CountyCare: A Medicaid Expansion Success Story

Cook County health system’s program got an early start on the ACA, thanks to a demonstration waiver
By Cheryl England

No matter how you measure it, CountyCare, the Cook County Health and Hospitals System (CCHHS) program to expand Medicaid for adults in Cook County, has been a huge success. By late 2014, CCHHS had more insured patients than uninsured for the first time in its history—an important step in keeping costs under control in the long run. One of the driving factors behind that success was CCHHS’ success in getting a head start on the Affordable Care Act’s Medicaid expansion for adults in Cook County.

In late 2012, the State of Illinois obtained a federal Section 1115 demonstration waiver to get an early start on Medicaid expansion, which allowed adults living in Cook County and making less than roughly $15,860 (or 133% below the federal poverty level) to get Medicaid even if they didn’t have children or weren’t disabled.

“We were fortunate to get a one-year head start in Medicaid enrollment in the health plan we own and operate,” says Jay Shannon, MD, CEO of CCHHS. “Everyone else had to wait until 2014 to start enrolling new Medicaid-eligible adults. We were the only plan in Illinois that was given a head start.”

Getting Started

The demonstration program was promptly named CountyCare and was designed to help the state and CCHHS build capacity and experience to support implementation of the official Medicaid expansion in January 2014. Over 618,000 uninsured adults were estimated to be eligible for the ACA’s Medicaid expansion in Illinois, with over 341,000 of them residing in Cook County. In just 12 months, the program had enrolled more than 82,000 Cook County residents. By March 2014, CountyCare members accounted for nearly half of the total statewide enrollment of adults into the Medicaid expansion program.

To meet its enrollment goals, CountyCare aggressively conducted outreach programs to potentially eligible individuals. The group placed articles in neighborhood newspapers and digests; flooded communities with posters and flyers; and conducted community outreach events. In addition, CountyCare targeted uninsured patients at CCHHS and network health centers. Health center staff also provided information about CountyCare to patients in waiting rooms.

Outreach was also conducted through other areas of Cook County government. For example, probation officers were given information and training on CountyCare eligibility requirements, the application process, benefits, and network to help connect their clients to coverage. Local elected officials included information about CountyCare in their newsletters and communications to district residents.

An initiative was also established to assist detainees in applying for CountyCare while going through the Cook County Jail intake process. This partnership between CCHHS, the Cook County Sheriff, and Treatment Alternatives for Safe Communities, a local non-profit organization, resulted in over 13,700 applications. In the end, more than 12,000 detainees at the Cook County Jail enrolled in Medicaid; more than 4,000 of those individuals chose to enroll in CountyCare.

In addition, CountyCare had to handle management of its waiver from the Centers for Medicare and Medicaid Services. For example, CountyCare needed to have a third party evaluate the effectiveness of the waiver showing that it enrolled enough patients; that those patients were geographically acceptable enough to encourage providers to participate in the plan; and showing that CountyCare could deliver the necessary services.

“The question was, ‘Did we generate enough claims processed through the state Medicaid agency that were medically necessary,” says Dr. Shannon. “Yes, we did. In six months, two-thirds of our claims were medically necessary and in 12 months we upped that to 85%.”

Financial Success

Understanding the financial success of CountyCare, however, can be a bit more complicated. The program spent more money than it brought in during the first six months of fiscal 2014, which ended May 31 of last year. Yet much of that expense went to reimburse care that the system itself provided. The end result is that even though CountyCare lost about $21.9 million for those six months, CCHHS gained $137.2 million because many of those patients sought care at county hospitals and clinics.

The six-month results speak to the belief that the program is crucial to the financial survival of the health system, and to the county itself, which subsidizes the system with tax dollars. “Before CountyCare, this organization historically had been spending $500 million to $600 million a year for uncompensated care. This was an opportunity for us to bring in resources to offset those significant dollars,” said Dr. Shannon. “The fact is that CountyCare brought in more than $100 million in payments that this health system would not have received without it.”

Transitioning to Managed Care

On July 1, 2014, CountyCare transitioned into a County Managed Care Community Network (MCCN). “At the time, adults were given choices of joining other health plans,” says Dr. Shannon. “So CountyCare transformed its health plan to also accept traditional Medicaid populations.”

As a result, CountyCare is now one of the largest Medicaid managed health plans in the Greater Chicago region with 180,000 members. That’s up from 99,000 members a year ago—almost a 100% growth—and 25,000 more members than the budgeted goal of 155,000 members for the fiscal year, which runs from July to June. In addition, CountyCare is currently only one of two provider owned and operated MCCNs in the state.

Now the group worries about patient utilization—the number of emergency room visits, how many people take medications, and how many medications they each take. And it worries about redetermination, the annual paperwork requirement that determines whether a person can still receive Medicaid. “If patients had Medicaid for a number of years, they are accustomed to the forms,” says Dr. Shannon.

“But Medicaid adults who were enrolled due to the expansion are not accustomed to redetermination. They don’t get a monthly reminder as they do for food stamps or housing so they are the people most likely to disregard the paperwork.”

To help resolve the issue, CountyCare and CCHHS have begun working with Medicaid patients to educate them about the redetermination process. As a result, in just the last year, CountyCare has seen a sharp decrease in the number of Medicaid cancellations after sending redetermination reminders to members at risk of losing their coverage.

The Bottom Line

“We’ve done great things,” says Dr. Shannon. “Today only 30% of CCHHS patients are uninsured. It used to be 75% uninsured.”

But not one to take credit for what CountyCare has done, Dr. Shannon says, “I give all the credit to President Obama. He recognized the state of the uninsured and expanded care.”