AcademyHealth
State Health Research and Policy Interest Group
February 9, 2010
Meeting Summary
The State Health Research and Policy Interest Group met on February 9, 2010 in
conjunction with AcademyHealth’s National Health Policy Conference in Washington,
DC. The meeting was sponsored, in part, by The Commonwealth Fund, the Georgia
Health Policy Center, the National Academy for State Health Policy, and the Robert
Wood Johnson Foundation’s State Coverage Initiatives.
The first panelist, Cindy Mann, J.D., Director of the Center for Medicaid and State
Operations at the Centers for Medicare and Medicaid Services (CMS), spoke about the
federal government’s role in strengthening the enrollment and retention of children in the
Children’s Health Insurance Program (CHIP) and Medicaid. Ms. Mann explained that the
lessons learned through the administration of CHIP serve as a helpful building block of
information for coverage expansions. In working to make Medicaid and CHIP the best
programs they can be, state and federal partnerships are more important than ever. States
are in the middle of a very difficult fiscal situation but federal resources and support are
available.
Despite rising premiums for private coverage and falling rates of employer-sponsored
insurance, a great deal of progress has been made in the area of children’s coverage
because of an expansion in public coverage. The provisions in CHIPRA and the
Recovery Act, both signed in February 2009, have helped move this progress along.
Some of the key provisions include:
• Increased federal funding for CHIP;
• New “Performance Bonuses” for Medicaid;
• New eligibility and enrollment options and federal outreach grants;
• New quality standards and demonstrations;
• New federally-financed incentive payments to local hospitals and providers to
adopt health information technology (HIT); and
• A temporary increase in the federal medical assistance percentages (FMAP – the
federal match rate).
States have taken key steps to simplify enrollment, such as offering continuous eligibility
in Medicaid and CHIP, having online applications for one or both of the programs,
adopting the new Express Lane Eligibility option, and eliminating the waiting period for
lawfully residing immigrant children.
To encourage states in these efforts, Ms. Mann noted that Performance Bonuses were
introduced as an important new incentive payment for states. She also noted that it was
one of the less understood provisions in CHIPRA. The Bonuses recognized that, when
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states were making enrollment efforts for CHIP, they often found children who were
eligible for Medicaid. By enrolling these children in Medicaid instead of CHIP, the states
ended up getting the Medicaid federal matching rate, which is lower than the CHIP rate.
The Bonus provision thereby rewards states for their efforts in reaching out to lowerincome children. States needed to meet the “5 out of 8” requirement for all of fiscal year
(FY) 2009 in order to receive the payments. Nine states qualified in FY 2009, totaling
nearly $73 million. While the “5 of 8” requirement is meant to encourage the adoption of
certain measures that have been proven to simplify enrollment, Ms. Mann explained that
they are by no means the only program features that a state should consider.
CHIPRA dedicated a total of $100 million to outreach and enrollment activities, with $40
million awarded in September 2009 to 69 grantees across 42 states. Grantees include a
diverse array of entities, such as state Medicaid/CHIP agencies, community-based
organizations, health centers, and faith-based organizations. In another area of federal
outreach and enrollment funding, $10 million was allocated for a national enrollment
campaign, but Ms. Mann noted that what happens on the ground makes a far greater
difference than a national campaign does.
Looking at administrative data, an additional 2.6 million children gained Medicaid or
CHIP coverage during FY 2009. Medicaid and CHIP together served nearly 40 million
children (1 out of 5) last year. This partly reflects the struggling economy but also states’
commitment to enrolling eligible children. Despite this growth, there are still an
estimated 5 million uninsured children eligible for Medicaid or CHIP under current rules.
Ms. Mann said that HHS Secretary Kathleen Sebelius thinks all of them should be
enrolled. To enable this, federal agencies will have to better coordinate their outreach and
enrollment efforts, programs will have to cut the red tape that serves as a barrier to
enrollment and retention, and there must be greater focus on broad ways to improve the
health and lives of low-income children. Ms. Mann stated that the federal government is
committed to consistently measuring and reporting this progress in a transparent way.
Near the end of her presentation, Ms. Mann turned to the often-held view that the
problem of uninsured children is intractable. She asserted that this is not that the case and
does not reflect what the evidence shows. As an example, she cited the fact that
Louisiana has virtually eliminated procedural terminations at the point of renewal across
the state (to less than 1 percent). The state has achieved this through a variety of
mechanisms, such as not having to send renewal notices to about two-thirds of cases
because the Medicaid agency finds that it already has all the information it needs about
these cases. Therefore, they can just send a notice saying that the coverage has been
renewed.
Federal and state governments need to continue to target children that are most likely to
be uninsured, such as African-Americans, Hispanics, low-income children, and rural
children. Ms. Mann closed by saying that President Obama best explained the importance
of insuring all children when he said that it is the obligation of a decent society to do so,
and she noted that the federal government will work toward that goal with its state and
community partners.
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The second presenter, Jason Helgerson, M.P.P., Medicaid Director in Wisconsin’s
Division of Health Care Financing, discussed efforts to achieve universal access to health
care in Wisconsin through enrollment efforts in the BadgerCare Plus program. Mr.
Helgerson first described Governor Jim Doyle’s vision for health care in Wisconsin. The
governor’s plan calls for incremental coverage expansions to ensure universal access to
health insurance, ensure every Wisconsin child has access to health care services,
continue to identify vulnerable sub-populations, and ensure health care programs are
simple and easy to access. Mr. Helgerson pointed out four key health care challenges:
expanding access; reducing costs; improving quality; and ensuring Medicaid’s financial
stability. He especially emphasized the fourth challenge, ensuring Medicaid’s financial
stability, noting that efforts in the other three areas, notably expanding access, are largely
dependent on the Medicaid program’s continuing viability.
Mr. Helgerson next described Wisconsin’s uninsured population. Of Wisconsin’s 5.8
million residents, 6 percent were uninsured for the entire year in 2008, while 5 percent
were without insurance for part of the year. This is the second lowest uninsurance rate in
the nation. Additionally, 94 percent of children with family incomes below 150 percent
FPL were enrolled in BadgerCare Plus. Despite this success, Mr. Helgerson noted that
there is still much work to do.
He then summarized Governor Doyle’s plan for health care reform, placing emphasis on
enrollment simplification. First, Mr. Helgerson noted that Wisconsin is fortunate to have
two-thirds of state residents receive access to health care through their employers.
However, BadgerCare Plus along with Medicare, Medicaid, and other public programs
continue to play a significant role. Mr. Helgerson explained that, along with specific
moves to simplify enrollment—merging three programs into BadgerCare Plus,
streamlining eligibility rules to simplify the jobs of case workers, and creating a one-page
application—,the state is focusing on a culture change. This change entails moving from
a system overburdened with bureaucratic barriers to enrollment to one where barriers are
minimized to ensure all eligible individuals are enrolled. To illustrate this change, Mr.
Helgerson displayed a graphic of the previous Medicaid eligibility system which was
dependent on county-level workers to decipher dozens of definitions of eligibility,
income, and income disregards to determine if an individual was eligible for one of three
state programs (Medicaid, BadgerCare, or Healthy Start). In contrast, the current
eligibility system centers around one program, BadgerCare Plus, with a single definition
of income, few income disregards, and clear eligibility criteria.
Mr. Helgerson moved to discuss the online system, ACCESS, which Wisconsin uses to
ease enrollment in BadgerCare Plus. The online ACCESS program can be used to
determine eligibility—obviating the need for community health workers to manually do
so—, apply for benefits, or access a personalized account where an individual can
complete an annual renewal or six month review. Since promoting ACCESS as a “one
stop shop,” for BadgerCare Plus, 40 percent of all new applicants use the online
application.
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However, as Mr. Helgerson notes, many uninsured Wisconsin residents lack computer
access or the familiarity with the internet required to use the ACCESS system. In
response to this, Wisconsin placed funding in the BadgerCare Plus program to do
community outreach. Currently, there are 200 community partner organizations across
the state that assist in enrolling eligible families. Many of these community outreach
organizations are health care providers. He pointed out that a particularly effective
strategy was to partner with federally qualified community health centers to assist with
enrollment. The effectiveness of this strategy is due to the fact that oftentimes uninsured
families are directed to these community health centers, thus having enrollment personnel
on hand ensures eligible families are enrolled in the BadgerCare Plus program.
Wisconsin has enhanced its partnership with community organizations with BadgerCare
Plus Mini Grants awarded to 31 organizations to assist families enroll in the program.
Additionally, Wisconsin has received a CHIPRA Outreach and Enrollment grant to
partner with community organizations to improve access to and retention of health care
coverage to children, and a Reaching Underserved Working Poor in SNAP
(Supplemental Nutrition Assistance Program) grant to help integrate applications for
BadgerCare Plus and Wisconsin’s FoodShare program.
Mr. Helgerson concluded by explaining the three phases of Wisconsin’s planned health
reforms. The first phase of these reforms consisted of implementing the Badger Care Plus
program for children and families. This program, implemented in February 2008,
provided access to health insurance for all children, as well as stream lining eligibility
requirements for pregnant women, parents, and caretakers. Since its inception,
approximately 200,000 individuals have enrolled. The second phase of Wisconsin’s
reforms consists of the BadgerCare Plus Core Plan, which is designed as an insurance
option for low income childless adults. Mr. Helgerson noted that the Core Plan includes
innovative program design features such as requiring all members to receive a physical
exam during the first year of the program. Initially, 12,500 individuals were transitioned
onto the Core Plan when it was approved in January 2009. When it was opened to public
enrollment in July 2009, 72, 000 applications were received. The majority of these
applications, 83 percent, were received through the online ACCESS system. An
additional 23,000 people are on the waitlist for the Core Plan. To help individuals on the
waitlist, the state is creating a self-funded health plan, known as the BadgerCare Plus
Basic Plan. This limited benefits plan is designed to provide those on the Core Plan
waitlist with lower cost—premiums are kept to $130 a month—access to health care. The
Baisc Plan is set to be implemented in spring 2010.
The final presenter, Lynn Quincy, M.A., Senior Policy Analyst at Consumers Union but
formerly with Mathematic Policy Research (MPR), discussed the findings of a study
conducted by MPR to determine what non-price features of coverage programs affect
enrollment of low-income adults. She noted that much has been learned about enrolling
children into coverage programs, so part of the question was if some of these lessons
learned also apply to enrolling low-income adults. The examples Ms. Quincy gave for
these features include outreach approach (e.g., targeting, intensity, expense), benefit
design and the provider network, and the nature of the enrollment process (e.g.,
application length, availability of enrollment assistance, etc.).
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Ms. Quincy explained that before starting the study, they were familiar with the evidence
that programs featuring similar premiums can attract different levels of enrollment. The
question then was when and how do non-price features attract or deter enrollment of lowincome, non-elderly adults into subsidized health coverage programs. Ms. Quincy and her
team synthesized the findings from discussions with 67 program representatives and
other informed observers. One of the main things that they wanted to learn was if the
coverage approach changed how the non-price features impacted enrollment levels. To
conduct this research, she categorized coverage programs into four approaches:
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Brokered access to subsidized care;
Subsidized non-group coverage for adults;
Premium subsidies for workers; and
Premium subsidies for employers and workers.
She noted the caveat that these coverage approaches overlap. Some of the results are
broadly applicable across every program type while others are specific to the type of
coverage program. Of those broadly applicable, Ms. Quincy presented their key findings:
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There is inadequate knowledge to guide program designers, often in the sense that
they cannot predict the level and pace of enrollment and do not know how
tweaking different program features will affect enrollment.
Outreach is critical, but it must be outreach that leads to more than just awareness
of the program. Therefore, the outreach should be targeted, decentralized, and
community-based. In addition, it is very useful to establish broad partnerships so
that a prospective enrollee can initially hear about the program from a trusted
source. Working well with outreach partners can involve:
o Engaging partners in the program’s design phase;
o Providing outreach and enrollment support from the program office; and
o For brokers, offering training sessions or continuing education credits and
a “sellable” product.
Trusted sources can be safety net providers, community leaders, etc. However,
this trusted source changes when there is an employer-based component. Then the
employer or broker will most likely be the trusted source.
Mass media can be useful for outreach when used in conjunction with targeted
outreach programs.
Applicants often find it difficult to understand income eligibility requirements and
health insurance concepts. To address this a program can:
o Allow for one-on-one enrollment assistance;
o Simplify program design and the application process as much as possible;
and
o Write materials at the sixth-grade reading level and in languages other
than English.
Stigma can deter enrollment but is easily avoided. Some ways to avoid it include:
o Not operating out of a Welfare or Medicaid office;
o Raising the upper end of the income eligibility threshold; and
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o Making the coverage as similar to commercial coverage as possible (e.g.,
charge modest premiums and co-pays, provide an insurance card, develop
a “brand” that doesn’t have government connotations).
Ms. Quincy then went on to discuss the study findings that were specific to the type of
coverage approach. Some of these findings echoed the generally applicable findings. For
example, for the category of subsidized coverage offered directly to adults, both
promotion by a trusted source and application assistance continue to be critical
components. In the area of programs that subsidize premiums for employers and workers,
a central challenge is that it is more difficult to reach workers via small employers than
by offering them coverage directly. Both the employer and the employee must be
persuaded to participate and owners of small firms often have little time to invest in
human resource issues. Some owners of small firms just cannot be persuaded to offer
coverage but the central point is that small-firm participation requires a design with broad
appeal. This can be achieved through some of the following means:
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Use brokers—this is critical;
Include health insurance education in outreach efforts;
Make coverage appeal to firm owners;
Minimize owners’ administrative burden; and
Allow the owner and all employees to participate.
In closing her presentation, Ms. Quincy noted that because the study was qualitative in
design, it reflects the views of a limited number of coverage program stakeholders, and
that the study did not look at retention or disenrollment. She also called for the need for
more research with rigorous evaluations that would relate program design and
implementation features to enrollment of nonelderly adults.
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