May 4, 2014:
As they scrambled to open the insurance gates to millions of Californians under the federal health law, state officials prioritized the open-marketplace enrollment system over one for low-income residents, according to state documents and officials.
That decision significantly contributed to the backlog of about 900,000 applications to Medi-Cal, the state’s low-income health program.
“People who don’t have health care are all in need,” said Frank Mecca, executive director of the County Welfare Directors Association, which closely monitors enrollment in Medi-Cal. “One group was prioritized over another, and I don’t think that’s good public policy.”
In the months leading up to the expansion of health benefits under the federal Affordable Care Act, two state entities jointly decided to focus on the launch of the California insurance exchange ahead of the expansion of Medi-Cal, even though the deadline for both to begin offering insurance was the same — Jan. 1. The state is now playing catch-up with the Medi-Cal enrollment software.
“Now that open enrollment (in the exchange) is over, we are able to reflect and make some needed fixes for performance improvement for Medi-Cal enrollment,” said Anne Gonzales, spokeswoman for Covered California, which operates the state’s insurance exchange website.
While about 1.4 million Californians enrolled in a health plan under Covered California before April 15, a greater number pursued Medi-Cal. About 1.9 million had enrolled in Medi-Cal as of March 31. About 900,000 applications to that program are still pending.
Timeline reflects priorities
The state Department of Health Care Services and Covered California were both responsible for overseeing the development of the California Healthcare Eligibility, Enrollment and Retention System, a computer program to enroll people in health insurance plans. The system was tasked with creating two enrollment interfaces — one for Covered California and one for Medi-Cal.
The Covered California enrollment website rolled out on time, on Oct. 1. There were a few glitches, but the site has been recognized as one of the better state exchanges in the nation, and has had far fewer problems than the federal exchange.
The Medi-Cal interface, however, is a different story. The state had originally discussed delivering that technology, which merged new software with an existing enrollment program, on Oct. 1. Later, the official deadline was set at Jan. 1, the date Medi-Cal expanded to include coverage for low-income single adults, among others. But the interface wasn’t actually released until Jan. 21.
Even after it rolled out, it was rife with glitches and programming errors. It was also missing components that Medi-Cal enrollment specialists had been told would be part of the package — and were part of Covered California’s site from the beginning, Mecca said.
More than three months later, many of the problems still have not been fixed. California now appears to have the largest backlog of Medicaid applications in the nation. Medi-Cal is California’s Medicaid program.
“There are people who can’t get their medications, people who can’t get to the doctor who need to,” said Elizabeth Landsberg, director of legislative advocacy for the Western Center on Law & Poverty. “This is people’s health at stake.”
While Landsberg praised California for being one of 26 states that has expanded Medicaid under the federal health law, she said her organization has concerns about the oversight of the process.
Part of the problem was that the same contractor was given a short timeline in which to turn around two interfaces that had “competing demands,” she said.
“There were certain decisions that were made that advantaged the Covered California side of the house to the detriment of Medi-Cal,” Landsberg said.
The Department of Health Care Services, which oversees Medi-Cal, should have been a stronger advocate for the development of that interface, she said.
The state health-care department said it was involved since the beginning but that certain decisions were made in order to meet federal health-care reform deadlines.
“The need to comply with the essential requirements of the ACA open enrollment period meant that certain IT (information technology) projects were prioritized over others,” department spokesman Anthony Cava said in an email message.
But in focusing on meeting the Affordable Care Act targets, the state failed to meet its own deadlines for processing Medi-Cal applications. By law, applications are supposed to be processed within 45 days. The state has said that it expects to begin processing applications within that time frame by the end of this month.
In order to solve the backlog problem, a number of glitches and errors embedded in the enrollment system must be fixed soon, Mecca said.
“To this day there continue to be programming errors where CalHEERS is rendering wrong answers,” he said.
For example, legal, permanent immigrants are now eligible for full-scope Medi-Cal. But the enrollment system identifies them as only eligible for partial Medi-Cal.
“Rather than process the wrong answer, people are pending and the counties are doing workarounds,” Mecca said. “It’s this cumbersome, lengthy, manual process of trying to trick the system into getting the right answer.”
The program is also slow, so that, “Sometimes it takes 40 hours to give an answer instead of being instantaneous, and that’s not uncommon,” he said.
In the appendix of a report that Peter Lee, executive director of Covered California, gave at an April 17 board meeting, there is a list of improvements the state is making to the Medi-Cal enrollment software. The list includes creating an electronic method for residency verification and income assessment, as well as fixing problems that affect cases involving children, pregnant women and immigrants.
Many of the updates are not scheduled to be completed until this summer.
Meanwhile, Medi-Cal enrollment workers across the state are trying their best to navigate the glitchy system.
Elvia Malvido, a quality-control monitor for the Los Angeles Department of Public Social Services, said her Medi-Cal enrollment office has a backlog of more than 10,000 applications. Case managers there are working unusual shifts — coming in early and on weekends — to try to log into the enrollment system before it’s overwhelmed with web traffic.
“It will maybe work for an hour or two in the morning, so they’ve been starting at 7 or 7:30 to try to beat the system,” she said. “Eventually, it shuts down and it won’t work, usually when people show up to work, around 9.”
The county enrollers, who hear from applicants daily who need health care, just want to be able to do their jobs, Malvido said.
“We have a workforce here that’s willing to do whatever it takes to get it done,” she said. “They’re just waiting to get the tools to be able to do it with.”