After the ACA Simplified Medicaid Enrollment, the Administration and Some States Are Making It Far More Complicated

For years, the federal government and states have sought to get rid of enrollment barriers in Medicaid. Now a number of states are reversing course: 14 states have approved or pending Medicaid 1115 demonstrations designed to restrict Medicaid eligibility. Attention has focused on the demonstrations’ work mandates, but the experiments involve much more. Other features include extensive reporting rules — in some proposals enrollees must report on their eligibility status weekly — as well as premiums, coverage lock-out periods for “noncompliant” people, and a return to cumbersome paper verification requirements and asset tests.

How Did the ACA Improve Medicaid Enrollment?

The ACA streamlined Medicaid enrollment in order to promote stability and avoid frequent breaks in coverage. Reforms aimed at making Medicaid work more like other forms of health insurance included a simplified online application coupled with an easier renewal process. The law eliminated in-person application requirements and unnecessary paper verification, and emphasized accessible community enrollment locations.

These reforms were meant to work in tandem with the health insurance marketplaces, to help lower-income working families that experience modest and periodic income shifts from wage fluctuations that necessitate moving between Medicaid and the marketplace. The reforms also grew out of states’ own experience with past eligibility reforms and build on the success of the Children’s Health Insurance Program.

The ACA’s simplified eligibility and enrollment reforms were also the result of research documenting the link between stable coverage and better health care access, both generally and for people with serious health problems. As dozens of states have sought to tackle Medicaid payment and delivery reform to improve care and lower costs, they have simultaneously tried to reduce coverage interruption, a phenomenon known as churn, by improving eligibility and enrollment processes.

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