The "glitches", "problems", "failures" of the federal health insurance marketplace and the HealthCare.gov website are headline news and a source of frustration, disappointment and embarrassment to many. Yet, research that I have been doing for First Focus based on experience with the roll out of the Children's Health Insurance Program (CHIP) beginning in 1997, suggests that enrollment in new major health insurance expansions will be slow at first and expose problems that even the most careful planning might not have anticipated. However, in the long run the success of the effort depends on how effectively and creatively problems are addressed and the learning from those efforts incorporated into a process of continuous improvement.
My recent brief for First Focus, "CHIP Roll Out and Early Enrollment -- Implications for the ACA," is the first brief in a series exploring how lessons learned from the early years of the Children's Health Insurance Program (CHIP) can inform ACA implementation. Although the ACA's coverage options are more comprehensive and complex than those created by CHIP, and the ACA faces a much tougher political climate, there are many important similarities between the programs:
- reliance on state and federal governments working together,
- a large expansion of coverage built on existing Medicaid and employer sponsored coverage with federal financial incentives, and
- a strong focus on enrollment and reducing the number of uninsured.
Though CHIP's launch was slowed by uneven and inconsistent variations across states, as well as technical and operational problems in individual states, today, CHIP is considered a great success. CHIP has provided coverage to millions of children over the 16 years since its launch, and spillover effects from CHIP innovations have helped modernize and improve the much larger Medicaid program.
As a result, the uninsured rate for children has declined fairly steadily since CHIP came on the scene, despite recessions, rising health care costs, and erosion in private insurance, reaching record lows in recent years. Millions of children, however, remain uninsured, as do many more parents. Successful implementation of the Affordable Care Act would reduce those numbers by almost half and significantly strengthen American families.
Many ACA policy elements derive from experience with CHIP, such as the ACA's "no wrong door" and "screen-and-enroll" provisions - these help to ensure that applicants who apply for one coverage option (like the new "exchange" insurance plans) but are eligible for another (like CHIP or Medicaid) get covered instead of denied.
The current problems with the federal marketplace website bring to mind an important lesson from the roll out of Healthy Families, the CHIP program in California. Shortly after the launch of Healthy Families, it became clear that the biggest challenge to enrollment was a comprehensive 28-page application booklet. This application was developed with great care through a public process that included advocates, attorneys and eligibility workers. It was attractive, translated into 13 languages, and tried to explain all the nuances of the eligibility process to applicants. But it didn't work for families. They found it intimidating rather than empowering.
Paying close attention to feedback from the field and advocates, California officials regrouped. Working with the community, they had a new streamlined four-page application in place in several months. Enrollment then started to grow rapidly, but it still took about three years to reach 50 percent of long-run peak enrollment.
Folks in the field still talk about California's 28-page application, and the lesson about the need to deal quickly and openly with problems is as important today as it was then. Moreover, the lesson is not unique to California. As Jason Cooke, the first Texas CHIP director observes, "You need a process focused on identifying problems as they happen, fixing problems for the individuals involved, but also looking for patterns that suggest systematic issues and jumping on those. Almost as important, the community needs to hear about the fixes to specific problems, as those resolutions are being pursued and completed. That is critical to maintaining community support."
The brief contains other lessons from the early years of CHIP implementation including the value of having ambitious, publically announced enrolment targets to focus attention and encourage innovative problem solving. In addition, if the CHIP experience is a reliable guide, ACA enrollment will be gradual, maybe uneven and vary by state and overtime.
The most important lesson, however, might not lie in CHIP's early years but at this very moment. Today, CHIP is a bipartisan success story. By learning from early experiences with CHIP and working together, policymakers can make the ACA work and cover millions of children, their families and other Americans.