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February 5, 2021

Expanding Presumptive Eligibility as a Key Part of Medicaid Reform

Author Affiliations
  • 1Yale School of Medicine, New Haven, Connecticut
  • 2Yale School of Management, New Haven, Connecticut
  • 3George Washington University School of Public Health and Health Services, Washington, DC
JAMA Health Forum. 2021;2(2):e210017. doi:10.1001/jamahealthforum.2021.0017

As the incoming Biden administration prepares its health reform agenda, simplifying access to Medicaid should emerge as a high priority. Medicaid has proven critical during the coronavirus disease 2019 (COVID-19) pandemic, in that enrollment has grown by 5.3 million individuals (to 76.5 million) from February to August 2020 as a result of reduced incomes and job loss. Even with this growth, further enrollment simplification is critical, given Medicaid’s role as a pathway for many individuals to affordable COVID-19 testing, treatment, and vaccination.

Simplifying enrollment means expanding the use of presumptive eligibility, long a staple of Medicaid policy. Even if near-term legislation expanding presumptive eligibility is not feasible, the Biden administration and states could expand presumptive eligibility as part of a broader effort to test approaches to improving Medicaid performance during public health emergencies.

History and Functioning of Presumptive Eligibility

Since 1986, federal Medicaid law has authorized the use of presumptive (ie, temporary) eligibility to enable people to secure coverage immediately on a short-term basis if they are determined to be likely to be eligible. State Medicaid programs use community clinicians and programs to make temporary eligibility determinations and assist in the application process. Often used by state-qualified entities, such as schools and community outreach centers, presumptive eligibility is a tool for increasing Medicaid enrollment in community settings and reducing barriers to health care.

Presumptive eligibility in Medicaid initially focused on pregnant people. These policies were extended to children when the Children’s Health Insurance Program was enacted in 1997.1 The Affordable Care Act made hospital-based presumptive eligibility part of the Medicaid program in every state to enhance access to medical assistance at times of greatest need.2 Unlike private health insurance and Medicare, both of which are governed by limited open-enrollment periods and special-enrollment rules, people can enroll in Medicaid at any time, including when they have critical health care needs.

Presumptive eligibility has become more common in Medicaid over the years, but its use remains surprisingly limited for nonpregnant adults. For example, 36 states use it for children, and 30 do so for pregnant people. In contrast, use of presumptive eligibility is far more limited for parents (9 states) and adults of working age without minor children (8 states).

Part of what makes presumptive eligibility so valuable is that it puts the enrollment system where the people are. Beyond hospitals, enrollment sites can be placed in community health centers, homeless shelters, community food pantries, and child care and Head Start centers—wherever health, educational, and social service professionals trained in administering presumptive eligibility and complying with its requirements can be located. Services offer invaluable assistance by serving as an alternative enrollment site for people who otherwise might not have the means to apply. They also are able to help people navigate the complex application process.

Presumptive eligibility may be particularly helpful in covering the approximately 6 million people nationwide who are eligible for Medicaid but not enrolled, a group that is often difficult to reach. Some research suggests that individuals may be unaware of their eligibility for Medicaid or perceive enrollment barriers, which presumptive eligibility can address in trusted community settings.3 Others may experience physical or mental health challenges, such as Alzheimer disease or schizophrenia, that in some clinical presentations make unassisted enrollment challenging. Presumptive eligibility simplifies the difficult process of gaining coverage when it is needed most.

Policy Recommendation

The current public health crisis will hopefully lead to a long-term health reform agenda that will improve our nation’s response the next time such an event occurs. Given the critical need for health care during a pandemic, the central role played by health insurance, and the many individuals who continue to lack coverage, one element of a long-term response should be a federally funded insurance pathway when a public health emergency is declared (whether regionally or nationally) that remains in place throughout the emergency and recovery period.

Presumptive eligibility should be a core element of such an emergency system. At a minimum, such a system could use hospitals and thousands of community access points created through the nation’s network of community health centers. Schools and other community organizations could make presumptive eligibility available for those who are or become uninsured, thereby making coverage available when health care is needed, if not before.

From its enactment, Medicaid was designed to care for the patients with the greatest vulnerabilities and operate without the types of enrollment restrictions that apply to Medicare and private insurance. The program thus offers the platform on which to build a federally funded emergency response insurance system. Along with states, the Biden administration could test and evaluate such a system using the special research authority that has enabled Medicaid experiments over many years. Given the ongoing public health emergency, the new administration could exempt such a demonstration from the normal budget neutrality rules to encourage broad enrollment practices.

Lowering barriers to Medicaid access is central to the Biden administration’s plan to strengthen and improve the Affordable Care Act. Presumptive eligibility is critical to strengthen Medicaid’s ability to operate effectively during public health emergencies.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Degife E et al. JAMA Health Forum.

Corresponding Author: Ellelan Degife, BA, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510 (ellelan.degife@yale.edu).

Conflict of Interest Disclosures: None reported.

Klein  R.  Presumptive eligibility.   Future Child. 2003;13(1):230-237. doi:10.2307/1602653PubMedGoogle ScholarCrossref
Brooks  T. Hospital presumptive eligibility. Published January 9, 2014. Accessed January 4, 2021. https://www.healthaffairs.org/do/10.1377/hpb20140109.508614/full/
Stuber  J, Bradley  E.  Barriers to Medicaid enrollment: who is at risk?   Am J Public Health. 2005;95(2):292-298. doi:10.2105/AJPH.2002.006254PubMedGoogle ScholarCrossref
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