Medicaid Expansion 2014: What Can We Learn about Getting Low-Income Adults Enrolled?

Purpose: In 2008, Oregon held a lottery for its Medicaid-expansion program for uninsured low-income adults, the Oregon Health Plan (OHP). 85,000 people signed up for the lottery, but in order to reach an enrollment goal of 10,000 new enrollees the state had to draw over 30,000 names. Why would an uninsured low-income person who won a health insurance lottery not apply or successfully enroll? What are the characteristics that predict the true ‘winners'? Methods: The Oregon Health Study (OHS) is a mixed-method large-scale fielding effort designed to assess the effects of randomized access to health insurance in 2008. Understanding the characteristics of those who successfully enrolled was critical for the overall study. This presentation focuses on a later qualitative follow-up with 90 individuals who won a similar lottery in 2010 to learn more about the decision to apply and the application process. Our sample was drawn from individuals in the Portland, metropolitan area who won the OHP lottery in July, 2010. Participants were recruited by phone or in-person. In semi-structured interviews, trained qualitative interviewers asked participants to describe their decision-making process when receiving the application and, if indicated, to describe their experience with the application process. Participants were also asked to share their narrative health care history; how their health has impacted parenting, employment, and social relations; and how their health insurance status has impacted their access to health care, personal finances, and physical and mental well-being. Interviews were recorded, transcribed, and coded in ATLAS.ti using a coding dictionary and multiple coders per interview. Textual content analysis was used to identify reoccurring or divergent narrative themes among applicants and non-applicants. Results: Our analysis found, while chronic conditions were equally present among all three groups, perceived need for care was higher for those who applied. In addition, applicants who were and were not accepted had different employment patterns: accepted applicants often had longer periods of unemployment, which made verifying income requirements less of a burden and connected applicants to application assistance through the safety net. Denied individuals were often experiencing a recent shift in fortunes (recent unemployment) or were working a variety of jobs to make ends meet. It was particularly difficult for the self-employed to enroll, due to confusion calculating income. For many applicants, managing chronic health conditions affected the ability to maintain employment. Denied applicants were clearly the most disadvantaged group, as they perceived immediate need for care and were still trying to support themselves without safety-net support. Implications: In 2014, Medicaid-eligibility will nationally expand to include non-disabled or pregnant low-income adults-- precisely the population targeted for this limited expansion in Oregon. This study offers suggestions for program implementation: Needy individuals may be more likely to successfully enroll if income verification requirements are simplified and if application assistance is provided for those who are unaccustomed to navigating safety net systems. These findings also suggest that service providers should be aware of the relationship between health and employment, particularly as newly uninsured individuals struggle to meet their care needs