Factors that Influence Health Care Coverage for Low-Income Populations

Under Welfare Reform

Jessica Toft, MSW, University of Minnesota

David Hollister, PhD, University of Minnesota

Mary Martin, PhD, Metro State University

Ji-in Yeo, MSW, University of Minnesota

Center for Advanced Studies in Child Welfare

Medicaid under Personal Responsibility and Work Opportunity Reconciliation Act

(PRWORA)

Apply for TANF and Medicaid separately Expansion of Medicaid

Income and family guidelines only Can work and receive Medicaid

Transitional Medicaid Assistance 6 months Another 6 months if < 185% FPL

Effects of “Delinkage” of Medicaid and TANF

Complicated eligibility rules Dual application procedures In-person interview during working hours Fewer welfare leavers have health care

coverage (Schott & Mann, 1998; Guyer, 2000; Garrett & Holahan, 2000)

Medicaid Coverage Before and After TANF (1995 vs. 1997)

Decline of 10.6% adults on Medicaid (Ku & Bruen, 1999)

1.25 million lost Medicaid Half uninsured in 1997 (Families, USA, 1999)

NSAF survey (Garrett & Holahan, 2000): 64% of parents lost Medicaid 41% became uninsured

Medicaid Coverage by Race, Children (US Census, 2000)

Native Americans not reported on

20.4%

35.8%

17%

32.8%

18.6%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

All Children AfricanAmerican

White Hispanic Asian

Medicaid Coverage

Uninsured Children in 2000(US Census Bureau)

11.60%

21.50%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

All Children Poor Children

Uninsured

Racial-Ethnic Disparities: Uninsurance in 2002

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

White AfricanAmerican

Asians Latinos

Uninsured Children by Race (US Census Bureau, 2000)

Native American Children not reported on in Census statistics

13.6%10.9%

24.9%

14.2%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

AfricanAmerican

White Hispanic Asian

Uninsured

Medicaid and Immigrants

43% of Non-Citizen Immigrants uninsured

Low-income Medicaid Use in 2001 (< 200FPL) 1/3 of citizens 13.2% of non-citizens Substantial increase for

citizens, but not non-citizens 0%

2%

4%

6%

8%

10%

12%

14%

Citizens Non-Citizens

1996

2000

Minnesota and Health Care Coverage

7.5% of adults uninsured (half the national average)

For adults with incomes < 200 FPL, 19.7% uninsurance (US has 34.9%)

Medicaid and MNCare 19.7% of adult coverage vs. 14.7% nationally 275% of FPL

Case of Welfare “Leavers” in Minnesota

Twice as likely as low-income adults to be uninsured

Compared to all adults, 5 times more likely to be uninsured

83% of welfare leavers would have been eligible for Medicaid or MNCare

Case of Racial-Ethnic and Immigrant Groups in MN

Little research in this area in MN MN DHS (2002) reports no significant

association of “race/ethnicity/citizenship” and leavers’ health care coverage Immigrant sample small (n=14) Only considers “leavers”

This finding conflicts with national studies

Gaps in Current Studies

Amount of work and health care coverage not carefully conceptualized

Do not consider work over time (focus on TANF over time) Assumes TANF exit, but not re-entry

Lack of studies considering health insurance over time (cross-sectional or short time periods*)

In Minnesota, lack of research on health care coverage of racial-ethnic and immigrant groups

Research Questions

Has amount of work over time affected health care coverage for low-income populations in

Hennepin County, Minnesota?

How does racial-ethnicity or immigrant status affect health care coverage for low-income

populations in Hennepin County, Minnesota?

Minnesota Family Investment Program (MFIP) Study

The Well-Being of Parents and Children in the Minnesota Family Investment Program in Hennepin County, Minnesota, 1998-2002

University of Minnesota, Center for Advanced Studies in Child Welfare, Center for Urban and Regional Affairs, Hennepin County Economic Assistance Department

Interviewed people who were on welfare at the beginning of MFIP implementation

Considered number of dimensions including health care Full report: http://ssw.che.umn.edu.cascw/cascw_papers

Sample

84 Respondents from County rolls in September, 1998

Random Sample & Oversampling of People of Color and Immigrants 22 African American 23 White 12 Native American 11 Hmong 11 Latino All Immigrants (n = 27) 5 Somali

Methods

Life History Calendar 42-month calendar

(Sept. 1998-Feb. 2002) Work histories MFIP receipt Health care coverage

(when and type) Matched racial-ethnic

and immigrant groups respondents and interviewers

Additional Interview Questions Type of provider most

used Problems with access Health condition Missed care due to cost Citizenship status

Worker Types

42-month Study Period

Extensive Worker (25) = Worked 36-42 months Moderate Worker (42) = Worked 6-35 months Minimal Worker (17) = Worked < 6 months

Work = Paid full-time (35+ hours per week) work and part-time (5-34 hours per week) work

Findings: Entire Sample

42 months x 84 participants = 3,528 months 71% always had health insurance Average uninsured months = 3.7 29% (n=24) uninsured for avg. of 12.9

months

Entire Sample (Parents): Coverage Statistics (3,528 months)

75%

9%

8%6% 2%

Medicaid

Uninsured

Employer

MNCare

Other

Number of Health Care Coverage Episodes

53%

26%

14%4% 2% 1%

1 episode

2 episodes

3 episodes

4 episodes

5 episodes

7 episodes

Health Insurance Episodes and Uninsurance

98%

2%

63%

37%

22%

78%

0%

20%

40%

60%

80%

100%

1episodes

2episodes

3+episodes

Uninsured

Insured

Uninsurance (Parents) by Worker Type

34.4

7.6

39.17

2.83

42

0

05

1015202530354045

Months(42)

Extensive Moderate Minimal

Worker Type Statistically Significant

*p < .05

Uninsured

Insured

Children: Uninsurance by Parents’ Worker Type (42 month period)

5.86

2.10.01

2.57

0

1

2

3

4

5

6

Extensive Moderate Minimal Total

*p < .05

Meannumber ofmonthsuninsured

Insurance Episodes (Parents) by

Worker Type

2.041.71

1.18

0

0.5

1

1.5

2

2.5

Extensive Moderate Minimal

InsuranceEpisodes

Health Care Coverage by Worker Type (Parents)

50%

15%

13%

18%4%

80%

3%8%7%

2%

96%

2% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Extensive Moderate Minimal

Other

None

Employer

MNCare

Medicaid

Average Number of Months Receiving MFIP by Worker Type

Extensive Worker = 10.9 Moderate Worker = 26.3 Minimal Worker = 35.2

The more MFIP one received, the more Medicaid coverage (and insurance in

general) one (parent) had

“Delinkage” of Medicaid from TANF?

Or no sense of a “linkage” between Medicaid and work?

Although TANF and Medicaid linkage may have connected workers and their families with Medicaid initially, not certain how this coverage would have been affected by employment, family and income

changes over time.

An Extensive Worker’s Account of Health Care Coverage:

Parent and Children (Sept. 1998 – April 2002)

Employer = 9 mos. Uninsured = 9 mos. MNCare = 24 mos. Uninsured = 2 mos.

Goes to the free clinic Both she and her kids have chronic health conditions.

Postpones medication due to doctor waiting lists, appointments only during working hours, and prescription expense

Uninsurance by Racial and Immigrant Status (Parents)

96%

4%

92%

8%

91%

9%

100% 100%

65%

35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

AfricanAmerican

White NativeAmerican

Hmong Somali Latino

Uninsured

Insured

Uninsurance by Racial and Immigrant Status (Children)

99%

1%

92%

8%

93%

7%

75%

25%

100% 100%

0%

20%

40%

60%

80%

100%

AfricanAmerican

White NativeAmerican

Latino Hmong Somali

Insured Uninsured

Racial-Ethnic Groups (Parents) by Health Care Coverage

91%

2%7%0%

58%

17%

8%11%

4%

75%

16%

9%0%

0%

20%

40%

60%

80%

100%

AfricanAmericans

Whites NativeAmericans

Other

MNCare

Uninsured

Employer

Medicaid

Immigrant and Racial Groups (Parents) by Health Care Coverage

94%

6%

42%

35%

11%8%4%

100%

0%

20%

40%

60%

80%

100%

Hmong Latinos Somalis

Employer

Other

MNCare

Uninsured

Medicaid

Conclusion: Worker Type and Racial-Immigrant Status Affect Health Care Coverage

Worker Type The more one works,

more likely one and ones’ family to be uninsured

Although “delinkage” important, lack of linkage of Medicaid and work may affect health care over time

Racial-Immigrant Groups Distinct patterns not

successfully explained by amount worked

Certain racial-ethnic groups use publicly-funded programs more successfully