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Analysts Outline Enrollment Challenges Under Health Law

By John Reichard, CQ HealthBeat Editor

July 22, 2011 -- Just because you build it doesn't mean they'll necessary come—at least not right away. That's been the history of various government programs to cover the uninsured, ranging from Medicaid to the Children's Health Insurance Program to, most recently, the Pre-Existing Condition Insurance Plan under the health care overhaul.

Given that track record, it's not a sure thing that enrollment will ramp up quickly when Medicaid and subsidized private plan coverage expands sharply in 2014 under the health law (PL 111-148, Pl 111-152).

Two analysts outlined some of the challenges involved and the lessons learned from existing health insurance exchanges in presentations this week to an Institute of Medicine workshop on "health literacy." The term refers to the ability to read, understand, and act on health-related information of various kinds. Surveys show that the nation's health literacy is low, hindering access to effective health care.

Alice Weiss of the National Academy for State Health Policy noted that the vision lawmakers had in passing the health law was of a speedy and efficient enrollment process. Applicants would be able to quickly and easily obtain information to compare plans and enroll. In this "enrollment superhighway," the uninsured would only have one stop to make to sign up for a plan, whether they are eligible for Medicaid or for subsidized private coverage in state health insurance exchanges. There would be no more repeated phone calls and shuffling from government office to government office.

An increasingly tech-savvy population adept at using computer technology such as smart phones, even in lower-income ranges, would be able to obtain needed information and enroll online.

But "there's obviously a great gap between where states are today and where they need to go," Weiss told the July 19 meeting. People trying to enroll in Medicaid for example are used to a technology-enabled environment but are entering an antiquated paper-based system that involves going from office to office as part of the sign-up process.

Weiss noted that according to a survey by the Pew Charitable Trusts, 35 percent of American adults now use smart phones, enabling them to download information from the Internet. That could mean frustration in a few years when health law enrollment begins. "This presents a major challenge for states, which are still stuck in a paper-based system," Weiss said.

Weiss noted that language also is a potential obstacle. One in six adults in the U.S. do not speak English, she said. Many families have "mixed status," with one parent legally in the country, the other parent an illegal immigrant and the children U.S. citizens. Trying to help them figure out how to navigate the system is going to be a challenge, she said.

Weiss also noted that fluctuating income levels during the year is going to require states to find a way to shift people back and forth from Medicaid to subsidized private coverage in exchanges. "States are going to have to make that process seamless," she said.

Another difficulty is the large number of new applicants many states will have to handle when Medicaid eligibility increases to 133 percent of the federal poverty level in 2014. Some states only enroll adults up to 32 percent of the poverty line, she said. So some "are going to have this incredible expansion of Medicaid," she said.

Where can states get help? Weiss noted the availability of grant money from the Department of Health and Human Services to assist with planning and federal matching funds in some cases for language translation services. In addition, she said that the California HealthCare Foundation is sponsoring a "UX 2014 Project" to better understand what users need or want and develop a "user experience prototype."

A second speaker, Sabrina Corlette of Georgetown University, described user experiences with health insurance exchanges already operating in Utah and Massachusetts. Exchange users in Utah objected to having to fill out detailed questionnaires about their health histories, she said. Fifty-five percent of exchange customers said the enrollment process was not easy and 74 percent said they used a broker to help.

In Massachusetts, people going to exchanges initially complained that there were too many plans to pick from and that they were overwhelmed by the level of choice. The state has switched to more standardized benefits and cost-sharing provisions to allow apples-to-apples comparison, Corlette said.

Another lesson from the state is the importance of public education to inform residents about the exchange and the "personal responsibility" provision of that Massachusetts' coverage law. State residents are required to sign up for coverage just as Americans elsewhere will be in 2014. Massachusetts made a "significant investment" in public education about the requirement and the exchange, using Boston Red Sox baseball players and other public figures to spread the word, she said. The state also set up call centers and used door-to-door visits to help people enroll. That kind of activity was "absolutely essential" to getting the big increases in coverage of the uninsured the state has seen under its health care overhaul, Corlette said.

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