In sum, the literature described above finds that apparently modest procedural burdens—the requirement to complete a form or even check a box, for example—can have a substantial impact on program participation, as can eliminating such burdens by completing forms on consumers’ behalf. This has important implications for implementation of targeted enrollment strategies permitted by the Centers for Medicare and Medicaid Services (CMS). In May 2013, CMS issued a State Health Official (SHO) letter that permits states to provide consumers with Medicaid based on their receipt of SNAP, pursuant to waivers under Social Security Act §1902(e)(14)(A) that bypass the normal requirement of individualized income determinations.47 SNAP recipients can automatically receive Medicaid under such waivers, so long as such recipients are known to meet Medicaid’s nonfinancial eligibility requirements.
This option offers the potential to reach numerous uninsured individuals. Of the estimated 26.9 million childless adults who will qualify for Medicaid if all states expand eligibility, SNAP already serves 9.4 million, or 35 percent.48 SNAP provides benefits to an even higher proportion—56.7 percent—of uninsured parents who will qualify for Medicaid.49
However, CMS has made clear that these waivers do not eliminate the legal requirement to file Medicaid applications. Each SNAP recipient has already submitted a SNAP application, which CMS takes into account in determining whether the Medicaid application requirement has been met. CMS’s SHO letter explained that the combination of data from the SNAP application and consumers taking any of the following steps can satisfy the Medicaid application requirement:
- Checking an “opt-in” box on the SNAP application or recertification form;
- Making a telephonic or on-line acknowledgement after receiving a Medicaid card; or
- After receiving a Medicaid card, “indicat[ing] that they are applying for Medicaid when they go through the process of selecting a managed care plan,” which “also activates the Medicaid card.”
Others have suggested a fourth option—namely, sending “a very short form to confirm [consumers’] desire to apply for Medicaid and collect a signature and any additional information the state may require.”50
The research described above makes clear that when consumers must meet apparently modest procedural requirements, such as checking an opt-in box, returning a simple form, or making a telephonic or on-line acknowledgement, they are much less likely to participate in available programs, because of inertia, procrastination, short-term orientation, distraction, confusion, actual underlying preferences, or other factors. The first four states to implement targeted Medicaid enrollment campaigns have sent mailings to consumers who were in the target group—that is, they were not enrolled in Medicaid and they appeared to qualify based on their receipt of SNAP or, in some states, family members’ eligibility for Medicaid or CHIP. Consumers were invited to sign up for Medicaid by returning a simple form or, in some cases, calling a toll-free number. Nearly a quarter of a million people enrolled by November 15, but as one would predict based on the above-described research, most did not respond (table 3). The overall response rate was 34 percent. However, in Arkansas and West Virginia, where officials made telephone calls to all mailing recipients who did not initially respond, response rates were much higher—41 and 46 percent, respectively, compared to 33 and 27 percent in Illinois and Oregon, which did not make such extensive calls immediately following the mailing.51
Table 3. Results of targeted enrollment initiatives reported by 11/15/13
|State||Target group: SNAP recipients||Target group: People with family members enrolled in Medicaid or CHIP||Phone response accepted?||People sent mailings||Mailing response rate||People found eligible for Medicaid and enrolled|
Source: Manatt Health Solutions and the Kaiser Commission on Medicaid and the Uninsured, 2013. Note: total response rate is the average for all states, weighted based on the number of mailing recipients.
Hundreds of thousands of consumers quickly gained coverage in these states because of response rates significantly higher than those achieved by past mailing initiatives aimed at eligible individuals not yet participating in health programs.52 For example, Oregon’s initial 27 percent response rate was more than five times the response rate achieved when it implemented ELE by sending mailings to the parents of children who qualified for Medicaid based on SNAP receipt.53 New enrollees in these four states thus represented tangible and significant early coverage gains that showed the potential impact of targeted enrollment strategies. However, if this approach can be adjusted to further incorporate the findings of behavioral economics research and eliminate the interposition of procedural obstacles before eligible consumers are enrolled into Medicaid—making program participation rather than nonparticipation the default if consumers fail to act—many more eligible uninsured would likely receive coverage.