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.

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