“Thank you for calling our free clinic. How can I help you?”
I have spent countless hours listening to the pleas of people in desperate need of medical attention, often with nowhere else to go. Our free clinic in Maryland provides comprehensive care free of cost to those who are uninsured and meet our eligibility criteria. Part of the screening process, though, is determining why someone might be uninsured and helping connect them to other resources that could assist them.
To many, it can be surprising why patients might lack health insurance, especially if they are eligible for state Medicare and/or Medicaid programs on paper. There is an assumption that people act in accordance with their best interest, or as “rational consumers.” In reality, that is not always the case. In my experience, some patients might not know that they are eligible for state services, like a homeless gentleman we helped enroll in Medicaid while we took care of the glass in his foot. Many others have trouble completing their application online or report months later that they never heard updates after its submission. This is not an rare occurrence: a KFF analysis of 2023 data found that almost a quarter of the 25.3 million uninsured adults age 19 to 65 years cited signing up being too difficult or confusing as a top reason for their uninsured status. As a patient once told me: “Everyone expects me to know what to do, but I don’t.”
For those who do submit their applications, other barriers exist. One of our patient’s Medicaid application was escalated three times by the Maryland Health Connection over the span of several months, for no apparent reason, before she received her card. Another patient finally enrolled in community medical assistance on the five-year anniversary of his green card, but his coverage was revoked shortly after because he did not apply to SSI – a requirement that he was never made aware of. The timing of open enrollment periods can also be a barrier for those who fall ill but do not have the option to purchase coverage at that time. (After all, insurance companies would lose a lot of money if people could purchase health insurance only when they get sick.)
The burden of navigating a complex health care system is even greater for older adults. An astonishing August 2024 study by the National Council on Aging found that only 30-49 percent of older adults eligible for cost-saving programs like the Supplemental Nutrition Assistance Program (SNAP), Supplemental Security Income (SSI), and Medicare Savings Programs (MSP) were actually enrolled. This means that 9 million adults eligible for SNAP are not currently receiving benefits, a statistic that contributes to the commonly cited “SNAP Gap.” Shockingly, less than 50 percent of adults eligible for MSP were enrolled, contributing to the unnecessarily high cost of premiums for 5.8 million individuals. Helping patients enroll in these programs at the clinic has helped me understand why so many struggle. The alphabet soup of programs and the offices that administer them can be incredibly confusing. For example: in addition to there being several different types of MSPs (e.g. QMB, SLMB, Extra Help, etc.), patients must already be enrolled in Medicare to apply to these savings programs; thus MSP applications cannot occur at the time of the original Medicare application, adding more steps to the process. Furthermore, QMB and SLMB enrollment typically does not occur through the Social Security Administration (SSA), but rather through each state’s local Medicaid office.
The high demand on the SSA nationally also contributes to the challenges faced by Medicare beneficiaries and dually eligible individuals during enrollment. The agent answer rate (percentage of people who call and successfully get through to an agent) was less than 40 percent by March 2025, and at the time of publication the average wait time for disability applications was 200-230 days. I personally have spent three hours on hold with the SSA to help a patient on dialysis apply to Medicare, only to be told that his zoned SSA location had no available appointments for Medicare enrollment, and that walk-in appointments were also discontinued as of December 2024. He was told that his local SSA office had three days to reach out to him with an appointment. If he missed the call, he would have to call the office back and wait on hold again.
Helping patients through the system
Luckily, the Maryland Health Connection (MHC) offers appointments with health insurance navigators for patients who need additional, one-on-one assistance applying for coverage. Some of the subsidized plans on the marketplace are surprisingly affordable and are available to taxpayers who make too much for Medicaid, including non-US citizens. However, the MHC can only assist patients up to the age of 65. For these potential Medicare beneficiaries in Maryland, the State Health Insurance Program (SHIP) is the volunteer-based organization available to answer questions about Medicare and assist with enrollment. However, it can be difficult to speak with a SHIP counselor to ask questions because there are no live agents. Instead, Medicare applicants receive a call back anytime in the next 2-3 days, with no guarantee of getting connected with someone who can help. A better model could be the New York’s Health Information Counseling and Assistance Program (HIICAP), which answered my call immediately and helps patients apply for Medicare and related programs at their office in person, as opposed to solely mailing the application like the Maryland SHIP program. Lastly, the 1-800-MEDICARE (1-800-633-4227) number is another resource able to review claim denials, enroll patients in a suitable part D plan, and help find providers.
In order to increase health care access, solutions must consider challenges from a behavioral economics lens and recognize how cognitive load – the mental effort required to navigate complex systems – interferes with making optimal health decisions. We saw this tactic employed during the COVID-19 pandemic, when automatic continuous enrollment for Medicaid was implemented to reduce interruptions to insurance coverage during a public health emergency. The Centers for Medicare and Medicaid Services (CMS) has led other efforts to integrate care and ease barriers to Medicare enrollment by automating some parts of the application process for people receiving Supplemental Security Income (SSI) or Medicare’s Part D Low-Income Subsidy (LIS), improving coverage through streamlined enrolment
As the new administration continues to roll out its agenda, though, we must not rely on reform alone to ease barriers to health care access. On the contrary, it is now more important than ever to promote resources that can help connect patients to the programs and services to which they are entitled. In Maryland, the Chesapeake Regional Information System for Patients (CRISP) is a non-profit health information exchange (HIE) providing health systems on an opt-in basis with lists of their patients who will be up for redetermination in the next 90 days. Similar data-sharing models are available and can be explored in other states. At doctors’ offices, attention can be paid to those patients who are about to turn 65 to ensure that they are aware of the open enrollment period for Medicare and any resources available to assist them in navigating the process. In workplaces, employers could suggest that employees inquire about plans on the state marketplace beyond presenting work insurance plans, which can be expensive. While we might not initially realize it, many of us are already choice architects with the power to shape decisions through the way we design and present information. At our clinic, for example, I streamlined our phone tree and updated our lengthy intake paperwork, reducing the number of required signatures and clarifying elements I noticed to be particularly confusing to complete.
A true commitment to social equity requires understanding how real people with limited time, energy, and resources – not just “rational consumers” – actually process and navigate complex health care systems. By working with community partners and learning from patients, we can design smarter processes and more user-friendly systems that ease the path to care for those most vulnerable.
About the author
Noor Al-Saloum is a patient coordinator/executive assistant at a free clinic in Baltimore, Maryland. She has a degree in public health with a focus in economics from Johns Hopkins University.
**Feature photo obtained with a standard license on Shutterstock.
