By Gene Lewit, Stanford University Health Policy Center for Primary Care and Outcomes Research

The countdown to October 1 has begun, when millions will begin to enroll in health insurance under the Affordable Care Act (ACA). The ACA seeks to make enrollment easier by asking states to provide online enrollment systems. These new portals are expected to provide a high-quality customer experience and encourage self-service application for Medicaid, CHIP or exchange coverage. In addition, the ACA provides Navigators and other in-person assisters to help enrollees understand the coverage options under the ACA and enroll in the alternative appropriate for them.

Prior to the enactment of the ACA, states were already implementing self-service online enrollment systems, frequently but not always, as complements to traditional in-person enrollment systems.  One such self-service online system is Health-e-Application Public Access (HeA PA) – a fully automated, web-based application California introduced in 2010 for its CHIP program Healthy Families and, until this year, as a screener for its Medicaid program Medi-Cal. HeA PA was a part of an enrollment system that included assisted online and paper applications as well as self-service mail-in paper applications.

In previous posts, I wrote about findings from an evaluation of HeA PA conducted by Mathematica Policy Research with support from the David and Lucile Packard Foundation and the California HealthCare Foundation in partnership with the California Managed Risk Medical Insurance Board. Issue briefs from the evaluation are available at www.mathematica-mpr.com/Health/health-e-app.asp. The first brief focused on the impact of HeA PA on enrollment, the second described HeA PA applicants and their experience with the tool, and the third examined outreach efforts intended to increase HeA PA use. A fourth brief, Perspectives on HeA PA from Certified Application Assistants, focusing on application assisters’ reactions to the tool, was released last week. This post highlights findings from that brief in the context of efforts to prepare for open enrollment under the ACA.

Since federal guidance encourages states to maximize self-service online enrollment, the latest issue brief reports on findings from interviews with 23 Certified Applications Assistants (CAAs) to provide insights about  barriers to the use
of self-service online enrollment tools (specifically He A PA), and the role enrollment assistants could play in raising applicants’ awareness of such tools. (In California, after successfully completing a web-based training and a certification exam, CAAs help families apply for or renew coverage; explain health care benefits; and provide impartial information about health, dental, and vision plans.)

Consistent with a previous survey of HeA PA applicants who said they rarely learned about HeA PA from a CAA (Issue Brief 2), the CAAs interviewed said they rarely told applicants about HeA PA. The CAAs gave several reasons for not referring clients: incompatibility with their organization’s mission; perceived applicant barriers; and concerns about client difficulties and errors. The CAAs interviewed believed that their clients face multiple barriers to using online enrollment tools, including lack of internet and computer access and literacy barriers. However, the CAA’s characterization of applicants was not independently verified. In contrast to the CAAs observations, previously reported data show that HeA PA users were frequent internet users and had access to computers at home or work.

If applicants correctly sort themselves into those who prefer self-service online applications and those who need in-person assistance, little might be gained, at least in the short run, from more aggressively promoting self-service online systems. However, if the sorting is prone to error because of insufficient information and to accommodate the large increase in applicants anticipated under the ACA, the brief’s authors suggest proactive outreach efforts so that applicants are more aware of all their application options. This strategy could also be helpful as computer literacy and internet access grow over time. In addition, applicants who received assistance with their initial applications might be able to renew their coverage independently online, if they were aware of that option.

The HeA PA evaluation underscores the wisdom of maintaining  and strengthening an assisted in-person enrollment infrastructure even while encouraging online self-service applications under the ACA. The brief’s authors offer several recommendations for facilitating better use of each application method, including:

• Cross promoting all application options so that applicants are informed about all the ways to apply for coverage and how to get help doing so;
• Making enrollment assistants more knowledgeable about self-service online tools and more comfortable helping clients use them;
• Helping outreach workers and enrollment assistants make more appropriate referrals by providing screening tools that can be used to quickly identify and refer good candidates for self-service online systems.

Gene Lewit is Consulting Professor of Health Research and Policy at Stanford University and affiliated with Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research.