“The DC Health Care Alliance is a model public insurance program. But its burdensome requirements cause many eligible residents – and their health – to lose out.”

The following was written by Nina Yamanis1, Taryn Morrissey1, Lisa Bochey2, and Cristiana Little2 (1Faculty and 2students at American University.) “As accomplished professors and graduate students at American University, we have been collecting stories and data about the effects the re-certification process has on the immigrant population and on DC’s overall public health outcomes.”

“The DC Health Care Alliance is a model public insurance program. But its burdensome requirements cause many eligible residents – and their health – to lose out.

The DC Alliance is a Model

DC has a public health insurance program — the DC Health Care Alliance — its residents should largely be proud of. Since 2001, the Alliance has provided health insurance to low-income District residents not eligible for Medicaid, including many immigrants. But there is one glaring problem that should be a source of embarrassment.

It’s far too easy for people enrolled in the program to lose coverage, even while they’re still eligible. Every 6 months, Alliance beneficiaries must recertify their eligibility in person, typically standing in long lines at crowded service centers. For well-meaning reasons — because they have to work or care for children, for example — many cannot do this and lose coverage.

Last month, Ricardoa, an Alliance recipient for eleven years, took time from work to see a doctor about a mouth infection and learned his Alliance coverage had expired. Because he couldn’t miss work again, his infection worsened, and he ended up admitted to the hospital with a much more severe condition.

It doesn’t need to be this way. Another public health care program in DC, Medicaid, only requires renewal every 12 months and it can be by phone.

Maintenance of DC Alliance coverage is important. It covers doctors’ visits, preventive care, prenatal care, and prescription drugs, all things that are difficult or impossible to afford without the program. And the Alliance has been very successful. It, along with other programs, has helped bring DC’s uninsurance rate down to 4% — one of the lowest rates in the country.

The Legal Aid Society has monitored the length of the Alliance renewal lines since 2014. According to their analysis, many enrollees often arrive as early as 4:00 am for renewals. Every weekday, in all kinds of weather, 50-100 people are waiting when the service center doors open at 7am. Those who have no choice bring their children to wait with them.

Despite waiting for hours, some are turned away due to staff capacity. One person we interviewed made six attempts before being seen.

Frequent and burdensome recertification causes people to fall out of public programs and lose important benefits. We know this from research on nutrition and child care programs. For example, one study in Michigan found that offering online re-enrollment cut exits of eligible applicants from the SNAP program by 10%. Another study found that the likelihood of dropping out of the child care subsidy program increases by two to three times in the month prior to recertifying, with most exiting families remaining eligible.

Predictably, this happens in the Alliance program too. The Department of Health Care Finance indicates that over the past 18 months, only 55% of Alliance participants renewed their eligibility when it expired.

Churn in Insurance has Consequences for Health and Costs

Ricardo’s experience is not unique. One study across three states found that people who experienced coverage disruptions were more likely to miss medication doses and experience poorer health.

The Alliance program costs more because of churn, too. Research shows that continuous Medicaid coverage leads to lower per-person care costs, likely because people aren’t waiting to enroll until they have very costly health problems. Reducing churn in Medicaid can also reduce emergency room visits and in-patient hospital stays.

What can we do?

We can solve this problem. In 2018, the DC Council unanimously approved extending the Alliance recertification requirement from 6 to 12 months. But Mayor Bowser did not fund the change, citing the overall cost of the Alliance program and her office’s belief that frequent recertification reduces fraud, for which no evidence has been provided. In March 2019, Councilmember Gray introduced emergency legislation that would extend recertification to 12 months and allow beneficiaries to recertify at community health centers, making the process dramatically easier by reaching beneficiaries where they receive health care.

DC’s leadership in expanding public health insurance has paid off for those who receive it. Our recent survey of Alliance beneficiaries found that 75% of DC Alliance beneficiaries said that their health either improved or remained constant after enrolling in the program. Reflecting the value of the program, New York City is now considering a similar program that expands insurance to residents not eligible for Medicaid, and California and San Francisco have adopted ones in recent years.

It’s a mark of distinction that DC has implemented a program to efficiently expand access to health care. Yet it’s a shame that eligible enrollees must spend hours several times a year to maintain that access, and through no fault of their own, cannot do so. Even a good program can be made better.”

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