Inside Louisiana’s Blockbuster Medicaid Expansion Roll Out

Louisiana’s Medicaid expansion marked a major breakthrough for Obamacare as the first state in the Gulf South to opt into the program, a move only possible after Democratic Gov. John Bel Edwards won the governor’s mansion last year.

But now that the program has been open for enrollment for two weeks, the dramatic success the state has had in bringing residents into the program has attracted national attention.

Since June 1, the first day Louisianans could sign up for the expanded program, more than 201,000 people have enrolled. The state is well on track to meet its 375,000-enrollee goal, which will save Louisiana an estimated $184 million in the next year.

Those numbers are even more remarkable given the obstacles facing the Edwards administration, namely the refusal of the GOP legislature to fund even one new employee to ease the transition to the expanded program.

“They say that necessity is the mother of invention,” Rebekah Gee, the secretary of Louisiana’s Department of Health and Hospitals, told TPM in an interview last week. “We certainly have had to think long and hard in the first weeks of the administration about how we were going to do it given that it was made clear to us that we were not going to have additional resources.”

Without any additional funding for the roll out — meaning no new state employees, no eligibility workers, nor any other new administrative tool to ensure that Louisianans were taking advantage of the expanded coverage — the state had to depend on the infrastructure of existing social service programs, whose participants were eligible for the Medicaid expansion.

The tactic had the dual advantage of saving the state money while creating an application process that was minimally burdensome for users and administrators alike. It was that creative approach, along with the assistance of non-governmental entities, that likely helped Louisiana achieve the numbers that it did.

“Louisiana, through doing this, is definitely being a leader in trying to use these available resources to streamline and make enrollment efficient,” Samantha Artiga, a Medicaid expert at the Kaiser Family Foundation, told TPM.

Edward’s predecessor, former Gov. Bobby Jindal (R), fiercely opposed expansion of Medicaid under Obamacare. Edwards campaigned on expanding Medicaid, and on his first day in office, Jan. 12, signed the executive order enabling it. However, almost immediately, his administration ran into a major obstacle: Republicans legislators in the cash-strapped state refused to fund any additional employees for the health agency, which was already running under a tight budget.

“We initially thought we had an impossible inflection point in the road,” Gee said. “It was certainly a dark day when we realized, ‘Oh my gosh, we’re not going to get any new people. How are we going to get this done?’”

To pull together the program, the state sought out the assistance of non-governmental organizations like Robert Wood Johnson Foundation, Kaiser and Milbank.

“As a former Robert Woods Johnson clinical scholar and someone who had been in academia, my mindset has always been focused on, ‘How do I get grants?” Gee said.

Making matters more difficult, the state was seeking out outside support after the wave of initial grant money — much of it going to early adopter states — had dried up.

“We missed out,” Gee said, of the initial round of Center for Medicare & Medicaid innovation grants that went to states that expanded Medicaid right off the bat.

“So here we are, needing it more than those places probably did without the ability to apply for those types of grants,” she said.

The state did find outside help, though mostly in the form of consulting and technical assistance, instead of hard cash. The approach that they settled on could provide inspiration to health care officials elsewhere in the country.

“There are versions [of what Louisiana did] that can be used by lots of states, depending on how their different systems are set up,” Kathy Hempstead, a senior advisor at the Robert Wood Johnson Foundation, told TPM. “It’s kind of a big data approach, in a way. It takes advantage of information that is already out there.”

Louisiana already offered health care programs– in the form of its state family planning programs and a limited Medicaid product known as Health Connection — that provided a jumping off point for the full expansion. Those programs were the biggest contributor to the first wave of expansion enrollees, at least in the short term.

But the biggest innovation and the one officials are most optimistic about in the long run is Louisiana’s use of the data in its Supplemental Nutrition Assistance Program (or SNAP, as the food stamp program is commonly known) to onboard potential enrollees, as the two programs have similar income requirements. While other Medicaid Expansion states have used SNAP data in a limited time period in their expansion rollouts, Louisiana is first in the nation to get federal approval to use it in a more permanent fashion.

In Louisiana, SNAP recipients are in the process of receiving letters informing them of their eligibility for Medicaid expansion, and asking them to answer just a few more questions to finalize their enrollment. Going forward, Louisianans applying for SNAP will also have the option to apply for Medicaid Expansion at the same time, making the processes a “one stop shop,” as Gee put it.

The example being set by Louisiana could be found useful by the other red states currently debating Medicaid expansion. Lawmakers in GOP-led states including Alabama, Kansas and Oklahoma revisited the idea this year, in efforts that still fell short, at least this time around.

“I do think it’s more of a when, not an if,” Hempstead said. “States are just going to find that it’s just not possible to resist that opportunity.”