Executive Summary
District of Columbia policymakers have built a strong safety net for low-income, vulnerable families and individuals. Nowhere has this commitment been better demonstrated than in the District’s expansion of eligibility for public health insurance and Food Stamps (or Supplemental Nutritional Assistance Program (SNAP)) benefits. The District government has made an unwavering commitment to health care access through the creation and maintenance of the D.C. Health Care Safety Net Alliance (Alliance) program,[i] and the (almost unrivaled) expansion of Medicaid[ii] and the Qualified Medicare Beneficiary (QMB) program.[iii] These programs have contributed greatly to the District’s small percentage of children and adults who are uninsured, regardless of age, disability or immigration status.[iv] Additionally, the District government has reduced food insecurity through SNAP benefit expansions.[v]
However, as the following report demonstrates, the promise of a strong safety net has been steadily eroded for far too many District families due to the service delivery breakdowns they have encountered when attempting to apply and recertify for public benefits. Problems like these have always existed in the District and in other states. Public benefits programs are complicated and, particularly in tough budgetary times, there are often not enough staff to administer programs as efficiently as consumers deserve. To make matters more difficult, implementation of the Affordable Care Act (ACA) has proven to be a herculean task. Over the course of the last two years, the District government has had to totally overhaul its Medicaid policies and procedures, and the information technology infrastructure which supports its robust public benefit offerings. The haste and scope of the overhaul has put sizeable strain on existing resources, contributing to the service and communications issues documented in this report. And because of inadequate staffing, insufficient space, technological glitches, inadequate policy dissemination and communications efforts from the agencies tasked by the District of Columbia to implement the elements of the ACA ‘ the Economic Security Administration (ESA) of the District Department of Human Services, District Department of Health Care Finance (DHCF), and the DC Health Benefit Exchange Authority[vi] ‘ frontline service delivery and case processing have suffered.
However, the challenges and disruptions faced by the District are consistent with those experienced by other states and, in some cases, have been less severe. The fact that the District has performed better than other jurisdictions in the development and rollout of the DC Health Benefit Exchange and Medicaid expansions indicates that the District has the means and capability to meet these service delivery challenges and lead the country in program implementation as well as in policy development. But such leadership can only come with additional resources, strategic planning and coordination among ESA, DHCF and the Exchange.
This report draws on individual cases (reported by legal and social services organizations) to document and illustrate systematic breakdowns in the administration of public benefits programs in the District of Columbia. (The names of the individuals whose experiences are cited in this report, and certain facts about them, have been changed or omitted to protect their identities.) Because the breakdowns illustrated herein are not attributable to one person, agency or set of agency employees, they will only be remedied through system-wide planning and change. Accordingly, this report makes recommendations designed to address these problems at a systemic, rather than merely an individual or agency, level.These breakdowns translate into real hardship for vulnerable District residents, like the ones featured throughout this report and in Appendix A. For example, Ms. Fox and Ms. Clark went without health insurance after receiving incorrect information from agency staff about how to apply or recertify for health insurance coverage. Lost paperwork resulted in benefits being cut off or inappropriately reduced for Mr. Abbott, Ms. Lewis and Ms. Epstein. And Ms. Dawson and Mr. Madison lost their benefits after they were turned away from ESA service centers without being able to recertify their eligibility. Their stories and others demonstrate the obstacles that too many District residents experience when they attempt to get and keep the public benefits upon which they and their families depend, despite the good intentions of policymakers and the leadership and staff of the agencies implementing these programs. These obstacles have lead to food insecurity for individuals like Mr. Abbott and Mr. Madison; fear of seeking, or inability to obtain, necessary medical treatment for individuals like Ms. Bonilla, Ms. Hoffman and Ms. Lewis; and unpaid medical bills for individuals like Ms. Clark, Ms. Fox and Ms. Epstein.[vii] These difficulties cause anxiety and hardship for already stressed and stretched families and individuals.
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[i] The D.C. Health Care Safety Net Alliance program provides coverage for adult immigrants who have income below 200 percent of the Federal Poverty Level and do not qualify for Medicaid because of their immigration status.
[ii] The District implemented the ACA’s Medicaid expansion early and increased eligibility beyond the federal law’s 133 percent of the Federal Poverty Level ceiling to provide Medicaid to otherwise ineligible childless adults with income up to 200 percent of the Federal Poverty Level. Prior to the passage of the ACA, the District provided Medicaid to children and pregnant women with incomes below 300 percent of the Federal Poverty Level and parents with incomes below 200 percent of the Federal Poverty Level. Childless adults without disabilities and with incomes under 200 percent of the Federal Poverty Level were covered under the Alliance.
[iii] The Qualified Medicare Beneficiary program (QMB) covers Medicare premiums, deductibles and cost sharing for Medicare beneficiaries with incomes below 300 percent of the Federal Poverty Level. The program also entitles beneficiaries to premiums and copayment assistance for prescription drugs through Medicare Part D.
[iv] Kaiser Family Foundation, State Health Facts: Health Insurance Coverage of the Total Population at http://kff.org/other/state-indicator/total-population/?state=dc (last visited on April 22, 2014) (stating that 25 percent of District residents get Medicaid, compared to 49 percent who receive employer sponsored coverage and 8 percent who are uninsured) (based on 2011-2012 data).
[v] In response to the recession and the growing crisis in the District’s low-income communities, the District of Columbia City Council passed, and the Mayor signed into law, a significant expansion to the SNAP program as part of the Fiscal Year 2010 Budget Support Second Emergency Act of 2009. See Fiscal Year 2010 Budget Support Second Emergency Act of 2009, Bill 18-0443, Act 18-207, §§ 5080-5083 (2009). Included in the “Food Stamps Expansion Act of 2009″ were two critical policy changes. First, through the LIHEAP Heat and Eat program, all SNAP recipients in the District are provided with a minimal Low Income Home Energy Assistance Program (LIHEAP) benefit which entitles them to the maximum Standard Utility Allowance which can offset beneficiaries’ gross income in some cases. The second policy expanded “categorical eligibility” for SNAP, thus, effectively, increasing the income eligibility limit for SNAP benefits. As a result of these expansions, more District residents are eligible for SNAP than they were prior to 2009, and many recipients receive higher benefits than they would have received in the absence of the Heat and Eat program.
[vi] The District of Columbia Department of Health Care Finance (DHCF) sets policies for the Medicaid, QMB and Alliance programs. The District of Columbia Health Benefits Exchange Authority (“the Exchange”) sets policies for DC Health Link (the public marketplace to purchase insurance and receive financial assistance created by the Affordable Care Act). The Economic Security Administration (ESA) is an agency of the District of Columbia Department of Human Services and is responsible for determining eligibility for public health insurance programs (including Medicaid, Alliance and financial assistance for private insurance plans purchased through DC Health Link), SNAP and TANF, among other cash assistance benefits
[vii] See Appendix A for all of the stories contained in this report.