A few days before New Year’s Eve, an unfamiliar health insurance card for me arrived in the mail. I assumed there must have been an error and called the human resources department of the medical center where I’m employed as a doctor.
“No,” the representative replied, “it’s not a mistake. You didn’t enroll this year, so you automatically got put on the basic plan.”
“That’s … that’s impossible,” I stammered. “I’ve always signed up my family for the same health plan.”
“I’m sorry, Dr. Ofri,” the representative said, rechecking her records, “but you didn’t enroll this year.”
Could that be? Could I have somehow forgotten? Or missed the notification? “But don’t worry,” she said. “We’ve put you on the basic plan.”
“OK,” I said, starting to relax and thinking out loud. “I guess my kids will get to meet some new doctors.”
But the representative did not match my tone. “I’m sorry, but the basic plan is just for the employee,” she said, “not your family.”
That’s when a coil of disbelief clamped my heart to a standstill. My spouse and children would be left without health insurance? The panicked questions quickly percolated: What about their ongoing medical treatments? What about their medications? What if someone got hit by a car, or got cancer? There’s hardly a more devastating feeling for a parent than to realize that you haven’t adequately provided for your family.
Swirling in panic, I hardly heard anything else the representative said. There was something about referring my case to a supervisor, but it was a holiday week, so many employees were on vacation. All I could think about was that in a few days it would be the new year, and my family would be uncovered. I felt tears creep into the corners of my eyes as I realized that I had jeopardized my family’s health. All, it seemed, from missing the email notifications.
The smaller question of my oversight turned out to be easily answered. My work inbox is teeming with dross; legitimate emails disappear in the sea of junk mail. We’ve been encouraged to clean up our inboxes using various tools, and one of the spam filters I enabled had apparently inadvertently swept up all the emails from H.R.
“But didn’t you know that October is open-enrollment month?” the representative had chastened me; I work in health care, after all. Well, yes, but there’s life and work and children and my patients. I must have assumed I’d already done it.
The larger question was why this could occur so easily. Why is the American health insurance system set up in a manner that a slip of the mind or a bureaucratic hiccup can render people uninsured?
As I thought about it some more, I was struck by a question that I’d never thought about before: Why do Americans have to “remember” to get health insurance every year? We don’t ask citizens to remember to enroll with the fire department every year, or to remember to sign up for electricity service or water. Yet with health insurance, we’ve set up an unwieldy mechanism where millions of people have to opt in every year or do without. (While some companies automatically re-enroll employees with their prior year’s selections, this is by no means universal.)
During the Covid-19 pandemic, the federal government forbade states from removing anyone from Medicaid. This so-called continuous enrollment resulted in coverage for an additional 23 million Americans and brought the nation’s uninsured rate down to a historic low of 8 percent. Once the public health emergency ended this year, however, states were free to resume culling the rolls, and more than nine million people have been disenrolled to date. This has tragic human consequences, as medical treatments and preventive care are abruptly amputated.
The stated reason for this bureaucratic merry-go-round is that eligibility must be ascertained every year so as not to allot services to someone who doesn’t qualify. But the process of determining eligibility is highly flawed. Only some of disenrolled Medicaid patients, for example, are truly ineligible; according to KFF, a health policy research organization, the majority of people (more than 90 percent in some states) were disenrolled for “procedural reasons,” such as missed deadlines, paperwork issues or outdated contact information. Many of these people are actually eligible for insurance, but lose coverage because of the byzantine logistics. And even beyond the pandemic related “unwinding,” some people on Medicaid face multiple disenrollments and re-enrollments if their income fluctuates, such as with seasonal work or gig jobs.
The net effect is that we require an enormous chunk of the U.S. population to continually re-enroll for health insurance. The inefficiency of this is staggering; we require tens of millions of people to prove eligibility over and over again to catch the few who might no longer be eligible. Beyond pure inefficiency, it’s also inhumane, leading to worse medical outcomes, plus higher costs.
A simpler solution would be to flip the script. After an initial eligibility assessment, people would stay with the same insurance plan unless they opt out, request a change or are ineligible for genuine — not procedural — reasons. For employer-based health insurance, this would be relatively simple, as most ineligibility stems from no longer working at the company, something that employers surely know. For everyone else, health insurance would auto-renew each year the same way it already does for the plans on the Affordable Care Act exchanges. This would be far simpler than having every person redo the paperwork every single year.
For Medicaid, the income eligibility requirement adds a layer of complexity, but there are nevertheless ways to reduce the hoop jumping. For starters, every recipient should be granted a full year of continuous coverage after enrolling to eliminate the wasteful short-term upheavals. But the simpler and more humane option would be to keep the continuous coverage we adopted during the pandemic, and only disenroll people if I.R.S. and other data sources demonstrate sustained higher income or insurance from another job. Random audits — as we do for taxes — can help ensure compliance.
Will there be errors? Of course. Some people will stay insured when they are no longer eligible. But our current system offers a crueler and more expensive type of error: mistakenly kicking off eligible people.
My own experience of jeopardizing my family’s insurance because of an errant spam filter drove home the harrowing point. Our health insurance system is capricious, and it takes little to upend people’s lives. For me, it took endless phone calls to fix the problem and a miserable week in which I was convinced that I’d failed my family. For millions of Americans, the system is simply unnavigable.
Of course, none of this would be necessary if the only requirement for getting insurance was — as it is in most countries — being born. Instead, Americans are forced to live within an illogical patchwork of plans and regulations that so easily allows people to fall through the cracks.
Danielle Ofri, a primary care doctor in New York City, is the author of “When We Do Harm: A Doctor Confronts Medical Error.”
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