Lukanen, Elizabeth
Planalp, Colin

Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement (Cross-Post)

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The following content is cross-posted from State Health & Value Strategies. 
Authors: Elizabeth Lukanen and Colin Planalp, SHADAC, and Kevin Caudill, GMMB

The unwinding of the Medicaid continuous coverage requirement represents the largest nationwide coverage transition since the Affordable Care Act. Not surprisingly, policymakers, advocates and the media are watching coverage transitions closely and many states have released Medicaid administrative data documenting their progress. While state and federal administrative data can quantify the number of successful Medicaid renewals and coverage terminations, they typically cannot provide details on what happens to people leaving Medicaid. For instance, are people gaining employer-sponsored insurance (ESI) upon leaving Medicaid coverage, or are they becoming uninsured? Those administrative data also are limited in their ability to tell us why patterns are occurring. For instance, among people who remained eligible for Medicaid coverage, why were some successfully renewed while others were not?

Individual-level surveys of people who were enrolled in Medicaid during the continuous coverage requirement can help to answer such questions. The federal government’s Household Pulse Survey, which the U.S. Census Bureau established during the COVID-19 pandemic, serves as one key example of how surveys can fill critical data gaps to answer questions during unique circumstances. Similarly, states may consider conducting their own survey of consumers.

Motivation for Conducting a Medicaid Consumer Survey

Targeted surveys of people who have been enrolled in health coverage (referred to as “consumers” in this expert perspective), can be a relatively inexpensive and quick way for states to obtain information on coverage transitions and consumer experiences. In the context of unwinding, surveys would target Medicaid enrollees who recently went through the redetermination process. These surveys could be leveraged by officials in Medicaid or the Marketplace to:

• Better understand coverage transitions.
  • Did an enrollee transition to employer-sponsored coverage, some other source of coverage, or become uninsured?
  • Why did the enrollee exit Medicaid if they were still eligible?
  • If they were eligible for a qualified health plan (QHP) but didn’t enroll, why?
• Gather information on what messages and message strategies resonated with consumers.
• Assess what shopping, assistance and customer service tools were used.
• Educate people on tools, resources, or coverage options available to them.
• Serve as a final nudge to consumers that they need to take action to stay covered or transition to new coverage.
• Inform future research, such as longer targeted surveys, user experience testing or consumer focus groups.

Survey Mode

Given the dynamic nature of the unwinding, surveying consumers quickly is important. For this reason, states should consider short surveys that are distributed by email or text message using a convenience sample (i.e., Medicaid disenrollees for whom the state has contact information). For the sake of administrative ease, states could work with a web survey vendor that offers a user-friendly interface and (if possible) with whom they have an existing subscription or contract.

Many web-based vendors can send surveys via email or text. When sent via email, these surveys can typically be distributed in two ways: 1) consumers are sent a generic survey—the same survey link goes to everyone on the distribution list; 2) consumers are sent a unique survey link—a unique survey link is distributed individually to everyone on the distribution list. These options entail trade-offs. A benefit of a generic link is that it can be sent using the state’s existing communication platform. This avoids the need to import consumer contact information into the survey vendor platform, which might raise privacy and other legal concerns. Alternatively, a benefit of using a unique, individualized survey link is the ability to connect survey responses to state administrative data on the respondent, notably, characteristics (e.g. income, age, race, household type, etc.). This reduces the need to collect demographic data via the survey, can result in richer demographic detail about survey respondents, and provides insights into those who did not respond to the survey.  

Text or SMS surveys can also be distributed in two ways. One option is to send a “2-way” survey, where respondents text their replies to each question (best suited for a one question survey). The second option is to distribute a link to the survey which is sent to the consumer’s phone and can be opened in a mobile browser. During the unwinding, states are often focused on very short surveys. In some cases, they might ask a single question (typically focused on assessing coverage transitions) or other very brief surveys (3 to 10 questions). In some cases, states might attempt both—starting with a single question survey to assess coverage transition, followed up by a longer survey that captures information about the consumer experience. While there is wide concern that state Medicaid programs might not have up-to-date contact information for Medicaid enrollees, especially in a time-sensitive situation such as the unwinding, it is likely most practical to reach out to people using contact information already on file—often including a cell phone number or email address.

The primary benefits of web-based surveys sent via text or email are speed and cost. If a state has in-house expertise, funding, and can leverage an existing partnership (e.g., a state–university partnership) or an existing survey effort, they could also consider a more robust, mixed-methods survey that supplements a mailed survey (and online option) with interviews. For example, New Mexico recently fielded the New Mexico 2023 Office of the Superintendent of Insurance (OSI) Health Access Survey, commissioned by the New Mexico OSI and conducted by the University of New Mexico. This was a larger and sophisticated effort—a statewide survey of 1,900 adults, conducted by a survey firm in both English and Spanish using multiple modes (telephone and online). While the focus of the survey was broad, to better understand the opinions and attitudes New Mexicans have regarding health insurance, the state recognized the opportunity to use this vehicle to gain insights into unwinding. The survey found that residents were generally aware that pandemic funding for Medicaid was ending, but this awareness was lower for Latino/a, Native American, Spanish-speaking and lower-income New Mexicans, which highlighted the importance of targeted messaging and outreach.

Target Population and Timing

During the unwinding, states should focus on consumers who are scheduled to be redetermined for Medicaid. Logistically, states could consider sending the survey in waves, aligning with unwinding cohorts. If state systems allow them to target more granular groups, the state could send slightly different surveys to different groups. For example, if a state is targeting those who exited Medicaid and shopped for plans in the Marketplace, they could send slightly different questions to those who ultimately selected a plan than to those who did not select a plan.

States should also carefully consider the timing of any consumer survey as they finalize their questions.  For example, questions about shopping and plan selection should happen fairly quickly, ideally within a couple of weeks of when consumers should have engaged in these activities. If a consumer can still submit redetermination paperwork or sign-up for a QHP, the questions and wording should make that clear and not imply the consumer has no option to take action. As mentioned above, given the nature of many states’ phased unwinding approach, states should consider sending surveys weekly or monthly based on renewal cohorts.

Questions of Interest

States considering consumer surveys related to the unwinding tend to be interested in a fairly narrow set of questions. They want to understand coverage transitions, specifically whether people enrolled in employer-sponsored or Marketplace coverage after leaving Medicaid, and the enrollee’s experience navigating the process. States might use these surveys to assess specific outreach methods (e.g. the impact of mailing campaigns to send people letters on colored paper). And for states with available customer service resources, they could use the survey to connect people with a customer service channel (for instance, asking respondents if they would like assistance with the application and enrollment process). By collecting demographic information along with these questions, states can also get a sense for whether there are population differences between those who successfully transitioned to another source of coverage and those who remain uninsured. 

Common survey question domains include:
(A list of sample questions is included at the end)

• Current coverage/coverage transitions
• Reasons/motivations to have or not have coverage
• Experience shopping for insurance
• Establish who shopped (if this cannot be identified using administrative data)
• Outreach and assistance
• Impacts of uninsurance
• Demographics
• Did an enrollee transition to employer-sponsored

As states consider what questions to ask, they should take care to tailor their surveys to the strengths and limitations of this data collection method. Surveys are good at collecting information on people’s experience and impressions, but they are less useful for collecting specific, detailed and nuanced information (e.g. specific information about ESI cost-sharing, specific detail on what programs consumers qualified for). 

Another best practice is to ask questions that only require the respondent to reflect on one concept at a time. For example, when constructing questions about the shopping process, avoid phrasing questions that conflate opinions about the shopping experience and plan choice, which could pose a challenge to respondents if they found the online interface easy to use but the plan options to be underwhelming, or vice versa.

Finally, states should consider the goals of the survey and tailor the questions to those goals. Especially in the unique circumstances of the unwinding, states may be looking for ways to make their redetermination processes more user-friendly for Medicaid in the near-term, so they can maximize the number of eligible individuals reenrolled in the program. In that case, states should prioritize questions that are likely to yield data that are actionable in the coming weeks or months, rather than years. Relatedly, states should take care in how they interpret survey data collected during the unwinding and temper their expectations for the generalizability of the survey findings into the future. Because the current circumstances are so unusual, it is possible that the experiences of Medicaid enrollees going through the redetermination process today may not resemble the experience of people going through the redetermination process in a couple of years. However, if states find these survey data useful, they could incorporate similar surveys even after the unwinding, as part of their ongoing, regular course of business.

Communications Best Practices

As states are developing survey instruments, it is important to also keep in mind the surrounding communications to potential respondents to maximize participation, reinforce validity, and mitigate against concern about scams. Below are some helpful tips that states should consider when developing communications to support consumer research. While these apply primarily to email, they can also be applied to other mediums such as text messages. 

Establish your tone/voice. The tone of your subject line and email should reflect your Marketplace or Medicaid agency brand. Reinforcing your role as an official program is key. Determine where you will fall on the spectrum of conversational (e.g. “A few minutes to share your feedback?”) versus professional (e.g. “We’d appreciate your feedback to help us serve you better.”)

Personalize as much as possible. Personalizing is more than a name; it’s reflecting the experience you want feedback on. For example: “How did we do with Medicaid/Marketplace enrollment?” or “Did you have all the enrollment information you needed?”

Talk about the benefits of completing the survey. Explain up front why their participation matters. For example: “Help us make Medicaid enrollment better” or “Your feedback will make Marketplace enrollment better.” Within the body of the email itself, briefly explain how their feedback will be used and express appreciation for their time and input.

Ask a question in the subject line.

Try to keep subject lines under 50 characters. This is so participants can get the full headline on their mobile device.

States should consider these recommendations as they develop customized messaging for survey communications. These steps can help states get the most helpful information from their survey efforts. Ultimately, communications should reflect the unique goals that each state will determine for its research effort so there is no one size fits all approach.

Interpreting the Results

This type of consumer survey can be very useful to gather information on consumers’ experiences, identify areas where they are struggling with the process and which resources or outreach methods are resonating. In this case, it can also be useful for gaining some insights into coverage transitions outside of Medicaid or the Marketplace. That said, it will rely on a convenience sample, it is likely to have a low response rate and the results will not be representative of the target population as a whole. When interpreting the results, these limitations should be considered. States shouldn’t assume that survey results collected using a convenience sample during the unwinding represent everyone who experiences the Medicaid redetermination process. For example, consumers’ experiences might be different during a more typical renewal period and might be different for those who did not respond to the survey.

Agency Coordination

States considering these surveys should work closely with their legal, marketing, customer service and other relevant teams. Support and guidance from a legal team can be critical as states consider specific details about how the surveys are sent and distributed. For example, can the state send text messages to consumers and with what limitations? Can the state upload consumer contact information into survey vendor platforms for the purposes of distributing a survey? Involving the marketing and public relations team is also a good idea as they can ensure the terminology is consistent and that messages are aligned with what is being sent regarding redeterminations. And it is important to let customer service teams know when these surveys are going out, particularly if they are designed to spur final action or are directing enrollees to specific supports.

Sample Questions

A list of sample survey questions can be downloaded using the link below. The sample questions can be customized and used by states interested in conducting a consumer survey during the unwinding.

SHVS_Sample Consumer Unwinding Survey