Medicaid mystery: Who are all the new members?

Ron Harney is still looking for work after being laid off from his marketing firm job three years ago. He's used up nearly all of his savings and says he's grateful for the state's Medicaid program, which covers the medical care he needs to manage his HIV.

"I rely on it week to week," the 43-year-old Stamford resident said.

Harney is part of a group that took state officials by surprise, one of more than 37,000 people who joined a new portion of the Medicaid program since it was created in 2010 to replace a state-funded form of coverage.

Enrollment in the program, Medicaid for Low-Income Adults, or LIA, now tops 83,000, including 46,156 who were in the predecessor program. That's far higher than had been anticipated or budgeted for by the state, which didn't expect that many enrollees until next August.

Officials in Gov. Dannel P. Malloy's administration say it's a major reason why the state's budget is in the red, and they have called the program unsustainable. They have suggested that at least some of the members could very well afford alternative insurance.

Why did the program grow so far beyond what was expected, and who are the new members?

No one knows for sure because, among other things, the state doesn't ask applicants for information on assets.

Health care providers and advocates for Medicaid recipients say the 37,000 are largely people like Harney, who became unemployed since the recession began, and those who were previously uninsured and would have otherwise had their care paid for by state grants or taken as losses by health care providers.

They say it's inaccurate to pin the budget woes on the new program, and note that the portion of the Medicaid program that serves children and parents has added nearly as many members -- almost 33,000 -- in the same time.

The Malloy administration, meanwhile, has speculated that some of the 37,000 are those who wouldn't traditionally be in Medicaid, such as college students who could be on their parents' health plans or retirees with minimal income but high levels of assets who have alternatives to state coverage.

"A significant number of these individuals are arguably not the type of individuals who the taxpayers should be subsidizing," state officials wrote in an application for federal permission to restrict eligibility in the program. The application is still pending.

Malloy's budget director, Benjamin Barnes, said he thinks there are a lot of college students in the program; he knows people who have enrolled their kids, although he said that's not likely a major driver of costs. In the past, he has cited the case of a retired couple with significant assets who chose to be uninsured and landed in the program after a medical crisis, but he said Monday that he doesn't think there are many recipients like that.

Instead, he said the way the program was designed in 2010 likely made it significantly more accessible to a wider group of people.

Enrolling in LIA

To get into LIA, you must have a very low income -- just over $500 a month (the limit is slightly higher in Fairfield County). That hasn't changed from the program that preceded it, which was known as SAGA -- state-administered general assistance.

But to meet Medicaid rules, the state had to get rid of the eligibility restriction that limited the old program to those with less than $1,000 in assets. There's currently no asset limit.

"If you're uninsured and you show up at the hospital, there are a lot of ways that you can become eligible for LIA relatively quickly," Barnes said. "Among other things, if you stop working," such as in the case of someone with a catastrophic illness.

Barnes said easier access to the public insurance program has likely led to less uncompensated care for health care providers and fewer patients facing collections for unpaid medical bills, including liens on their homes.

"It's a very effective piece of the safety net," he said. The overall health care system, he added, "is very porous, so a lot of people fall through and land in the program."

Providers: LIA serves the poor

Health care providers who serve LIA members say the clientele is similar to those covered in the previous program. Many have opposed the state's efforts to restrict eligibility to those with less than $10,000 in assets and to count parental income assets in the case of some young adults under 26.

"It's not a subsidy for the middle class," said Jeff Walter, president and CEO of Meriden-based Rushford, which provides substance abuse and mental health treatment. "My experience is that there is no real shift towards covering college-age kids or adult children of middle class families. This is really continuing to be a program for the indigent."

Walter, who sits on the council that oversees Medicaid, said the enrollment trends likely reflect larger forces, like the economic downturn.

"It's not so much that the LIA enrollment is skyrocketing, it's that the state had made a projection in the biennial budget of the growth rate in all of the categories, and we're beating the growth rate significantly in HUSKY A," Walter said, referring to the Medicaid program for children and their parents. "That's the biggest thing. But LIA has been creeping up a little bit [in recent months], and I think it's because we still have a very soft economy."

When people who had been uninsured get coverage, he added, they tend to initially need more services to address problems they hadn't gotten treated earlier.

Some health care providers, like Katherine Yacavone, president and CEO of Southwest Community Health Center in Bridgeport, have been pressing the state Department of Social Services to provide data on who the new members are. She's also skeptical of the idea that they're people with alternative options for health insurance.

"My perspective is that people we see are very needy, have multiple problems, medically as well as in the behavioral health field," she said. "My experience is not that we have this flocking of college-age or young adult kids who could otherwise have insurance. That is not our experience. Maybe it's an experience in a private practice, but it's not an experience at the health center."

One new member who might not appear much like a client of the old program is Sarah Esposito, a college student from Hamden.

But her story isn't quite so simple. Her parents are self-employed; her mother, Marni, was downsized from a corporate job in 2006. The family maintained health insurance through COBRA, and when that ran out, they turned to HUSKY A, the Medicaid program for minor children and their parents.

When Sarah turned 19, she became ineligible.

She attended Gateway Community College and got coverage through the student plan. But after a medical emergency -- a burst ovarian cyst -- her family learned that it wasn't especially comprehensive coverage, Marni Esposito said, and the family is still paying bills from Sarah's time in the hospital.

Sarah eventually qualified for LIA. But she now attends college in Massachusetts, and to comply with that state's insurance mandate, she had to buy a separate insurance policy. Her mother says having an alternative insurance option came with a steep cost.

"She had to take out an additional student loan to pay for that," Marni Esposito said.