Administrative burden is an individual's experience of policy implementation as onerous. Such burdens may be created because of a desire to limit payments to ineligible claimants, but they also serve to limit take-up of benefits by eligible claimants. For citizens, this burden may occur through learning about a program; complying with rules and discretionary bureaucratic behavior to participate; and the psychological costs of participating in an unpopular program. Using a mixed-method approach, the authors explain process changes that reduced individual burden and demonstrate how this resulted in increased take-up in Medicaid in the state of Wisconsin. The findings inform the planned expansion of Medicaid under the Patient Protection and Affordable Care Act. A key design principle for Medicaid and other means-tested programs is that it is possible to increase program take-up while maintaining program integrity by shifting administrative burdens from the citizen to the state.

Shifting Administrative Burden to the State: The Case of Medicaid Take-Up

The Affordable Care Act (ACA) expanded eligibility for Medicaid to millions of low-income adults. While many expanding states implemented their expansion in 2014, five states and the District of Columbia expanded eligibility as early as 2010 by taking advantage of provisions in the ACA and Medicaid waivers. We used restricted data from the National Health Interview Survey to examine the impact of California's Low Income Health Program, an early expansion program that began in 2011. Our study demonstrates that the county-by-county rollout of expanded public insurance coverage in California significantly increased coverage, by 7 percentage points, and significantly reduced the likelihood of any family out-of-pocket medical spending in the previous year, by 10 percentage points, among low-income adults.

California’s Early ACA Expansion Increased Coverage And Reduced Out-Of-Pocket Spending For The State’s Low-Income Population

The effect of Medicaid premiums on enrollment: a regression discontinuity approach.

/pdf/a-doctor-in-the-house-balancing-work-and-care-in-the-life-of-51zdr2dkoy.pdf

A Doctor in the House: Balancing Work and Care in the Life of Women Doctors in Pakistan

Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.

Continuity of Public Insurance Coverage: A Systematic Review of the Literature

Wisconsin's BadgerCare Plus (BC+) program was designed to ensure access to health insurance coverage to virtually all Wisconsin children and to bolster coverage for parents and other caretaker adults. The program, launched in February 2008, expanded upon BadgerCare (Wisconsin's Children's Health Insurance Program) and Medicaid. BC+ combines its predecessor programs into one streamlined umbrella program and its introduction was characterized by the following reforms: an eligibility expansion augmented with an autoenrollment initiative; simplification of eligibility rules and enrollment and verification processes; and an aggressive marketing and outreach campaign.

This paper provides estimates of the impact of the reform effort on program enrollment and the continuity of coverage. We find that the introduction of BC+ was associated with increases in enrollment and decreases in exit rates, suggesting that the Wisconsin experience may be instructive for other states interested in achieving similar aims.

/pdf/wisconsin-s-badgercare-plus-reform-impact-on-low-income-3smnnhiam2.pdf

Wisconsin's BadgerCare Plus Reform: Impact on Low‐Income Families' Enrollment and Retention in Public Coverage

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Wisconsin's BadgerCare Plus Reform: Impact on Low‐Income Families' Enrollment and Retention in Public Coverage