Association for Public Policy Analysis & Management

California’s Medicaid expansion paved the way for more than 12 million individuals to enroll in the program, and another 1.3 million residents have enrolled in qualified health plans (QHPs) they selected through Covered California, the state’s health insurance marketplace. In connection with these health insurance expansions, California launched an ambitious effort to collect and publicly report key data on the pathways to publicly subsidized health care coverage. The data include information on applications for coverage, eligibility determinations, enrollment, and renewals for Medicaid and QHP coverage. We supported the launch of this reporting effort by designing measures for each step of the eligibility and enrollment process and helping California officials interpret and disseminate the results.

California has published three reports, covering October 2013 through March 2015, and several noteworthy findings have emerged from the early data:

• The open enrollment period boosts enrollment in both QHPs and Medicaid. Even though people may enroll in Medicaid year-round, the jump in applications that come in during Covered California’s open enrollment period increased enrollment in both programs. Covered California’s second open enrollment period ran from November 15, 2014, through February 15, 2015. From January to March 2015, eligibility determinations for Medicaid rose 28 percent relative to the last quarter of 2014, and the number of people who selected a QHP increased 85 percent. These patterns suggest that the state should be prepared to manage large fluctuations in application volume for both programs.

• Enrollment is more persistent over time than expected. Seventy-seven percent of Medi-Cal beneficiaries whose eligibility was reviewed during the first quarter of 2015 remained eligible for coverage. Similarly, the vast majority of individuals enrolled in QHPs retained their coverage (92 percent) during the first annual renewal.  Approximately 94 percent of those who renewed stayed with the same insurance carrier (35 percent by choosing that carrier after exploring options and 65 percent by default). If insurance coverage remains relatively stable over time, it strengthens the incentive for issuers and payers to invest in preventive health services and could lower administrative costs.

• Shifts in common eligibility codes for Medi-Cal beneficiaries have implications for research. The ACA established the modified adjusted gross income (MAGI) standard as the basis for determining Medicaid eligibility. Under pre-expansion eligibility rules, there were many pathways through which individuals could qualify for Medicaid, based on household income in combination with other characteristics such as disability status. These non-MAGI pathways still exist, but many beneficiaries who would have been classified under non-MAGI codes are instead eligible under MAGI rules. Although this change streamlines enrollment for consumers, it introduces challenges for those aiming to study similar non-MAGI individuals over time. Researchers will need to consider using criteria aside from eligibility codes to identify beneficiaries of interest.

  California now has the foundation for more data-driven policymaking and for continuous improvement in the business processes that underlie pathways to insurance coverage. In particular, 58 county offices help administer the Medicaid program, offering a natural place to look for variation in outcomes and potential best practices.