Colorado Medicaid SAVR: A Significant Opportunity to Improve Registration Rates
Continuing to be a leader in secure and efficient elections, Colorado approved automatic voter registration (AVR) for Medicaid enrollment transactions as part of its recent AVR upgrade.1 While full implementation of this system must await approval from the federal Center for Medicaid Services, Medicaid AVR in Colorado represents an exciting opportunity to substantially improve voter registration rates among low-income citizens. Building on Colorado’s use of Secure AVR at motor vehicle offices, Medicaid AVR has the potential to significantly streamline voter registration during Medicaid enrollment, ensuring that the maximum number of eligible citizens are registered to vote or have their registration updated based on information provided during a Medicaid transaction, while also maximally protecting non-citizens from unintentional registration.
Colorado’s SAVR system utilizes existing Medicaid verification procedures, relying on the fact that all Medicaid enrollees have their citizenship status externally verified by the Social Security Administration.2 With SAVR, if an adult Medicaid enrollee is verified as a U.S. citizen as part of the application process, the information needed for voter registration (name, address, date of birth, etc.) is automatically shared with election officials. Election officials use this information to register any unregistered eligible people and to update the information of any existing registered voters. Newly registered or updated voters are sent a mailer informing them of the new registration or update and providing an opportunity to decline.
Medicaid AVR modernizes the current voter registration procedures during Medicaid enrollment transactions. Since 1993, Section 7 of the National Voter Registration Act (NVRA) has required state Medicaid offices to provide enrollees with a voter registration opportunity.3 However, this Section 7 opportunity is far from automatic and relies on the applicant to re-enter all of the information needed for voter registration on separate voter registration forms, requiring extra effort and duplication of information that has already been provided. With Medicaid AVR, Colorado can update this 1993 process for the 21st century, creating a more streamlined process that saves applicants, Medicaid offices, and election officials time and effort, while registering more voters and improving list maintenance.
Data suggests that updating from the current process to Medicaid AVR could lead to a massive increase in the number of Medicaid enrollees whose information is used for voter registration. Only a small percentage of Medicaid enrollees in Colorado are registering to vote under the current system. As discussed more below, we estimate that less than 2.5% of eligible Colorado Medicaid enrollees are registering to vote or updating an existing voter registration as part of a Medicaid application under the existing NVRA Section 7 process. This is known as the “conversion rate” for voter registration, reflecting the share of eligible people offered voter registration who accept the opportunity. Similarly, the current system has an estimated “declination rate” of more than 97.5%, reflecting the share of eligible people offered voter registration who decline.
The conversion and declination rates in a Medicaid AVR system are the exact opposite. At the Colorado DMV, SAVR has a conversion rate of 99%, and a declination rate of only 1%, as the vast majority of newly registered voters choose to stay registered, and only a handful decline by returning the post-transaction mailer.4 By implementing Medicaid AVR, Colorado can move from a clunky, non-integrated system that registers fairly few Medicaid enrollees to a streamlined one that registers nearly all of them.
Estimating the Current Conversion Rate
The conversion rate for the current NVRA Section 7 process at Medicaid is based on the following fraction:
(Valid Voter Registration Forms Received Annually by Colorado Medicaid Offices) /
(Annual Adult Citizen Medicaid Enrollees)
With respect to the numerator, the number of voter registration forms received annually by Colorado Medicaid offices is not publicly reported. Therefore, to estimate this total, we rely on data from the U.S. Election Assistance Commission (EAC). According to the EAC’s 2020 Election Administration and Voting Survey (EAVS), 38,028 voter registration and update forms were filed at Colorado public assistance agencies in the 2020 election cycle.5
Obviously, not all of the 38,028 forms filed at Colorado public assistance agencies were filed as part of Medicaid applications. Public assistance agencies include numerous agencies beyond Medicaid, such as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and the Temporary Assistance for Needy Families (TANF) program.6 However, for purposes of this estimate, and in the absence of data specific to Medicaid, we assume that all of these voter registration forms were filed through Medicaid.
Notably, assuming all of these forms were filed through Medicaid significantly overstates the true number of registration forms received at Medicaid offices. Inflating the denominator in the conversion rate thus makes the conversion rate likely a significant overestimate. However, even using this very generous assumption, the conversion rate at Medicaid is still extremely low.
Of these 38,028 forms, the EAVS data reports that 1,758 were invalid, meaning that an estimated 36,270 valid forms were received by Colorado Medicaid offices over a two-year period from 2019 to 2020. Assuming these forms were split equally across the applicable two-year period, we estimate an annual total of 18,135 people registered or updated through a Colorado Medicaid transaction in 2020.
Moving to the denominator, the number of annual adult citizen Medicaid enrollees in Colorado is similarly not publicly reported. To estimate the number of Medicaid transactions conducted by eligible voters in a given year, we first calculate the total Medicaid adult population in Colorado as of November 2020, which is reported by the Center for Medicaid Services as 842,987.7 Notably, this total excludes Medicaid enrollees who are 16 and 17 years old and eligible for pre-registration. Deflating the denominator in this way also slightly inflates our estimated conversion rate.
We then estimate the share of the adult Medicaid population that are U.S. citizens. Lacking data on this number, we look to national data, as well as the share of Colorado’s population that is non-citizen. In 2020, 7.8% of Americans were non-citizens, while 11.3% of Medicaid enrollees nationally were non-citizen.8 Using this same ratio in Colorado, where 5.7% of the overall population was non-citizen in 2020, implies an 8.26% non-citizen rate among Colorado Medicaid enrollees in 2020. If we assume that 8.26% of Colorado’s 842,987 adult Medicaid enrollees are non-citizens, this results in an estimated adult citizen Medicaid enrollee population in Colorado of 773,376.
Medicaid beneficiaries re-enroll annually, meaning each of these Medicaid enrollees engaged in a Medicaid transaction where they should have been offered voter registration in 2020.9 Out of these 773,376 Medicaid transactions, only 18,135 people submitted a valid voter registration form, implying a conversion rate of 2.34%. As noted, this number is likely a significant over-estimate, meaning the true conversion rate for voter registration during Medicaid transactions is actually substantially lower. The same is true for other years. Using EAVS and Medicaid data for 2018 and 2016 yields a conversion rate of 2.41% for 2018 and a conversion rate of 2.5% for 2016.
Although this estimate is relatively basic, it makes an important point. The current system is registering very few voters, and can be significantly improved upon. This estimate also relies on fairly generous assumptions about the success rate of the current system. Even with these assumptions in place, the current NVRA Section 7 process has a paltry conversion rate of less than 2.5%. With SAVR in place, Colorado can revolutionize this process, moving from a 2.5% conversion rate to a 99% conversion rate for voter registration in Medicaid enrollment.
1. See Colo. Rev. Stat. 1-2-502.5.
2. See Centers for Medicare and Medicaid Services, Federal Data Services Hub (Oct. 2014), https://www.medicaid.gov/state-resource-center/mac-learning-collaboratives/downloads/acct-trnsfr-bsns-serv-def.pdf.
3. 52 U.S.C. 20506(a)(2); U.S. Dept. of Justice, The National Voter Registration Act of 1993, https://www.justice.gov/crt/national-voter-registration-act-1993-nvra.
4. See Justin Grimmer & Jonathan Rodden, Changing the Default: The Impact of Motor-Voter Reform in Colorado (2022), https://www.sos.state.co.us/pubs/newsRoom/pressReleases/2022/CO-AVRAnalysisRoddenGrimmer.pdf.
5. U.S. Election Assistance Commission, Election Administration and Voting Survey (EAVS) Datasets, Codebooks, and Survey Instruments, https://www.eac.gov/research-and-data/datasets-codebooks-and-surveys.
6. U.S. Dept. of Justice, The National Voter Registration Act of 1993, https://www.justice.gov/crt/national-voter-registration-act-1993-nvra.
7. Medicaid.gov, November 2020 Medicaid & CHIP Enrollment Data Highlights, https://web.archive.org/web/20210608001350/https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html#panel1 (842,987 adult Medicaid enrollees calculated by subtracting Total Medicaid Child and CHIP Enrollment (610,397) from Total Medicaid and CHIP Enrollment (1,453,384)).
8. U.S. Elections Project, 2020 November General Election Turnout Rates, https://www.electproject.org/2020g (providing non-citizenship rates nationally and by state);https://www.macpac.gov/wp-content/uploads/2021/12/MACStats-Medicaid-and-CHIP-Data-Book-December-2021.pdf (Exhibit 4, identifying 88.7% of Medicaid and CHIP enrollees as citizens).
9. See Health First Colorado, Renewals FAQ, https://www.healthfirstcolorado.com/renewals/