The Challenges To Expanding Medicaid, Enrollment To Vary From State To State

Republican governors who complain about the effect of Affordable Care Act’s expansion of Medicaid on state budgets, would be happy to read John Reichard’s report about the uncertainty surrounding the program’s enrollment growth. Two analysts speaking before an Institute of Medicine workshop on “health literacy” last week — Alice Weiss of the National Academy for State Health Policy and Georgetown University’s Sabrina Corlette — laid out the following challenges beneficiaries could face in applying for Medicaid of private insurance coverage through the exchanges:

1) Outdated paper-based systems: “People trying to enroll in Medicaid for example are used to a technology-enabled environment but are entering an antiquated paper-based system that involves going from office to office as part of the sign-up process. Weiss noted that according to a survey by the Pew Charitable Trusts, 35 percent of American adults now use smart phones, enabling them to download information from the Internet.”

2) Language barriers: “One in six adults in the U.S. do not speak English, she said. Many families have ‘mixed status,’ with one parent legally in the country, the other parent an illegal immigrant and the children U.S. citizens. Trying to help them figure out how to navigate the system is going to be a challenge, she said.

3) Changing eligibility: “Weiss also noted that fluctuating income levels during the year is going to require states to find a way to shift people back and forth from Medicaid to subsidized private coverage in exchanges. “States are going to have to make that process seamless,” she said.

Corlette noted that exchange users in Utah — which established the marketplaces before the Affordable Care Act became law — “objected to having to fill out detailed questionnaires about their health histories” and claimed that the “enrollment process was not easy.” Seventy-four percent “said they used a broker to help.” “In Massachusetts, people going to exchanges initially complained that there were too many plans to pick from and that they were overwhelmed by the level of choice.”

A lot of this rests on the shoulders of the various state systems and the state government’s willingness to adopt reforms that would help establish the kind of “enrollment superhighway” that federal health care reform advocates envisioned. But given the concerns about increasing Medicaid costs, some governors — particularly those who are not interested in expanding public health programs — may be less than willing to adopt changes that aim to increase enrollment and expand the state’s spending on Medicaid. Should that occur, health care reform will fail to bring much needed uniformity to the country’s patchwork of a health care system.