Health insurance coverage after welfare

Health Affairs

Volumn 19, Issue 1, 2000, Pages 175-184

  Garrett, Bowen ^a   Holahan, John ^a  

^a URBAN INSTITUTE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; ARTICLE; CHILD; EMPLOYMENT; EPIDEMIOLOGY; FEMALE; HUMAN; INSURANCE; MEDICAID; PATIENT; POVERTY; QUESTIONNAIRE; REIMBURSEMENT; SOCIAL SECURITY; SOCIOECONOMICS; STATISTICS; UNITED STATES;

ADULT; AID TO FAMILIES WITH DEPENDENT CHILDREN; CHILD; EMPLOYMENT; FEMALE; HEALTH CARE SURVEYS; HUMANS; INSURANCE COVERAGE; INSURANCE, HEALTH, REIMBURSEMENT; MEDICAID; MEDICAL INDIGENCY; MEDICALLY UNINSURED; POVERTY; QUESTIONNAIRES; UNITED STATES; WOMEN, WORKING;

EID: 0037575982     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.19.1.175     Document Type: Article

References (26)

1. U.S. Department of Health and Human Services, Change in Welfare Caseloads as of December 1998 (Washington: DHHS Administration of Children and Families, 1999); M.R. Ellwood and L. Ku, "Welfare and Immigration Reforms: Unintended Side Effects for Medicaid," Health Affairs (May/June 1998): 137-151; and L. Ku and B. Bruen, The Continuing Decline in Medicaid Coverage: 1995-1997, ANF Brief A-37 (Washington: Urban Institute, forthcoming).
2. U.S. Department of Health and Human Services, Change in Welfare Caseloads as of December 1998 (Washington: DHHS Administration of Children and Families, 1999); M.R. Ellwood and L. Ku, "Welfare and Immigration Reforms: Unintended Side Effects for Medicaid," Health Affairs (May/June 1998): 137-151; and L. Ku and B. Bruen, The Continuing Decline in Medicaid Coverage: 1995-1997, ANF Brief A-37 (Washington: Urban Institute, forthcoming).
3. U.S. Department of Health and Human Services, Change in Welfare Caseloads as of December 1998 (Washington: DHHS Administration of Children and Families, 1999); M.R. Ellwood and L. Ku, "Welfare and Immigration Reforms: Unintended Side Effects for Medicaid," Health Affairs (May/June 1998): 137-151; and L. Ku and B. Bruen, The Continuing Decline in Medicaid Coverage: 1995-1997, ANF Brief A-37 (Washington: Urban Institute, forthcoming).
4. Families also are eligible for TMA if they lose welfare because their child-support payments increased. The caretaker is required to report the family's income quarterly and must continue working to remain eligible. PRWORA extended states' obligation to provide TMA until 2001. See J. Kaplan, "Transitional Medicaid Assistance" (Washington: Welfare Information Network, 1997).
5. Federal law requires states to provide Medicaid to children under age six with family incomes below 133 percent of the poverty line, as well as to older children born after 30 September 1983 with family incomes below 100 percent of poverty. In 1997 children between the ages of six and about thirteen with family incomes below the poverty level were eligible for Medicaid. Most states have expanded coverage beyond these minimum requirements.
6. States have the option of lowering the income limits on eligibility to the level that applied 1 May 1988. States also are able to adjust the way countable income is computed for the purposes of determining Medicaid eligibility using the AFDC-based rules. See C. Mann, "An Analysis of the AFDC-Related Medicaid Provisions in the New Welfare Law" (Washington: Center on Budget and Policy Priorities, 19 September 1999). By increasing the amount and types of income that are disregarded, states can expand their Medicaid programs. See J. Guyer and C. Mann, "Taking the Next Step: States Can Now Take Advantage of Federal Medicaid Matching Funds to Expand Health Care Coverage to Low-Income Working Parents" (Washington: Center on Budget and Policy Priorities, 1998).
7. States have the option of lowering the income limits on eligibility to the level that applied 1 May 1988. States also are able to adjust the way countable income is computed for the purposes of determining Medicaid eligibility using the AFDC-based rules. See C. Mann, "An Analysis of the AFDC-Related Medicaid Provisions in the New Welfare Law" (Washington: Center on Budget and Policy Priorities, 19 September 1999). By increasing the amount and types of income that are disregarded, states can expand their Medicaid programs. See J. Guyer and C. Mann, "Taking the Next Step: States Can Now Take Advantage of Federal Medicaid Matching Funds to Expand Health Care Coverage to Low-Income Working Parents" (Washington: Center on Budget and Policy Priorities, 1998).
8. See P. Loprest, How Families That Left Welfare Are Doing: A National Picture, New Federalism: National Survey of America's Families, Series B, no. B-1 (Washington: Urban Institute, August 1999), for a detailed description of the economic circumstances of welfare leavers in the 1997 NSAF, which reports that the median total monthly family earnings of welfare leavers was $1,149, and the median hourly wage was $6.61. See also S. Parrott, "Welfare Recipients Who Find Jobs: What Do We Know about Their Employment and Earnings?" (Washington: Center on Budget and Policy Priorities, 1998).
9. See P. Loprest, How Families That Left Welfare Are Doing: A National Picture, New Federalism: National Survey of America's Families, Series B, no. B-1 (Washington: Urban Institute, August 1999), for a detailed description of the economic circumstances of welfare leavers in the 1997 NSAF, which reports that the median total monthly family earnings of welfare leavers was $1,149, and the median hourly wage was $6.61. See also S. Parrott, "Welfare Recipients Who Find Jobs: What Do We Know about Their Employment and Earnings?" (Washington: Center on Budget and Policy Priorities, 1998).
10. See M. Ellwood and K. Lewis, "On and Off Medicaid: Enrollment Patterns for California and Florida in 1995," Occasional Paper no. 27 (Washington: Urban Institute, 1999).
11. The NSAF was conducted February-November 1997 using computer-assisted telephone interviewing technology. Interviews were conducted in households with and without telephones. Families in households without telephones were interviewed using cellular phones. For more detail, see D.P. Brick et al., 1997 NSAF: Survey Methods and Data Reliability, Methodology Report no. 1 (Washington: Urban Institute, 1999).
12. Ibid.
13. This part of the survey does not probe for state-specific AFDC program names aside from AFDC, or "ADC." The income section of the survey, however, does probe using state-specific AFDC program names in collecting information on the receipt of AFDC payments in the prior year. Because this method captures only fourteen additional families, the effect of not using this probe in the latter part of the survey should be negligible.
14. We exclude men who formerly received welfare from our analysis because there were too few of them to examine separately and because men and women differ, on average, across all of the key variables in this study.
15. Variance estimates are computed using the method of balanced repeated replication (BRR). A description of the BRR method and its application to the NSAF is given in I. Flores-Cervantes, J.M. Brick, and R. DiGaetano, 1997 NSAF Variance Estimation, NSAF Methodology Report no. 4 (Washington: Urban Institute and Child Trends, 1999).
16. For women who formerly received welfare, 2.5 percent had both Medicaid and private coverage and 1.7 percent had both Medicaid and other public coverage. For children who formerly received welfare, 4.3 percent had both Medicaid and private coverage and 0.5 percent had both Medicaid and other public coverage.
17. Even when we limit the sample to women who were working, who should thereby meet the requirements for TMA, only 63 percent who left welfare less than six months ago were on Medicaid.
18. See R. Moffitt and E. Slade, "Health Care Coverage for Children On and Off Welfare," Future of Children (Spring 1997): 87-98, for a national study of the health insurance coverage of women and children who left welfare between 1989 and 1992 using data from the National Longitudinal Survey of Youth. To better compare our results with those reported by Moffitt and Slade, we pooled the first six months and the second six months of the first year from Exhibit 2 to generate an estimate for the entire first year after leaving welfare. Our figures for being uninsured are the most comparable because they are invariant as to whether or not a hierarchy was imposed (we did not impose a hierarchy, but the earlier study did). Despite several differences in the data sources, the results of the two studies are fairly similar. Our results for uninsurance among welfare leavers are somewhat higher than those reported in the earlier study: 36 percent versus 23 percent for women, and 24 percent versus 17 percent for children. This comparison suggests that if there was a change, the problem of uninsurance among former welfare recipients has worsened since the early 1990s.
19. We examined the sources of private coverage for this sample and found that only 7 percent had private coverage that was not sponsored through employ-ment.
20. Loprest, How Families That Left Welfare Are Doing, reports that 61 percent of welfare leavers were working. We find that women were less likely than men were to be employed after leaving welfare; thus our figure, which is restricted to women, is lower. We obtain identical estimates when we do include men in our sample.
21. Of the women who formerly received welfare and were not working, 65 percent had family incomes below the federal poverty level. Of those who were working, 53 percent had family incomes below the federal poverty level.
22. Children who were older than thirteen in 1997 were not all eligible for Medicaid because of the ongoing phase-in for children age six and older with incomes less than 100 percent of poverty. When we limit this analysis to children who are thirteen years old and under, all of whom are Medicaid eligible, only 63 percent had Medicaid.
23. These patterns do not mimic health insurance coverage for low-income persons overall. Comparing the health insurance coverage of former welfare recipients with incomes below 200 percent of poverty to published NSAF results for all nonelderly adults and children below 200 percent of poverty, we find that former welfare recipients are more likely be on Medicaid, less likely to have private insurance, and more likely to be uninsured. See N. Brennan, J. Holahan, and G. Kenney, "Snapshots of America's Families: Health Insurance Coverage of Children" (Washington: Urban Institute, 1999); and S. Zuckerman and N. Brennan, "Snapshots of America's Families: Health Insurance Coverage of Nonelderly Adults" (Washington: Urban Institute, 1999), both available online at www.newfederalism.urban.org/nsaf/health.html.
24. These patterns do not mimic health insurance coverage for low-income persons overall. Comparing the health insurance coverage of former welfare recipients with incomes below 200 percent of poverty to published NSAF results for all nonelderly adults and children below 200 percent of poverty, we find that former welfare recipients are more likely be on Medicaid, less likely to have private insurance, and more likely to be uninsured. See N. Brennan, J. Holahan, and G. Kenney, "Snapshots of America's Families: Health Insurance Coverage of Children" (Washington: Urban Institute, 1999); and S. Zuckerman and N. Brennan, "Snapshots of America's Families: Health Insurance Coverage of Nonelderly Adults" (Washington: Urban Institute, 1999), both available online at www.newfederalism.urban.org/nsaf/health.html.
25. U.S. General Accounting Office, Demographics of Nonenrolled Children Suggest State Outreach Strategies, Pub. no. GAO/HEHS-98-93 (Washington: GAO, 1998).
26. M. Ellwood, "The Medicaid Eligibility Maze: Coverage Expands, But Problems Persist," Occasional Paper no. 30 (Washington: Urban Institute, 1999).