Arizona Gov. Jan Brewer signed her highly sought Medicaid expansion.

A bipartisan coalition of state legislators overcame conservative opposition last week to enact Brewer's Medicaid expansion plan. Brewer, a Republican and once a staunch foe of the law authorizing the Medicaid expansion, pushed legislators to pass the expansion by threatening to veto all other bills, which she did to several unrelated measures, until the Medicaid expansion passed.

Opponents are planning a citizen's referendum that would block the law that could be filed as early as Tuesday. A lawsuit is also possible. To block the law with a referendum, opponents will need to gather more than 86,000 signatures in three months. A successful effort would prevent expansion from going into effect in January and put it on the November 2014 ballot.

Follow Rich Daly on Twitter: @MHrdaly


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