Curing Health Insurance Headaches (by Brian Gottlieb)

brian.gottlieb-insurancePaperwork-smallLast week Donald Trump revealed his plan for healthcare reform, should he be elected as our next president: repeal the Affordable Care Act, and then expand Medicaid to ensure “that no one slips through the cracks simply because they cannot afford insurance.” No doubt it is because expansion of Medicaid and the Children’s Health Insurance Program was one of the bigger successes of the Affordable Care Act, insuring over 10 million additional people within the first year. Yet even today millions of adults and children who are eligible for Medicaid are without coverage. Even some children who qualify for coverage at no cost are not enrolled. I am curious why these people are being left behind.

Historically about two thirds of uninsured people have been eligible for Medicaid and CHIP coverage, but not receiving it. There are a variety of reasons, but much of it boils down to paperwork and complexity of the enrollment process. In addition, most states require members to go through the complicated re-enrollment every year (or every 6 months in some states), or they automatically drop coverage. Automatic enrollment (instead of automatic dumping) into Medicaid and CHIP programs would greatly reduce the uninsured population by eliminating these significant administrative barriers for those who qualify. Ultimately a change to a single-payer system, such as in Bernie Sanders’s “Medicaid for all” proposal, would completely remove such obstacles not just for the poor, but for everyone.


Sommers, Benjamin D. “Why Millions Of Children Eligible For Medicaid And SCHIP Are Uninsured: Poor Retention Versus Poor Take-Up.” Health Affairs 26.5 (2007): w560-w567. Academic Search Premier. Web. 4 Mar. 2016.

This article predates the Affordable Care Act, but it is still relevant. It demonstrates that regardless of access to Medicaid, it is still underutilized due to systemic flaws (some of which still exist today, as seen in the post-ACA study in Minnesota below). This article examined Medicaid and SCHIP coverage of children from 2000 to 2006, and found that more than two-thirds of the uninsured children were qualified for coverage. This is literally children not getting the treatment they need even though it is there, just waiting for their parents to figure out how to claim it. Children without insurance do not just miss doctor visits, they miss out on some of their childhood.

“Chronically uninsured children, as well as those experiencing coverage lapses, have lower rates of check-ups and vaccinations, experience more illness-related restrictions on activities, and are more likely to forgo needed care when sick, compared with children whose insurance coverage stays constant.”

The study found that it was not just an issue of getting people signed up, but also of retention. Most states require annual re-enrollment in Medicaid, rather than continuing coverage into the next year. Anyone who does not re-enroll is automatically dropped from coverage. The study found that one third of uninsured children had been insured the year before. Simply not dumping these eligible children from the programs they have already enrolled in would reduce the number of uninsured by one third, and improve child healthcare dramatically. An experiment in Wisconsin found a similar result when they loosened Medicaid eligibility and automatically enrolled newly eligible parents and children.

DeLeire, Thomas, et al. “Wisconsin’s Experience With Medicaid Auto-Enrollment: Lessons For Other States.” Medicare & Medicaid Research Review 2.2 (2012): E1. MasterFILE Premier. Web. 9 Mar. 2016.

Rather than dropping coverage for qualified people who did not re-apply annually, Wisconsin implemented automatic enrollment into Medicaid and CHIP. As part of a 2008 expansion of Medicaid, they looked at the families of children who were already enrolled in Medicaid. Any parents or siblings meeting the new eligibility requirements were automatically enrolled in the program, resulting in significant increases in membership even a year later. Auto-enrollment was most effective at retaining uninsured who are eligible for free healthcare, but not as effective for those who would have to pay premiums. They estimate that about half of parents who are newly eligible under the ACA expansion could have been automatically enrolled nationwide.

Opt-out systems have higher enrollment rates than opt-in policies. Medicare B has 95% of eligible seniors enrolled by automatically enrollment.

Call, Kathleen Thiede, et al. “Coverage Gains After The Affordable Care Act Among The Uninsured In Minnesota.” American Journal Of Public Health 105.(2015): S658-S664. Academic Search Premier. Web. 9 Mar. 2016.

A study in Minnesota looked at the improved insurance coverage in the first year of Obamacare. Half of the previously uninsured found insurance in 2014, with over 10 million receiving Medicaid and CHIP, and another 10 million purchasing health plans in the marketplace. The study examined differences between those who stayed uninsured and those who got coverage, and the experience with the enrollment process. Difficulties enrolling seems to be a big problem, trouncing 84% of the uninsured, and troubling 60% of those who eventually signed up. Those who found coverage were 7 times more likely to have sought help in person, which suggests that some of the others might have needed just a little help. Many reported not being able to get all the information they needed in order to enroll, though 45% of the remaining uninsured also reported cost of insurance premiums as a primary issue. The study suggests that a focus on outreach, simplification of enrollment, and improved affordability would be most effective at improving the situation.

What Can Be Done

Too many people are without health coverage, and the complexity of our fractured insurance system is to blame. An inclusionary system, such as Wisconsin’s automatic enrollment, would be much better than excluding people by default. Having fewer hoops to jump through would make the process more accessible, especially for the poor, uninsured people who really need it. Those who qualify for Medicare with no premium should be automatically enrolled based on their tax return, and start getting the care they need.

If you really want to make a difference, I say vote Bernie Sanders for President. His single-payer, tax-funded “Medicaid for all” plan would eliminate the paperwork headaches (and 80% of the administrative costs!) of health insurance. In a national health insurance system, there would be zero uninsured. There would be no confusing enrollment process. There would be no “shopping around” trying to compare the various insurance providers incompatible coverage plans. We would all be covered. In the meantime, if you are uninsured try enrolling in Medicaid. Statistically speaking, you are probably eligible.



  1. Alexa Fery

    Thank you for sharing your thoughts on this topic! I think it was a great topic to choose as it is very controversial. I thought it was really good how you brought in politics and what is going on right now. I think that really helped back up your opinion. In the first paragraph when you introduced the plan that Donald Trump wants to put in place I thought that you wanted Donald Trump as president and as I read on I found out that you really did not want that. I like how you set that up. I could see how this topic would be difficult to write your own opinion on but i thought you handled that very well. I agree that the only thing one individual can do to help this problem is to vote for the appropriate presidential candidate.

    I really don’t have anything advice for you! I think your writing is very good and I enjoyed reading it. I think it was a perfect length, as it is still packed with good information. I also think your blog is very well organized. You separated each of the sources nicely but they also all related to each other in some way. Over all really great job! Very interesting 🙂

    -Alexa Fery

    • brian gottlieb

      Thanks for the feedback. Trump was just what prompted me to write this topic, but OMG I would never vote for him. I wanted to write about the differences between his Obamacare-esque plan, and Obamacare, but in the course of writing a new introduction I came up with a more interesting topic. Medicaid expansion is everyone’s answer (Obamacare, Trump, Bernie Sanders), but the expansion of the ACA failed to achieve its potential, leaving millions eligible for free Medicaid still uninsured. Why weren’t people enrolling in free healthcare? It can’t be because they like getting sick. In a large percentage, it was the enrollment process itself being too difficult. None of the health plans based on existing insurance paradigms would eliminate the barriers that were keeping eligible sick children from receiving care. We need a system that includes everyone, so people can go to the doctor when they need it, rather than trying to decide if it is worth it.

  2. Amanda Harrelson

    I was really excited to read your post after reading about your research question in the discussion posts. This is an important topic that I think really does need mature adults to sit down, put their pride aside, and just fix it. As you said, everyone deserves obstacle free access to health care. I have a personal interest in this topic actually, as I am one of those people who has had problems with it in the past and am now in debt up to my eyeballs from medical issues and hospitalizations when I wasn’t insured because even though I am an intelligent individual the healthcare system is insane. So your work really resonated with me on a personal level, as did your photo, because that is what my kitchen table looks like at this point.

    The only thing I would say for a “work on” since we’re supposed to, is that originally I was sort of confused by the annotated bibliography being in the middle of the piece. Once I figured that out, however, the piece was awesome and powerful. Great job!

    • brian gottlieb

      Thanks for the review. I can totally commiserate with you about navigating the healthcare system. As I was pulling pages from my huge pile of medical bills to stage that photo, I just kept shaking my head. When I wrecked 2 years ago, I had insurance (and the event had insurance) that paid for most of it, which was good, but there was such a ridiculous amount of paperwork, most of which seems like bureaucratic waste.
      My medical diagnosis documents easily fit in a folder, with all the images (xray, catscan, mri) on a CD. The associated billing and “administrative” paperwork fills a pretty big box (the stuff I kept, anyway. I threw away a lot of duplicates). There were so many pages that looked like bills, and had everything itemized like bills, but then said “NOT A BILL. DO NOT PAY” in the tear-off section. What is that? They were sending me inaction items. Just wasting time and energy to inform me that I still didn’t need to do anything yet. “OK. Got it. I’ll just sit here and open more useless notices disguised as bills.”
      I think I got one of those each from Life Flight, the ambulance company, the hospital, Gem State Radiology Lab (multiple from them, I guess from each of the imaging sessions) and a few clinics every month while they were waiting for the insurance company to negotiate how much it was actually going to cost, so they could decide how much they were actually going to cover, and how much I would actually owe. It was all just waste, but I had to open it all, just in case!
      I read about people in Canada and the UK going to the doctor and not having to deal with billing. They’re paying for it with their taxes, but that’s the only bill. The rest is just that folder full of the diagnosis and treatment. It sounds wonderful. I probably would have healed faster without all of that extra red tape. And I was insured! My experience was, as far as I can tell, a good one. Most of it went right, but it was still a confusing hassle of a mess! Bring on the socialized medicine!

  3. Andi Esguerra

    Thanks for sharing your work! I really enjoyed reading about your topic of health care and it was very interesting to see what side you are on in this topic. I liked that you brought current politics into the essay, making it more relatable in my opinion. I think you had some really great facts in there and I learned a lot.

    I think you had a very heavily informative essay, but it wasn’t overbearing and seemed like it was the perfect amount. I like that you added your own opinions into it. I also really enjoyed what you wrote in the what we can do section. I don’t think there is anything you could’ve worked on. Overall, I think you did a great job!

    Andi Esguerra

  4. brian gottlieb

    Thanks Andi. I’m glad you didn’t think it was too much of an informative piece. I was kind of concerned about being too research driven, and not bloggish. I think I justified it to my self by overloading the annotated bibliography to expand on the writing, and keeping the intro and conclusion shorter. This was an interesting assignment.

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