Stan Dorn
Senior Research
Associate
Urban Institute
202.261.5561
sdorn@ui.urban.org
SCI
Winter Meeting
January 25, 2007

1.
Enrollment models
2.
Applying auto-enrollment to state coverage reforms
3.
Challenges
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 Substance
 Necessary to improve access to health care
 Politics
 Enrollment costs money – do you really want it?
 The standard enrollment growth curve creates political vulnerability – for example, see next slide
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PRESS RELEASE
The Maine Heritage Policy Center
FOR IMMEDIATE RELEASE
August 16, 2005
CONTACT:
Muskie Survey Shows Dirigo’s Failure and High Cost to
Taxpayers
Taxpayers are spending $15 million a year to reach 1,800 uninsured Mainers.
Portland, ME - The Maine Heritage Policy Center today cited the DirigoChoice Member Survey: A Snapshot of the Program’s Early Adopters, a report prepared by the Muskie School of Public Service, as definitive proof of the failure of the DirigoChoice health insurance product. The survey reveals that only 1,800 or 22.4% of
DirigoChoice enrollees were uninsured and that the state is spending nearly $8.00 for every $1.00 of savings to the health care system attributed to providing coverage to those previously uninsured individuals.
“DirigoChoice is a costly failure,” said Tarren Bragdon, director of health reform initiatives for the Maine
Heritage Policy Center. “It is not significantly covering the uninsured and it is costing the Maine taxpayers millions of dollars a year. Maine taxpayers are paying $15 million a year to cover 1,800 previously uninsured people.”
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
Government’s role
 Provide program information – “outreach”
 Process applications
 Individual must
 Apply
 Provide individual information showing eligibility
 Complete the application process
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

Many people can be covered, with hard work
 Simple and streamlined application procedures
 Effective outreach
BUT – the model must deny coverage to:
 Eligible people who do not apply
 Eligible people who do not complete the process
 It can take years for a new program to reach most of its targeted beneficiaries
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 Default enrollment
 Data-driven enrollment
 Proactively assisted enrollment
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“An object at rest tends to stay at rest…”
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1.
2.
3.
4.
5.
SCHIP vs. Medicare Part D
Retirement savings
Medicare Part B
Community-based, proactive facilitation of child health enrollment
Retention of health coverage in
Louisiana
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Example #1: SCHIP vs. Low-Income
Subsidies (LIS) for Medicare Part D
SCHIP enrollment by eligible children: first five years
100%
75%
50%
25%
0%
Effective
10/1/97 44%
54%
60%
1997 1998 2000 2002
Source: Selden, et al., 2004 (MEPS data).
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100%
LIS Enrollment by Eligible Seniors as of 6/11/06,
Less Than Six Months After 1/1/06 Effective Date
Total enrollment: 74%
75%
14%
50%
60%
Applied
Auto-enrolled
25%
0%
Source: CMS enrollment data. Calculations by Urban Institute.
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 Can apply to SSA
 Without application, automatically enrolled in drug plan, with LIS, if received Medicaid or SSI the prior year
 General correspondence, not precise match, in eligibility rules
 Prior year income
 MSP – 5 states have no asset tests, unlike LIS
 Different income methodologies
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Percentage of eligible workers who participate in tax-advantaged retirement accounts
90%
33%
10%
Independent enrollment in
IRA
Firms where new hires enroll in 401(k) only after completing a form
Firms where new hires go into 401(k) UNLESS they complete an opt-out form
Sources: Etheredge, 2003; EBRI, 2005; Laibson (NBER), 2005.
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Percentage of eligible individuals who receive various Medicare benefits
96%
33%
13%
Voluntary enrollment in
MSP - SLMB
Voluntary enrollment in
MSP - QMB
Medicare Part B, in which seniors are enrolled
UNLESS they opt out
Sources: NASI, 2006; Remler and Glied, 2003.
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Medicaid/SCHIP take-up rate among low-income,
Latino children in Boston: standard outreach vs. community-based case managers
96%
57%
Standard outreach
Source: Flores, et al., Pediatrics , 12/05.
Community-based case managers
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Renewal outcomes for Medicaid children in
Louisiana, before and after implementation of data-driven renewal and related procedures
100%
75%
50%
25%
0%
28%
8%
72%
92%
June 2001
April 2005
Percent losing coverage Percent retaining coverage
Source: Summer and Mann, Georgetown University Health Policy Institute
(prepared for Commonwealth Fund), June 2006. Note: other policy changes included telephone contact, rather than forms, to supplement data.
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3.
4.
1.
2.
Subsidizing employer-based coverage
Individual responsibility
Subsidies from public programs
“Cover all kids”
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 Low income is the key variable to effectively targeting subsidies to uninsured workers
 Low wages and low income are not identical

Can’t ask employers to means-test
 Privacy
 Hassle
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Among microfirms’ employees, most uninsured workers have low incomes
Workers at establishments with fewer than 10 employees, by insurance status and family income: 2005
10 7.3
Millions of workers 5 3.0
2.0
2.2
Uninsured
Insured
0
Under 200% FPL Over 200% FPL
Income
Source: Clemans-Cope and Garrett (Urban Institute) 2006. Unpublished estimates based on the
February 2001 and 2005 Contingent Work Supplement of the Current Population Survey
.
(CPS) and the March 2001 and 2005 Annual Social and Economic (ASEC) Supplement of the CPS.
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Among small firms’ employees, most uninsured workers have low incomes
Workers at establishments with 10 to 24 employees, by insurance status and family income: 2005
10
6.3
Millions of workers 5
1.8
1.4
1.4
0
Under 200% FPL Over 200% FPL
Income
.
Source: Clemans-Cope and Garrett.
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Uninsured
Insured
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Among mediumsize firms’ workers, most uninsured have low incomes
Workers at establishments with 25 to 99 employees, by insurance status and family income: 2005
10.6
12
Millions of workers
8
4
2.2
1.7
1.2
0
Under 200% FPL Over 200% FPL
Income
.
Source: Clemans-Cope and Garrett.
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Uninsured
Insured
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Among large firms’ workers, most uninsured have low incomes
Workers at establishments with 100 or more employees, by insurance status and family income: 2005
56.7
60
Millions of workers
40
20
4.4
8.4
3.1
0
Under 200% FPL Over 200% FPL
Income
.
Source: Clemans-Cope and Garrett.
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Uninsured
Insured
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 Obtain automatic access to income databases
 Other means-tested programs
 State workforce agency earnings data
 State income tax data
 The application depends on the reform
 In a premium assistance program, use data to identify low-income employees who qualify for refunds of worker premium payments
 In a program that gives small firms access to health insurance exchanges or purchasing pools, use data to identify low-income employees who qualify for premium subsidies
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Income vs. hourly wages – percentage of workers without health coverage
60% 60%
54%
50%
39% 39%
40%
40%
21%
20%
6%
0%
Less than $7
$7 to
$9.99
$10 to
$14.99
$15+
.
Source: Clemans-Cope and Garrett.
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20%
16%
4%
0%
Under
100%
FPL
100-
199%
FPL
200-
399%
FPL
400%+
FPL
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$15+,
22%
Under
$7,
24%
400%+
FPL,
11%
Under
100%
FPL,
22%
200-
399%
FPL,
31%
$10 to
$14.99,
27%
$7 to
$9.99,
27%
100-
199%
FPL,
36%
.
Source: Clemans-Cope and Garrett.
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 Key enrollment junctures – e.g.:
 Income reports to state workforce agencies;
 Health care visits;
 Filing state tax forms; etc.
 Automatically enrolled into coverage at these junctures
 Premium based on income, determined by data
 Note: default enrollment can be alternative or predecessor to mandate
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Application #3 – public programs
 Cover people based on the income determinations of other means-tested programs
 May need 1115 waiver to disregard methodological differences, use valid SSN as evidence of satisfactory immigration/citizenship
 LIS auto-enrollment precedent
 IT investment crucial
 Eligibility factors other than income
 Citizenship – some databases
 DHS – immigration status documentation
 The next four slides focus on nutrition programs, but state EITC may also provide a huge opportunity – more research needed
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Most low-income, uninsured children live in families that receive meanstested nutrition assistance
Percentage of Low-Income, Uninsured Children Whose
Families Participated in Means-Tested Nutrition Programs:
2002
71%
59%
22%
8%
NSLP WIC Food Stamps Any of those three programs
Source: Dorn and Kenney, Urban Institute (prepared for Commonwealth Fund), June 2006.
Notes: (1) Analysis based on 2002 NSAF. (2) NSLP is the National School Lunch Program. (3) Low-
Income is at or below 200% of the FPL.
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Health Coverage Among Low-Income Children Whose
Families Participated in Means-Tested Nutrition Programs,
2002
17%
ESI Medicaid/SCHIP Other coverage Uninsured
12%
2%
6%
2%
2%
16%
2%
56% 66%
84%
57%
25%
NSLP
Source: Dorn and Kenney.
20%
WIC
8%
Food Stamps
24%
Any of these programs
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Most poor, uninsured parents live in families that receive means-tested nutrition assistance or child health coverage
Percentage of Uninsured, Poor Parents Whose Families
Participated in Means-Tested Nutrition Programs or
Whose Children Received Medicaid, 2002
83%
55%
39%
53%
22%
NSLP WIC Food stamps One or more children receive
Medicaid
Any of these nutrition or child health programs
Source: Dorn and Kenney. Note: Poor parents have the following characteristics: their income is at or below the FPL; they are ages 18 to 64; and they live with a stepchild, biological child, or adopted child under age 18.
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Health Coverage Among Poor Parents Whose Families
Participated in Means-Tested Nutrition Programs or Whose
Children Received Medicaid, 2002
46%
ESI Medicaid/SCHIP Other coverage Uninsured
48%
32% 41% 46%
4%
34%
16%
NSLP
Source: Dorn and Kenney.
2%
37%
13%
WIC
4%
3%
57%
3%
36% 49%
8%
Food Stamps
7%
Child in
Medicaid
14%
Any of these programs
High-impact, efficient
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
Identify uninsured children at key life junctures –
 Starting school year – child health form
 Hospital-based birth
 Use data to:
 Provide ongoing Medicaid/SCHIP coverage to children known to eligible
 Provide presumptive eligibility to children potentially eligible, following up with community-based, proactive application assistance for ongoing coverage
 For children ineligible for Medicaid/SCHIP:
 Allow buy-in
 Default enrollment into buy-in, unless parents object
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The Auto-Enrollment motto:
“Applications? We don’t need no stinkin’ applications!”
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
Real risk, but not necessarily a huge problem
 Medicare Part D default enrollees average more prescriptions per month than other enrollees
 Potential remedies
 Consumer education
 Health plan incentives
 Limited withhold of partial capitated payments based on number of default enrollees receiving zero services
 Award future default enrollment shares based on prior performance with default enrollees
 Monitor with encounter data, compare default to other enrollment
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 State statutory changes may be needed to access data
 Federal statutes limiting access to national data
 In some cases, federal law change may be needed – e.g., national New Hires Data Base
 In some cases, consumers can consent to disclosure
 IRS and SSA data is open to Medicaid programs
 Federal procedural safeguards
 Computer Matching and Privacy Protection Act of
1988 (Pub. L. No. 100-503)
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 Use limitations
 Interagency agreements
 Prevention of unauthorized access, use, modification, or disclosure of data
 Data transparency, including notice of databases and data controller
 Individual access to and correction of data
 Accountability
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Data: current, accurate and complete?



State workface agency data – quarterly
 Gaps: work in other states, federal employees, sometimes several months out of date
Income tax data – prior year
Immigration status – DHS data not strong
 Real ID may force improvements
 Strategies
 Combine recent wage data with prior-year tax data re other income
 Estimate, inform consumer, give consumer the ability to call and correct
 Post-eligibility audits, corrections
 Define eligibility based on prior year income
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 MMIS enhanced match (90/75) generally unavailable for eligibility purposes
 50/50 FMAP for general administration
 Possible access to 90/75 FMAP under MITA: incorporating eligibility information into EHRs
 For proactive facilitation, target likely eligibles


Possible foundation interest
Multiple benefits of IT investment – coverage, integrity, efficiency
 Enrolling eligible individuals
 Preventing erroneous grants of eligibility
 Lowering administrative operating costs
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 In default enrollment system, failure to pay first month’s premium = opt-out
 With personal responsibility requirements:
 Very intensive income screening and enrollment into subsidies based on data, hands-on application assistance
 Exceptions for unaffordable coverage
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 Automate payment of premiums
 Paycheck withholding, building on current systems –
W-4, payroll companies, inexpensive software for small firms
 Credit card payments
 Requirements or incentives – e.g., premium discounts for automated or multiple payments
 Back-end collection, if individuals do not pay
 Income tax liability
 Other, nastier mechanisms?
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 For new state initiatives to succeed, enrollment and retention methods must be effective
 The more you ask consumers to do, the fewer consumers will do it
 If you want new initiatives to cover as many eligible individuals as possible, use default enrollment, data-driven enrollment, and proactive assistance to eliminate the need for consumers to complete forms
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