Sept. 11 lesson: States are finding that simpler programs are the best

One of the most important insights of the New York Disaster Relief Medicaid (DRM) experience is the value of a simplified enrollment process. That’s the finding of Michael Perry of Lake, Snell, Perry & Associates in Washington, DC, who conducted focus groups with DRM recipients to learn about their reaction to the emergency program.

Mr. Perry says that while much of the country’s reflections in September 2002 related to the horrors of Sept. 11, there also are opportunities to improve delivery of social services by looking at how the emergency programs initiated after the attacks worked out.

His study of the DRM program, commissioned by the Kaiser Commission on Medicaid and the Uninsured and the United Hospital Fund, provides insights that states can draw on not just for emergency programs but for improving the efficiency and effectiveness of ongoing programs.

DRM was a temporary program that used a vastly simplified, expedited application process. Higher income eligibility guidelines and new immigrant eligibility rules were implemented, making many more New Yorkers eligible for the coverage.

Mr. Perry says they found:

  1. DRM enrollees were a diverse group with many who previously lacked access to care.
  2. The enrollees had very positive views about DRM and praise for the simplified enrollment process.
  3. Enrollment in DRM led to use of primary and preventive services.
  4. Enrollees were confused about the transition process that followed the end of the temporary program.

"It is tempting to look at DRM and conclude that it was a distinct program created in response to a unique situation facing New York, and therefore not particularly relevant to other Medicaid programs around the country," Mr. Perry writes. "In many regards this is true. The Sept. 11 attacks may have made New Yorkers more concerned about their health, more stressed about the future, and more vulnerable to losing their jobs and health insurance coverage, all of which made them more likely to enroll in DRM. The buzz’ and positive word-of-mouth about DRM may also have been the result of increased concern New Yorkers were feeling about each other and the networking to obtain services that followed the attacks. However, there are also aspects of DRM that may not be so unique and which may have relevance to Medicaid programs across the country. These tended to be process and rule changes that attracted New Yorkers to the program in the first place and which allowed so many to qualify and created such a positive buzz about the program."

"In the last year or two, many states have simplified their forms and processes," Mr. Perry tells State Health Watch, "but it hasn’t been enough. DRM had a one-page form with no supporting documentation required and people were approved on the spot. The buzz in the community was that it was simple — you didn’t have to come back with a lot more information and you could get approved in one day. That all made it seem worthwhile for many people to stand in long lines."

Some of the findings to be considered, Mr. Perry says, are that higher income eligibility levels and no asset test made a difference; an easier enrollment process paved the way; enrollees benefited from assistance completing applications and in-language forms and workers; and creating a positive word-of-mouth was a key.

Mr. Perry reports that by applying higher income levels and excluding assets from consideration, more uninsured New Yorkers obtained health coverage than before, especially childless adults. He says that easing the enrollment process in ways that mirror the DRM process may reap significant benefits, especially since much of the positive word-of-mouth was about the easy enrollment process. Participants also liked that they could use their coverage almost immediately.

Word-of-mouth was important

Word-of-mouth promotion was a key element in the broad enrollment that occurred and apparently occurred because of the way the program was described — as free health coverage that was quick and easy to get.

"This kind of description could be applied to Medicaid programs across the country if changes were made to enrollment processes that reduced hassle and time spent by applicants," Mr. Perry says. "Similarly, there was a perception that DRM allowed people with higher incomes to qualify. While states will always have income limits for Medicaid and other programs, focus group participants overwhelmingly feel these limits are currently too low. However, some states have already raised their income levels for Medicaid and the State Children’s Health Insurance Program and other programs have higher income levels too. It may be possible to spread the word about these different eligibility rules so that potential enrollees see that the program is not just for the very poor, but also for families like their own."

The New York DRM experience validated use of forms and workers in various languages, so much so that there were no complaints in the focus groups about language problems. Providing in-language help and forms really was a big help, Perry reports. "It was shocking that we didn’t hear about complaints about language barriers. It just wasn’t a problem."

A final policy implication that Mr. Perry sees is that there was a perception among the focus group participants that DRM was a different kind of government program, which may have appealed to New Yorkers who never applied for Medicaid before. The fact is, he says, that DRM was different — a temporary health program that implemented higher income limits, had no asset test, and required few documents.

"However," he says, "it could be argued that changes some states have been making to their Medicaid program, not to mention the new programs introduced in recent years such as Family Health Plus, constitute a new breed of health programs. A way to create a positive buzz about these programs, consequently, may be to update the public’s image of government health programs and advertise changes to the programs and who qualifies for them."

Still to be determined is what happens when people leave DRM and either transition into other programs or again become uninsured. While Mr. Perry will be studying the transition for the Commonwealth Fund and expects to have preliminary results in the first quarter of 2003, he says it already appears that many people are not transitioning — perhaps because the agency has reverted to the old enrollment process that requires several trips and a lot of paper and delays approval for up to a month.

"Going through the whole process again can be a turnoff," he declares. "And people may be feeling that they can’t qualify again, unaware that the higher limits were from the new Family Health program. They got enrollment so right, but communications don’t seem to be as good on the transition side."

[To download the report, go to www.kff.org/content/2002/4062. Contact Mr. Perry at (202) 776-9066.]