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ESSAYRadical Simplification: Disaster Relief Medicaid In New York City
In the four months following the 11 September 2001 attacks on the World Trade Center, nearly 350,000 people signed up for Disaster Relief Medicaid. The process was quick and simple; applicants completed a one-page form and got a decision on the spot or the next day. While the program’s success stemmed in part from the unique circumstances facing New Yorkers in the fall of 2001, Disaster Relief Medicaid was an experiment in radical simplification that demonstrated a new way of thinking about how to design a simple, effective public health insurance program stripped of the vestiges of welfare.
Between the end of September 2001 and the end of January 2002, nearly 350,000 people signed up for Medicaid in New York City. They did not sign up in the usual way; the usual rules did not apply. This time-limited experiment in radical simplification, Disaster Relief Medicaid (DRM), met with an extraordinary response and, however unintended, offered a new way of thinking about public health insurance programs. The United Hospital Fund (UHF), the Robert Wood Johnson Foundation (RWJF), and the Henry J. Kaiser Family Foundation supported program implementation and analyzed its implications.
After September 11 the UHF was one of many organizations that felt the need to help New York City, its home, recover from the devastating attacks. We cautiously returned to our Empire State Building offices, struggling with daily fear and uncertainty. How could we be part of the recovery? We decided to work from our strength, and so we focused on health insurance—what were the ramifications of the attacks on coverage, and what were the likely effects on low-income New Yorkers’ coverage? New York already had a serious coverage problem. Even before the attacks we estimated that about 1.6 million New Yorkers did not have health insurance. Most uninsured workers had low-wage jobs that did not offer coverage; many had incomes within the limits of New York’s public health insurance programs.1 New York was in the forefront of states’ efforts to expand eligibility but not in streamlining enrollment requirements.2 In September 2001 we were looking forward to the imminent implementation of Family Health Plus, a statewide Medicaid expansion covering more low-wage workers and expanding child-focused outreach and enrollment assistance programs to include adults. But these expansions dealt more with income rules. Advocacy efforts to simplify the eligibility, application, and recertification processes met with a tepid response. Unlike some other states, New York still used most of its old program rules for adults. The state had developed a new application that, while shorter, was still eight pages long. Adult Medicaid applicants still faced a resource test and daunting requirements for documenting income, assets, and many other elements. Then, in the face of a crisis, public officials made an extraordinary decision. Within days of the September 11 attacks, Gov. George Pataki announced immediate disaster relief measures. The Medicaid program would be operating under special provisions until 31 January 2002.3 The city, state, and federal governments had agreed to temporarily suspend annual recertification requirements for many of those already covered and to forgo most of the questioning and documentation in the application process, so that New York City residents could apply using a one-page form. These provisions were not limited to those who were in the immediate zone of the attacks. In September 2001 nothing in New York City could operate in a business-as-usual manner. Phone lines and transfer stations were severely damaged. City Medicaid offices had no access to the state’s Medicaid computer system. Many of those people living or working near the disaster site could not get access to their homes or offices, and even for those distant from the site, simple errands took hours. Under these extraordinary circumstances, New York’s officials announced an approach to administering a public benefit that went far beyond any policy prescription ever proposed. This presented an opportunity to make this bold stroke widely known throughout the city and to enable organizations working with low-income New Yorkers to help them get health insurance coverage.
By late September 2001 the city’s Medicaid offices were handling DRM. Applicants had to go to one of twenty-two Medicaid offices to complete the special DRM application. Medicaid workers were instructed to review the form, verify only the applicant’s identity (but not request any other documentation), and then make a decision. Most applicants received a Medicaid authorization at the end of their eligibility interview. What made DRM different from the program in place prior to September 11? Two elements stand out: (1) The application was only one page, with virtually no documentation requirements. Applicants had to attest (but not prove) that they were giving true information. As a result, the eligibility interview took only about fifteen minutes, and Medicaid workers made decisions on the spot. (2) Coverage began right away. Successful applicants left the Medicaid office with an authorization good for four months of coverage. They could seek medical care immediately and know they would be covered. DRM also implemented two coverage expansions already in the works. Family Health Plus raised the income ceiling for parents and other adults, making a new group of low-income adults eligible for public coverage. Further, in June 2001 the state Court of Appeals ruled that New York had to extend Medicaid benefits to all immigrants legally residing in the state, regardless of whether they arrived before or after the August 1996 deadline that triggered federal financial participation in state Medicaid costs. Public officials faced a nearly overwhelming operational challenge in turning the governor’s announcement into a citywide program almost overnight. They scrambled to put Medi-caid office procedures in place, deploy workers to handle substantial walk-in traffic in offices that were not geared to handle large volumes of applicants, and develop "work-arounds" so that health care providers would be paid. We seized on the governor’s announcement to convene a group of organizations involved in Medicaid and Child Health Plus (New York’s State Children’s Health Insurance Program) outreach and advocacy. Together we identified several ways to spread the word about DRM and assist the city. Several philanthropic organizations quickly stepped forward to support the activities we outlined. The UHF board voted to allocate $1 million from its endowment to support disaster response efforts. The RWJF awarded the UHF a $750,000 grant, and the Kaiser Family Foundation supplied $56,000 to support the implementation assistance strategy our coalition devised. In addition, Kaiser supported focus groups of people enrolling in Medicaid as a result of these efforts. The foundations offered their support in part because they wanted to help New York at this critical time. Initially, supporting DRM implementation provided an opportunity to directly assist in solving a specific problem that fell within the long-term focus areas of these funders. Beyond this initial motivation, it soon became evident that New York was engaged in a de facto experiment in radical simplification that could contribute to the longer-term policy discussion about how public programs can better reach the people who need them, and so analysis and evaluation became critical elements of this foundation-supported program as well.
Working with a coalition of community-based organizations, advocates, and representatives of health care providers and managed care plans, we devised a three-part strategy to support the implementation of DRM. Getting the word out. The first information about DRM appeared in Governor Pataki’s 19 September 2001 press release. Among other things, it announced that the federal government had approved the governor’s request to expedite emergency health care coverage for New York City residents. Because the state government did not seem to be planning to widely disseminate information about expedited coverage, we were concerned that this bold announcement might not materialize into a substantial program. We embarked on a multiprong campaign to make sure that potential beneficiaries as well as providers were familiar with the new temporary program. Our effort began with two training efforts to explain the new rules: one directed toward organizations that work with potential applicants, and another aimed at providers. Experienced organizations with a citywide presence carried the message to smaller groups throughout the city, with particular attention to reaching adult immigrants who would not previously have been eligible for public coverage. There were more than 100 sessions attended by more than 2,000 people in October and November 2001. Training was provided to agencies that work with clients speaking a multitude of languages. Flyers outlining basic program information, translated into many languages, were made available as well. Agencies that attended these training sessions touch many of New York’s vulnerable populations, including the uninsured, low-income people, children, immigrants, and the mentally ill. A range of providers—hospitals, health centers, and mental health care providers—received training as well. These sessions described the eligibility process and addressed providers’ concerns about eligibility verification, billing, and payment. We also embarked on a public information campaign to spread the word. We placed ads at bus stops, on billboards, and in newspapers, and we pitched stories to the national and local newspapers, television, and radio. We succeeded in getting news spots on virtually all of the major local television outlets. The city and state were facing substantial operational challenges and had limited capacity to supply potential applicants with consistent information about where and how to apply. Beyond a posting on the New York State Department of Health’s Web site and a New York City Human Resources Administration (HRA) advisory to agencies trained to prepare Medicaid applications, it was unclear what plans for public education were being made. To help bridge this gap, we secured from the Healthcare Education Project of the Greater New York Hospital Association and Service Employees International Union Local 1199 use of its toll-free number in all of our materials. Supporting local government. Not surprisingly, our offers of assistance with public education, outreach, and enrollment were greeted with ambivalence by a stressed and stretched city administration. Where we saw potential for expanding program participation through community education, the city saw increased demand and potential breaches in program integrity. They rejected proposals to allow providers to submit DRM applications on behalf of their clients, fearing that the emergency paper system would be too easy to abuse. City administrators did accept our offer to help pay for messengers to move the volumes of paper generated by this temporary process. Although this might seem like an unusual expense in the twenty-first century, we were dealing with a process designed to work without any local computer support because the computer system did not work. Advocacy and compromise. During this time advocacy organizations and city government developed a closer working relationship than had been the usual case. It was a risky process for both sides; advocates provided rapid feedback on developments on the ground, and city administrators shared a candid picture of operational challenges. Through dialogue, compromises and accommodations were developed that strengthened the implementation of DRM. The training organizations met regularly to report on their activities, ensuring that efforts were not being duplicated. They also shared feedback about applicants’ problems. Early on, we anticipated that even though applicants could apply at twenty-two locations, the offices were likely to be overwhelmed. Many of the city’s Medicaid offices are very small and unaccustomed to accommodating extensive walk-in traffic. Because the new procedures represented a radical departure from the requirements that eligibility workers had been trained to use, uneven implementation was inevitable, even though city administrators quickly wrote up new procedures. Despite the city’s best efforts, which included hiring new staff and redeploying staff from other activities, Medicaid offices were quickly overwhelmed with applicants. A monitoring effort led by the Children’s Defense Fund (CDF) documented people’s experiences applying for DRM. The CDF found long lines, long waits, and offices that closed intake midmorning. With this evidence we were able to negotiate with city administrators a role for managed care plans and community-based facilitated-enrollment contractors in providing additional application sites and staffing to ease the burden on city offices. The regular coalition meetings brought to the surface many problems that required the intervention of senior Medicaid managers. The Legal Aid Society often took the lead in coordinating the presentation of these problem cases, ensuring that the problems were resolved, and sharing their experiences with others working as client advocates.
As the enrollment numbers rose, we began to think about what would happen when the program’s four-month enrollment window closed. Persons who applied in October 2001 were slated to lose coverage at the end of January 2002. On 3 December 2001 two New York State Assembly committees held a hearing to explore how the temporary program was operating and what provisions were being made for beneficiaries as their coverage expiration date drew near. The impaired Medicaid computer system was still not completely back to normal, calling into question the city’s ability to process full, old-style applications. And no agency, public or private, had yet been authorized to accept Family Health Plus applications. This was important because DRM enrollees who were in the Family Health Plus income range would be required to enroll in a managed care plan, and they seemed likely to face interrupted coverage since the process of both eligibility determination and plan enrollment takes several months at best. On 9 January 2002, when the earliest enrollees had only about three weeks of coverage left, state policymakers began publicly outlining their transition plans. New enrollment would end on 31 January 2002 as initially announced, but coverage for those already enrolled would continue beyond the original end dates. DRM enrollees would be required to complete the state’s new application covering both Medicaid and Family Health Plus, provide all required documentation, and appear for a personal interview at a Medicaid office. Because DRM enrollment was so large, the interviews stretched into November 2002. Beneficiaries received coverage extensions for the period between the expiration of their initial four-month coverage and the date of their application interview. The transition process contains many wrinkles and requires that applicants be attentive to mailed notices and detailed requirements at several points. The complexity of these provisions, while in part driven by the limitations of an out-of-date information system, means that many of those who got temporary coverage are unlikely to manage to stay covered. The state adopted some modest application and recertification reforms in January 2002, but none of these will be implemented in time to aid transitioning DRM enrollees.
When DRM enrollment closed on 31 January 2002, nearly 350,000 people had gained health insurance coverage through this extraordinary program. We sponsored several efforts to sketch a preliminary portrait of those who applied, including a survey of nearly 3,000 applicants by selected managed care plans and community-based enrollers, a CDF survey of nearly 700 applicants and site observations at twenty-two HRA Medicaid offices in January 2002, and a joint focus-group project with the Kaiser Commission on Medicaid and the Uninsured. Preliminary findings show that DRM applicants who came to managed care plans and community organizations to enroll during December 2001 were a diverse group. Only about one in four spoke English as their primary language, and most reported that they had not applied for Medicaid in the past.4 Nearly one-third of that group said they hadn’t tried before because they had been covered through their job or because their financial circumstances had recently deteriorated.5 The transition process, then, would be the first time that most DRM enrollees encountered the public programs’ full application and documentation requirements. This finding, coupled with the language diversity, underscores the challenge many DRM recipients faced.
Direct comparisons are difficult to make, but it appears that during DRM’s four-month application period, city Medicaid offices authorized ten times the usual volume of community applications. Worker productivity skyrocketed, as workers completed four interviews per hour, rather than the usual six to eight per day. And the city redeployed a large number of eligibility staff who were transferred from recertification tasks. The unprecedented outpouring of applicants caused many observers to ask why so many people were seeking Medicaid. Our studies are unlikely to yield definite answers to this question. However, a few characteristics of the program’s design, along with information we have gleaned about applicants, suggest some explanations. Income expansions. DRM adopted the higher income ceiling associated with New York’s Medicaid expansion (Family Health Plus), which was enacted in December 1999 but was not yet available in New York City before September 2001. Although the Family Health Plus/DRM income ceilings were still low when compared with the cost of privately purchasing health insurance, the increase was important for parents because it reached up into income levels where previously only children were covered. Family Health Plus made an even bigger difference for childless adults, taking the ceiling from roughly half the poverty level up to 100 percent. Coverage for noncitizens. A June 2001 court decision ordered New York State to make Medicaid available to all eligible, legal adult residents, striking down state policy, modeled on federal law, that covered only adult immigrants who arrived before 1996.6 DRM eligibility guidelines effectively implemented this court decision and were widely disseminated in the city’s immigrant communities. Immediate coverage for people with health problems. More than half of the respondents to the December 2001 survey reported that they were applying for DRM because they had a health condition that needed treatment.7 Many of the focus-group participants described serious, chronic health concerns that they attended to upon receiving their DRM coverage.8 Community health center testimony prepared for an April 2002 city council hearing on the transition process tallied abnormal pap smears, cancer diagnoses, and other indications that major and sometimes life-threatening conditions were detected and treated.9 The city’s public hospitals reported treating nearly 14,000 patients, covered by DRM, for chronic and advanced illnesses; almost 20,000 sought primary and preventive care at various New York City Health and Hospitals Corporation service locations.10 Participants stressed the immediacy of coverage—yes, they would have to stand in line, but they would get covered right away or within days. Some had been trying to enroll for years, so the promise of getting coverage after one trip clearly supplied the incentive they needed. The economic and psychological aftermath of September 11. Many of those applying for Medicaid for the first time had had a change in their financial circumstances or lost a job that had supplied health insurance. But economic uncertainty was not the only factor. In focus groups we heard from enrollees who had been uninsured before, and probably would not have applied for Medicaid, but the unsettling events made them feel more acutely the need to have insurance in case something happened to them. Perhaps because of the Disaster Relief label, some of those who might not have been willing to sign up for a public program felt that, at this time, it was all right to seek government help. A new attitude. In focus groups we heard repeatedly about powerful friend-to-friend communication that spread word of DRM throughout the city. Also, in communities where people had experience trying to get and keep Medicaid, the word on the street was that the city workers were giving out Medicaid. This description contrasted sharply with their past experiences: encounters with rude workers, demands for documents they did not have, multiple trips back to the Medicaid office to try to fulfill all of the application requirements—in short, a system that was not giving away anything.
The unprecedented application volume, coupled with the absence of traditional fraud controls, raises concerns that some DRM recipients did not fall within the program’s income guidelines. In some communities there may have been a sense that with the computers unplugged, nobody was looking, and so people who probably could not afford coverage any other way went ahead and applied. Program administrators are attempting to assess the extent of client—and provider—fraud, but their efforts will likely be frustrated by several factors. Some workers are paid in cash, so their earnings will not show up on tape matches with employers’ wage reports. Addresses change for low-income, fragilely housed families, so some recipients will be difficult to locate for further verification. In the transition period’s early stages, only about half of DRM recipients came in for eligibility review interviews, roughly matching the usual return rate for Medicaid recipients at recertification.11 In light of what we know about the applicants—people new to Medicaid, required to piece together extensive documents for the first time, and act on notices not written in their language—we suspect that confusion and frustration rather than fraud largely explain the low return rate.
No means-tested public health insurance program actually covers all of those entitled to enroll. In most states Medicaid’s separation from welfare has been unsure and incomplete. In the name of program integrity, Medicaid carried forward cash-assistance program requirements geared toward denying assistance to all but those who could definitively demonstrate need. Reforms have come gradually, usually starting with children, and in New York State have remained well within the orientation of ensuring that all possible questions about personal, financial, and household circumstances are documented and resolved before eligibility is granted. DRM did not design new strategies for increasing program participation while ensuring program integrity. It was not the obvious next step in a carefully choreographed incremental strategy for reducing enrollment barriers. As a Medicaid policy for ordinary times, it arguably went too far and created a sense that no one was watching. But that does not consign it to irrelevance as an aberration born in disaster. Instead, it recasts the way we approach a public health insurance program. It did what outreach campaigns, TV ads, and incremental reform have failed to do—it got people excited enough to press their friends and family to go down and get in line. It demonstrated that low-income people need and want health insurance and will apply when the program operates on terms that make sense to them: an application that can be completed within minutes and an answer that comes right away. The challenge going forward is to begin our program design discussions from a new starting point. Now we know what a simple health insurance application looks like. It does not ask you to explain how you manage on a paltry income; it does not demand that you prove that potential sources of income do not exist, or that you do not have resources that are found in less than 1 percent of the households in your income range; and it does not require you to offer information that might subject you to unwanted contact with a child’s absent parent. Instead of starting with the full list of welfare-based questions and requirements and asking what could be eliminated, the DRM experience instructs us to start from the model that works and determine which elements absolutely must be added to address legitimate concerns with program integrity. Yet fidelity to program integrity must do a better job so that procedures to screen out the ineligible do not exclude large numbers of eligibles. Outreach is easy when the product sells itself.
Kathryn Haslanger is a vice-president at the United Hospital Fund of New York, a health services research and philanthropic organization in New York City. The author thanks James Tallon and David Gould for their comments on an earlier version of this manuscript; Danielle Holahan for comments and research assistance; and Carole Tiernan and Elise Hubert for assistance in preparing the manuscript. This paper describes activities and research funded by the United Hospital Fund, the Robert Wood Johnson Foundation, and the Henry J. Kaiser Family Foundation.
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The Outlines Of Recovery
Disaster Relief Medicaid Begins
