Running Into the Fire

You know what’s better than a form? Not a form. Which is not a pipe dream—at least not for millions of Medicaid users across 10 states, who had their health coverage renewed automatically post-pandemic without filling out a single piece of paperwork. The process, known as ex parte renewal, had been possible for years under the Affordable Care Act, which allowed Medicaid providers to confirm eligibility using tax and wage data without requiring recipients to resubmit any information. But few states had adopted the practice: by the time Luke Farrell was assigned to tackle the problem, the national ex parte rate was less than 20%.

Time was of the essence. Renewal requirements had been paused during the pandemic, but that ended with the conclusion of the public health emergency, leaving an immediate, three-and-a-half-year backlog of recipients that fell mostly to the states to untangle. Millions stood to lose coverage—not because they weren’t eligible, but because of administrative hurdles, like undelivered mail or disconnected phones. Thankfully, there seemed to be an obvious solution.

“The ex parte renewals were a free silver bullet here that could really help make the process way more efficient,” said Luke Farrell, a senior advisor for technology and delivery on the White House Domestic Policy Council and a product manager at the US Digital Service (USDS).

Luke Farrell: — Running into the fire

The problem was how to do it. It wasn’t that states weren’t interested, but many lacked the in-house technical expertise to create a system to carry out automatic renewals. Others had been stymied by the bureaucratic reality of implementing tech with ties to both state and federal policy. However they worked it out, it was clear that Luke and his team would have to be on the ground in each state. So for a year, that’s what they did—hopped on flights, rented vans, gathered stakeholders together in rooms, and worked through the problem.

“In just about every state we visited, ex parte rates increased by around 20% within a month,” Luke said. “It was just a very manual process. Every state was a little bit different, in terms of what was wrong or what they wanted help with, but it basically worked everywhere, in red states and blue states and everything in between. In the end, we saved state governments nearly $100 million in paperwork processing time, while also cutting 2.5 million hours of paperwork burden for enrollees and caseworkers.”

The Centers for Medicare and Medicaid Services has since begun building an in-house team to continue that work, but because the tech is relatively simple, it can be replicated in a host of other programs. Luke’s team is in the process of implementing a similar system for SNAP benefits, using basically the same method: sitting all the stakeholders around one table, and helping them untangle the knots, one by one.

“The secret sauce is getting a team in the room with states, especially the states that are low-capacity,” Luke said. “You have the caseworkers at the table, you have the engineers at the table, you have the vendors at the table, you have the policymakers at the table, and you get them to align, quickly, on how you’re going to improve implementation of the system. All of these people are never talking to each other, and once you make it easier for them to do it, it works extremely well.”

The project was only Luke’s second since moving from private tech to the public sector, a transition he made during the pandemic in hopes of working on “really existential, hard problems that only government could solve.” Choosing to start that work at a time when all of the problems were existential and hard was a typical move for Luke, who described himself as someone who “always really enjoyed running into the fire.”

“Unfortunately for my well-being, that is my default mode of operating,” he added. “Even when I was at Google, I enjoyed working on crisis projects, and at USDS, that is very much the role — focusing on big crises that are affecting the most vulnerable people. I’ve always found myself very attracted to that, and I think I will continue to look for the firestorm entry.”

FormFest Session Abstract & Details

Reducing Form Burden at the Federal Level

Breakout Session | December 4, 2024 | 12:50-1:50 PMET

Hear from the Department of Homeland Security and the United States Digital Service about their work to reduce form burdens for internal and external users.

The Best Form is No Form: Protecting Health Coverage for Millions of Americans

Luke Farrell

Over the past year, there has been a revolution in how people renew and stay enrolled in Medicaid. USDS partnered with 10 states to keep millions of Americans enrolled in Medicaid with little-to-no burden by using automatic ex parte renewals. This work helped slash over 2.5 million hours of burdensome paper forms for over 5 million Americans, lowered the burden on state caseworkers, and even saved state governments millions of dollars. This presentation (potentially featuring State Leaders) will discuss how we achieved these results, challenges state implementers have run into, what tools states have at their disposal, and chart the course for what staying enrolled in critical benefits – without forms – could look like in the future.