Streamlining Access to the Safety Net

By Paul Shafer, PhD
September 13, 2022

This week’s contributor is Paul Shafer, an Assistant Professor in the Department of Health Law, Policy and Management at the Boston University School of Public Health and co-director of the Boston University Medicaid Policy Lab. His research focuses on the effects of state and federal health insurance policy on coverage, health care use and health equity. Paul is a member of the 2022 Tradeoffs Research Council.

It’s not often the word streamlining is used to describe something that the government is doing. But last week, the Biden administration took a step towards doing just that to keep low-income families enrolled in health insurance. 

On September 7, the Centers for Medicare and Medicaid Services (CMS) published a Notice of Proposed Rulemaking in the Federal Register. This newly proposed rule potentially takes a big step towards making it easier for individuals and families to get and stay enrolled in Medicaid and the Children’s Health Insurance Program (CHIP), a pair of public health insurance programs focused on adults and children with low incomes and people with disabilities. 

The rule, titled “Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes,” does a lot. At its core, though, it aims to simplify applying for and renewing eligibility for Medicaid and CHIP. 

This latest rule follows an executive order signed by President Biden last December, aimed at improving the customer experience that Americans receive from their government. In that order, the Biden administration designated CMS as one of 35 High Impact Service Providers, with heightened focus on reducing administrative burdens.

This is key. Administrative burdens refer to the often mundane and infuriating hoops that people must jump through to take advantage of government benefits — hoops that unfortunately can have a big impact on health. These burdens can make it harder for people to access benefits that they are eligible for — a so-called “time tax.” Evidence suggests that the more we leave up to caseworker discretion in safety-net programs like unemployment insurance, the more we double down on existing inequities in health and financial well-being.

The new rule focuses on improvements in application and renewal processes and shifts more of the burden onto government, away from those already in or applying for these public programs. One potential benefit of these shifts is reducing the costly and harmful churn that roughly 1 in 10 Medicaid enrollees experienced in 2018. The term “churn” encompasses the chaos of switching types of insurance, having a coverage gap and re-enrolling later, or losing coverage altogether.

This new proposed rule addresses churn through simplifications like allowing Medicaid and CHIP to accept each other’s eligibility determinations, sending pre-populated renewal forms, and requiring states to try harder to reach people

Why is reducing churn important? State policies that allow 12 months of continuous Medicaid enrollment for kids are associated with better health, and, critically, better access and health care use for children with special needs. Less churn also means more low-income adults have consistent physician networks and can stay up-to-date with medications.

Improvements like those proposed in this new rule take on added urgency and importance as the end of the COVID-19 public health emergency declaration looms, threatening to disrupt millions of people’s coverage through Medicaid and CHIP. It is also a move towards greater health equity, given that Black and Latinx enrollees are at higher risk of being hospitalized after churn than white enrollees. Making our safety net programs work better helps lower the “time tax” and can improve health. Hopefully, these are the sorts of common sense changes we can all get behind.

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