How to Enroll 30 Million in Health Insurance

With health-care reform now the law of the land, the Obama administration faces a logistical challenge no simpler than wrangling votes in Congress: enrolling more than 30 million Americans in health insurance. If the Congressional Budget Office prediction holds true, 19 million additional Americans will carry health insurance when the individual mandate becomes law on Jan. 1, 2014. By 2019, another 13 million will be on the rolls. The federal government will provide matching funds for the Medicaid expansion—in 2014, the program will open to all Americans living below 133 percent of the Federal poverty level—as well as grants to help states build their insurance exchanges. Washington will also handle enforcement via the Internal Revenue Service, requiring Americans to file proof of insurance with their tax return.

But many of the administrative tasks fall to individual states: creating exchanges; raising awareness; deciding on enrollment processes; building an enrollment infrastructure, both physical and technological; and making all of it easy for consumers to use. "It's an aggressive timeline," says Genevieve Kenney, a health-policy analyst at the Urban Institute, of the 2014 deadline. "But we're not going into it blind."

From the passage of Medicare in 1965 up through Massachusetts's universal coverage program in 2007, health-care administrators have conducted an ongoing trial in wide-scale enrollment. The results? Successful transitions are indeed possible but incredibly complicated. They have historically required a sweeping outreach effort alongside meticulous attention to details, and they stumble without both key elements in place. "Its nonsexy stuff," Kenney says of the enrollment processes. "But if coverage is your goal, and this legislation does reflect that belief, [then] all the evidence we have shows the importance of creating good systems to support enrollment."

Medicare, the first large-scale, no-military government health-insurance program, demonstrated the brute force of bureaucracy. President Lyndon B. Johnson signed Medicare into law on July 30, 1965 with a daunting directive: have the program up and running by July 1, 1966. In "Reflections on Implementing Medicare," Robert Ball, the commissioner of Social Security during the implementation, remembers enlisting the help of the United States Post Office, the Internal Revenue Service, and the Forest Service, who had "rangers out in the woods looking for hermits to sign up on the voluntary plan." The Social Security Administration itself hired 8,000 additional employees, opened 100 offices in that first year and printed up 100 million leaflets on the program. The intensive approach worked: 93 percent of seniors signed up for the voluntary, $3-per-month Medicare Part B program within just 11 months of Johnson's signature.

Medicare was bolstered by a pro-government zeitgeist at the time, managed by Great Society Democrats who, on the heels of their 1964 landslide victory, were accustomed to creating government agencies with the stroke of a pen. Theodore Marmor, author ofThe Politics of Medicare, says, "There was the sense that government agencies could move quickly and competently without the huffing and puffing."

Thirty years later, faith in government had significantly eroded when Congress created a more piecemeal program: the State Children's Health Insurance Program, or SCHIP (pronounced ess-chip). Its $4 billion in yearly matching grants went to states that insured low-income children. While the law took effect even faster than Medicare—it was signed in August 1997, enrolling children in October of the same year—participation numbers were much lower. While Medicare reached nearly all of its target enrollees in less than a year, 21 percent of SCHIP-eligible children remained unenrolled a decade after the program became law, according to a report from the Urban Institute. Moreover, from state to state, enrollment numbers varied widely, from a high of 93 percent in Massachusetts to a low of 59 percent in Texas in 1999.

If Medicare underscored the importance of widespread outreach, SCHIP was a crash course in behavioral economics: small nudges throughout the enrollment process had huge effects on consumer decisions. SCHIP was not a sweeping, federal program in the vein of Medicare; no federal agency mandated how to track down potential beneficiaries. So each state developed its own program that, depending on usability, could encourage or discourage potential beneficiaries from signing up. When Texas, for example, required SCHIP participants to renew benefits every six months instead of every 12, SCHIP enrollment dropped by 29 percent. Changes can also push enrollees in the right direction. After Georgia revamped its SCHIP program by launching an online application and loosening renewal requirements, participation numbers shot up from 48,000 in 1999 to 300,000 in 2005. The most recent reauthorization of SCHIP, signed by President Obama in February 2009, included a list of eight best practices in enrollment, rewarding states that use at least five of them. "States are innovating," says the Urban Institute's Kenney, "and they're coming to a growing consensus about how to do this best."

Massachusetts, the most recent experiment in health-care reform, drew on lessons of the importance of both wide-scale outreach and low-level details. The state legislature approved a universal insurance mandate in April 2006, and the Connector, a newly created organization to regulate the insurance exchange, was charged with the task of putting the policy into action. The group spent $4 million on outreach alone, hosting 150 events across the state in the course of 21 months. The Connector partnered with the Boston Red Sox, local grocery stores, pharmacies, and local faith groups. "The biggest challenge was volume of requests coming in," says Joan Fallon, the Connector's communications director, who ran the outreach campaign. "We were a small staff and the people that reached us needed to hear back. I remember feeling a little overwhelmed." They developed an online portal that has won awards for its usability. The site handled 80 percent of the state's new enrollments. As of 2008, lack of insurance in the general population had dropped to 2.6 percent, the lowest rate in the nation.

For today's health-care reformers, Massachusetts has become the latest chapter to study: 42 states sent representatives to the state's January conference on how to implement universal coverage. Anxious administrators barraged Fallon with questions about how to execute the impending law. Massachusetts officials presented panels on their public awareness campaign, the structure of their enrollment campaign, and state-administered benefits. "You can leave no stone unturned," Fallon instructed them. "If a state has a fine for not having health insurance, it also has a responsibility to let people know the law is there and help them come into compliance." A wise lesson, but one that, if the history of health-care reform is any indicator, administrators will find to be much easier said than done.