Enrollment under the ACA: examples and best practices HLC Policy Committee April 6, 2011 Stan Dorn, Senior Fellow The Urban Institute Washington, DC 

Topics Enrollment: not necessarily a slam dunk Some examples of success Other best practices 2

ENROLLMENT: NOT NECESSARILY A SLAM DUNK Part I. 3

Why enrollment matters Access to care Enforcement of the individual mandate Stability of insurance markets 4

5 CHIP and Food Stamps: Early history Source: Selden, et al., 2004 (MEPS data). Effective 10/1/97 Food stamps, after 2 years: 31% take-up

6 More history Medicare Savings Programs (MSP) reach < 33 percent of eligibles  In 2002, Social Security outreach to 16.4 million eligible people led to 74,000 enrollees After much effort, Food Stamps reached an all-time high participation rate of 67 percent in FY 2006 CHIP and Medicaid reached 82 percent of eligible children in 2008

Percentage of eligible children enrolled in Medicaid or CHIP, highest and lowest states: Source: Kenney, et al., 2010.

It’s not just low-income people! 8 Source: Laibson 2005.

EXAMPLES OF SUCCESS Part II. 9

10 Medicare Part D Low-Income Subsidies (LIS) Total enrollment: 74% Source: CMS enrollment data. Calculations by Urban Institute.

11 Coverage expansion in Massachusetts Extraordinary results  Only 2.6 percent of state residents were uninsured in 2008  Most new coverage was highly subsidized Well-known policy changes  Subsidies up to 300% FPL, through Medicaid and the new “Commonwealth Care” (CommCare)  All adults mandated to purchase coverage  Health insurance exchange (the “Connector”)

Massachusetts: less well-known policies Massive PR campaign  Public-private partnership Consumer-friendly application process  One application form for multiple subsidy programs  “No wrong door” Automatically qualified people for subsidies based on data from prior free care pool  After 15 months, this accounted for roughly 1 in 4 newly insured Application assistance  60% of all successful applications completed, not by consumers, but by application assisters 12

Renewals in Louisiana In many states, 30-50% of Medicaid/CHIP children lose coverage at renewal  Failure to complete and return the renewal form ends coverage, even if children continue to qualify In LA, <5% lose coverage at renewal  When data matches show a reasonable certain of continued eligibility, automatic renewal  If more information needed, families encouraged to provide it by phone  <15% of families are asked to complete paperwork 13

SOME BEST PRACTICES Part III. 14

How do we know? Lots of work around child health Many experts, including:  Center on Budget and Policy Priorities  Families USA  First Focus  Georgetown Center for Children and Families  National Academy for State Health Policy  State Coverage Initiatives program of AcademyHealth  The Children’s Partnership  Urban Institute 15

Examples of best practices Use authoritative data to qualify people for benefits Simple applications in multiple languages Diverse modalities for submitting applications “No wrong door” Consumer assistance Streamlined renewals 16

ACA implementation New federal resources and guidance to support IT development Early innovator grants  Examples: Wisconsin and Oklahoma Other exciting innovation  Louisiana rides again 17

Conclusion High enrollment under ACA is possible  The legislation has many good elements  HHS is committed to effective implementation But ACA is vast, and implementation duties will outstrip available resources, at both federal and state levels.  Nitty-gritty enrollment issues can easily fall through the cracks  Significant obstacles in many states An outside coalition of stakeholder groups can keep the focus on enrollment best practices and make a significant difference, at the federal and state levels 18