Do we suppress health care the way we suppress voting?

Photo by Unseen Histories on Unsplash

Voting policy and health care policy face many of the same challenges — achieving universal uptake, efficiently registering millions of eligible users, and ensuring access for vulnerable populations. It’s no surprise, then, that recent legislative efforts to suppress access to voting share a lot in common with policies that limit access to health care services.

From complicated registration processes and ID requirements to exclusion of incarcerated populations, comparing voting policy with health care policy can reveal patterns in how we regulate access to basic human rights and lend insight into how to combat unduly restrictive legislation.

Here, I’ll discuss four analogous policies between voting and health care regulation:

  1. Voter purges vs. health insurance purges
  2. Automatic voter registration vs. auto-enrollment in health insurance
  3. Criminal disenfranchisement vs. Medicaid Inmate Exclusion
  4. Voter ID laws vs. ID requirements for health services

Voter Purges and Health Insurance Purges

Voter purges are when election officials remove the names of ineligible voters from registration lists. As the Brennan Center describes, “When done correctly, purges ensure the voter rolls are accurate and up-to-date. When done incorrectly, purges disenfranchise legitimate voters (often when it is too close to an election to rectify the mistake), causing confusion and delay at the polls.” Inaccurate voter purging can affect many people. During the 2016 presidential primary, for example, the New York City Board of Elections improperly deleted the names of 200,000 registered voters.

Health insurance purges are when insurers attempt to drop expensive patients from their coverage plans, often by imposing prohibitively high premiums. Patients with preexisting conditions are disproportionately impacted by health insurance purges. In 2009, Congress conducted an investigation into purging practices of six major health insurance companies.

Despite the protections outlined in the Affordable Care Act (ACA) for patients with preexisting conditions, their reality is still precarious.

The ACA outlined four measures to eliminate discrimination against those with pre-existing conditions: 1) guaranteed issue, 2) adjusted community rating, 3) prohibition against preexisting condition exclusions, and 4) essential health benefits. States can decide how many of these four protections to adopt , and thereby receive legal and financial support from the federal government. As of October 2020, many states have not adopted a single one of these four protections.

In 2018, Missouri resident and newly diagnosed pancreatic cancer patient Andy Edgerton was one of thousands of patients who were dropped by Blue Cross Blue Shield of Kansas City. Due to his cancer diagnosis, he was unable to purchase any plans from Blue Cross Blue Shield. Missouri is one of the states that has not adopted any of the four ACA protections for patients with preexisting conditions.

Automatic Voter Registration and Auto-Enrollment in Health Insurance

Automatic voter registration is a policy designed to increase registration rates by automatically registering eligible citizens who interact with government agencies (like the DMV). By making registration opt-out as opposed to opt-in, and by linking voter records to electronic government records as opposed to paper forms, automatic voter registration saves money and helps clean up the voter rolls. To date, 19 states and DC have approved the policy. When automatic voter registration was implemented in Vermont, voter registration jumped 62% in the first six months.

Auto-enrollment in health insurance is a policy designed to increase health insurance coverage by automatically enrolling uninsured patients without requiring an application. Of the 30 million uninsured Americans, half are eligible either for Medicaid/CHIP or for individual marketplace tax credits. Auto-enrollment is not without precedent in American health care. Medicare Part B automatically enrolls people turning 65, eligible seniors are auto-enrolled in the low-income subsidy for Medicare Part D, and Louisiana implemented auto-enrollment in Medicaid for families who were eligible for other need-based programs like SNAP.

Source: Blumberg LJ, Holahan J, Karpman M, Elmendorf C. Characteristics of the remaining uninsured: an update, Washington (DC): Urban Institute; 2018 Jul 11.

Most proposals for auto-enrollment involve automatically enrolling uninsured patients in Medicaid upon contact with the healthcare system and later transferring them to another plan if they are deemed ineligible for Medicaid.

The Brookings Institute identified four key challenges to implementing auto-enrollment: 1) obtaining eligibility information, 2) collecting a premium, 3) selecting an insurance plan, and 4) managing false positives and false negatives.

Of these challenges, financing is top of mind for both policymakers and voters. How do you automatically collect a premium for uninsured patients who are not eligible for Medicaid?

Christen Young of The Brookings Institute proposes a retroactive backstop plan”. Here’s how it would work.

An uninsured patient shows up at an ER seeking care. The provider would screen for Medicaid eligibility. If the patient is eligible, they are automatically enrolled in Medicaid. If not, they are enrolled in a “backstop plan”, which may the lowest-cost Bronze plan on the individual market. Premiums (minus any applicable subsidies) are collected at the end of the year tax return filing for every month the individual was enrolled in the backstop plan.

To date, no states have successfully implemented auto-enrollment.

Criminal Disenfranchisement and Medicaid Inmate Exclusion

Criminal disenfranchisement laws strip voting rights from ~6 million Americans with past criminal convictions. These laws are in effect in twenty nine states. To make matters worse, election officials who misunderstand their states’ disenfranchisement policies mistakenly bar hundreds of thousands from voting by disseminating misinformation.

The Medicaid Inmate Exclusion Policy prohibits Medicaid from reimbursing health care that is provided to inmates unless they are patients in a medical institution. This means that any health care delivered within correctional facilities — including mental health care, preventive care, first aid, etc. — cannot be reimbursed by Medicaid.

This policy is yet another barrier to health care faced by incarcerated populations. A 2009 study found that “among inmates with a persistent medical problem, approximately 14% of federal inmates, 20% of state inmates, and 68% of local jail inmates did not receive a medical examination while incarcerated”. Some inmates aren’t even given access to soap.

States spend over $8 billion in 2015 dollars on correctional health care — 20% of their total corrections budget. Moreover, states are aware that Medicaid can help them drastically cut costs. In 2016, the Center for Medicare and Medicaid Services released guidance clarifying that for inmates who are eligible but not enrolled in Medicaid, “states may secure retroactive Medicaid coverage and therefore federal reimbursement so long as the person applies for the program within three months of receiving treatment.” States that took advantage of this retroactive Medicaid reimbursement saw major savings: Arkansas, Colorado, Kentucky, and Michigan reported savings of $2.8 million, $10 million, $16.4 million, and $19 million, respectively over 2014–2015.

Repealing MIEP would cut costs by ~$4.7 billion, reduce recidivism, and improve the quality of care for millions of inmates nationwide. Short of repeal, efforts are underway to improve access for Medicaid-eligible inmates around the time of release when the risk of mortality is particularly high. For example, HR 4005, the Medicaid Reentry Act, would reactivate Medicaid 30 days before a person is released from prison.

Voter ID laws and ID policies for health services

Laws that require a government-issued photo ID for voting are designed to minimize voter impersonation fraud, but numerous studies have found that this type of fraud is exceedingly rare (rarer than getting struck by lightning). Voter ID laws are a blunt policy instrument that inappropriately disenfranchises up to 11% of voters (25% Black and 8% White) who do not have the right form of ID.

Source: Brennan Center

The list of health and social services that have required photo ID includes vaccination, health insurance, food stamps/SNAP, supplemental security income, and even water. During the Flint water crisis, one undocumented Michigan resident recalled her experience at a water distribution center, “I got close to see what they were giving out, and it was water. And the first thing they asked me for was my license.

The ethical and safety considerations regarding ID laws are considerably different for voting, emergency health services like water and vaccines, and long-term services like health insurance and supplemental income. Nevertheless, the fundamental question in all these scenarios is, “Which is less desirable, giving access to someone who doesn’t deserve it, or depriving access to someone who deserves it?”

In the case of voter ID laws, it’s not clear whether one impersonated vote is better or worse than one deprived vote, but the number of deprived votes is so much greater than the number of impersonated votes that these policies do more harm than good.

In Florida, ID requirements were imposed for receiving a COVID-19 vaccine after people from around the world began flying to Florida to get vaccinated. One could argue that the government of Florida has a greater obligation to residents of Florida than to residents of the world, but implementing ID requirements inevitably shuts out eligible Floridians (including up to 775,000 undocumented immigrants) who may not have an ID. Although Florida’s vaccination statistics for non-Floridians and Floridians without IDs is not readily available, it’s clear that the current policy is too blunt and risks excluding thousands of eligible residents.

Is it possible to impose ID requirements without excluding large swaths of the eligible population? Shaw and Gonzales describe their recommendations for improving the government’s Remote Identity Proofing procedure for obtaining health insurance, which currently makes it difficult for certain immigrants, children, and others to apply for health insurance in a timely manner.

The Department of Health and Human Services requires ID verification when applying for Medicaid, CHIP, or certain health plans through the ACA marketplace because of personal information that is shared between HealthCare.gov and other government agencies that may be inferred by the applicant. Essentially, the policy is in place to protect personal information from being released to the wrong party (interestingly, the policy is not in place to prevent unfair utilization of government resources).

The authors detail improvements that would maintain the security of the ID verification process while reducing the challenges for eligible applicants. These include:

  • performing frequent risk assessments to quantify the risk that the policy is intended to prevent
  • expanding the list of acceptable ID documents to include foreign driver’s licenses, school transcripts, lease agreements, and signed affidavits
  • allow all applicants to submit online applicants

Conclusions

Can insights from the voting and health fields inform efforts to pass equitable policy across the board? To what extent are voting policy and health policy even comparable? Having discussed the four policy areas above, here are some takeaways:

  • Tie auto-enrollment to interactions with government agencies. Automatic voter registration is implemented by registering anyone who interacts with government agencies (like the DMV). Louisiana implemented a similar system where any resident who was claiming SNAP benefits was automatically enrolled in Medicaid. Tying auto-enrollment to interactions with government agencies may be an effective way to implement opt-out voting and Medicaid registration.
  • Inmate exclusions are discriminatory policies that need to be abolished. Policies that limit access to voting or health care for incarcerated populations are a reflection of racist values, not of logistical barriers.
  • Improvements to ID requirement policies can apply to both voting and health services. There are scenarios where ID requirements are warranted, but those requirements need to be carefully designed to not mistakenly exclude eligible individuals. Quantifying the risks of applying or not applying such requirements is critical (and in the case of voting, shows that strict ID requirements are not warranted). If requirements are needed, expanding the list of acceptable documents and allowing for online verification may lead to a more equitable verification process.

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Akshay Swaminathan

Akshay Swaminathan

Data scientist, global health researcher, language learner