Many eligible to remain unenrolled even after Medicaid expansion

An estimated 23 million non-elderly Americans will remain uninsured after 2014, including 15 million eligible for Medicaid coverage, according to a March 2011 Congressional Budget Office report.

"The large number of eligible but unenrolled people with the Medicaid program has always been a problem," says Michael Perry, a partner at Lake Research Partners, a Washington, DC-based national public opinion and political strategy research firm.

There are many reasons for this, according to Mr. Perry, who has researched innovative Medicaid enrollment processes for the Kaiser Commission for Medicaid and the Uninsured in Washington, DC. "People still have knowledge gaps about Medicaid. They are unsure what the eligibility levels are, and even how to enroll," he says.

People who have lost jobs and their health insurance during the recession are new to public health programs, says Mr. Perry, and many never consider that they may be eligible for Medicaid.

"Many of the people in this income band have fluid incomes that vary from month to month. That makes it hard for them to qualify," he adds. "Many keep holding out for that next job, thinking that their period of being uninsured and unemployed will be brief and that they do not really need Medicaid."

The enrollment process itself for Medicaid is a barrier, according to Mr. Perry, and many people simply don't want to go through the effort if they don't believe they will qualify.

While schools do some promotion of Medicaid and the Children's Health Insurance Program (CHIP), state budgets don't allow for much Medicaid outreach these days, says Mr. Perry. "There really are not many TV commercials, billboards, or ads about these programs," he says. "People really need to seek them out."

Mr. Perry says that "embedding" Medicaid enrollers in community organizations and hospitals is a particularly effective way to reach people in need of insurance. "In some smaller communities where there are big layoffs or big companies shutting down, I have heard of Medicaid and CHIP eligibility enrollers being asked to come speak to employees about the programs and help them enroll," he says.

Mr. Perry points to Louisiana's approach, where food stamp applicants are asked if they have health insurance, and are given the option of having the Medicaid program process their application. "This is great, because it means the family only needs to fill out one application. They are automatically processed for Medicaid, too," he says.

Similarly, Marylanders who indicate that they lack insurance on their state tax forms are sent Medicaid applications, notes Mr. Perry, while Chicago's public school system identifies children who lack health insurance so families can be sent applications for Medicaid and CHIP.

"In Oklahoma, there is a newborn enrollment program. Uninsured infants are enrolled in CHIP or Medicaid, and assigned to a pediatrician, before they even leave the hospital," says Mr. Perry. "The key is to make enrollment as automatic as possible for families."

While most Medicaid enrollees are currently children because eligibility levels are typically too low for a working adult without children to qualify, says Mr. Perry, this is going to change in 2014 when millions of adults will qualify. "There will be a need to rethink outreach and enrollment strategies," he says.

State budgets are one big obstacle to streamlining enrollment processes, adds Mr. Perry, and many have old computer systems that need updating. "Collecting all of the paperwork needed to process a family in Medicaid is cumbersome and a barrier," he says.

States are looking into being able to pull current income information from other state databases to reduce the need for all of this paperwork, he says. "Many states are really looking to make the enrollment process more of an online experience, where people can apply from their homes and just mail in paperwork," says Mr. Perry.

In addition, Mr. Perry argues that the Medicaid program should be "rebranded" to remove any negative associations or stigma. "The goal should be to make Medicaid more of a health insurance program and less of a poverty program, which it is now," he says.