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Mind the Details, or Medicaid Coverage Expansion Will Falter, Say Bingaman, Dorn

By John Reichard, CQ HealthBeat Editor

January 15, 2010 -- The mind-numbing details of Medicaid enrollment procedures aren't sexy stuff—but handled poorly they will cause many vulnerable Americans who are now without health care coverage to continue to go without, overhaul legislation or no overhaul legislation.

That was the warning issued this week by Sen. Jeff Bingaman, D-N.M., one of the more knowledgeable members of the Senate about Medicaid issues, and Urban Institute researcher Stan Dorn.

"This is a very important issue when it comes to implementing the new law," Bingaman said in a telephone press briefing Jan. 13.

Under health care overhaul legislation, subsidies will be available from multiple sources for gaining health coverage—and therein lies a big problem. The uninsured could gain coverage with the help of subsidies to help pay premium costs in insurance exchanges, or through the Medicaid and Children's Health Insurance Programs. The variety of sources increases the danger that people will fall between the cracks, Dorn said.

Dorn, who joined Bingaman on the call, said that the approach taken by the state of Massachusetts in determining eligibility and conducting enrollment under that state's coverage expansion law is a good model.

He described the state's approach as follows in a new Urban Institute report on the issue.

"No matter where or how that form is filed, eligibility for all subsidy programs is determined automatically without any need for the applicant to complete additional paperwork. The relevant government agencies work together behind the scenes to determine eligibility seamlessly and invisibly to the consumer. A consumer can seek subsidized coverage without completing a full application," the report said. "Each applicant has the option to simply provide identifying information and request a determination of eligibility based on information in government hand, including income tax data."

The idea in the overhaul legislation now pending on Capitol Hill should also be to allow existing data in government hands to be used to determine eligibility, Bingaman and Dorn said. Applicants should be able to request that an eligibility determination be based on the use of that data, they added.

The report notes that with "Medicaid accounting for 41 percent of the coverage expansion forecast by the Congressional Budget Office (CBO), a failure of Medicaid to achieve its goals could undermine the overall effectiveness of reform. And with multiple subsidy systems operating under either version of the legislation, consumers could easily fall between the cracks and fail to receive coverage."

Coverage goals could best be met by including in the final bill provisions in section 1413 of the Senate bill (HR 3590) requiring a single application form and eligibility system for all subsidies under the overhaul, the report said. The section also includes other steps that should be taken to base eligibility on existing government data whenever possible. In addition, corrections to the section should be adopted that were contained in a Bingaman amendment that apply to Medicaid the same streamlined procedures, the report recommended.

"I'm not aware of any active opposition" to including the recommended language, said Dorn in the press briefing. But a deficit of attention may be a key obstacle. "We're dealing with issues that are tedious and boring," he noted.

Getting the details right in overhaul legislation may be particularly important, however, because of the fiscal budget crunch faced by state governments. "Medicaid may be at particular risk of enrolling less than its share of the uninsured," Dorn noted in his report. "Facing serious budget problems and the potential for increased Medicaid costs under reform, states may not have compelling financial incentives to maximize enrollment."

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