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Achieving the goals set by most major health care reform proposals will require eligible, uninsured Americans to enroll in health care coverage. The process of signing up for health coverage will be many Americans’ first contact with the new health care system and will shape their initial impressions of it. It is a crucial step because improving quality, managing chronic disease, and controlling costs hinge on enrolling people and maintaining coverage so they can access needed care, and so that providers and insurers can manage that care. And if health care reform includes a requirement that all individuals obtain health insurance, promoting participation will help people obtain coverage and avoid any penalties that may be imposed if they fail to do so.
Congress and the Obama administration can draw on more than a decade’s experience increasing participation in the Medicaid program—the federal/state health and long-term care program for low-income people—as they build the “front door” through which people enter a new health care system. State and the federal government efforts have focused on increasing enrollment of eligible children in Medicaid and the Children’s Health Insurance Program, which together currently cover nearly 45 million children, as well as ensuring Medicaid participation by other eligible groups.
Efforts to boost enrollment have been successful: participation has grown from 66 percent to 78 percent of Medicaid and CHIP-eligible children, and overall Medicaid participation rates are higher than those of many other means-tested programs. Under health care reform, though, participation rates will need to be substantially higher to help people comply with coverage mandates. More work remains to be done, but Medicaid’s experience offers important lessons about what works and what does not work in promoting participation in health coverage.
Most of the major health care reform proposals under consideration in Congress envision three layers that will provide health coverage, within an overall approach that is likely to require both individuals to obtain and employers to provide health insurance. The first layer generally covers the lowest-income Americans by offering Medicaid to people who are currently eligible, as well as expanding coverage to some people who are currently not eligible. The second layer provides subsidies to uninsured people of modest means with incomes above the proposed Medicaid eligibility levels. These individuals would purchase insurance through a common purchasing mechanism referred to as an “exchange” or “gateway” in most proposals. CHIP may provide coverage to some children in this group. The third layer is a reformed version of the nation’s current system of employer-based coverage, potentially including a requirement that employers offer coverage. Medicaid’s experience promoting enrollment applies primarily to the layers of the new system that serve low-income people: expanded Medicaid coverage of the lowest income groups and subsidized coverage in the exchange.
Many of the health care reform proposals under discussion in Congress contemplate linking the process of enrolling in coverage with selecting an insurance plan through the exchange. Yet it can be challenging to provide beneficiaries with information that clearly explains that they must choose a plan, illustrates differences between plans, and provides accurate information about participating providers. Presenting information so that consumers can make informed decisions is not addressed in this paper but is likely to be a significant challenge in implementing any health care reform plan.
Medicaid’s experience yields six key lessons on ways that policy design, enrollment processes, and outreach can promote participation in a reformed health care system:
1. Eligibility structures must be uniform and simple to understand.
2. Different coverage “layers” should work together seamlessly.
3. The application and enrollment process should minimize the burden on applicants.
4. The renewal process must be simplified.
5. Marketing should be used to help build public awareness of new programs, but is not enough to sustain participation gains.
6. Hands-on outreach and assistance is critical, especially for low-income populations.
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