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Reform Update: Lack of awareness may be keeping Medicaid enrollment numbers lower, study shows


By Virgil Dickson
Posted: January 28, 2014 - 4:00 pm ET
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Enrollment rates of people who are newly eligible for Medicaid under the healthcare reform law may be lower than anticipated because of a lack of awareness.

Researchers from PerryUndem Research/Communication studied the enrollment trends so far for the Medicaid and CHIP Payment and Access Commission and unveiled their findings during the Congressional advisory panel's Jan. 23 meeting.

The researchers conducted eight focus groups in California, Nevada and Maryland, three states that have opened their programs to residents making up to 138% of the federal poverty level, as called for by the healthcare reform law.

Few of the participants knew that Medicaid had expanded in their state and only found out when they attempted to get health insurance on the exchange. Even upon being told, many were unfamiliar with what Medicaid was and how it worked.

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Participants included Latinos, young adults 18 to 34, parents of young children, and childless adults who have either applied to the program or are eligible but have yet to seek coverage under the program.

“There's been a significant communications failure,” Andrea Cohen, a MACPAC commissioner and director of health services in the New York City mayor's office, said at the meeting.

That failure could be a casualty of the states' efforts to publicize the private coverage and the subsidies available through the insurance marketplaces, said study co-author Michael Perry, partner at Perry Undem Research/Communication. “My sense is that explicit messaging about Medicaid has not been a part of many states outreach,” Perry said.

States may be relying on organizations working under state and federal grants as “navigators” to get the word out about Medicaid via grassroots outreach, “but nothing on the airways,” he said.

There is evidence of weak numbers of newly eligible enrollees in other states that have expanded their programs. In response to requests for data from Modern Healthcare, Washington state officials said that about 65% of the 380,911 people who signed up for the state's Medicaid program between Oct. 1 and Jan. 9 were in the program in 2013. In West Virginia, another expansion state, only about 75,000 of the more than 420,000 people who enrolled between Oct. 1 and Jan. 15, were new to the Medicaid program.

In addition to lack of awareness, stigma associated with being on the program could be playing a part in why newly eligible enrollees are for now steering clear, said Aaron Katz, a health policy lecturer at the University of Washington's School of Public Health.

“As (the newly eligible) have higher incomes than those who've been on Medicaid previously … it may just take them some time to accept they need the help and figure how to get it,” Katz said.

Another factor could be the ongoing technology problems with the state and federal exchanges, according to Dan Hawkins, senior vice president of public policy and research at the National Association of Community Health Centers.

The CMS still has limited ability to transmit completed Medicaid applications from HealthCare.gov to state Medicaid agencies. State exchanges are also experiencing trouble in sending applications to the agencies in their regions. As a result, people have been asked to apply multiple times before they're actually enrolled.

“I'm afraid some people just give up,” Hawkins said.

Some states that have chosen not to expand their programs, however, are seeing a flood of new interest in Medicaid coverage.

In Florida, for instance, state officials told Modern Healthcare that of the 303,374 new enrollees added to Florida's program, more than half had not been enrolled during the last 12 months.

“The state has done little or nothing to aid these individuals to get enrolled, but they are finding a way,” Hawkins said.

The numbers suggest a so-called “woodwork” effect—people who were already eligible but not enrolled in Medicaid are signing up as a result of the publicity around the healthcare reform law.

The report commissioned by MACPAC also indicated that state Medicaid agencies are struggling to follow-up with new enrollees to help them get access to care.

Medicaid directors from Maryland and Tennessee told the panel that staffs are stretched thin because the responsibilities of their offices have grown in recent years to include oversight of the exchanges, new health information technology programs, managed-care programs and waiver demonstrations.

CMS bulletin addresses presumptive eligibility FAQs

The CMS has released an informational bulletin that outlines a set of frequently asked questions about presumptive eligibility, a state option under the Affordable Care Act that allows hospitals and other qualified entities to make on-the-spot, temporary eligibility decisions based on an assessment of the person's income.

The aim of the provision, which was effective Jan. 1, is to ensure immediate access to medical services to patients who may be eligible for Medicaid but are not enrolled in the program.

As part of temporary enrollment, hospitals are directed to encourage the person to complete an application to confirm eligibility and ensure they will be able to keep coverage after the presumptive period ends.

The guidance (PDF) released by the CMS on Jan. 24, breaks down inquiries related to the application process, the eligible populations, information on the qualified entities that can make the temporary determinations, qualification standards for participating hospitals, and the federal matching funds available.

“We're happy to see that the federal guidance addresses some of the specific questions hospitals have had, such as the ability to work with third-party vendors in the screening process,” said Greg Vigdor, president and CEO of the Arizona Hospital and Healthcare Association.

Follow Virgil Dickson on Twitter: @MHvdickson


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