The Medicaid enrollment assisters at Baltimore's Health Care for the Homeless call it the Leonidas problem. Earlier this fall Christina Barnes, whose job entails signing up people for Medicaid, was finishing an application for a homeless woman when Maryland's health care website malfunctioned. Suddenly the female applicant’s information belonged to a man named Leonidas -- even though the nonprofit didn't have a client by that name. Barnes couldn’t correct the name and couldn’t finish the online application.
It happens all the time, says Katie League, an outreach and enrollment manager for Health Care for the Homeless. The Leonidas problem and other serious glitches have forced Medicaid enrollment assisters to think of creative ways to circumvent an unreliable web portal. In Maryland, several thousand of the state's poorest individuals are depending on the ingenuity of people like Barnes and League to obtain health insurance.
A provision within the Affordable Care Act allows states to expand Medicaid coverage for people with incomes at or below 138 percent of the federal poverty line.* It's a particularly important change for poor adults without dependent children, who have been ineligible for Medicaid until now. The Medicaid expansion could be an enormous boon for homeless people, whose lack of housing often coincides with health conditions they can't afford to treat.
Nonprofits like Health Care for the Homeless provide outpatient addiction counseling, psychiatry and primary care, but that still leaves some gaping holes in people's health care, says Barbara DiPietro, policy director for the National Health Care for the Homeless Council.
"What Medicaid brings, what we can’t currently provide, is the comprehensive care they need," DiPietro said. "They need specialty care -- orthopedics, cardiology, pediatry. They need cancer treatment. They need surgery."
No one knows exactly how many homeless people in the United States are without health insurance and stand to benefit from the Medicaid expansion. However, a group of 246 health care nonprofits that serve the homeless across the country found that about 61 percent of their 837,000 clients were uninsured in 2012. About 31 percent were already on Medicaid. About 4,550 of the clients served by Baltimore's Health Care for the Homeless in 2012 did not have health insurance, DiPietro said.
The potential benefits of extending Medicaid insurance to more homeless people in Maryland have been hampered by technical problems in the enrollment software. Maryland Health Connection, the state's online marketplace for buying private insurance plans and enrolling in Medicaid, has experienced an error-laden debut in its first two months, with crashed web pages and frozen screens. The Maryland official who oversaw the state's health insurance exchange rollout, Rebecca Pearce, resigned after not fixing the website's serious technical flaws within two months.
Maryland Gov. Martin O'Malley announced Dec. 12 that nine major problems with website had been fixed, though frozen screens remained an issue. "We've made progress by degrees," he told reporters at a press conference. At one point on Dec. 23, however, accessing MarylandHealthConnection.gov resulted in two error messages before one could even get to the web portal's home page. Many of the drop-down options, including one titled "consumer assistance," led to a message about scheduled maintenance.
On Dec. 20 another Leonidas problem popped up at Baltimore's Health Care for the Homeless. League, the enrollment coordinator, dialed the state’s Consolidated Call Center for help. She tried three times in a half-hour span, but the line was busy and the center’s automated voicemail wasn’t working. “I forgot what a busy signal even sounds like,” League said. Next, she asked an enrollment assister to use some pedestrian tricks that sometimes overcome the software glitches. Clear the cache. Try another web browser. Reboot the computer. Nothing worked. They called one of the state’s six certified connectors, HealthCare Access Maryland, but the person who answered didn't know what to do either. She suggested calling the state’s Consolidated Call Center -- but the line was still busy.
When the health care exchanges went live in October, the system required every Medicaid applicant to provide an email address. “A lot of our clients don’t even have a reliable mailing address, much less an email,” League said. Health Care for the Homeless staff were ready to register a flurry of new gmail accounts for people who couldn’t otherwise meet the requirement. In the end, it didn’t matter though -- the website didn't work and nobody could sign up online. It took about two weeks before assisters could toggle between live web pages. By that time, the U.S. Department of Health and Human Services had waived the email requirement.
Some of the applicants who come to Health Care for the Homeless tried to enroll themselves at a public library first. But with the myriad ways the website can go wrong, they typically get frustrated and need help. “Even I get frustrated,” said Barnes, the enrollment assister.
Phil Henson, 24, is an example of someone looking for help with his Medicaid enrollment. Dec. 20 was Purple Friday in Baltimore, so Henson came dressed in a Ravens jacket and a necklace of purple beads. He works at a nearby restaurant as a dishwasher, bar back and busboy. A couple months ago, his boss cut back his hours to about two days a week. Now Henson is living at a shelter down the street from Health Care for the Homeless, taking meditation and drug addiction classes while looking for a full-time job. He’d settle for another part-time position at a restaurant, but he says his long-term dream is to become a technician that fixes refrigerators and air conditioning units.
Henson's enrollment assister didn't bother with the health exchange website because Henson was already signed up for Primary Adult Care (PAC), a Maryland-specific health insurance program for low-income adults whose income is no higher than 116 percent of the poverty line. For a single adult, that income threshold would be about $13,000 a year. Anyone already on PAC will be automatically enrolled in Medicaid in January.
PAC has become the secret weapon of Medicaid enrollment assisters in Maryland. Instead of dealing with a glitch-prone Medicaid website, people can enroll in PAC using paper forms. Among the 117,000 Maryland residents who are on track to receive Medicaid coverage in January, about three-quarters are currently enrolled in PAC, according to a Dec. 20 government report. Since the Maryland Health Connection website went live in October, Baltimore's Health Care for the Homeless has processed about 400 PAC applications for people who will all switch over to Medicaid in January.
Although PAC has existed for almost eight years, the Affordable Care Act provided grant funds to temporarily increase the number of workers tasked with signing up people for Medicaid and private insurance. As a result, those temporary workers in Maryland are able to enroll people in PAC who were eligible in the past, but didn't have an army of assisters to guide them through the application process. PAC offers a simple solution to technical problems with Maryland’s health care website, but it isn’t a perfect substitute. People with incomes between 117 percent and 138 percent of the poverty line won’t be able to take advantage of the PAC workaround.
And PAC comes with one more caveat: It's a temporary fix. In 2014 the Health Care for the Homeless staff will have to think up other ways to work around the state’s broken website. In anticipation of the Medicaid expansion, PAC dissolves on Jan. 1.
*Correction: An earlier version of this article stated that the Medicaid expansion pertained to people between 100 percent and 138 percent of the federal poverty line. In fact, the income eligibility thresholds prior to the Affordable Care Act varied widely. For instance, in most states, parents of dependent children could only qualify for Medicaid if their incomes fell below 100 percent of the poverty line.