The Patient Protection and Affordable Care Act creates a continuous set of coverage options for every American with income below 400 percent of the federal poverty level, or about half of the nation’s population. Sounds simple, right? To participating families it needs to be, but it will take a tremendous amount of work and creativity on the part of states and the federal government to achieve this vision.
The Affordable Care Act’s guarantee of coverage is actually a patchwork quilt that includes Medicaid, the Children’s Health Insurance Program, employer-sponsored coverage, and plans purchased with subsidies through the new insurance exchanges. While almost everyone will be eligible for some form of coverage, the source of coverage matters because it determines the benefit package, the cost-sharing provisions (deductibles and co-pays), and how costs are allocated between state and federal governments.
This complexity must be invisible to the person seeking coverage. We need to build a system where a person provides basic information about his or her own circumstances and linked databases instantly verify that information and convert it into a set of coverage options. Manual processes, reserved for complex functions like determining if someone has a disability, must become the exception, not the rule.
Through the Robert Wood Johnson Foundation’s Maximizing Enrollment for Kids program, for which the National Academy for State Health Policy (NASHP) serves as the national program office, we have been working with eight states to simplify and streamline eligibility, enrollment, and retention processes. By reducing documentation demands on families and improving behind-the-scenes data transfers, we are supporting states in their efforts to enroll eligible children.
What does it take to move in this direction? Two particular challenges must be overcome. First, separate data systems, each established for their own reasons with their own designs, must be brought together. Critical data for eligibility includes citizenship verification, income verification through tax and employment records, and enrollment information from other programs that have income eligibility criteria. Second, we need to move from the imperatives of the welfare bureaucracy—to screen out those who are ineligible—to the imperatives of a program of universal coverage—to rapidly determine which option is best for the applicant. Overcoming these challenges requires addressing important privacy concerns, investing in systems process improvements and information technology, and shifting federal oversight of eligibility determinations toward performance measures that reflect the importance of finding, enrolling, and retaining those who are eligible.
States have made important progress in their own right, and have learned lessons that can be applied to other states and at the federal level. Most of all they have learned that system improvements require leadership, commitment, and a willingness to make up-front investments that yield significant long-term savings.
Simplification of the enrollment system is the linchpin of success for the reformed health care system. Failure to achieve this vision will leave millions of people without insurance coverage even though low cost or no cost options are available to them. And failure to achieve this vision will mean more money spent on administrative processes when we need every available resource devoted to providing needed health care services.
Alan Weil, JD, has been the executive director of the National Academy for State Health Policy (NASHP) since 2004; previously, he served as director of the Urban Institute’s Assessing the New Federalism project. He is co-editor of two books, publishes regularly in peer-reviewed journals and has testified before Congress numerous times.