By Julie Hudman, PhD, Director, Department of Health Care Finance, District of Columbia
And no, it isn’t #1 in murders, infant mortality, or a
high concentration of policy wonks. It is #1 in enrolling and keeping children
enrolled in Medicaid and CHIP. A Health Affairs article by Dr, Jenny Kenney and others found that the District’s
Medicaid/CHIP participation rate for children is 95.4% compared to the national
average of 81.8%. The District’s high participation rate for children is the
main factor in the District being #2 (right behind Massachusetts) in uninsured
kids – only 3.2% of the District’s children lack coverage.
There are many good research reports (some I’ve read
about right here on Say Ahhh!) on what states need to do to help kids get into
coverage for which they are eligible.
The District has implemented many of those proposed policies (no asset
tests, no procedural differences between Medicaid and CHIP, and 12-month
continuous eligibility) but some key ones we have not (on-line enrollment and
eliminating unnecessary documentation).
We are working towards further simplification but are not quite there
So, why is the District the best in the county in
enrolling eligible children into public programs? Dr. Kenney and her colleagues at the Urban Institute list possible reasons why they found wide variation among states including population
density, per capita income, political culture as well as policy decisions such
as eligibility thresholds for families and retention efforts. I think there is a lot of truth in the
possible reasons they lay out for differences in participation. Here are the three key reasons for the
District’s success in getting kids covered:
- Policy and Program Choices Are Paramount – While we
still have some simplification changes to make, the District has managed to put
many policies in place that facilitate enrollment. I believe the two most
important policies are expansive eligibility and no financial barriers.
Due in part to the high cost of living, the District covers children (and
pregnant women) up to 300% FPL through a Medicaid expansion using its CHIP
program. And, maybe more importantly, everyone under 200% is eligible for
public coverage including parents, childless adults, and undocumented
residents. We utilize
Medicaid wherever we can – and just became the 2nd “state” in the country to take
advantage of the ACA provision to allow us to cover everyone under 133%.
Anyone, including those unable to prove citizenship status, are in our
look-alike locally-funded Alliance program. Heck – we even put undocumented
kids into our Medicaid program (with local dollars of course) so they can have
a chance to grow and thrive with access to need care provided by
Medicaid’s EPSDT and benefit
package. Providing access to such crucial coverage and covering parents and
undocumented residents allows for us to help whole families at a time. We also have a “no wrong door” approach
– come in for food stamps, housing, cash assistance or whatever benefit you
need, and you will be screened for Medicaid or the Alliance program.
- No Financial Barriers. In our Medicaid/CHIP and Alliance
programs, we have no premiums, no enrollment fees, and no cost-sharing. Families have no reason NOT to enroll
the entire family into coverage – and the whole family can be together in the same
health plan. Research shows that
financial barriers cause folks to delay or not enroll in coverage – that’s why
we got rid of those barriers here in the District.
2. Political Culture Does Matter. I hate to use the six letter word “stigma” but research and my personal experience suggests that it is alive and well in some parts of the country. I grew up in Oklahoma, but have lived and worked in DC, Baltimore, Boston and upstate New York. How Oklahoma residents feel/think about government services is fundamentally different than these other places (and the OK participation rates for kids are lower than these other places). I don’t blame the people – I blame many of the leaders who set up and talk about the programs in a way that discourages people from participating in public programs.. Here in the District , leaders try to make people feel welcome and encourage them to come in and get the coverage that they need and qualify for.