Making it Easier for People to Keep Critical Benefits

How work by civic tech organizations and government agencies has been advancing a powerful solution for Medicaid renewals

Enrolling in a government benefit can be difficult—and sometimes keeping those benefits through a confusing and burdensome renewal process can be just as hard. Through the “ex parte” process, though, states can use existing client data to renew Medicaid, saving clients and caseworkers valuable time. More and more states are working to adopt and grow the rate at which they use ex parte renewals. They’re aided by several organizations in the civic tech space, as well as federal agencies, all of whom are working to ensure this solution is deployed accessibly, equitably, and at scale.

Recently, we sat down with Shalaka Gole, a Lead Product Manager at Code for America, Jennifer Wagner, the Director of Medicaid Eligibility and Enrollment at the Center on Budget and Policy Priorities, and Luke Farrell, a Lead Product Manager at the U.S. Digital Service within the Office of Management and Budget. We asked them a few questions about the individual and state-level impact of clunky benefits processes, what the solutions-oriented work by these organizations and agencies has looked like recently, and what fixes like ex parte renewals are teaching us about improving the benefits experience as a whole.

Why do ex parte renewals hold so much potential to improve people’s experience with safety net benefits? Why this lever of all possible solutions?

Jennifer Wagner: The Public Health Emergency unwinding has really brought to the forefront something that we’ve known for a long time: That a lot of eligible people lose coverage at renewal, not because they’re no longer eligible, but because there’s some issue with the paperwork. They didn’t receive the notice, they didn’t understand it, they sent it back and the state didn’t process it or something. Ex parte is fundamentally a way to eliminate unnecessary procedural terminations. 

Luke Farrell: It’s one of the rare win-wins for beneficiaries, for case workers, and for states. Beneficiaries no longer need to complete a complicated packet, which saves them time, reduces administrative burden, and ensures that they stay enrolled. It’s a win for eligibility workers at the state level who are super overworked and can now focus on more complicated cases. And for the state, a more efficient process saves them money and time. Most importantly from where we sit, it helps build trust in government among beneficiaries. They have a more seamless and trustworthy experience with their state government, and I think that pays dividends in the long term around these kinds of benefits programs. 

Why are ex parte renewals such a good project for the field of civic tech?

Shalaka Gole: It’s a perfect policy window for us to support with technology—the ex parte policy says that states should check existing data sources to see if someone can be renewed, and there are existing digital data sources states are connected to. This also frees up that caseworker’s time for other things. It’s letting the computer do some of the work.  It’s saying, “Hey, try to renew somebody before humans have to touch this.” And that is a really good candidate for technology.

Most importantly from where we sit, it helps build trust in government among beneficiaries. They have a more seamless and trustworthy experience with their state government, and I think that pays dividends in the long term around these kinds of benefits programs. 

What are some of the big challenges we’re seeing with ex parte adoption?

Luke: Legacy systems are enormously difficult to operate in some states—you’re using Apollo-era code systems to do relatively complex determinations. It means the policy-to-technology translation can be a significant failure point. When the outcomes don’t match what was promised, there’s often an assumption that, oh well, the policy just wasn’t as powerful as we thought it was. When in actuality, there was a failure on the implementation side or on the vendor side. And so, I think the huge challenge for states during the unwinding period was all this new, really helpful policy being made—but when translated into systems, it was losing a lot of its potency. 

Shalaka: I can say from our work in Minnesota, the biggest challenge wasn’t working in a legacy system or getting caseworkers on board—it was helping policy teams at the state level feel comfortable reinterpreting policy in a more flexible and open way. It’s challenging for states to shift from a compliance perspective to an outcome-based way of prioritizing—because in prior years, that wasn’t the federal or state focus. 

What unique benefit do civic tech organizations provide in a situation like this?

Luke: Well states have this capacity issue, right? Coming out of the COVID-19 Public Health Emergency, states had been on high alert, making really rapid policy and systems changes for three years—and now they need to make even more system changes to unwind some of those policies. States often don’t have any in-house technical talent inside Medicaid programs. They’re underwater, and that’s where civic tech organizations can help.

Jennifer: The capacity piece speaks to the larger picture of why we got to where we are. Keep in mind, ex parte policy has been on the books for many years. But historically the focus has been getting people on Medicaid, and less attention has been paid to the renewal process. And so it actually has taken the unwinding crisis to force states to prioritize this particular issue and address it. 

One thing organizations like ours can do is show states what’s possible, since we have the data now. We see some states with really high ex parte renewal rates—60% or 70%—and so we can show that to a similarly situated and lower performing state and say: It’s possible, you can do something. So many states are naturally risk averse, but if they hear another state is doing it, especially a state that is geographically or politically aligned, that is sometimes all they need to go ahead.

Listen: Jennifer Wagner talks about ex parte renewals

So many states are naturally risk averse, but if they hear another state is doing it, especially a state that is geographically or politically aligned, that is sometimes all they need to go ahead.

Luke: I can’t tell you the number of times we’ve made a recommendation to a state, and they’ve asked, “Who else has done this?” And we’re like, okay, let’s pick up the phone and call another state together and we’ll talk about what the impact was for them when they did this. And I think the more opportunities we have for folks to be able to connect those dots, it really helps move the needle.

Shalaka: Sometimes just getting people to talk to their own colleagues is enough. We can be conveners in a way that the states themselves are not able to make the time or the space to do. My colleague Tez Cortez led a prioritization workshop around different renewals interventions in Minnesota that somebody said was the best meeting they’d ever attended in government. 

Do you think collaboration is a key piece of closing that policy to implementation gap so that processes like ex parte can live up to their promise?

Luke: Yes. This is something that I think Center for Medicaid and CHIP Services (CMCS) has made a lot of progress around, thinking, when we write the policy, how do we make sure that this is actually operationalizable by state staff who are going to receive this in their hands? So there’s been a number of really helpful pieces of policy guidance going out that take a more implementation-oriented approach.

Jennifer: And I think it’s really important to recognize how innovative a model ex parte has been for federal oversight of these programs. In the past there’s been more of: Here’s the policy, go forth, and states are really left on their own to to reckon with the challenges of that. But this is a model where the federal government is recognizing the complexity of the implementation crisis, the lack of resources, and providing not only a deeper level of clarity than they often do, but also providing boots on the ground to help a state actually make it happen. And it’s really just a complete change in a role from a formal enforcer to a partnership model. It just will make it much better for everybody. 

Shalaka: I think a big piece of this is having the people with the right information at the decision making table, regularly. Minnesota had been measuring how changes in logic were negatively impacting renewal rates, but the folks who were doing that analysis raised that up in another time, when Minnesota was having more challenges around fraud. When the unwinding came around, that info was still true, but not immediately part of the prioritization conversation. People who have the day-to-day knowledge of how this is working should have their voices in the prioritization process regularly—that feels like a replicable step of this that doesn’t have to wait for an emergency to happen.

People who have the day-to-day knowledge of how this is working should have their voices in the prioritization process regularly—that feels like a replicable step of this that doesn't have to wait for an emergency to happen.

Can we talk about the impact of ex parte renewals in really human terms for a minute? What do these policies mean for individuals and communities?

Luke: The bottom line is that ex parte renewals keep people enrolled in life-saving health coverage. USDS with CMCS has been on the ground with eight states. We’re there for a full week in person, and then we’re grinding out solutions with them over the course of weeks and months. As a result, states have ex parte renewed millions of additional people, which will likely keep millions from losing coverage. And these changes are often long lasting and will continue to help beneficiaries, eligibility workers, and states for years to come. Most importantly, every person that gets renewed can go to the doctor, they can get lifesaving preventative care, and they can pick up their prescription without worrying. 

Jennifer: And if we talk caseworkers—back when  I was a food stamp eligibility case worker in 2004, I had 400 cases. When I worked in Illinois later, I had staff with 3,600 cases. That’s less than 45 minutes per family per year. Families—especially the ones who have a child with a disability or who needs special services—they deserve more than that. Freeing up staff time by automating a simple process means that those families who need it are able to get personal attention.

Listen: Shalaka Gole talks about ex parte renewals

What about this project makes you hopeful for the future?

Luke: I think there can be a seismic shift in the way that benefits are delivered to individuals by placing the burden on government as opposed to on families and individuals themselves. I think the lessons that we’ve learned here in Medicaid can be broadly applied to reducing administrative burden across programs and making people’s lives and experience of government better. People deserve to have their government do some work on their behalf.

Jennifer: I hope this is the first of many of these kinds of collaborations between civic tech, federal government, state government, and community organizations. And I think the best is yet to come. I mean, if you look at the data, you can see a measurable improvement. Going from like 34% to 38% ex parte renewals on a nationwide basis—okay, it’s small, but that’s hundreds of thousands of people each month. And each of these changes in the system are going to be lasting and affect people in the future quite a bit.

I think we really need to keep up the momentum around reducing administrative burden on individuals and simplifying processes for agencies. These problems have been around for a really long time. But now we have the data, we have the focus, we have national news coverage, we have the federal government looking at it. Until now, we’ve just accepted this unnecessary administrative burden placed on clients, and disproportionately people of color. And there’s such a clear solution here. We can fundamentally reimagine the system, and we have to keep on working on these problems until they’re solved.

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