Right now Medicaid expansion is going fairly well. People who were previously eligible but not enrolled are signing up, and people who are newly eligible in the non-stupid states are signing up. States with Democratic control have overwhelmingly expanded Medicaid eligibility and states with Republican control where the faction of Republicans who can count to eleven with their shoes on are the dominant players are expanding Medicaid. Arkansas has pioneered the “private option” for Medicaid enrollment, and they look like they should be good to go on Jan. 1, 2014.
States have a variety of options as to how they manage their Medicaid programs. States can either act as an insurance company by setting up provider networks, paying claims, researching denials and appeals, and providing member service or they can set up a series of non-state managed care organizations. Most states have gone the managed care route. Expansion quality will vary across states. The states that have been planning for expansion the longest should have the easiest time. Ohio will most likely have a rough kick-off because they decided to expand only a few weeks ago. Michigan was also a late decider, but they are not expanding until April 1, 2014 so they should have a smoother launch than Ohio.
The managed care organizations have a significant number of tasks that need to be done for a successful expansion.
The first thing that a managed care organization needs to do is figure out if the rules have changed for the expanded eligibility population. For instance, states can modify co-pays and premiums as recipients go up the income ladder. If an organization has a standard configuration but the expansion pool has a series of new $5 co-pays, the managed care organization will need to reconfigure plan structures. New membership groups and lower member divisions may be needed. For instance, my state requires additional maternity care at no co-pay so young women who previously were on Medicaid basic are temporarily moved to a seperate group during their pregnancy to insure a smooth application of better benefits.
Once the base set of rules are defined and configuration occurs, several other long lead time actions need to happen. Ohio is anticipating an additional quarter of a million people joining Medicaid in the next year. Those people will need to talk to customer service reps, and those reps need to be hired and trained. Those people will need their complex conditions managed so new case managers will need to be hired and trained. Those people will need advocates when denials are issued and they go to appeal, so the advocates need to be hired and trained. Providers will see an increase in care coordination and appeals requests so provider service representatives will need to be hired and trained.
After the back-end/invisible long lead tasks are taken care of, the front end tasks need to be accomplished. The first is getting word out to the target populations. This is a big marketing campaign that has to work in multiple languages, multiple cultural mileaus and also work against cultural and political stigma. The next step is a screening step. Most of the screening is intended to take place on the Exchange websites, but direct sign-ups are also possible. I anticipate a lot of churn as people re-assess their options and choices as they get close to the top of the income limitations. Exchange may be better than Medicaid for someone who projects their income to be $1 over the state expansion income limit rather than $1 under the limit. After that, regular enrollment and procedures can start taking place at a much larger scale.
This is a fairly straightforward set of tasks that are at most variations on previous themes. The task set is big, but it is not a task of re-inventing the wheel.
Baud
This doesn’t sound like a train wreck at all.
You lie!
Soonergrunt
Thanks again, Richard. Great information, as always.
Matt McIrvin
Do the states that decided not to expand get another chance (without a change in the law)?
Richard Mayhew
@Matt McIrvin: It is an open offer… so if Alabama comes to its senses next summer and accepts expansion, it would get 100% fed funding until Dec. 31, 2016 for the expansion and then would get a slow taper to 90% fed funding after that.
Richard Mayhew
@Matt McIrvin: States don’t have to go live on Jan. 1. IIRC, all of the expansion states with the exception of Michigan are planning on going live with the Medicaid expansion for Jan. 1. As a little drone for a Medicaid managed care organization, I think Ohio may be in trouble with an 8 week implementation build-out period for their managed care organizations. I would imagine/hope that some of the MCOs did some contingency planning for a quick expansion decision but I don’t know.
aimai
I’m wondering what a hypothetical jump to single payer would have looked like, if it could have been done? Not that I’m jonesing after single payer or am a single payer truther. Far from it. I’m just wondering how on earth a population of 300 million would have moved into an NHS style system–how would you have brought people into contact with their doctors and hospitals, how would you have encoruaged them to get to see the people they need to see?
Also: a subsidiary question. Just reading Josh Micah Marshall’s reader reports it seems obvious that the wealthier more liberal and more urbanized states have better provider networks and offer more insurance plans. Is it not the case that rural areas are already underserved and that they will neither offer so many plans nor such cheap prices? Aren’t we going to need to massively subsidize rural areas, just as we must massively subsidize their post office service, both for humanitarian and political reasons? How is the ACA handling that problem given how resistant red state/rural states are to accepting the medicaid expansion and how few insurance companies may be in the market in those states in the first place?
rikyrah
good info – thank you
Lolis
I used to have Medicaid and I had no idea how good it was. I had no copays for pretty much everything. It was sometimes a struggle to find a doctor or see a specialist but overall it was pretty awesome.
Mnemosyne
@Lolis:
I had to get workers’ comp after a work-related injury here in California and holy crap did they make things easy on me. No copays, assigned me to a good orthopedic surgeon who replaced my torn ACL, even paid for a leg brace (that I’ve never used). The one thing they skimped on was physical therapy, which was kind of annoying.
And they only take a few bucks out of my weekly paycheck to cover it for everyone in the state.
JoyfulA
Here in Pennsylvania, Gov. Corbett weaseled around forever and then a month ago sent some proposed plan to HHS that would give the extra Medicaid money to private insurers, who would then insure proposed Medicaid enrollees (sort of like the Arkansas plan, as I understand both, which is not much).
He’s now officially awaiting a response from HHS and hoping it doesn’t arrive until mid-November 2014, after the polls close.
Of course, for decades, we used to have an insurance company-subsidized (for the right to sell health insurance in the state) health insurance policy for the working poor, although with a waiting list in the hundreds of thousands. Gov. Corbett shut that down even before he cut a billion from public school funding in the name of fiscal prudence.
fake ted & helen
@aimai: isn’t NHS national health (government-run healthcare), not single payer (government-insured halthcare)?