Is Medicaid going to be ready for a "culture of coverage?"

Medicaid and the Children's Health Insurance Program (CHIP) will have roughly 16 million additional enrollees as a result of the Patient Protection and Affordable Care Act (PPACA), according to the Congressional Budget Office in Washington, DC, but how quickly will these individuals enroll? According to Jocelyn Guyer, co-executive director of Georgetown University's Center for Children and Families in Washington, DC, "If there is an expectation of people having coverage, that will happen more quickly and be more widespread."

A January 2011 survey shows that while improvements have been made for low-income children, eligibility for low-income adults lags behind.1 According to the survey, 49 states held steady or made targeted improvements in their Medicaid and CHIP eligibility rules and enrollment procedures.

In addition, a total of 13 states expanded eligibility, mostly for children, and 14 states improved enrollment and renewal processes to reduce burdens on families and streamline administrative processes.

"We found that only two states had rolled back coverage. A major reason is the maintenance of effort requirements," says Ms. Guyer, one of the study's authors. "What was surprising to us was the 14 states that took affirmative steps to improve enrollment systems."

According to Ms. Guyer, states are doing surprisingly well with eligibility and enrollment simplifications. "Despite the serious budget situations, a number of them have made improvements over the last several years," she says. "They've been able to hold onto those improvements, even during the downturn."

While many states have made significant progress, says Ms. Guyer, "it continues to be a tough budget time, so we'll see what happens in the years ahead. But it has been surprising that states have been quite stable in their enrollment simplifications."

Seamless system

Operating a seamless enrollment system between Medicaid and the health insurance exchanges, says Ms. Guyer, "will require a lot of work for virtually every state between now and 2014."

Ms. Guyer notes that only a couple of states have implemented online enrollment, and most have a significant amount of work to do. "It's easier to get your technology up and running if you have a very simple enrollment process," she adds. "If you can streamline how much paperwork you are asking families to provide, it makes it easier to offer an efficient enrollment system."

However, says Ms. Guyer, no matter how good a state's online enrollment system is, there will always be some families who need assistance from a community-based expert. "We've heard from both Massachusetts and Wisconsin that the technology is too daunting for some individuals," she says. "So it's important to keep those doors open."

Ms. Guyer notes that it took Wisconsin about five years to implement online enrollment for its Medicaid program. "When renovating a house, no matter how long the contractor tells you it will take, you should probably double it," she says. "I think that it's probably similar with online enrollment."

Outreach needed

States need to send a clear message that if individuals apply for the program, they will likely be found eligible, says Ms. Guyer. When Massachusetts launched its health reform campaign, she notes, a massive outreach campaign was launched.

"It involved everything from the Red Sox to the governor. So something similar will probably be necessary," says Ms. Guyer. "But because this will be taking place across the country, there will presumably be a much higher level of awareness than when a state does it on its own."

One potential obstacle involves health reform's reliance on the income tax system to determine the extra help that people need to buy coverage, says Ms. Guyer. "A lot of people who are very low-income don't file tax returns. So one of the major doors through which people will obtain coverage won't be as relevant to them," she explains.

Contact Ms. Guyer at (202) 784-4077 or


1. Heberlein M, Brooks T, Guyer J, et al. Holding steady, looking ahead: Annual findings of a 50-state survey of eligibility rules, enrollment and renewal procedures, and cost sharing practices in Medicaid and CHIP, 2010-2011. The Kaiser Commission on Medicaid and the Uninsured, Washington, DC. January 2011.