Testimony at the Oversight Hearing on “The Public Health Element of the District’s COVID-19 Response” About Health Care Access

Chairman Gray and members of the Committee, thank you for the opportunity to testify today. My name is Kate Coventry, and I am a senior policy analyst at the DC Fiscal Policy Institute (DCFPI). DCFPI is a nonprofit organization that promotes budget choices to address DC’s economic and racial inequities and to build widespread prosperity in the District of Columbia, through independent research and policy recommendations.

DCFPI recommends the DC Council to require the Department of Healthcare Finance (DCF) and the Department of Human Services (DHS) to stay all terminations from the DC Healthcare Alliance and Immigrant Children’s Program (ICP) and to extend all enrollees’ participation in the programs for at least six months, or longer if needed, to address the problems that enrollees and community providers have reported. We also ask that Council require DHS and HCF to take several steps to notify enrollees of these changes, including:

  • Mailing the notice of this extension to all enrollees;
  • Sending the notice through the application portal to all enrollees;
  • Posting the notice to the agencies’ websites; and,
  • Printing copies of the notice and disseminating them at DHS Service Centers.

The District Should Ensure DC Healthcare Alliance and Immigrant Children’s Program Enrollees Are Not Terminated

The Healthcare Alliance is a program that provides critical health care coverage to residents with low incomes who do not qualify for Medicaid, most of whom are immigrants. The ICP is a program that provides health care coverage to individuals under the age of twenty-one who are not eligible for Medicaid.

Health care is a human right and truly vital during the current COVID-19 pandemic. The District should be doing all it can to ensure that as many residents as possible have health insurance. Instead, the District is set to terminate nearly 7,500 Alliance and ICP recipients for “failure to recertify.”[1] This is approximately 30 percent of the caseload of the two programs, and their termination could lead to poorer health outcomes for these individuals and the broader community.[2]

Program enrollees and community providers have reported a number of problems with the recertification process that policymakers should address before the District terminates anyone from the program, including:

  • Lost documents. Multiple enrollees and providers report they have submitted documents by mail or by drop off at a DHS Service Center, but there is no record of documents in DHS’s system. Some clients have been provided a confirmation number that an application or document has been submitted but then the application or document cannot be found in the portal.
  • Problems with the online recertification process. It is not clear what specific additional documents participants need to submit when recertifying through the web portal. When participants submit the signed recertification, the system tells them that DHS needs additional documents. But then the recertification application is not visible in the system, forcing participants to drop off the documents they think DHS might want “loose,” meaning not attached to an application, at a Service Center.
  • Problems with notices. DHS has mailed English notices to Spanish-speaking participants. DHS has also mailed documents to outdated addresses. Some recipients have previously received “false alarm” notices, which are notices indicating that they need to recertify when they did not. Finally, some participants have receivedconflicting information about recertification methods or did not receive information at all. The latter two issues have created confusion among participants.

Given these challenges, DCFPI asks the DC Council to require the Departments to halt all terminations for six months, or longer if needed, to address these issues. We also ask that notice of the stay of terminations be mailed and sent though the application portal to all enrollees as well as posted to the agencies’ websites and made available at DHS Service Centers.

Moving Forward, the District Should Ensure Alliance Recertification Is as Easy as Possible

Given their shared purpose, the Alliance and Medicaid program should have identical, low-barrier application and recertification requirements. But the DC Healthcare Alliance requires participants to recertify every six months and, prior to the pandemic, required an “in-person interview” as part of each recertification. Medicaid only requires annual recertification and does not require in-person recertification.

The fiscal year (FY) 2022 budget took positive steps by allowing Alliance recipients to renew their insurance by phone or online twice per year and suspended the in-person interview requirement for at least FY 2022. But the Mayor and Council should allow Alliance recipients to renew annually and permanently end the in-person interview requirement, aligning the program’s recertification process with Medicaid’s.

We should not erect higher barriers just because of a resident’s immigration status or very low income—DC is a welcoming city, and our policies should reflect that value. The District suspended recertifications during the public health emergency. DC needs to make this permanent and move to annual, virtual recertification to reflect our DC values.

Shortened Eligibility Period Has Led to Turnover, Poorer Health, and Higher Costs

Figure 1

In 2011, DC implemented restrictive procedures to maintain Alliance eligibility that immediately led to a sharp drop in participation (Figure 1). Thousands of residents who should have health insurance do not. It has also led to a higher uninsured rate among Latinx residents, 6.8 percent compared to 5.5 percent for Black residents and 1.4 percent for white residents.[3]

The restrictive rules also contribute to a high rate of turnover in the Alliance, as residents join the program but then drop off due to the time-intensive requirements. Only 55 percent of Alliance participants renew their eligibility when it comes up, data from HCF show.[4] Given that many Alliance members are working at jobs without paid leave and that visiting a DHS Service Center can take an entire day or longer, it is not surprising that many are not able to renew their benefits.

This lack of continuous coverage contributes to poor health outcomes and high costs per person in the Alliance. Churn from frequent recertification increases health program costs because it limits access to preventive care, which means participants often are sicker when they re-enroll, and because sicker residents.

are most willing to go through the process of maintaining coverage. Healthcare Alliance costs have doubled in the past four years, even though participation has not grown. The cost increases appear to reflect other factors, including a growing number of older participants.[5]

Figure 2

Research from Medicaid, for example, shows that average health care costs go down the longer participants have coverage (Figure 2). DCFPI recommends the agency look at recipients who normally would have cycled off the Alliance but did not because of the waiver of the recertification requirement during the public health crisis to see how the longer coverage affected their health and health care costs.

DC has been a leader in expanding health insurance coverage to improve resident health and reduce health disparities. The Council should eliminate barriers in the Alliance as a critical component to reaching these important city goals and which would go a long way towards affirming support for our immigrant neighbors.

Thank you, and I am happy to answer any questions.

[1] Department of Health Care Finance Chief of Staff and Interim DCAS Director Melanie Williamson, Email sent to DC Council Staff, “Important – Potential Alliance Coverage Loss,” October 29, 2021.

[2] DCFPI calculation using the above and the DC Department of Health Care Finance. “Medical Care Advisory Committee Monthly Enrollment Report,” August 2021.

[3] Kaiser Family Foundation (KFF). “2019 Uninsured Rates for the Nonelderly by Race/Ethnicity,” Retrieved November 2, 2021.

[4] Ed Lazere, “No Way to Run a Healthcare Program: DC’s Access Barriers for Immigrants Contribute to Poor Outcomes and Higher Costs,” DC Fiscal Policy Institute, revised March 17, 2019.

[5] Ibid