I was going to write this blog earlier in the week but got waylaid by meetings, meetings and more meetings! Today I wake up and see a front-page story in the Washington Post: Medicaid Tops Private Plans in Tallies of New Sign-Ups.
It's not very often that you see a front page story on Medicaid in the Washington Post, so, apparently the editors think it is big news that Medicaid is enrolling more people than the Exchanges so far.
As a practical matter, I think accepting 100% federal funding to extend Medicaid coverage to adults and getting that coverage up and running is easier than setting up a state-based marketplace, implementing the new insurance reforms and tax credits, etc. States obviously already have Medicaid programs up and running - in many cases with managed care companies providing the service and eager for more business.
Even if we stipulate that adding people to an existing program is easier than setting up a new system of coverage, comparing Medicaid enrollment to exchange enrollment at this point in time is not even close to an apples to apples comparison. Here is why: Most of the Medicaid enrollment has been through streamlined application strategies offered by CMS to states. For example, in Arkansas the eligible received a letter in the mail that they simply had to sign and return in order to enroll. Let me say that again - they had to sign a simple letter and return it. Does that sound like the exchange enrollment process to you?
Interestingly in Arkansas, the majority of those signing up for Medicaid have not gone to the website to pick a plan - which is a much more complicated task analogous to what exchange enrollees must do. Most of these folks will likely be auto-assigned.
Here is one thing the future Medicaid beneficiaries by and large did not have to do - pay a premium. Medicaid serves the lowest income Americans - those who simply cannot afford to pay a premium. Many of them will face cost-sharing when it comes time to use services, but there is no charge in the states mentioned to sign up. Those enrolling in Exchange coverage for January 1st pay a premium before their coverage goes into effect. What is the incentive to pay two months ahead?
As my colleague, Dr. Jack Hoadley, blogged about, enrollment for Medicare Part D--a more analogous comparison to Exchange sign ups since premiums must be paid--ramped up very slowly and, in fact, peaked in January.
According to the Post article, "the financial implications of heavier-than-expected enrollment in Medicaid aren't entirely clear... States do, however, have to help pay for residents who were eligible before the health law but are just signing up. That could be costly." This phenomenon is what we, at the Center for Children and Families like to call the "welcome mat" effect. And many of these already eligible residents are actually children, who are inexpensive to cover and whom will now be getting health care coverage that they desperately need.
There has been LOTS of research on the costs to states of the Medicaid expansion, including one that Dr. Jack Hoadley and I published finding that the state of Florida would actually save money by expanding Medicaid, even after accounting for the welcome mat effect. The Urban Institute has done much research in this area too, as well as many state specific reports. The credible studies all took into account the welcome mat effect, so, this surely comes as no surprise to anyone who has been paying attention.
Finally, in the handful of stories on robust enrollment I have seen on this issue this week (most even more inaccurate than the Post's), I am left with a sassy remark for these news outlets: you say that like it is a bad thing!
Yes,I know that trashing the ACA is the media feeding frenzy right now, but hey, I thought the point of the law was to cover people -- so why does it really matter where they get their coverage, as long as their health needs are being met? The cost-effective Medicaid program is efficiently and successfully opening its doors to uninsured, low-wage earners and their families who cannot afford coverage on the private market - isn't that a good thing?
I would call that an early sign of ACA success. But I guess good news doesn't usually land on the front page.