Enrollment Problems in Public Health Insurance Programs

I found this article on a wonderful blog, Healthy Policy. This article was published in the LA Times and serves as an educational peice for the uninsured and discusses different programs that people may qualify depending on their income. Such options (in California) include:

• Medi-Cal: for low-income children, pregnant mothers and disabled adults who are U.S. citizens.
• Healthy Families: for low-income children who are U.S. citizens
• Healthy Kids: A county-run program for low-income undocumented children, if the county has the program and if there are spots available in the program
• Kaiser Child Health Plan: A program available to low-income undocumented children, if Kaiser has available slots open.
• CaliforniaKids: A program for undocumented children, which is currently full and not open to new enrollees.
• AIM: A program for pregnant mothers
  

Susan Brink, the author frames the article in her first sentence: "No one doubts that there are ample holes, but America's, and California's, healthcare safety net might be a little more tightly knit than many expect." The message is clear: people (i.e. kids) have options, if only parents would get off their butts and sign them up. The common cited statistic was quoted: "About two-thirds of the uninsured children in California could, if only they'd apply, qualify for Medi-Cal or Healthy Families, according to the UCLA Center for Health Policy Research." Yes, programs exist and people aren't enrolled. There are many reasons: not knowing about programs, stigma, poor past experience with medical providers, difficult family situations, etc. However, this glosses over a huge issue: the large number who apply but are denied because of the bureacratic enrollment process.

I worked at a Community Health Center last year doing Medi-Cal/Healthy Families applications with parents. The state created an "easy" application form -- to ease enrollment for parents. It is 4 short pages and parents need only include 3 documentation forms (proof of child's citizenship; proof of income; proof of California residence). The application is colorful and appears to be straightforward. However, the process is far from such. I will share one story demonstrating the nightmares of eligibility.

• The mother was paid once a month and I xeroxed her income statement and included it in the application. Her pay-stub said "Feb 2005." Typically it takes 14 working days to process a Healthy Families application. One can check on application status through an automated touchtone system. "Application in Process" is what the automated voice says until an application is accepted or denied. This means if the state takes issue with your application, you cannot find out on the voice system that there is a problem. (The state calls families and sends a letter. However, application assistants cannot easily find out over the phone unless they are persistent to get transfered to speak to an operator and spend around an hour getting transfered.) I went through this game of being transfered from person to person until I found out this application was red-flagged and on the denial pathway. Why? All the information was correct. I was told that the pay stub was "not good enough" because it said "Feb 2005" instead of "Feb 1 - Feb 28 2005". I was told to tell my client to have her employer issue a new paystub with the beginning and ending date of the pay period. In the world of multinational corporations, how are families supposed to have control over how paystubs are made? The kicker? This person worked at the United States Postal Service. Apparently federal employees paystubs don't cut if for the State of California.
  

This is just one story; I have dozens of other similar stories of documentation problems. Over half of my applications would have "issues" that were resolved immediately after spending hours on the telephone trying to get transfered to supervisors and advocate for my clients. The truth is, most clients don't have an advocate. And most advocates and caseworkers don't have the time to follow-up to the degree I did. The result: denied applications. I wonder how many of the well-quoted statistic: "2/3 of California's kids qualify for health insurance, just aren't enrolled" went through the application process to some degree, but were denied.

Public health insurance programs like Medicaid and SCHIP that are intended for low-income folks are not designed for easy enrollment. This serves a stark contrast from Medicare. Both are considered government "entitlement" programs; however, Medicaid is far from an entitlement for those who qualify.

The state of California started a "point-of-entry" program (CHDP) that automatically enrolls uninsured children in Medi-Cal for two months when the child goes in for a well-child visit (immunizations, physical). This is called "presumptive eligibility", i.e Medi-Cal/Healthy Families applications are presumed to eligible until paperwork is processed. Basically, families go in for a well-child visit (immunizations, physical), get on this program, and have between one and two months to complete paperwork. Here are some statistics I found at MRMIB (Managed Risk Medical Insurance Board) who administers Healthy Families, on how eligibility worked for this program that was supposed to improve enrollment in public health insurance programs. Statistics are from July 2003-October 2003:

• 151,000 applications mailed to families whose children entered through CHDP
• 11,410 applications turned in. That is 7.5 percent success rate
• 7,438 applications were for Medi-Cal and 4,864 were for Healthy Families
• Of the Healthy Families applications, only 1,105 children had complete applications. 3,596 were denied due to incomplete applications. The main reason for incomplete applications was "missing documents."
• 31.2% of families had an assistant working on the application with them. 68.7% filled out the application on their own. Of those filling out the application with an assistant, 10.7% of applications were incomplete. Of those filling out applications without an assistant, 89.3% were incomplete.

That enrollment rate is embarassing. Programs not existing is a problem, especially for people who are not documented. However, enrollment difficulties pose just as much of a problem. When considering how to improve the health insurance status of popualtions -- or when considering on how to design health insurance coverage expansions -- policy designers need to pay more attention to enrollment issues.