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The Uninsured and Public Program Eligibility

We can say with near certainty that health reform will contain an expansion of Medicaid, possibly even to all individuals up to 150% FPL as seen in the House bill. Expanding eligibility is only half the battle, though, as actual enrollment and retention in the program requires a concerted effort of its own. Today almost 10 million uninsured Americans are eligible for Medicaid and CHIP, but are not currently enrolled in the programs; this is the case for nearly two thirds of all uninsured children. Genevieve Kennedy of the Urban Institute recently reported on significantly positive perceptions of public programs and some success in improving enrollment procedures, but acknowledges significant existing barriers: 45% of low-income uninsured don’t think their child is eligible and 55% don’t know where to start for enrollment.

A number of states and cities have attempted to ease enrollment and renewal processes. Louisiana has automated many renewal processes through third party data usage and online communication. Massachusetts is finding success through the recently instituted individual mandate. Iowa and Maryland have included questions about health insurance status in their tax forms in order to facilitate enrollment, with options for automatic enrollment to eligible families.

The Children’s Health Insurance Reauthorization Act (CHIPRA) passed earlier this year includes new provisions for states to receive additional federal funds by implementing at least five of the following eight provisions:

• Eliminate in-person interviews for application and renewals
• Eliminate asset tests or simplify verification of assets
• Use administrative or ex parte verification of ongoing eligibility at time of renewal
• Adopt presumptive eligibility while a final eligibility decision is pending
• Adopt 12-month continuous eligibility regardless of changes in financial status
• Use same application and renewal forms and verification procedures for Medicaid and CHIP
• Offer “Express Lane” eligibility based on eligibility for other government programs
• Offer premium assistance to support enrollment in employer coverage

In the post-reform ‘implementation’ world, it will be important to learn from the successes and shortfalls of mandates as seen in Massachusetts, while attempting to understand the systemic and perceived barriers in order to streamline enrollment. Automatic enrollment procedures currently being considered could ease many of these barriers and rapidly expand coverage.