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Lessons from the Medi-Cal Expansion Frontlines

Lessons from the Medi-Cal Expansion Frontlines
Photo by Lance Cheung / CC BY 2.0
UCSF Philip R. Lee Institute for Health Policy Studies
UC Berkeley Center for Labor Research and Education

Executive Summary

Enrollment in California’s health insurance program for low-income individuals, Medi-Cal, grew by 35% between 2013 and 2014 under the Affordable Care Act (ACA). This historic enrollment growth was bolstered by factors such as the implementation of early and strategic statewide efforts to maximize enrollment, collaboration between government agencies at the state and county level, the provision of foundation and federal funding to support enrollment efforts, and the commitment of frontline workers who assist with enrollment. However, barriers in the enrollment process remain.

This report is based on research conducted by a team of University of California researchers between November 2014 and May 2015 involving eight focus groups with county Eligibility Workers (EWs) and Certified Enrollment Counselors (CECs) in four California regions. Additionally, key informants from 26 organizations were interviewed. The purpose of this study is to assist counties, health centers, community-based organizations, the California Department of Health Care Services (DHCS), and Covered California in developing strategies to make the Medi-Cal enrollment process smooth, efficient, and timely for applicants as well as the workers that assist them.

EWs, CECs, and key informants who participated in this study reported that CalHEERS challenges have been the biggest barrier to smooth and timely enrollment. EWs reported that workload was too high to achieve the level of customer service and thoroughness that they desired. EWs and CECs also reported that some eligible applicants decided not to apply for Medi-Cal due to immigration-related fears, concerns about the state’s estate recovery policy, and stigma associated with Medi-Cal enrollment. EWs and CECs reported not having sufficient information and support to efficiently and smoothly assist applicants with enrollment.

While all of these Medi-Cal enrollment barriers are crucial to address, this report focuses on the communication and training challenges because our study focused on the direct experience of EWs and CECs who comprise a substantial channel for enrollment. While challenges with CalHEERS continue to be a significant barrier for workers and applicants, this study was not designed to do a root-cause analysis of the technical challenges associated with enrollment.

Workers who participated in this study reported an ongoing desire for training and communication that is up-to-date, engaging, and reflective of real world examples—even after CalHEERS is stabilized. In brief:

  • EWs and CECs identified a need for more training, delivered in regular, engaging, case-based instruction to improve their effectiveness and insure consistent implementation of eligibility policy. They especially desire modes of communication, beyond email, that allow them to keep up with the changing policy and IT environment, such as weekly capacity building sessions with supervisors or local experts, and centralized, up-to-date repositories of information, such as a frequently-updated FAQ or Wiki.
  • They focused on a need for improved communication within and between DHCS and Covered California, and between counties and enrollment entities at the local level. They advocated for additional Medi-Cal training for CECs, increased communication between CECs and EWs, and phone lines and online resources to promote the timely and accurate dissemination of new policy changes and CalHEERS updates. They also asked for support from local “experts” in the form of supervisors or content experts who can attend centralized trainings and update workers at their office about changing policy or CalHEERS issues at weekly meetings, and function as resources to address questions between meetings.
  • EWs and CECs need assistance in defining the limits of their responsibilities and identifying appropriate resources for applicants who have questions about ACA tax policy, immigration issues, and the Medi-Cal Estate Recovery Program.
  • The combined Medi-Cal and Covered California application should be simplified to the extent allowable under the ACA.
  • Eligibility determination should be clearly and consistently communicated to applicants.
  • Written communication to applicants should be at an appropriate reading level and accurately translated.
  • Enrollment of populations with Limited English Proficiency can be improved with increased community partnerships and more bilingual staff.

Efforts are already underway at the state and local level to implement some of these recommendations, and a number of modifications were already made to improve the post-ACA Medi-Cal enrollment system prior to this study. As the Medi-Cal enrollment system continues to evolve, the effectiveness of the strategies adopted should be evaluated. Involving frontline workers such as EWs and CECs in the implementation and continuing evaluation of the recommendations presented in this report will be critical to ensuring a strong Medi-Cal enrollment system.