Complex government programs, such as Medicaid, are often accompanied by strict registration and eligibility requirements. These administrative burdens can frustrate and stymie potentially eligible individuals, limiting individuals’ access to public programs and legally-entitled benefits. On the latest episode of Policy Outsider, University at Albany Associate Professor Ashley Fox discusses her recent article in Public Administration Review, which found rule-reduction changes to ease Medicaid enrollment can improve program take-up (i.e., increase enrollment). The conversation covers the consequences of administrative burden on states and individuals and ways governments can use administrative easing to improve public programs.


Ashley Fox, Associate Professor, University at Albany

  • Transcript

    Transcript was generated using AI software and may contain errors. 

    Alexander Morse 0:04

    Welcome to Policy Outsider. I’m Alex Morse. Do administrative burdens and social barriers limit enrollment for Medicaid and other social welfare programs? Does stigma play a role in any of this? As we’ll find out states can reduce burdens to increase Medicaid take-up and provide adequate health care to a greater number of people. But will increasing enrollment also increase state expenditures, or will actually save money? On today’s episode, we have University at Albany Professor Ashley Fox to discuss her recent paper that examines some of these questions, we will highlight how some states are addressing Medicaid enrollment policies, and discuss what implications administrative easing can have for both the individual and for the government, coming up next.

    Alexander Morse 1:20

    Hello, Professor Fox, thank you for joining the podcast today.

    Ashley Fox 1:24

    Thanks for having me. Full disclosure, I’m working from home today, my kids are home on February break. So if you hear any noises in the background, it’s probably them. And I apologize in advance.

    Alexander Morse 1:33

    Oh, not a problem. Totally understand it in this world today. So I’m with Professor Ashley Fox, who teaches at the University at Albany’s Rockefeller College of Public Affairs and Policy. And you specialize in policy analysis with a focus on comparative health policies, and the effects social policies have on health outcomes. Now, full disclosure, Rockefeller College is my alma mater. But you and I never crossed paths while I was there. So I’m glad we get to work together now, especially since I won’t be graded on anything. So, again, thank you for joining. So we have you here to talk about these health policies, specifically Medicaid and enrollment. You recently published a paper in the Public Administration Review titled “Administrative Easing, Rule Reduction, and Medicaid Enrollment.” Medicaid is a federal social welfare program that provides health care to millions of Americans, including the low-income adults and families, pregnant women, the elderly, people with disabilities. And although it’s a federal program, it’s administered by the states. And so state administration makes for a unique opportunity to measure the different policies and approaches against each other. Let’s start there with a brief comparative analysis. How does one enroll in Medicaid? And how can that change between states?

    Ashley Fox 2:16

    That’s a great question. So I think a lot of this has really changed since the introduction of the Affordable Care Act, the most typical way that somebody would enroll now would probably be to go on to the exchanges, which are either the state specific exchange, which is like an online marketplace where you go and apply for insurance, you can check if you’re eligible for subsidies or if you’re eligible for Medicaid. And there’s the federal exchanges, in each state, also has their own exchange. So really, since the introduction of the Affordable Care Act, that is probably where most people go to find out if they’re eligible for Medicaid. But prior to the Affordable Care Act, it was much harder to find out if someone was eligible. Usually, you would probably go to a provider or maybe you get assistance from other programs. And you might find out that you’re eligible, but there was no really direct way to find out if you’re eligible prior to the Affordable Care Act. And it varies a lot by state and some state eligibility is determined at the county level. So you might go to a county office to find out your eligibility status. I think the Affordable Care Act has really made it a lot easier for people to learn about their eligibility for Medicaid, and in ways that have really had significant ripple effects.

    Alexander Morse 4:27

    Let’s start with two states, maybe New York versus what state has a more burdensome administrative process?

    Ashley Fox 4:37

    I think since the Affordable Care Act states have really equalized, in that sense. But surprisingly, New York is one of these states that tends to administer public assistance at the county level. So actually, New York probably was a little bit more complicated in some ways than other states that where eligibility is not necessarily determined at a county level or where you don’t have a county office that you would have to interact with. So surprisingly, some states, for instance, like Utah, has now implemented what they call an integrated eligibility system that actually integrates eligibility not just for Medicaid but for other programs like TANF, SNAP, and childcare subsidies. And so in Utah, you can actually, while you’re finding out if you’re eligible for Medicaid, potentially find out if you’re eligible for these other programs. Now, that’s since the Affordable Care Act, I’m not sure exactly what they did before the Affordable Care Act. But New York actually doesn’t have an integrated eligibility system. And part of that is because the eligibility rules are just so different in New York for each of these programs that I know that there have been some efforts to try to integrate eligibility, but it’s been looked at and determined that it’s too hard to integrate the eligibility across these different programs because they have such different rules.

    Alexander Morse 6:06

    Let’s focus on that eligibility component. It varies greatly between different states. So these are political choices, and administrative choices. Why do states have different eligibility standards?

    Ashley Fox 6:20

    That’s a great question. It may be better left to the people that actually craft the policies to really answer why that is. But I think there’s an increasing recognition of the ways that administrative burdens do reduce uptake in program participation. And so states are increasingly moving in the direction of trying to simplify their enrollment processes. And some of it really dates back historically to welfare reform, honestly, in 1996. So previously, under the AFDC program, which was Aid for Families with Dependent Children, eligibility for different programs was more integrated. So if you were eligible for AFDC, you were often eligible for food assistance and for Medicaid. Then with welfare reform, the rules became so different that different states went in very different directions in terms of how people would get enrolled with different programs, which greatly increased the amount of administrative burdens to signing up for them. But I think now states are starting to recognize the problems that that’s caused and how that’s affecting people’s uptake of the programs and are moving in the direction of trying to simplify rules, at least for Medicaid and perhaps for SNAP as well.

    Alexander Morse 7:43

    With regard to welfare reform, you said it was 1996. I guess that provides a unique opportunity to see what changes states made and how that had an effect on health outcomes. And so we’re talking about the administrative burdens being increased in those 90s years. How has that had an effect on Medicaid enrollment, specifically? What is the gap between those who are legally entitled to benefits versus who are actually receiving those benefits?

    Ashley Fox 8:12

    Previously, like before the Affordable Care Affordable Care Act actually made it a lot easier to figure out who is eligible for Medicaid? And to figure out what is the gap between the people that would be eligible and the people that actually enroll in Medicaid. But prior to the Affordable Care Act, it was very difficult to even know how many people were eligible for Medicaid. You would think that policymakers would have, like, some target that they know like this proportion of my population is in fact eligible for Medicaid. And that they would be working towards trying to get to that maximum number of people. But in reality, we don’t really actually know how many people are eligible for Medicaid, at least historically, because there’s so many complicated things to consider. It’s not just about income, there might be an asset test. Even thinking about what counts as income can be very complicated. Does child support count? What kinds of other benefits might count against your income? So determining eligibility before the Affordable Care Act was very complicated. The Affordable Care Act moved towards this system of using modified adjusted gross income and mostly got rid of the asset test in almost all instances. So it became much easier to figure out how many people were actually eligible for Medicaid. And so now there are some attempts at estimating what proportion of the population is eligible and then what proportion is actually enrolled. And actually, what studies have found is that there’s pretty high enrollment rates now in Medicaid. So in 2016, 94 percent of kids that were eligible for Medicaid were enrolled.

    Alexander Morse 10:02 

    Oh, wow.

    Ashley Fox 10:03

    Yeah, it’s very high. And 80 percent of parents who were eligible were enrolled.

    Alexander Morse 10:10

    Now, is that uniform? I’m sorry. Is that is that uniform across states? Or are some states driving those higher figures?

    Ashley Fox 10:17

    There’s definitely variation across states. And that variation can be further explored to see what exactly are driving those differences. But we only have estimates for two years on those eligibility. Like how many people that are actually eligible are enrolled. So the Urban Institute has created these estimates based on projecting what proportion of the population based on the different characteristics that determine eligibility, what proportion actually is on the program who are eligible. But that’s only been done for two years currently. So it’s difficult to do really advanced studies that can really determine what the factors are that vary across states that determine that.

    Alexander Morse 11:07

    Yeah, so it’s too early to draw any conclusions about these policies.

    Ashley Fox 11:12

    Any really solid conclusions. I would say, yes.

    Alexander Morse 11:15

    Okay, so changing gears just a little bit. Why is Medicaid take-up so important? Why do we want to reduce administrative burden?

    Ashley Fox 11:25

    I think there’s different perspectives on this. I tend to take the perspective that our benefits are a legal entitlement. And insofar as people who are legally entitled to the benefit are not using it or don’t have access to it, or there’s a concept known as bureaucratic disentitlement, so that we’re being disentitled, just based on these bureaucratic procedures, that we shouldn’t be concerned about it from a normative perspective that people aren’t able to claim, what is legally owed to them. But I think there are other pragmatic reasons for being concerned as well. So of course, if people aren’t on Medicaid, who are otherwise eligible for Medicaid, they may not get the health care that they need, they may develop costly conditions and end up in the emergency room in ways that could have been prevented and end up passing on costs anyway, since they weren’t enrolled. So I think there’s a lot of reasons, both from a normative and health perspective, to get more people enrolled.

    Alexander Morse 12:31

    That’s interesting. This might be a side point. Are there any studies based on the past on costs of someone not enrolled in health care versus if they were enrolled in Medicaid? Do we know what those differences may be? Do they even out or is one worse than the other?

    Ashley Fox 12:47

    There are studies. Off the top of my head couldn’t tell you an exact number without doing further research. But generally, people tend to believe that the costs are larger. Because if you people are continuously have health care coverage, they can go and get preventive checkups. And generally that prevents the much more costly things that end up coming down the line. So yes, I think that there’s pretty good evidence that it costs more not to insure people than to insure them. But I can’t cite a specific amount right off the top of my head.

    Alexander Morse 12:48

    Sticking on higher costs, what does higher take-up of Medicaid look like to states, if more people are enrolled in Medicaid, will that cost states more money?

    Ashley Fox 13:03

    Yeah, that’s a good question. It’s a complicated question to answer, because of the way that Medicaid is funded in part. So Medicaid funding is quite complex. For instance, Medicaid is largely paid for by what’s known as the FMAP, the Federal Medical Assistance percentage. So that’s the proportion that the federal government contributes to Medicaid programs. This can get very wonky very fast. But the FMAP is calculated from a formula that takes into account the average per capita income of a state relative to the national average. And then states are responsible for the amount that’s above that FMAP. So in a sense, I think in theory, yes, states are responsible for, if there is greater uptake for instance of Medicaid than what they were anticipating or in a sense by keeping uptake lower states would incur less of the cost of those additional participants. So I think there can be incentives to keep enrollments lower, whether it how much that actually factors into what states are doing. You’d have to ask probably the states themselves.

    Alexander Morse 14:55

    And so switching from the fiscal costs to the social costs. What are the ramifications of administrative burden on the individual? How are we defining administrative burden here? What does that mean for the person’s self-worth or social efficacy? How does that play out in real life?

    Ashley Fox 15:13

    Yeah, so scholars of administrative burden, talk about largely three types of costs. One is learning costs that has to do with the costs associated with learning about whether you’re eligible for a program. And I think even this like framing of it as a cost implies that there are certain costs to the individual involved in trying to determine whether or not they are actually eligible for a program. Then they talk about compliance costs. So assuming that you actually get on a program, there’s additional burdens you may encounter in trying to stay enrolled in that program or things you might have to do to continue to prove your eligibility. That can also impose a considerable amount of costs on individuals, in terms of their time and in terms of their effort, their stress levels. But the third category is probably the most relevant to what you’re talking about, which is psychological costs. So there’s psychological costs to applying for programs staying enrolled in programs. And just the very fact of it being a safety net, or a welfare program often confers a certain amount of stigma upon trying to access those benefits. But the process can be more or less stigmatizing depending on how the rules are actually structured. And so I think another element of the Affordable Care Act, and being able to apply online and on the exchanges, that has helped reduce some of that psychological burden is the ability to just go online and check your status and not have to necessarily go to a welfare office or have it be, in fact, a lot of people going on the exchanges, they may not even know that they’re looking to see if they’re eligible for Medicaid, they’re just checking if they’re eligible for a subsidy perhaps or what health insurance plan they might be eligible for. And then they can find out that they’re eligible for Medicaid. And so that really also significantly changed how people were thinking about the program itself, and how they come to find out that they’re eligible, I think, in a way that also reduces some of those psychological costs.

    Alexander Morse 17:23

    Yeah, I remember learning in grad school that some benefits for social welfare programs are made purposely burdensome or purposely undesirable. So for example, for food assistance, you have a small office with a line outside the door and it would take you an hour or maybe longer to receive food or benefits. And so it was it was a political decision or maybe an administrative decision to make these programs appear as undesirable. You used the word stigma earlier, but we’re talking about how we want to reduce psychological burden in that sense. What other reductions in administrative or what other administrative easing has gone on since the ACA?

    Ashley Fox 18:06

    So I think that’s one of the big ones, the implementation of the exchanges, in general, was really helpful. But also, there was the implementation of what’s known as real time eligibility that was also built into the exchanges. And what this allowed people to do was to first of all use self-attestation of income, meaning that you basically just self-report what your income is and then that information goes into the system. And then the system can actually just check based on your social security number, based on like other administrative records that the state has, what your actual income is. So you can use existing electronic resources to verify people’s self-attested income, and then get back to them within 24 hours to say, “Okay, yes, you are, in fact eligible for Medicaid” or to flag right away like, “You may be eligible for Medicaid.” And so that really helps to engage people and let them know quickly that they could sign up for Medicaid. So that we found to be actually very impactful on uptake of Medicaid. Some other rules that predated the Affordable Care Act, and actually were part of the CHIPRA reauthorization, which is the Children’s Health Insurance Program Reauthorization, were some different measures that states had implemented with the explicit aim of really making it easier to find out that you’re eligible. So one of those was presumptive eligibility, which authorizes qualified entities. So things like healthcare providers, community based organizations, schools, it enables them to screen for Medicaid and CHIP eligibility and then immediately enroll people who appear to be eligible. And so that in information goes to whoever is handling Medicaid in the state. And they can determine whether or not that person really is eligible, but at least they’ve been flagged as somebody who’s potentially eligible and automatically enrolled. And similarly, express lane eligibility enables states to use data on program eligibility from other public benefits programs to determine whether or not children are eligible for Medicaid and CHIP. And often when it’s determined that a child is eligible that also can then signal that adults might be eligible as well. So there’s also this welcome mat effect that people have found that if you find out that your child is eligible, you might look into whether you’re eligible or it can be it can be determined, if you, in fact, are eligible. So I think what these have in common is really that they’re putting the onus more on the state to verify whether or not somebody is ineligible, as opposed to putting the onus on the individual to seek out and prove that they in fact, are eligible. So it’s innocent until proven guilty standard.

    Alexander Morse 21:10

    Sure. Now, the Medicaid expansion was a federal rule that was part of the Affordable Care Act. But some of these initiatives done by states to increase Medicaid have been voluntary, right?

    Ashley Fox 21:24

    Some are voluntary, but there were quite a few that were mandated by the Affordable Care Act. But yeah, so in terms of some of the more impactful ones that we found, real time eligibility, not all states adopted that and some states have done a better job implementing real time eligibility than other states. And some of the use of presumptive eligibility and express lane eligibility still varies by states. And some of the different ways that people can renew their coverage continues to vary by states. And that can also be very impactful. So how frequently you have to renew coverage, what that process looks like, that can also promote what people refer to as churn in the program. So people cycling on and off the program.

    Alexander Morse 22:16

    Are there any other types of initiatives that states can employ to increase enrollment, something that you found through your research that’s been the most successful model that hasn’t been done by a majority of states?

    Ashley Fox 22:29

    I definitely think that the real time eligibility is a very promising way that states can, for the states that have not yet implemented real time eligibility or not maybe using it to its full capacity. That was one of the ones that we found was the most impactful on uptake. And also, I would say, there has been some other research that’s looked at things like making the application available on a smartphone as opposed to just on a web page. So making it like an app that people can use, so you can save the information. We didn’t actually find in our study that that made a huge impact. But other studies that have done more like case studies of different states that have implemented these approaches, find that, at a minimum people really like to apply that way. So most people are not applying on a laptop, they’re applying on a smartphone. Of course, this varies by different groups of people. So younger people tend to be more comfortable with applying online, more comfortable with using their phones to apply for things. Older adults tend to still like to be able to go to an office to apply. So I think that’s another lesson is that having more different ways for people to apply is what’s really important and not necessarily, entirely moving away from any kind of ability to apply in person, or apply on the phone and only going to online, because that could also burden different types of groups who maybe aren’t as good at technology or could benefit from more of that face-to-face interaction. On the other hand, though, people who are disabled or have children or have other kinds of physical or other limitations, may find it very challenging to have to physically go somewhere. So that ability to apply online or apply on a smartphone can make all the difference. So I think having more and varied different ways to discover that people are eligible and let them know that they’re eligible and then just making it easier for them to enroll, especially without having to produce, at least at the outset, as much documentation of their income and other types of things and relying more on these automated eligibility systems that check people’s income against public records can really help facilitate people getting enrolled.

    Alexander Morse 24:58

    I like what you said about the various approaches being more beneficial to different groups of people, and especially against the backdrop of the COVID recovery, and the fallout from the pandemic, to your point earlier about why Medicaid is important for health prevention for maintaining health costs and just making sure that we have a healthy populace, it makes sense that we’d want to try to reach as many people as efficiently and effectively as we can. So with that…

    Ashley Fox 25:29

    I do have a number of the people that came on to Medicaid during the pandemic. As of July of 2021, 83 million people were enrolled in Medicaid. And that’s an increase of 8 million from before the pandemic.

    Alexander Morse 25:49


    Ashley Fox 25:50

    So there was a big increase of people taking up Medicaid during the pandemic. And I think, I don’t know, but I suspect that that number would have been smaller if the ACA hadn’t made it easier to check and find out if you’re eligible.

    Alexander Morse 26:06

    But I also find interesting is that these lessons don’t have to be strictly limited to Medicaid, they can be applied across different social welfare programs. So what other programs exist that can take a page out of these administrative easings?

    Ashley Fox 26:22

    Yeah, so I think other programs are also taking various initiatives to try to make it easier for people to enroll. SNAP, in particular, has been moving in the direction of…

    Alexander Morse 26:36

    That’s the Supplemental Nutrition Assistance Program.

    Ashley Fox 26:39

    Yes. Sorry, so many acronyms. So SNAP is the Supplemental Nutrition Assistance Program. So it’s basically food assistance. And in some ways, it has easier eligibility rules, I guess. It’s easier to know whether you’re eligible, it’s just a flat 130 percent of the federal poverty level for everybody. But there are different things that states do that make it easier or harder to, beyond income, to really determine whether or not you’re eligible. So, states have been moving in the direction of removing asset tests, for instance, so that you don’t have to prove that you don’t have a certain amount of assets anymore in a number of states. Some states used to do fingerprinting, for instance. And that has been removed in many states to make it less stigmatizing. And in fact, SNAP itself used to be referred to as Food Stamps, and people would have to physically go in, and they would have these physical stamps that they would use to pay for food, which was also very stigmatizing and imposed a lot of psychological burden on people. And so increasingly, states have moved towards using EBT cards, electronic benefit transfer cards, which basically look like a credit card. So when people go up and pay, it’s not like obvious that they’re using food assistance money to pay for their food. So I think SNAP is also moving in the direction of reducing some of the burdens associated with signing up. And also some of the psychological burdens associated with the program. And during the pandemic, I think there was a lot of policy learning as well from these experiences in terms of, for instance, the way that the stimulus checks were delivered to people. So I think there was a recognition that if we need to have people apply and say, “Hey, we need money,” that would be such a costly endeavor on so many fronts. So instead, what the government did was they just looked at people’s tax returns and determined based on that whether they met the very basic income threshold that was determined, and then they automatically deposited the stimulus checks into people’s accounts for people who they had an account on record. For people that don’t have an account on record, there was some additional delays involved because they had to actually track people down, you mailed a check to their address. But I think that’s an example of how we can use a lot of the electronic systems that we have and the information that we have to simplify these procedures and make sure that people are really getting benefits in a timely manner.

    Alexander Morse 29:30

    It’ll be interesting to see what research comes out of this. I’m sure that there’s teams of researchers across the country measuring the different outcomes, health outcomes or social welfare programs based on these changes in rules. Now, what about what opponents might say. They might say that there’s fraud engaged in these social welfare programs. That’s often what you might hear from punditry or from others. And so what are the current levels of fraud in Medicaid or SNAP or other programs? And what is the risk that we might increase the levels of fraud?

    Ashley Fox 30:09

    Yeah, so I think this is a really important point. And I can’t give a specific number to the amount of fraud. But what I can say is that studies have definitely found that fraud is not nearly as much as we might think it would be. It’s a very small percentage of cases. But that in the effort to detect and deter fraud, that states have enacted a lot of policies that have also really discouraged people who are otherwise eligible from signing up. So the way that I talk about this, in my paper, is I talked about this in terms of what we often referred to as type-one error and type-two error. So type-one error, in this instance, would be accidentally giving benefits to people who are in fact not eligible for the program. So that would be fraud. So like type-one error is basically fraud. Whereas, type-two error is tacitly denying eligible participants who are either unable or unwilling to submit the amount of paperwork that they would need to prove their eligibility. So in our effort to deter this type-one error, this fraud, we’ve actually incurred a lot more type-two errors, so missing people who would otherwise be eligible because we’ve made the rules so complicated and so difficult. So I think there is a trade-off between those two that policymakers need to be conscious of. Also, I think, another argument that really both sides are, if you think about for instance, why some people are advocating moving towards a universal basic income, you often get people that are more conservative even favoring that because of the fact that it reduces the need for administrative burden actually, that it reduces the costly administration that goes into determining people’s eligibility. So the more that you have this complex eligibility procedures, the more you have to spend on administration, actually, you have to have lots of caseworkers who are determining whether or not somebody is eligible, that are going through all their records all of the documents that they produce to determine eligibility. If you simplify eligibility, actually, you can reduce some of those administrative costs and save costs that way. So I think there actually is an increasing alignment between people on different sides in terms of at least the cost savings that could come from simplifying those eligibility, which actually, the savings from that might be greater than whatever you’re losing out to in terms of fraud.

    Alexander Morse 32:51

    Well, Professor Fox, really thank you for joining today. This is a really great, informative conversation. I’m going to let you have the last word, is there anything else that you want to cover? Or say before we say goodbye?

    Ashley Fox 33:02

    Yeah, I guess the one thing I will mention is that I recently heard that President Biden signed an executive order on transforming federal customer experience and service delivery to rebuild trust in government. So this is an initiative that’s explicitly aimed at reducing administrative burden in government and that the idea is that it will help to rebuild some trust in government if we can take some of the administrative burden out of it. So administrative burden, I think is an issue that’s getting attention at the highest levels right now.

    Alexander Morse 33:38

    Well, thank you, Professor Fox, we really appreciate your time.

    Ashley Fox 33:41

    Thank you, it’s my pleasure.

    Alexander Morse 33:59

    Thanks again to our guest Professor Ashley Fox, who teaches at the University at Albany’s Rockefeller College of Public Affairs and Policy. If you’d like to learn more about rule reductions and social welfare programs, you can find her paper “Administrative Easing, Rule Reduction, and Medicaid Enrollment” in the Public Administration Review journal. If you liked this episode, please rate subscribe and share. It will help others find the podcast and help us deliver the latest in public policy research. All of our episodes are available for free wherever you stream your podcasts. Special thanks to the Rockefeller Institute staff, Joel Tirado, Heather Trela, and Laura Schultz for their contributions to this episode. Thanks for listening. I’m Alex Morse. Until next time.

    Alexander Morse 36:20

    Policy Outsider is presented by the Rockefeller Institute of Government, the public policy research arm of the State University of New York. The Institute conducts cutting edge nonpartisan public policy research and analysis to inform lasting solutions to the challenges facing New York State and the nation. Learn more at or by following RockefellerInst on social media. Have a question, comment, or idea? Email us at mailto:[email protected].

Policy Outsider

Policy Outsider” from the Rockefeller Institute of Government takes you outside the halls of power to understand how decisions of law and policy shape our everyday lives.

Listen to a full episode archive on Anchor, or subscribe on your preferred podcast platform.