Most of us have heard for two years how dramatically different Medicaid programs will be under healthcare reform compared to the current system. After hearing a session on Medicaid and health benefits exchange linkages, it's more apparent to me than ever before.

Speaking at the exchange conference as part of America's Health Insurance Plans Institute in Salt Lake City on June 20, three experts painted a picture of a new world order for a significant part of the health insurance landscape.

The Affordable Care Act essentially reorders Medicaid (provided it survives the constitutional test). Rather than being eligible because you're a pregnant mom or disabled, for instance, you'll come into it because of your income level, which will be set at 133 percent of the federal poverty level, or roughly $30,000 a year for a family of four.

Who are those 16 million newly eligible Medicaid beneficiaries? An estimated 60 percent will be aged 19 to 33 and 70 percent will be childless adults. Unlike current Medicaid, which provides few if any enrollment doors for males, new Medicaid will have millions of young men enrolled.

Many of them will have been longtime uninsured, and as a result, will not have had a relationship with a physician. John Kaelin, senior vice president of health reform implementation for UnitedHealthcare, also said a large number of Medicaid and exchange enrollees won't be familiar with insurance terminology such as copays and deductibles.

Kaelin and speakers from Health Management Associates and the Oklahoma Health Care Authority explained to health plans at the conference who they'll be covering come 2014. Besides a lack of health literacy or good health itself, the enrollees also could have widely fluctuating incomes. That means that in one month they could be eligible for receiving a subsidy to enroll in an exchange plan, but by the next they could be eligible for Medicaid, or vice versa.

Joan Henneberry, from HMA, who has been doing work in Colorado, says one of the interesting findings from that state is that 30 percent of the uninsured don't file income tax returns. If that is true elsewhere, it will be a challenge to offer tax subsidies for poor Americans enrolled through exchanges. She also said research in Colorado showed that potential enrollees who are working poor and part of exchanges feel strongly that they not be treated any differently from those who don't get subsidies on the exchanges.

Meanwhile, there are seemingly hundreds of unanswered questions about how exchanges and expanded Medicaid will get off the ground. One big one voiced by Michael Fogarty of Oklahoma's Medicaid program was how states will accomplish online enrollment systems by 2014. He said it took Oklahoma years to develop its online enrollment, but once it did, it was extremely popular. If you build a system, he said, they will come.

Medicaid has been an overcomplicated and bureaucratic program, different in every state. Imagine any other industry enrolling members by paper applications. Henneberry said at least that inadequacy is about to disappear. Regardless of what the Supreme Court does, she said, we're not going back to a paper world.

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