At its core, ELE is intended to simplify the processes used to find eligible children, then enroll and retain them in Medicaid and CHIP. As discussed, benefits from more efficient processes can accrue to states in administrative savings—permitting states to do more with less—but also to beneficiaries, by removing barriers to application or renewal processes that historically have prevented many families from insuring their children.
Although the study of ELE impacts on processes was not a focus of first-year evaluation activities, in our discussions with administrators for the descriptive analysis of costs and enrollment, several themes emerged about what factors facilitated ELE process improvements. Among them, states should think carefully about their selection of a viable Express Lane agency partner: it is a critical first step in the ELE process. First-year findings do not suggest that a single type of agency, whether the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid or tax agency, assures a certain outcome. Rather, the processes in place for how the ELE program uses partner agency information and whether that partner agency is likely to have data either on many children not already enrolled in public coverage or data on enrolled children (in the case of renewals) seem to affect ELE outcomes. States might consider “test” data matches with potential partners to understand how ELE might function in practice. For example, Alabama considered an ELE partnership for its CHIP program with the state’s child care subsidy program because the income eligibility levels for both programs are similar. Through a test data match, Alabama administrators found that few eligible children were identified through the match with the child care subsidy program, and that, given its older information systems, the costs of the systems changes that would be needed far outweighed the potential gains to coverage.
State administrators also said it was easier to implement ELE processes when they could build upon existing relationships, because of the familiarity with agency staff and their operations, as well as the existence of data use agreements that could easily be modified to accommodate ELE. Of the seven ELE programs studied in the qualitative analysis, six chose an Express Lane partner with which they had a prior data-sharing relationship—only Maryland did not.
Some state administrators said that ELE did not need to be implemented all at once, and that there could be advantages, particularly for ironing out processes, to implementing ELE gradually. For example, Alabama’s ELE, currently a manual process, plans to automate ELE in future phases. Alabama can incorporate lessons from its current ELE processes in its future plans, such as identifying which processes would save the most time through automation, and try to focus resources on those areas. Similarly, two states implemented ELE with either applications or renewals before moving forward on both fronts, or began with supervisors examining a few test cases before resolving policy and operational issues that would later be implemented statewide.
Not every ELE program studied included traditional outreach components as part of its ELE process, such as mailings to those identified through the Express Lane agency findings, but several did. Findings about outreach processes are mixed. ELE may have led to enrollment of children not reached by traditional outreach methods. However, mailing costs can be significant, and states’ use of application mailings have shown only modest enrollments according to the descriptive analysis presented in Chapter III. The one state that used automatic data matches to identify eligible but uninsured children and begin enrolling them into coverage—Louisiana—reached many more children at a much lower marginal cost, compared to states that used traditional mailings. Future work through this evaluation will help interpret these mixed findings, identifying the kinds of state policy choices that maximize enrollment of eligible children while achieving administrative savings.
Improvements in enrollment and retention processes achieved through ELE do appear to remove barriers for beneficiaries in most states studied, which is an important procedural achievement. As discussed in Chapter II, five of the seven ELE programs studied (all except Alabama and Maryland) required less documentation from applicants to process ELE applications compared to standard applications, and required fewer interactions with state staff. In six of seven programs (all except Maryland), ELE applications were processed more quickly than standard ones: in these six states, enrollment through ELE takes about one week or less, compared to up to 30 days using standard processes.
Finally, ELE processes have sometimes had helpful effects on standard processing procedures. For example, in New Jersey, the use of tax information in ELE has led to more extensive use of tax information in standard application processing, and its application simplifications made in support of ELE were also carried over to standard applications in the state. In Alabama and Louisiana, state staff suggested that the time saved by diverting some applications to ELE routes has meant that standard processing times for non-ELE applications are quicker than they would otherwise have been.
Identification of process lessons is a key focus of the second-year evaluation activities, both through case studies and the 51-state survey. Recent literature has identified other potential process lessons, such as minimizing demands on the partner agency and clarifying that differences in program rules are legitimate when training caseworkers, which we can investigate through future evaluation work (Dorn et al. 2012).
The enormous differences among state ELE approaches mean that it is difficult to generalize about ELE effects. As this evaluation continues, we hope to identify state approaches that appear more and less promising as strategies to increase enrollment of eligible children and improve administrative efficiency while safeguarding program integrity. Distinguishing between inherent effects of ELE and the effects that result from particular state choices involving policy and operational approach will be an important contribution of future work.