By Nicole Rodriguez-Robbins
Mississippi, a place with perhaps the greatest need for more investment in health care, is one of 24 states that are not expanding Medicaid under the Affordable Care Act. To provide some context, a key provision of the Affordable Care Act, Medicaid expansion intended to raise the income eligibility ceiling to 138% of the federal poverty level in order to allow low- income and working poor people to obtain health coverage. Kaiser Family Foundation projected[i] that Mississippi might have received nearly $9.9 billion dollars in federal funding for the Medicaid expansion over the five-year period from 2014-2019, with an expense to the state of just $429 million, or $1 in state funds for every 23 dollars received from the federal government. However, with the decision to opt out, a large segment of the population in Mississippi, as in the other 23 states that have opted out of Medicaid expansion, will fall into a coverage gap where they find themselves simultaneously ineligible for Medicaid benefits and unable to meet the income requirement to qualify for a tax subsidy if they purchased private marketplace insurance.
Mississippi is the poorest state in the country. Its average life expectancy ranks lowest in the country and it has among the highest rates of adult obesity, diabetes and heart disease. The state also has the highest rate of infant mortality, equal to that of many developing countries. In a place with such vast health disparities compared to the rest of the country and with the greatest numbers of poor people in the nation, Kaiser also estimates[ii] that only 50% of those presently uninsured will qualify for financial assistance in gaining coverage, limiting their access to care.
Jessica Hunt, Director of Special Projects at Aaron E Henry Community Health Center, a federally qualified health center in the Mississippi Delta, shared the center’s experiences signing up individuals for health insurance during the ACA’s first enrollment season. Ms. Hunt, a certified marketplace navigator led a team of 12 CACs and several navigators in coordinating the Center’s Outreach and Enrollment activities. Their outreach entailed holding enrollment fairs and informational sessions about the ACA, conducting presentations to educate the public about the ACA implementation in Mississippi and informing the community at large and individuals about what options were available to them. The staff reached out broadly across the community, holding enrollment fairs in churches, schools, civic buildings, and even at the County Sherif’s Community Center. An initial October enrollment kickoff event garnered a large and enthusiastic turnout. However, the Outreach and Enrollment team faced significant challenges signing up individuals due to the myriad of problems with the healthcare.gov website registration pages and the ACA call center.
One of the biggest obstacles resulted from problems with health.gov website and hours-long wait times to speak with a representative at the call center. Consumers who tried to enroll were persistent and often returned multiple times to try and complete their application, only to have their applications rejected for technical reasons by the website registration page or to be put on hold for hours in attempts to speak with an ACA call center representative. Paper applications took weeks to be processed; this added additional time to the eligibility determination and required the applicant to return to the enrollment counselor to complete an online portion of their application. Because many of the applicants had limited financial resources, they often had no access or limited access to internet, lacked personal phones or couldn’t afford the phone credit to receive call back calls from the call center representative. Jessica recounted how difficult it was for her team to keep these individuals from getting discouraged because the process was both confusing and time consuming. In spite of all these obstacles there was overwhelming desire among the applicants to obtain insurance and they were willing to return multiple times to complete their application.
These technical and practical problems aside, by far the most significant barrier to enrolling individuals in coverage was due to the limitations of Medicaid eligibility. People came to the enrollment fairs in the hopes that they’d finally be able to obtain affordable coverage and were unable to enroll because they did not qualify for Medicaid; yet they also did not qualify for marketplace subsidies to offset the prohibitive cost of insurance premiums. Thus, many uninsured adults in Mississippi who would have been newly-eligible for Medicaid will remain without coverage. The overwhelming numbers of people that enrollment counselors assisted couldn’t afford to pay the insurance exchange rates and enrollment counselors made it a habit to keep a box of tissues handy because many tears were shed when applicants tried to unsuccessfully qualify for insurance. Jessica recounted stories of people who had little or no income being quoted premiums in the range of $600 to $1,000 dollars. For many, the quote might as well as have been millions –the costs were simply out of their reach. Many said they preferred to pay the penalty rather than shoulder the cost of an insurance premium. Jessica recalled a particularly disheartening story of a mother of two who was suffering from breast cancer. The plan she qualified for had a monthly premium that was more than 30 percent of her salary, something she couldn’t afford on her $24,000 yearly income. Unable to afford the health plan premiums, her only option is to go into debt in order to receive cancer treatment. Those individuals left out of Medicaid expansion in Mississippi were never the intended consumer of private coverage, and private insurance plans are simply not an option. As word got out about the coverage limitations, it became harder for the Outreach and Enrollment team to get a strong turnout at outreach events and morale among the team dropped.
Still, the enrollment team remained proactive and no application was allowed to fall through the cracks. When an opportunity presented itself, counselors seized on the chance to sign up applicants on the spot. They relied on a word of mouth and tried to be flexible about scheduling visits in order to try and reach everyone who needed assistance. With this strategy, the team was successful; for example, they helped to enroll a group of 30 people from 11 Vietnamese families with the help of an interpreter. They made a conscious effort to celebrate their positive outcomes for those individuals who did successfully obtain coverage. In total, the enrollment team successfully enrolled 139 people in insurance plans and had over 1,800 contacts.
One silver lining for those individuals who were unable to enroll was a raised awareness about the services offered at Community Health Centers like Aaron E Henry Community Health Center. Many individuals didn’t know about community health centers and the sliding fee scales for services before their contact with the enrollment team. O and E staff gave them information about community health centers in their area, assuring them that even those who remained uncovered could access care at the health center and would not be turned away.
Going forward, the fate of the Affordable Care Act and the potential for Medicaid expansion in Mississippi remains very uncertain. In spite of these uncertainties and the current limitations, Jessica and her team continue to remain optimistic and hopeful about the Affordable Care Act and the potential to make positive change in Mississippi. For the next enrollment season they plan to apply the knowledge and strategies gained last October to continue enrolling residents who missed the application window last fall. They will play a large role in educating the newly insured about how to utilize their managed care plans. They will continue to educate those who remain uninsured about the importance of preventative health and encourage them to seek care from the state’s FQHC network, which continue to play a critical role as safety net providers in caring for the uninsured and underserved.
[i] John Holahan and Irene Headen, (2010) Medicaid Coverage and Spending in Health Reform:
National and Stateby- State Results‐for Adults at or Below 133%, P 42.
[ii] How Will the Uninsured in Mississippi Fare Under the Affordable Care Act? (2014) http://kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-mississippi/