Obamacare’s Medicaid Trap

The White House’s “tech surge” fixed many of the Affordable Care Act’s high-profile problems, but glitches continue to hurt some of the nation’s poorest patients.

National Journal
Sophie Novack
April 10, 2014, 1 a.m.

The tech­no­logy be­hind a huge part of Obama­care’s ef­forts to ex­pand in­sur­ance cov­er­age — the part aimed at low-in­come Amer­ic­ans — re­mains far from fixed, and the glitches are keep­ing some of the na­tion’s most vul­ner­able pa­tients from get­ting in­sured.

The ad­min­is­tra­tion launched a “tech surge” to im­prove the Health­Care.gov ex­per­i­ence for those shop­ping for private in­sur­ance, but the web­site’s pro­cess for en­rolling in Medi­caid re­mained mired in glitches. And for Pres­id­ent Obama’s ef­forts to ex­pand health cov­er­age that’s a ma­jor prob­lem.

To reach would-be Medi­caid re­cip­i­ents, the Af­ford­able Care Act re­lies on po­ten­tial en­rollees be­ing able to ef­fect­ively nav­ig­ate the law’s web­site to en­roll. And there, just as with the early days of Health­Care.gov, tech­nic­al fail­ures have cre­ated a high hurdle for those look­ing to join the ranks of the newly in­sured.

Some ap­plic­a­tions sent from the ex­changes nev­er make it to the state Medi­caid of­fices. Of those that do, jumbled or miss­ing data can make the ap­plic­a­tions im­possible to pro­cess in any kind of auto­mated way. In the mean­time, these in­di­vidu­als are without cov­er­age as they wait for their ap­plic­a­tions to be re­viewed, and their pro­spects for get­ting in­sured soon are dim­ming as back­logs build.

And then there’s the ex­treme ex­ample, where some ap­plic­ants — typ­ic­ally those whose in­comes put them on the cusp of Medi­caid eli­gib­il­ity — have been trapped in a cir­cu­lar pur­gat­ory. Con­sumers are in­cor­rectly deemed eli­gible for Medi­caid by the ex­changes, then re­jec­ted by the Medi­caid of­fices. Their ap­plic­a­tions then need to be sent back over to the mar­ket­places, but they don’t al­ways make it there.

The size of the prob­lem is dif­fi­cult to pin­point, as ex­per­i­ences vary by state and in­form­a­tion is largely an­ec­dot­al. But back­logs of Medi­caid ap­plic­a­tions stretch­ing to the hun­dreds of thou­sands have been re­por­ted in states in­clud­ing Texas, Illinois, Cali­for­nia, and New Jer­sey.

All of this is the op­pos­ite of what the White House in­ten­ded: The fed­er­al and state ex­change web­sites were meant to serve as a one-stop shop for in­sur­ance, where con­sumers could im­me­di­ately find out wheth­er they were eli­gible for sub­sid­ized private cov­er­age or Medi­caid. The law’s Medi­caid ef­forts are aimed at clos­ing a gap in the so­cial safety net that left out people with in­comes that were high enough to miss their home state’s Medi­caid qual­i­fic­a­tions but not high enough to af­ford in­sur­ance.

And through the law, the hope was that if people were eli­gible for Medi­caid, the site would for­ward their ap­plic­a­tion to their state’s Medi­caid of­fice and they would be en­rolled right away.

But from day one, that wasn’t the real­ity for many Medi­caid en­rollees.

“Right out of the gate, we knew the trans­fer wasn’t ready and wasn’t hap­pen­ing,” says Matt Salo, ex­ec­ut­ive dir­ect­or of the Na­tion­al As­so­ci­ation of Medi­caid Dir­ect­ors. “Every­one was hope­ful it would get fixed quickly; it turns out some of the prob­lems with Health­Care.gov con­nect­ing to Medi­caid were big­ger than an­ti­cip­ated.”

But while the ad­min­is­tra­tion went all-in to fix the high-pro­file prob­lems with the en­roll­ment pro­cess for private in­sur­ance, work on Medi­caid has moved more slowly.

“Medi­caid is al­ways the for­got­ten stepchild,” Salo says. “[The mar­ket­place] has open en­roll­ment com­ing to an end; people eli­gible for the ex­changes will have pen­al­ties [if they don’t en­roll]; there are le­git­im­ate con­cerns from a so­cial in­sur­ance mod­el if we don’t get enough people — and enough re­l­at­ively healthy people — signed up. None of that really mat­ters to Medi­caid.”

The pro­gram’s year-round en­roll­ment and ret­ro­act­ive cov­er­age meant less pres­sure to fix the Medi­caid prob­lems im­me­di­ately.

But the need for cov­er­age has still been there, des­pite the in­ab­il­ity to handle the de­mand. The ad­min­is­tra­tion re­por­ted last week that Medi­caid en­roll­ment has jumped by 3 mil­lion since Oc­to­ber, largely as a res­ult of the health care law.

From the be­gin­ning, dif­fer­ences in tech­nic­al cap­ab­il­it­ies left the state and fed­er­al sys­tems out of sync, so ap­plic­a­tions could not be trans­ferred suc­cess­fully. The IT prob­lems spiraled more out of con­trol with the volume of ap­plic­a­tions and lim­ited re­sources to pro­cess them by hand. States were not pre­pared for the in­flux of ap­plic­a­tions, and it turns out pre­par­a­tion for Medi­caid staff was also side­lined, even be­fore en­roll­ment began.

“There was so much en­ergy in ad­vance of open en­roll­ment to make sure nav­ig­at­ors and ex­change staff were fully trained — but not as much on the train­ing of Medi­caid agen­cies. Even in states that didn’t ex­pand Medi­caid, they still had to change the way they did eli­gib­il­ity, which could cause some con­fu­sion,” says an en­roll­ment ex­pert from a pro­gress­ive or­gan­iz­a­tion who asked not to be named.

States have since in­creased staff­ing, but re­sources are still lim­ited and manu­al en­roll­ment is slow, so ap­plic­a­tion back­logs have con­tin­ued to grow.

With those set­backs long bey­ond its con­trol, however, the ad­min­is­tra­tion is now tasked with mak­ing Medi­caid work as well as pos­sible, now that open en­roll­ment for private in­sur­ance has (mostly) ended.

The Cen­ters for Medi­care and Medi­caid Ser­vices is still test­ing the sys­tems as ap­plic­a­tions con­tin­ue to be trans­ferred. “As part of our dis­tri­bu­tion pro­cess to states, we are work­ing with them to share files in waves in or­der to help them man­age volume and handle pro­cessing,” a spokes­man wrote in an email.

Since the launch in Oc­to­ber, CMS has been provid­ing all states with weekly sum­mar­ies of the people whose ap­plic­a­tions the Medi­caid of­fices should be re­ceiv­ing. Be­gin­ning in Novem­ber, states had the op­tion to simply take the fed­er­al agency’s de­term­in­a­tions of eli­gib­il­ity and en­roll those res­id­ents im­me­di­ately, as a tem­por­ary emer­gency work-around. Only five states are cur­rently us­ing that op­tion.

But no quick fix has made it­self ap­par­ent, and ad­voc­ates and ap­plic­ants alike are wor­ried about when re­lief will come. The race is on to find solu­tions be­fore the next open-en­roll­ment peri­od be­gins in just a mat­ter of months and at­ten­tion is again pulled else­where.

In the mean­time, states may opt to use the sum­mary re­ports to con­firm they have re­ceived all ap­plic­a­tions. In states that don’t, however, there is no way of know­ing if an ap­plic­a­tion didn’t make it, and in­di­vidu­als may be stuck wait­ing for an an­swer that isn’t com­ing.

People who have not re­ceived con­firm­a­tion or been giv­en an in­sur­ance card are likely to forgo care or rely on clin­ics and the emer­gency room in the mean­time. If they do seek any private care while in limbo, those who are ul­ti­mately de­term­ined Medi­caid eli­gible will re­ceive ret­ro­act­ive com­pens­a­tion. But those who end up be­ing de­term­ined in­eligible and sent back to the ex­changes could end up stuck with high med­ic­al bills they may have ex­pec­ted to get covered.

With some states re­port­ing back­logs near­ing a mil­lion, it could be a long while be­fore they’re in­sured, or even hear back at all.

As these is­sues con­tin­ue to be worked through, gov­ern­ment of­fi­cials and en­roll­ment groups are en­cour­aging Medi­caid-eli­gible in­di­vidu­als to en­roll dir­ectly with their state agen­cies.

What We're Following See More »
DRUG OFFENDERS
Obama Grants 111 More Commutations
5 hours ago
THE DETAILS

In a release Tuesday afternoon, the White House announced that President Obama has commuted and/or reduced the sentences of another 111 convicted criminals, mostly convicted of drug possession or trafficking. About 35 were serving life sentences.

BUT HE’S NOT ADVOCATING FOR IT
Grassley Open to Lame Duck Hearings on Garland
7 hours ago
THE LATEST

Senate Judiciary Committee Chairman Chuck Grassley (R-IA) said Monday he'd now be willing to hold a hearing on Supreme Court nominee Merrick Garland in a lame-duck session of Congress. While he said he wouldn't push for it, he said if "Hillary Clinton wins the White House, and a majority of senators convinced him to do so," he would soften his previous opposition.

Source:
DEFINITELY MAYBE
Rubio Can’t Guarantee He’ll Serve a Full Term
8 hours ago
WHY WE CARE

We can call this the anti-Sherman-esque statement: If reelected, Marco Rubio ... might serve his whole term. Or he might not. The senator, who initially said he wouldn't run for a second term this year, now tells CNN that if reelected, he wouldn't necessarily serve all six years. “No one can make that commitment because you don’t know what the future is gonna hold in your life, personally or politically,” he said, before adding that he's prepared to make his Senate seat the last political office he ever holds.

Source:
DUTERTE BECAME PRESIDENT IN JUNE
Obama to Raise Multiple Issues in Meeting With Philippines Prez
8 hours ago
THE DETAILS

Since Rodrigo Duterte took over as president of the Philippines in June, he has made a serious of controversial statements and launched a war on drugs that has led to nearly 2000 deaths. He called the US ambassador to the Philippines, Philip Goldberg, "a gay son of a bitch." Next week, President Obama will meet with President Duterte at the East Asia Summit in Laos, where he " will raise concerns about some of the recent statements from the president of the Philippines," according to White House Deputy National Security advisor Ben Rhodes.

Source:
LATE SEPTEMBER
Conservatives Preparing ‘Dry Run’ for Constitutional Convention
9 hours ago
WHY WE CARE

The Convention of States Project, which seeks to force a constitutional convention under Article V of the Constitution, will hold a "dry run" in Colonial Williamsburg starting Sept. 21. "Several states have already followed the process in Article V to endorse the convention." Thirty-four are required to call an actual convention. "The dry run in Williamsburg is meant to show how one would work and focus on the changes and potential constitutional amendments that would be proposed."

Source:
×