1、Automatic enrollment and state health reform,Stan Dorn Senior Research Associate Urban Institute 202.261.5561 sdornui.urban.org,State Coverage Initiatives Program AcademyHealth Baltimore, MD May 22, 2007,Urban Institute,2,Overview,Enrollment models Applying auto-enrollment to state coverage reforms
2、Cross-cutting issues,Preliminary topic: Why enrollment matters,Urban Institute,4,If you build it, will they come?,Urban Institute,5,Why enrollment matters,Necessary to accomplish the goal of coverage expansion Cost offsets with eligible but un-enrolled: when they get sick, they will use services, an
3、d the state will pay Different from ineligible uninsured, whose later illnesses may not become the states responsibility Standard enrollment growth creates political vulnerability for example, see next slide,Urban Institute,6,At one year, Mass. healthcare plan falls short By Sally C. Pipes | May 15,
4、 2007,“So one year in, we have a plan that, even if no more concessions to liberal advocates are made, falls 20 percent short of its stated goal.”,Part I: Basic enrollment models,Urban Institute,8,Traditional public benefits model,Governments role Provide program information “outreach” Process appli
5、cations Individual must Apply Provide individual information showing eligibility Complete the application process,Urban Institute,9,Implications of traditional model,Denies coverage to eligible people who: Do not apply Do not complete the process It takes several years for a new program to reach man
6、y of its targeted beneficiaries High ongoing administrative costs for state BUT: Familiarity means less risk, culture shock, uncertainty, mid-course adjustment after initial stumbles Permits covert caseload controls that lower cost with less risk of successful opposition Procedural barriers “prevent
7、 waste, fraud and abuse” Reduced outreach may never come to public attention,Urban Institute,10,A different model: Auto-enrollment,Mechanisms Default enrollment Data-driven enrollment Proactively facilitated enrollment Promise lessening the historic tension between safeguarding program integrity and
8、 simplifying application procedures. More eligible people get covered A smaller percentage of ineligible people get covered Operational administrative costs drop (after infrastructure development),Urban Institute,11,Basic principle: Newtons First Law of Motion,“An object at rest tends to stay at res
9、t”,Urban Institute,12,Examples of auto-enrollment,SCHIP vs. Medicare Part D Retirement savings Medicare Part B Community-based, proactive facilitation of child health enrollment Retention of health coverage in Louisiana,Urban Institute,13,Example #1: SCHIP vs. Low-Income Subsidies (LIS) for Medicare
10、 Part D,Source: Selden, et al., 2004 (MEPS data).,Effective 10/1/97,Food stamps, after 2 years: 31% take-up,Urban Institute,14,Example # 1, continued,Total enrollment: 74%,Source: CMS enrollment data. Calculations by Urban Institute.,Urban Institute,15,Data-driven enrollment Medicare Part D, LIS,Can
11、 apply to SSA Without application, automatically enrolled in drug plan, with LIS, if received Medicaid or SSI the prior year Tremendous accomplishment largely unheralded,Urban Institute,16,Example #2: retirement savings,Sources: Etheredge, 2003; EBRI, 2005; Laibson (NBER), 2005.,Urban Institute,17,E
12、xample #3: Medicare Part B,Sources: NASI, 2006; Remler and Glied, 2003.,Urban Institute,18,Example #4: Community-based facilitators of child health enrollment,Source: Flores, et al., Pediatrics, 12/05.,Urban Institute,19,Example #5: Retention in Louisiana,Source: Summer and Mann, Georgetown Universi
13、ty Health Policy Institute (prepared for Commonwealth Fund), June 2006. Note: other policy changes included telephone contact, rather than forms, to supplement data.,Part II: Applying Auto-Enrollment to State Coverage Reforms,Urban Institute,21,Potential applications vary with the type of reform,Sub
14、sidizing low-income workers at small firms Child-focused expansions Expansions that include adults Individual mandate,Urban Institute,22,Application #1 subsidizing low-income employees of small firms,Low income is the key variable to effectively targeting subsidies to uninsured employees of small bu
15、siness Cant ask employers to means-test Privacy Hassle,Urban Institute,23,Among micro-firms employees, most uninsured workers have low incomes,Source: Clemans-Cope and Garrett (Urban Institute) 2006. Unpublished estimates based on the February 2001 and 2005 Contingent Work Supplement of the Current
16、Population Survey (CPS) and the March 2001 and 2005 Annual Social and Economic (ASEC) Supplement of the CPS. .,Urban Institute,24,Among small firms employees, most uninsured workers have low incomes,Source: Clemans-Cope and Garrett. .,Urban Institute,25,How to identify subsidy-eligible workers?,Trad
17、itional approach have workers complete application forms Expedited approach #1 use wages as proxy for income Expedited approach #2 automatic enrollment, based on state-accessible income data,Urban Institute,26,Wages vs. income: target efficiency,Percentage of workers without health coverage, by wage
18、s and income: 2005,Source: Clemans-Cope and Garrett. .,Urban Institute,27,Wages vs. income: effectiveness,Distribution of uninsured workers, by wages and income: 2005,Source: Clemans-Cope and Garrett. .,Urban Institute,28,Disadvantages of wage level as key to eligibility,Difficulty accessing federal
19、 dollars through Medicaid and SCHIP Potential for embarrassment if a low-wage worker has high family income,Urban Institute,29,Auto-enrollment strategy to identify eligible workers based on income,Obtain automated access to income databases Other means-tested programs State workforce agency earnings
20、 data State income tax data The mechanism depends on the reform In a premium support program, use data to identify low-income employees who qualify for premium payments In a program that gives small firms access to health insurance exchanges or purchasing pools, use data to identify low-income emplo
21、yees who qualify for premium subsidies,Urban Institute,30,Application #2 children,Key life event strategy Master list strategy Express lane eligibility,Urban Institute,31,Key life event strategy: two parts,Identify uninsured children at key life events Enroll them into coverage,Urban Institute,32,Ke
22、y life events: identify uninsured children,Key life event defined: life event that most uninsured children experience Ideally, build on existing mechanisms well-suited to learning insurance status Examples Annual start of school school health form Health care Hospital-based birth billing, outstation
23、ed E.W.s Other pediatric care provider billing Retroactive coverage gives provider and patient financial incentives to complete enrollment State income tax forms,Urban Institute,33,Key life event strategy enrollment,Let family request enrollment (e.g., on child health form for school) Waive confiden
24、tiality Opt-out mechanism Use state-accessible income data to ascertain potential eligibility Presumptive eligibility, if eligibility seems likely. Is PE allowed for this group only? Unclear Cant be less than statewide Cant be for subgroup of children But: PE is never for all its scope is whoever th
25、e qualified entities try to reach,Urban Institute,34,Key life events enrollment, cont.,Going from PE to ongoing Medicaid/SCHIP Reduce burdens on family Use state-available data whenever possible Pre-populated forms, seeking corrections Intensive follow-up educate re using health care and transitioni
26、ng to ongoing eligibility MCO role here? Potential trade-offs between savings to state and conflict of interest in choice of plan Precedent: sponsored enrollment in WA state If no PE Enroll if you know theyre eligible If theyre probably eligible, but youre not sure? Act as if going from PE to ongoin
27、g coverage Reduce burden on family Use intensive application assisters,Urban Institute,35,Key life events children with incomes too high for subsidies,Offer unsubsidized SCHIP Mail card, activated by toll-free call Lower premiums to reflect good risks,Urban Institute,36,Master list strategy,Simple s
28、trategy in concept List #1: all children in the state List #2: all children in the state with insurance Compare the lists identify the uninsured children then enroll them Compiling list #1 (all children) State income tax records (if state grants EITC) School attendance (local records can be more cur
29、rent than state records) Birth certificate data Correct with Postal Service move data, records of marriage, death and divorce Errors and gaps are inevitable,Urban Institute,37,Master list strategy Compiling list #2 (all children with insurance),State can learn who gets Medicaid and SCHIP For private
30、 coverage DRA Section 6035 (TPL) Each state must require insurers to provide information re enrollment of Medicaid beneficiaries Explicitly applies to group plans under ERISA CMS developing data-sharing mechanism Use this mechanism to identify all privately insured children, not just Medicaid enroll
31、ees The state law required by DRA can be broadened What about ERISA? Always a question but: Congress thinks states can compel information about employee benefits. Otherwise, no Section 6035!,Urban Institute,38,Master List Strategy: comparing lists, enrolling children,Children on list #1 but not list
32、 #2 may be uninsured OR: May have different address May be insured but not on list #2 (e.g., private insurer may not have all children in records or the childs identifiers dont match because of clerical error) May not live in state May not exist Must contact the family to confirm address and uninsur
33、ance before providing even PE After that, enrollment as with Key Life Events,Urban Institute,39,Express lane eligibility strategy,Concept: if another means-tested program has already found a family to have sufficiently low income that the children qualify for Medicaid or SCHIP, enroll the children i
34、n Medicaid or SCHIP!,But there are obstacles to overcome!,Urban Institute,40,Most low-income, uninsured children live in families that receive means-tested nutrition assistance,Source: Dorn and Kenney, Urban Institute (prepared for Commonwealth Fund), June 2006. Notes: (1) Analysis based on 2002 NSA
35、F. (2) NSLP is the National School Lunch Program. (3) Low- Income is at or below 200% of the FPL.,Urban Institute,41,Obstacle #1: IT,Must match, convey, analyze, enter data Inadequate IT infrastructure - Enhanced FMAP via MMIS (90% for start-up, 75% for operations) is denied to “eligibility systems,
36、” by federal regulation from Options MITA todays MMIS - add eligibility data to EHRs Medicaid transformation grants Cuts waste, fraud and abuse $52 million 100% federal dollars Applications due 6/15/07,The 1970s,Urban Institute,42,IT needed to identify the already insured,Source: Dorn and Kenney.,He
37、alth Coverage Among Low-Income Children Whose Families Participated in Means-Tested Nutrition Programs: 2002,Urban Institute,43,Obstacle #2: methodologies,Problem: each program has its own methodology Generally, Medicaid will determine children to have lower income than will other programs But not a
38、lways e.g.,food stamps, excess shelter cost deduction Upshot: health program must recalculate eligibility,Urban Institute,44,Overcoming methodology obstacle,Pick non-health program with income threshold far below Medicaids. E.g.: Medicaid to 150% FPL (after disregards) Free school lunch - 130% FPL (
39、gross income) SSA 1902(r)(2) income disregard. E.g.: Disregard all income above net family income found by food stamp program FS net income limit = 100% FPL 1115 waiver to disregard methodological differences Budget neutrality: unspent SCHIP allocations,Urban Institute,45,Will federal government say
40、 yes?,Uncharted terrain - but Bush Administration supported Express Lane in context of Frist-Bingaman bill (S. 1049) CMS already provides more aggressive Express Lane eligibility for seniors with Medicare Part D Auto-enrollment from MSP into LIS, even though: 6 states waive asset test for MSP, and L
41、IS has asset test 18 states disregard in-kind income for MSP 10 states define household to include resident grandchildren Statutory standard: “Substantially the same”,Urban Institute,46,Proposed legislation,Express lane becomes state option Children and adults Enhanced FMAP for IT connections betwee
42、n health agencies and others More access to federal data Context: SCHIP reauthorization,Urban Institute,47,Application #3: state expansions to cover adults,Same basic strategies as with children Key life events File W-4 forms for withholding when start job State income tax forms Seek health care Enr
43、oll as with children, except no PE Master list comparison same Express lane? Less “warm and fuzzy”,Urban Institute,48,Most poor, uninsured parents live in families that receive means-tested nutrition assistance or child health coverage,Source: Dorn and Kenney. Note: Poor parents have the following c
44、haracteristics: 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.,Urban Institute,49,Health Coverage Among Poor Parents Whose Families Participated in Means-Tested Nutrition Programs or Whose Children Receive
45、d Medicaid, 2002,Source: Dorn and Kenney.,High-impact, efficient intervention via SPA,Urban Institute,50,Application #4 How auto-enrollment can help individual mandates,Mandates are not self-executing In 2004, 14.6% of drivers had no auto insurance, even though almost all states required it Auto-enr
46、ollment can help these laws work Automatically enrolled into coverage at key life junctures or based on master list comparison Premium based on income, determined by data (correctable by individual) If premiums are not paid, collect on income tax form Auto-enrollment can soften the framing Everyone
47、is enrolled (dont say “mandate”) Were just making sure everyone is enrolled and paying premiums, based on income not punitive,Urban Institute,51,If you dont like individual mandates:,Auto-enrollment can be an alternative Default enrollment, with opt-out “Instead of mandating coverage for everyone, l
48、ets use the same kind of default enrollment system that Medicare has used for years to reach almost all seniors” Successful auto-enrollment can avoid mandates. State policy can operate in two phases: Phase 1 default enrollment, with opt-outs Phase 2 - If by date X, less than Y% of the population is
49、covered, then everyone is insured no opt-outs,Urban Institute,52,“Applications? We dont need no stinkin applications!”,The Auto-Enrollment motto:,Part III: Cross-cutting issues,Urban Institute,54,Issues,Citizenship and immigration status documents Data adequacy Privacy and data security Default enro
50、llment and service utilization Premium payment Risk of error,Urban Institute,55,Citizenship and immigration status,Current law: limited options under Titles XIX, XXI Use automated data sources for citizenship if possible: birth and school records, etc. SAVE to confirm satisfactory immigration status
51、, based on A number or I number Presumptive eligibility for non-citizen children, then confirm immigration status during PE period Intensive application assistance for likely eligibles Intense pressure to improve automated systems Real ID Employer verification Good chance of statutory change this year,
