• Express Lane Eligibility, so why haven’t states used it?

    Paul Shafer is an assistant professor of health law, policy, and management at the Boston University School of Public Health. He tweets at @shaferpr.

    A few weeks ago, I wrote about an often ignored pathway for streamlining enrollment into Medicaid and the Children’s Health Insurance Program (CHIP) called Express Lane Eligibility (ELE). ELE allows states to use information collected by other agencies to determine eligibility for Medicaid and CHIP. This follow-up post explores the why, why ELE is underutilized and what capabilities we are missing as a result that could be game-changing in the midst of this pandemic.

    States didn’t have the authority to do this sort of information sharing before, so granting it should lead to all sorts of excitement at the prospect of administrative efficiency and better reach at serving those targeted by these programs, right? Not exactly.

    Less than a third of states (14) are currently using it. Why?

    A 2016 report from the Department of Health and Human Services (HHS) highlighted several barriers to states implementing and continuing use of ELE. Eleven of 14 states surveyed noted difficulties related to collaboration with relevant agencies and information sharing. These were often overcome but the short-term nature of these partnership agreements led to several states discontinuing ELE after a few years.

    Very few states implementing ELE were able to partner with their state tax agency because information sharing would have required new legislation and other changes. Other states noted that ELE was a short-term plan to boost enrollment and/or upgrades to enrollment and eligibility determination systems as part of the Affordable Care Act coverage expansions had “reduced the need for ELE.”

    Another concern could be less than perfect information sharing resulting in eligibility errors. A pair of 2016 reports from HHS estimated that over 95% and 88% of eligibility determinations for CHIP and Medicaid through ELE were correct, respectively, based on very small audit samples. Even with little guidance, states were implementing ELE in a way that yielded generally accurate eligibility determinations.

    But perhaps the elephant in the room is simply the cost to states of having more people enrolled. A 2012 letter on ELE from the Government Accountability Office (GAO) to Senator Baucus, then chair of the Senate Finance Committee, noted

    significant budget pressures that states are facing, which might make them reluctant to undertake options that would increase Medicaid or CHIP enrollment and costs, including costs for the services additional enrollees would receive.

    Making government operate more efficiently could have a real cost in this case, fiscally and politically, if Medicaid and CHIP rolls grow.

    In the same letter, GAO added that allowing ELE for adults makes it a much more attractive option for states. As currently legislated, it can only be used for children. 1115 waiver authority can be used to extend ELE to adults, but has been rarely used despite promising evidence (e.g., Massachusetts). Still, numerous states have embraced ELE, and we have an idea of what makes it work well (e.g., automated processes, permanent information sharing authority).

    Even if a state could get past those barriers, the transient nature of ELE makes states reticent to invest the political capital and dollars to set it up. ELE has been historically tied to CHIP reauthorization, which was most recently extended through fiscal year 2027 in the Bipartisan Budget Act of 2018. The Medicaid and CHIP Payment Advisory Commission (MACPAC) has recommended “permanently extending the authority” for ELE but Congress has yet to do so.

    States are experimenting with other mechanisms for streamlining enrollment. The Maryland Easy Enrollment Health Insurance Program allows anyone to check on box on their state tax return to get more information from the state exchange and approval for a special enrollment period, which more than 18,000 Marylanders had taken advantage of as of early March. An opt-in system isn’t nearly as powerful as an opt-out, as demonstrated by the Louisiana experience discussed in my first post, but it is nonetheless a step.

    A crisis is not the time to overload social service agencies and the American people with paperwork and documentation requirements. We should consider robust ELE-like information sharing across state agencies as part of our disaster preparedness strategy, allowing us to pair short-term stimulus, like checks and expanded unemployment benefits, with the capability to efficiently get those affected covered by Medicaid when they qualify.

     
    front-page-item.php
  • Sources for COVID-19 information

    The following post by Vivian Ho originally appeared on the Baker Institute Blog. Dr. Ho is the James A. Baker III Institute Chair in Health Economics and Director, Center for Health and Biosciences at Rice University. She tweets @healthecontx. (If you find this post useful, see also this and this.) Like many of you, we […]

    Read More
     
    front-page-item.php
  • How Will We Know When It’s Time to Reopen the Nation?

    The following originally appeared on The Upshot (copyright 2020, The New York Times Company)   Everyone wants to know when we are going to be able to leave our homes and reopen the United States. That’s the wrong way to frame it. The better question is: “How will we know when to reopen the country?” Any date that […]

    Read More
     
    front-page-item.php
  • Schools are essential. Don’t rule them out.

    Keith J. Loud, MD, MSc (@LoudKJ) is Chair of the Department of Pediatrics at Children’s Hospital at Dartmouth-Hitchcock and the Geisel School of Medicine at Dartmouth It remains to be seen just how much President Trump’s extension of social distancing guidelines in the United States until April 30 defers the debate over when to safely […]

    Read More
     
    front-page-item.php
  • The Option-Preserving Value of Social Distancing

    The following post is by Ian Ayres, Yair Listokin and Robert Schonberger. Ayres and Listokin are professors at Yale Law School and Schonberger is an associate professor at the Yale School of Medicine. Critics of measures to mitigate Covid-19, including until Sunday President Trump, argue that the benefits of a long period of social distancing fall […]

    Read More
     
    front-page-item.php
  • More COVID-19 Questions & Answers

    We’re answering 40 more COVID-19 questions from viewers! You can go to the timecode in the video description to see an answer to a specific question. Stay safe!   @DrTiff_PhD

    Read More
     
    front-page-item.php
  • Recent publications from Boston University’s Department of Health Law, Policy and Management: April 2020 Edition

    Below are recent publications from me and my colleagues from Boston University’s Department of Health Law, Policy and Management. You can find all posts in this series here. Azevedo KJ, Gray CP, Gale RC, Urech TH, Ramirez JC, Wong EP, Lerner B, Charns MP, Vashi AA. Facilitators and barriers to the Lean Enterprise Transformation program at the […]

    Read More
     
    front-page-item.php
  • Drivers of health and the coronavirus

    I don’t have time for a fully formed post or column on this, but I want to make note of a few ways in which the COVID-19 pandemic is intersecting with drivers of health (which include social determinants and health system factors). The following list is not necessarily exhaustive and my focus is on the […]

    Read More
     
    front-page-item.php
  • Incentivizing High-Value Drug Development: An Interview with Dr. Peter Bach

    As a physician, healthcare researcher, prolific writer, and Director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center, Dr. Peter Bach is one of the world’s foremost experts on prescription drug development and policy. Dr. Bach’s work has been published in the New England Journal of Medicine, Journal of the […]

    Read More
     
    front-page-item.php
  • Economic analysis of COVID-19 responses (part 2)

    Julian C. Jamison, PhD, is a Professor of Economics at the University of Exeter Business School and is affiliated with the Jameel Poverty Action Lab (MIT) and the Global Priorities Institute (Oxford). In part 1 I emphasized the importance of clearly specifying counterfactuals when making comparative judgments; consequently defined dichotomous policies of lockdown vs moderate […]

    Read More
     
    front-page-item.php
front-page.php