Last 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.