For outreach to newly eligible, consider reframing Medicaid as "new" program

States may have a fairly accurate picture of the number of individuals who will be newly eligible for Medicaid as of 2014, but getting them to actually enroll may be more difficult than expected.

"There will be challenges associated with trying to enroll this population," says Robin Rudowitz, MPA, a principal policy analyst for the Kaiser Commission on Medicaid and the Uninsured in Washington, DC. "Historically, many low-income adults have not been eligible for Medicaid. They may have tried to apply in the past and been denied."

These individuals may not have any connections to other public programs, and there may be literacy or language barriers. "Some subgroups may be even more difficult to reach," says Ms. Rudowitz. These include individuals with mental health needs and younger individuals who don't see the immediate value of health coverage.

Rachel L. Garfield, PhD, an assistant professor in the Department of Health Policy & Management at the University of Pittsburgh Graduate School of Public Health, says that states face several challenges in reaching out to the newly eligible Medicaid population. "This population includes many different groups that may have different perceptions of and experience with Medicaid," says Dr. Garfield.

Some newly eligible individuals may have had previous contact with the program, either because they were previously enrolled, tried to apply in the past but were denied, or have family members served by the program.

"For this population, experts have stressed the importance of reframing the program as 'new,' to erase any misinformation that they are not eligible," says Dr. Garfield.

Other newly eligible individuals have had no or minimal contact with state Medicaid programs or state administrative systems in general. States will need to educate this group about the existence of the program.

"There is a lot of discussion about negative views of Medicaid and how these views dampen participation. But when surveys ask people if they would enroll if eligible, most say yes," says Dr. Garfield. "The key will be educating people that there is a new program, and that they are eligible for coverage."

Partnerships needed

Many states partner with providers or community agencies in their current outreach efforts. "These partnerships will be invaluable in getting out the message about the Medicaid expansion," says Dr. Garfield. "However, state Medicaid directors may need to consider bringing additional agencies into these arrangements to reach out to the newly eligible."

Rhonda Seltz is coordinator of Radford University's FAMIS (Family Access to Medical Insurance Security) Outreach Project. She says that Virginia's Department of Medical Assistance Services works very hard with statewide community partners to simplify the application process. Better coordination with outreach efforts for the state's FAMIS and Medicaid programs is another goal.

"With the recent downturn in the economy, however, eligibility worker caseloads at most local Departments of Social Services have more than doubled," says Ms. Seltz. "This overwhelming increase in demand for services certainly cries out for the need for more workers and resources at local agencies."

More state-supported outreach and education efforts with employers are needed. "One of the most challenging types of outreach I have encountered is trying to sell the program to employers," says Ms. Seltz. "Employers and employees could greatly benefit from allowing families the opportunity to sign their children up for Medicaid or FAMIS."

With the average price of a family plan costing more than $1,000 a month, an employee with FAMIS or Medicaid-eligible children could bring home a much bigger paycheck that does not deduct a full family plan premium, according to Seltz.

"Healthier children would translate into less missed days at work, and may even allow the employer to be eligible for less expensive employer-sponsored coverage, if sick children are not part of the employer policy," says Ms. Seltz.

Ms. Rudowitz notes that "along with eligibility expansions, there are a whole series of requirements on coordinating health care enrollment."

A person may be applying for coverage through the HIE with income that makes him or her eligible for Medicaid. In this case, there must be a process in place to put that individual into the right program, Rudowitz says.

"There is a new requirement for uniform income rules to determine eligibility for Medicaid and for the exchange," says Ms. Rudowitz.

Culture change is needed

Michael Perry, a partner at Lake Research Partners, a Washington, DC-based national public opinion and political strategy research firm, has researched innovative Medicaid enrollment processes for the Kaiser Commission on Medicaid and the Uninsured. Based on interviews he has conducted for this project, he says that one key is having "visionary Medicaid leaders who have been working on modernizing systems and streamlining enrollment for the last few years."

"This takes a long time," says Mr. Perry. "States which have not been working on this will have a tough time in 2014."

Another key factor is forming good relationships with community partners. This will help vulnerable and non-English speaking populations to enroll in the program. "There also needs to be a will to change the culture of eligibility workers, so that they welcome applicants rather than treat them badly and try to keep them out of programs," adds Mr. Perry.

The sheer size of the expansion is daunting. "We're looking at tens of millions of adults who will become eligible for Medicaid for the first time," says Benjamin D. Sommers, MD, PhD, an assistant professor at Harvard School of Public Health in Boston. "This will significantly strain the enrollment and renewal systems that states are using." It requires major infrastructure investment in the next three years to prepare for 2014."

Outreach efforts will need to reach individuals who are quite distinct from the traditional Medicaid population. "They will be primarily . . . adults who are not disabled and who do not have young children at home," says Dr. Sommers. "Most will have had fairly little experience with Medicaid and with social welfare programs in general."

It's not enough just to get individuals enrolled. They may need help finding providers who will see them. "This will likely be more difficult than for the current Medicaid population, which at least to some extent, already knows how the program works," says Dr. Sommers.

Make it easier to apply

Dr. Sommers says that one top priority should be making the application process straightforward and accessible through multiple avenues. People will need to apply by telephone, online, and through provider-assisted applications.

This process needs to work seamlessly with the state-level HIE, since many individuals will transition back and forth between Medicaid and the exchange as incomes fluctuate, he says.

"There are many low-income parents who have children already in Medicaid or CHIP [the Children's Health Insurance Program], and who now for the first time will become eligible for Medicaid themselves," notes Dr. Sommers.

Contact Dr. Garfield at (412) 383-7279 or rachelg@pitt.edu, Mr. Perry at (202) 776-9066 or mperry@lakeresearch.com, Ms. Rudowitz at (202) 347-5270 or RobinR@kff.org, Ms. Seltz at (540) 831-7693 or rgseltz@radford.edu, and Dr. Sommers at (617) 432-3271 or bsommers@hsph.harvard.edu.