By Suzanne Wikle

The COVID-19 pandemic reminds us how fragile our health insurance system is—and how, all too often, insurance is either tied to someone’s employment, unaffordable, and/or entirely inaccessible. The crisis is causing people to scramble to find health insurance, maybe because they or their spouse lost a job that provided insurance or they’ve been uninsured but are now even more frightened to be without insurance. 

Many workers that have finally been recognized as “essential” in our communities—child care providers, grocery store stockers and cashiers, gas station attendants—are often the same ones who are uninsured. Most low-wage jobs, which are disproportionately held by people of color, don’t provide health insurance or have unaffordable employee contributions if they do. 

Now, more than ever, it’s important to expand access to health coverage. This is especially true for our front-line essential workers who are in jobs that have historically been less likely to have insurance. It’s also true for people who have been laid off but need access to health care to return to work, such as child care providers that are temporarily closed. We describe below enrollment options for individuals and steps for states to make insurance more accessible. 

Health insurance enrollment options for individuals:

• Meet (in person or by phone) with an expert. The Affordable Care Act (ACA) created jobs called Navigators and Certified Application Counselors (CACs) to help people figure out what they are eligible for, how to enroll in coverage, and how tax credits and subsidies work. You can find a list of Navigators and CACs in your area and make an appointment through this resource.
   
• See if you are eligible for Medicaid in your state. You can apply in person, by mail, or online through your state health and human service agency or through healthcare.gov. Because there are no open enrollment periods for Medicaid, you can enroll at any time if you’re eligible. Medicaid’s eligibility is based on your current monthly income, so if you’ve recently lost a job you will most likely be eligible if your state has expanded Medicaid. In a non-expansion state, it’s much harder to qualify for Medicaid. However, you may be eligible if your household income has been eliminated or nearly eliminated and you are pregnant, disabled or have dependent children at home.
   
• If you’re over the income limit for Medicaid, you may qualify for subsidies (through tax credits) to help purchase insurance on the ACA’s Marketplace. Subsidies are available for households earning between 100 percent and 400 percent of the poverty level (138 percent to 400 percent in Medicaid expansion states). Go to healthcare.gov to start this process.

  Unlike Medicaid, in order to enroll in Marketplace coverage outside the typical open enrollment period (held each year in the fall) you will need a “qualifying life event,” like the loss of employer health insurance. If so, you are eligible for a special enrollment period (SEP). The most common qualifying life events  are the loss of employer insurance (note that the loss of a job does not trigger an SEP; you must lose insurance with your job loss), marriage, the birth of a child, and moving. 

When exploring health insurance options, people should be wary of anything that isn’t certified as a qualified health plan. People may see short term or association plans advertised, but these plans don’t offer the protections of the Affordable Care Act. As such, they may not cover pre-existing conditions and may have a limit on expenditures they will cover, among other limitations.

States can take these steps to make insurance more accessible:

• Expand Medicaid. Fourteen states have yet to expand Medicaid, leaving 2.3 million people in the coverage gap—meaning they earn too little to receive tax credits to purchase insurance on the Marketplace, but they earn too much to qualify for Medicaid—and unable to access affordable health insurance. In the face of a global pandemic, states should be rushing to expand Medicaid, which both provides health insurance to the uninsured and offers some fiscal relief from the pandemic’s effects on states’ budgets.
   
• Amplify Medicaid. States should be making every effort to find people who are eligible for Medicaid but not enrolled. Strategies for doing this include data matching with other programs (e.g., people receiving SNAP who are not receiving Medicaid), partnering with other resources people turn to for assistance during this crisis (e.g., unemployment insurance, foodbanks, faith organizations), and using paid and earned media for traditional outreach efforts.
   
• Simplify Medicaid. During this crisis states will see an increase in Medicaid applications at the same time they are likely short staffed or struggling to implement remote work for caseworkers. Doing everything possible to simplify and streamline the application and enrollment process, while diverting staff time away from unnecessary paperwork or verifications, is the most efficient approach. Among the approaches states can take are expanding presumptive eligibility, maximizing self-attestation, and extending reasonable opportunity periods. The Centers for Medicare & Medicaid Services (CMS) has offered a template State Plan Amendment outlining many of the changes states can take to get people enrolled as quickly and efficiently as possible.

  In the 37 states that have expanded Medicaid, most workers earning low wages can qualify for coverage, but we know that not everyone who is eligible enrolls, at least in part because of paperwork and red tape in the application process, which is why simplifying helps.
   

• Create special enrollment periods. States with their own health insurance exchanges (rather than the federal Marketplace) can add special enrollment periods beyond those required by the ACA. To date, 12 with this option have elected to implement a special enrollment period right now, allowing people to enroll during the COVID-19 crisis.
   
• Implement a state-only Medicaid program to insure essential workers. States have the option to cover people otherwise ineligible for Medicaid if they choose to use state funds for all costs, rather than the typical split costs between the state and the federal government. This option, while solely at the expense of the state, does allow an avenue for states to provide Medicaid coverage to people who are otherwise ineligible for Medicaid. During a time of crisis such as the COVID-19 pandemic, states should consider this option.
   
• Provide state funds to help people purchase exchange coverage. People who are stuck in the coverage gap or otherwise ineligible for subsidies on the Marketplace are still eligible to purchase coverage—but at full cost (unfortunately, this is not true for people who are undocumented). States could offer funds to pay for premiums and cost-sharing obligations for Marketplace coverage. This is likely more expensive than the previous option, and people would still need to qualify for a special enrollment period for this option to be viable in those states using the federal Marketplace.

  In a similar approach, the state of Washington is asking permission from CMS to use Medicaid dollars to help people with Marketplace coverage better afford their premiums and cost-sharing. The state’s proposal would use Medicaid dollars to drastically reduce or eliminate out-of-pocket costs for premiums, co-pays, and deductibles for people enrolled in a qualified health plan and with income under 200 percent of poverty. *Update: CMS denied this request by Washington on April 21, 2020.

At this time of crisis, states must take any and all steps to connect people with health insurance. And, people need to understand their options, which unfortunately vary drastically depending on whether their state has expanded Medicaid. Our attention during the COVID-19 pandemic must rightfully focus on connecting people to coverage. However, we also must face the reality that our current health insurance system still leaves out too many people, is unaffordable for many, and is often cumbersome and too difficult to navigate. As we look past this pandemic and our options for improving the system, CLASP has outlined principles that policymakers should incorporate into our country’s next steps in health care reform.