Small (often unnoticed) changes in law can help — or hinder — drive for universal health care

Expanding health care coverage has been a long-standing but elusive goal for many Americans. The U.S. is the only industrialized country that does not provide some form of universal health care. 

In my lifetime there have been two significant federal improvements to the U.S. health care system: Medicare and Medicaid in 1965 and the Affordable Care Act in 2010. Each expanded coverage for health care.

It can be a mistake, however, to focus too much on such once-in-a-generation legislation. In America’s political system, most policy change is incremental, and often state-by-state rather than federal.  

This is particularly true with Medicaid. It is a federal program, but each state has its own variation; there are essentially 51 Medicaid programs in the U.S. 

Medical Assistance  — Minnesota’s name for our Medicaid program — undergoes constant change. Look at the spreadsheet for any major health and human services legislation and you will see dozens of changes to MA. 

In 2023, one of those changes adopted a new federal option under Medicaid that will expand health coverage for Minnesota’s children. 

This new provision ensures that children eligible for MA get 12 months of continuous coverage. This may not seem momentous. In fact, you may wonder: Why wasn’t this already the case? Most health insurance works on an annual basis. Why not MA?

The answer is complicated, but it is the result of MA eligibility processes that often seem intentionally designed to make it hard for people to keep their health care. 

Enrollment requirements for MA are burdensome, requiring applicants to provide various forms of information and engage in ongoing two-way communication with counties. Families can often lose their coverage because of miscommunication, lost mail, misunderstanding of complex requirements and similar factors. 

When there is miscommunication between a parent and the county, children can lose coverage. 

The new legislation fixes that problem, so children keep their coverage for 12 months, even if their parent misses a mailing. This is critically important for child development. Also, because children of color are more likely to be covered by MA than white children, it can help address Minnesota’s health disparities. 

It’s an incremental change, not a headline story. But it is progress; improving continuity of coverage is the sort of under-the-radar improvement that ensures people — in this case kids — have access to coverage.  Even better, DHS is applying to the federal government to allow 72 months of continuous eligibility for children under the age of six. 

Once fully implemented in 2025, these provisions would add over 30,000 children to MA. 

Unfortunately, incremental policy making never provides a straight line to any goal: It is always two steps forward, one step back. 

Over the past 25 years or so, the backwards steps in MA coverage have often been driven by efforts to reduce costs. Health care is expensive; if fewer people have it, the state saves money. 

One of those backward steps came from the 2015 Legislature and is still in law. It’s called the “Periodic Data Match.”

Periodic Data Match emerged from typical end of session messiness. It was driven by the Republican-controlled House, which sought to address concerns raised by the Legislative Auditor about the accuracy of MA eligibility determinations. They were also seeking to save money to pay for other initiatives. 

Periodic Data Match matches public data with MA data to check whether people remain eligible for MA. It is designed to catch families who may be ineligible for MA due to some change in their situation, such as an increase in income. 

DHS issued a report in 2020 examining Periodic Data Match. In a review of over 500,000 people subjected to Periodic Data Match, they found about 1,300 people were “caught” – identified as being ineligible for MA. 

That’s a quarter of one percent of the half million people reviewed. 

This might be an acceptable outcome if it had been accomplished without harming anyone. Unfortunately, that’s not the case. The Periodic Data Match process required about 43,000 people to prove that they were still eligible for MA. As a result, 16,000 people lost coverage because they got confused by the process or never responded to mailed notices. Another 26,000 people kept their coverage but were subjected to the stress and hassle of proving they were still eligible. 

That’s quite an inefficient process: 16,000 people lose coverage and 26,000 are stressed and hassled, all in the name of “catching” 1,300 people. 

And if that’s not bad enough, consider this: The Legislative Auditor conducted three audits of health care eligibility in 2018, each of which concluded DHS “generally complied” with program requirements. All the audits covered periods before Periodic Data Match was even implemented. Many of the problems identified in earlier audits had been corrected without the “help” of Periodic Data Match. 

Now would be a great time to repeal Periodic Data Match, as we move back to normalizing MA eligibility processes post-pandemic. But given the state budget situation, a repeal is unlikely this year. 

It’s more likely Periodic Data Match will hang around for a while longer, another little roadblock to the goal of ensuring all Minnesotans have health care coverage.