Testimony of Jodi Kwarciany at the FY 2018 Performance Oversight Hearing for the Department of Health Care Finance

Chairman Gray and other members of the committee, thank you for the opportunity to testify today. My name is Jodi Kwarciany and I am a Policy Analyst at the DC Fiscal Policy Institute. DCFPI engages in research and public education on the fiscal and economic health of the District of Columbia, with a particular emphasis on policies that affect low- and moderate-income residents.

I am here today to applaud and thank the Department of Health Care Finance (DHCF) for their part in providing access to health care for the District’s lowest-income residents, and to share where I believe the Department can improve access to services and ensure better health outcomes.

Leading the Way

DC has led the way in implementing the Affordable Care Act, and in no small part because of the work of DHCF. Whether it’s expanding Medicaid eligibility beyond federal requirements, creating two Health Home programs that coordinate care for Medicaid beneficiaries with chronic health conditions, or instituting performance metrics in Medicaid managed care contracts, the department has embraced many elements of health reform that will further improve access to coverage and health outcomes while making good use of the District’s dollars.

DC’s uninsured rate has continued to shrink since the enactment of health reform, and is now at just 3.8 percent, one of the best rates in the country. DHCF has played an enormous role helping close this gap. At the same time, amidst the uncertainty we’re now seeing at the federal level with respect to Affordable Care Act repeal, DHCF has been an instrumental partner in understanding, analyzing and communicating what possible changes could mean for the District. For all these reasons, DHCF should be commended for their work.

Areas for Improvement

An area where DCFPI along with a coalition of other organizations and providers urge the Council’s attention on are the ongoing issues surrounding the DC Healthcare Alliance program’s six-month in-person eligibility requirement.

The requirements that all beneficiaries renew their benefits every six months instead of annually, and complete a face-to-face interview at ESA service centers at the time of application and for each renewal led to a rapid decline in enrollment by roughly 10,000 beneficiaries, and now stands today at about 15,300.

We in the advocacy community understand why the new requirements were put into place, and we support program integrity and effective use of the District’s dollars. However, we remain concerned about the policy’s unintended effects: an undue burden on Department of Human Services’ service center capacity, and a barrier for eligible residents who are not enrolling, re-enrolling, and ultimately accessing the care they are entitled to because of the burdensome process.

We’ve identified four problems with the current policy:

  • It’s hard for eligible beneficiaries – especially those who work and/or have young children – to maintain their benefit. The renewal requirement leads to a large volume of people coming into ESA service centers, who may arrive hours beforehand to stand in line, or go several times to complete one re-certification. And even for those who do secure coverage, we know that at the six-month period, about 33 percent do not re-apply. That’s many individuals who are not receiving regular care.
  • It costs DC money. The requirement appears to have a direct impact on health costs in the program, as many residents avoid regular care and only sign up for the Alliance when they are in high medical need. Per-member monthly costs for Alliance members grew by 22 percent in just one year, compared to a corresponding 6 percent increase for adults in our Medicaid program. For those who are going without coverage entirely, we have to be conscientious of the costs we’re potentially shifting to our emergency rooms.
  • It is operationally troublesome for Department of Human Services. As mentioned, the added volume at service centers puts a strain on DHS, and a study conducted by DCFPI and the Legal Aid Society of the District of Columbia in 2014 found that Alliance beneficiaries make up 25 percent of service center traffic, even though they represent a small number of beneficiaries who get services there. While DHS is working hard to implement an extensive business process redesign initiative that will no doubt alleviate some of this congestion and streamline processes, we remain concerned about the deterrence this has already caused.
  • It sends mixed signals to individuals of immigrant status about their place in the community. The District has long been known as a welcoming city for immigrants, including its designation as a Sanctuary City. However, it is difficult to encourage immigrants to take advantage of programs like Alliance when the District imposes additional barriers to their participation. Some applicants have described the enrollment process with words like confusing, intimidating, discriminatory, and inflexible. What’s more, the uninsured rate for DC’s undocumented immigrants in particular stands at 13.4 percent, or about three and a half times our District-wide average of 3.8 percent, meaning we are still not reaching many eligible individuals.

Looking to FY2018, DHCF should pursue changes to the program by switching the recertification period to a year and allowing health centers, where beneficiaries often have established and trusted relationships, to help with applications and renewals. DHCF has estimated that these changes would cost about $14.9 million per year, and is currently conducting an analysis to better understand rising programmatic costs and application renewal trends. We applaud these efforts, and hope to continue working with the agency on identifying policy alternatives that would balance legitimate program integrity concerns with respect for the needs of eligible District residents.

Thank you for the opportunity to testify, and I am happy to answer any questions.