Signed Up with No Say


In California, less than 30% of those who are eligible for both Medicare and Medicaid (dual-eligible) are enrolled in these insurance programs. Residents belonging to this dual-eligible group, both elderly and low-income, are particularly vulnerable. Enrollment is especially low for eligible immigrants, despite anti-immigration rhetoric surrounding their use of public resources.

In a good-faith effort to help more residents enroll and to coordinate their care between Medicare and Medicaid, California developed a managed care program in 2014. The new program, called Cal MediConnect (CMC), automatically enrolled dual-eligible residents from 7 counties, including Los Angeles. Unfortunately, this happened without the consent, sometimes even notification, of consumers. And not everyone who wasn’t previously enrolled in Medicare or Medicaid had been uninsured but instead had private health care plans, and enrollment into the CMC program significantly changed and complicated their treatment options.

Kaitlyn McBride and colleagues spoke directly to some of the automatically enrolled beneficiaries, including both immigrants and US-born residents, to gain insight into their experiences and thoughts on the enrollment process and new program. The interviews uncovered significant problems with the automatic enrollment. Many had profound misgivings over having been enrolled in a health care plan they never agreed to, compounded by negative interactions with program personnel.

Most participants were first notified of their enrollment through a mailed pamphlet with a toll-free number they could call if they had questions. Others never received a mailed notice. Some beneficiaries first found out their coverage had changed when they tried to schedule appointments and were shocked to discover their doctor was no longer covered under the newly integrated plan they didn’t know they had.

Some beneficiaries first found out their coverage had changed when they tried to schedule appointments and were shocked to discover their doctor was no longer covered under the newly integrated plan they didn’t know they had.


Beyond issues with the enrollment process, beneficiaries were largely left in the dark about how to access and use their new health care plan. The mailed notices and website were written in English, making the material especially confusing and inaccessible for some immigrant beneficiaries. Translators were offered when participants called the toll-free phone number, but the wait on hold was long.

Those who made it as far as to speak with someone from the CMC health plan faced intimidation and pushback from personnel if they expressed interest in unenrolling and felt coerced into staying enrolled. One participant shared that when she asked to be unenrolled, CMC employees reached out to a family member to try and persuade her to stay on.

The automatic enrollment frustrated many consumers but was additionally challenging for immigrant beneficiaries who were left feeling disempowered. Immigrant participants appreciated the access to affordable quality care in the US, particularly if they had prior negative experiences with the health care system in their native countries. However, they understandably did not appreciate feeling forced into a health care plan without their consent, especially a publicly funded program they felt stigmatized for using. Many preferred to remain enrolled in their private health care plans if they had the option.

If programs wish to utilize automatic enrollment, there are ways to help the process go more smoothly. Access to community support helped alleviate frustration for beneficiaries. Those who had somewhere to go to ask questions, or designated people whom they could contact with concerns, were more comfortable than those without any connections. Immigrant participants preferred conversation over informational reading material.

Automatic enrollment can be a powerful tool for helping people obtain health insurance. An additional 30,000 children gained coverage through Medicaid when Louisiana implemented automatic enrollment. Maryland recently proposed to automatically enroll eligible residents in a health insurance plan offered through the individual market rather than imposing a penalty for not having insurance. In light of massive unemployment due to Covid-19, health policy experts have recommended automatically enrolling individuals who apply for unemployment benefits into either Medicaid or the individual market.

Making enrollment easier for everyone is a noble endeavor, and there is a time and place for automatic enrollment in that effort. Regardless of time and place, beneficiaries should be involved, informed, and notified every step of the way.

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