How to Game-Change Enrollment with a *SNAP* of a Finger

by Sanjay Kishore

[Editor’s note: This post originally appeared on Obamacare Nerds, a blog you should absolutely follow for news and commentary on ACA enrollment.]

Over the past few weeks, we’ve been caught up in monitoring the horse-race over national enrollment figures.   But, we’ve also realized some fascinating things are happening at the state-level.  There’s an interesting trend if you look at states who have the highest-performing private exchanges, and compare them to states who have enrolled most of their total uninsured population.  (Hint:  they’re different)cms-proportion-1-14


Interestingly enough, some of the lowest-performing exchanges (like WV and OR) are leading the pack in terms of proportion of total uninsured covered.  What could explain this discrepancy?  It’s because of – drum roll, please – Medicaid!   Oregon and West Virginia shot to the top because of robust Medicaid enrollments.  But, this didn’t happen in the environment of your standard, run-of-the-mill Medicaid expansion.

A few months ago, the Centers for Medicare and Medicaid Services granted permission to states to accelerate enrollment in Medicaid by targeting those who were likely already eligible.  For instance, states now had the ability to automatically enroll folks who were part of the SNAP program (a.k.a. food stamps) after it was estimated that~97% of recipients would be eligible for Medicaid.  Other options, like enrolling to the parents of kids who are already on Medicaid (because they’re probably under the income threshold), were also allowed.

These accelerators are important for a couple reasons:  they help extend coverage to more low-income folks, and they also help reduce the administrative costs of outreach.  The implementation process  states have used thus far has been pretty simple.  Basically, the state government mailed a letter to all the SNAP beneficiaries who didn’t have Medicaid, and asked them to consent their enrollment by checking a box over the phone, web, or mail.  Boom.  No glitches, no hour-long phone calls to consumer support, etc.  In case you’re interested, the Robert Wood Johnson Foundation has an awesome resource guide with some insight into the nitty-gritty.

As mentioned before, a few states have used the SNAP transfer with great success. West Virginia*** cut their uninsurance rate by 25%, and Oregon by 10% in months with this option.  Arkansas and Illinois have implemented it, as well — leading to an aggregate of 238,000 individuals enrolled in Medicaid across these four states. Interestingly enough, we’re only scratching the potential for what this could mean.  So far, response rates for these letters have ranged from 27 – 46%, meaning that hundreds of thousands of more eligible individuals could be reached with a better outreach scheme.

And, get this.  The Center on Budget and Policy Priorities has estimated that about 7 million folks across the country could gain coverage through the SNAP mechanism.  Even if this targeting was applied just in the states that have already expanded Medicaid, a back-of-the-envelope calculation based on the proportion of SNAP recipients that live in each state leads us to believe nearly 4 million folks could be reached (of course, there may be some SNAP recipients who have already enrolled by now).  To put that number in perspective, that’s a little less than double the total enrollment of all the federal and state marketplaces to-date, which have an aggregate enrollment of ~2.2 million.

The policy community has rightly obsessed about investing in direct outreach through navigators and awareness through media to boost enrollment.  However, early results show that targeted strategies — like the SNAP scheme — could be a huge game-changer for enrollment across the board.

*OK, so this probably takes more work than a snap of a finger implies.  But, it’s a lot better than training navigators and making them go talk to people.  And, we couldn’t resist the pun.

** Data in the graphs sourced from Brainwrap at (thank you, kind sir!), and recent numbers posted by the Department of Health and Human Services.

*** This number was obtained via correspondence with the leader of a WV advocacy group, and don’t think it’s in print anywhere just yet.  Shout-out to folks at Families USA (my employer) for getting that figure.


Sanjay is currently a fellow at a progressive health advocacy group, and a recent Duke alum. Follow him on Twitter at @sanjaykishore31 or check out his blog.


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