It's too early to panic over ACA enrollment
The Urban Institute and the National Academy for State Health Policy (NASHP) are cosponsoring an upcoming event to explore state experiences enrolling families into Medicaid and the Children’s Health Insurance Program (CHIP). Sharing lessons to guide implementation of the Affordable Care Act (ACA), the December 17 session features findings from the Robert Wood Johnson Foundation’s Maximizing Enrollment program, which NASHP directs, along with fresh analysis from state officials and national experts.
One important lesson is already clear: the need for patience. News media have hyperventilated about the first days and months of ACA enrollment. But low enrollment during the ACA’s first few years is both likely and entirely consistent with past state experience. It would certainly not doom ACA to eventual failure in covering the eligible uninsured.
Opening its doors in 1998, CHIP is now remarkably effective, along with Medicaid, enrolling nearly 9 in 10 eligible children (87.2 percent). Nevertheless, CHIP struggled during its early years. The Congressional Research Service observed in 2001 that, “there was general disappointment with...low enrollment rates early in the program.” Recent reports from First Focus and the Center on Budget and Policy Priorities remind us that, nationally, CHIP took five years to reach an enrollment “steady state,” with significant variation among states.
Enrollment under the ACA is likely to take a similar path. Like CHIP, the ACA divides responsibilities between states and the federal government, offering states flexibility to experiment. An initiative that achieves good results in one state can be replicated by others, while policies that prove problematic can be avoided. Even at this early stage of ACA implementation, diverse enrollment outcomes have already emerged, promising a rich future harvest of lessons learned.
On the other hand, dividing authority between state and federal agencies can inhibit the kind of rapid, nimble forward movement that becomes possible when one level of government firmly holds the reins. Among the few health coverage expansions that quickly provided most eligible consumers with need-based assistance were Massachusetts’ 2006 reforms and Medicare Part D’s Low-Income Subsidies (LIS). After one year, Massachusetts reduced the percentage of uninsured residents to the lowest level ever recorded in any state; and less than six months after LIS was first available, nearly three-fourths of eligible seniors (74 percent) were enrolled.
In each case, leaders at a single level of government proactively enrolled eligible consumers, using strategies that eliminated any need for them to complete paperwork. One such strategy used data from existing programs to qualify and automatically cover eligible consumers. This approach generated 80 percent of enrollment into LIS and, during its first nine months, Massachusetts’ new health subsidy program.
Another strategy lifted consumers’ burdens by having application assisters complete necessary paperwork. In Massachusetts, community-based organizations received grants to help consumers enroll. Safety-net hospitals and clinics used their own funds to hire application assisters, because the state reimbursed health care only for patients with completed forms. Ultimately, more than half of all successful applications came not from Massachusetts consumers themselves, but from others acting on consumers’ behalf.
Quick, national action along similar lines is unlikely with the ACA’s federal-state structure, which incorporates both the advantages and challenges of state flexibility. Last May, the Centers for Medicare and Medicaid Services (CMS) authorized state Medicaid programs to enroll consumers based on records from Medicaid and the Supplemental Nutrition Assistance Program (the program formerly known as “food stamps”). By the end of October, only four states had implemented this option, but together they reached nearly a quarter of a million people. With more time, these initiatives can be fine-tuned to enroll even more eligible consumers, and other states will surely join the early adopters.
Resources to support application assistance likewise differ dramatically from state to state. The ACA itself gave administrative grants to state-run marketplaces, but marketplaces administered by HHS depend on later Congressional appropriations. As a result, states with federally operated marketplaces have just one-seventh the dollars per uninsured resident that are available to enroll people in other states.
Early participation levels under the ACA will probably be low. Almost certainly, they will vary greatly from one state to the next. Such results will not prove whether the ACA can eventually accomplish its core objective of covering the uninsured. Instead, any short-run disappointments are likely to demonstrate one fundamental fact: the ACA is being implemented in the real world.