Factors that Influence Health Care Coverage for Low-Income Populations Under Welfare Reform

1. 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

2. 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 Income eligibility guidelines for adults on medicaid For 2 in family (adult + 1 child) = $1,010 For 3 = $1,272 For 4 +262 for each add�l memberIncome eligibility guidelines for adults on medicaid For 2 in family (adult + 1 child) = $1,010 For 3 = $1,272 For 4 +262 for each add�l member

3. 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)

4. 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 NSAF = National Survey of American Families (1997)NSAF = National Survey of American Families (1997)

5. Medicaid Coverage by Race, Children (US Census, 2000) Native Americans not reported on

6. Uninsured Children in 2000(US Census Bureau)

7. Racial-Ethnic Disparities: Uninsurance in 2002 Comes from 2002 Census Bureau data as analyzed by Center on Budget and Policy Priorities 10.7 = whites 20.2 = African Americans 18.4 = Asians 32.4= Latinos Aizer & Grogger (2003) found than Exapnsions in state Medicaid policies resulted in different results for different racial and ethnic groups. For African American mothers, Medicaid expansion increased by 7% points. For Hispanic mothers, increased by 4.8% points. For whites, mothers were slightly less likely to be covered. These differences were statistically significant Whites = 10.7 uninsured African Americans = 20.2 uninsured Asians = 18.4 uninsured Latinos = 32.4% uninsuredComes from 2002 Census Bureau data as analyzed by Center on Budget and Policy Priorities 10.7 = whites 20.2 = African Americans 18.4 = Asians 32.4= Latinos Aizer & Grogger (2003) found than Exapnsions in state Medicaid policies resulted in different results for different racial and ethnic groups. For African American mothers, Medicaid expansion increased by 7% points. For Hispanic mothers, increased by 4.8% points. For whites, mothers were slightly less likely to be covered. These differences were statistically significant Whites = 10.7 uninsured African Americans = 20.2 uninsured Asians = 18.4 uninsured Latinos = 32.4% uninsured

8. Uninsured Children by Race (US Census Bureau, 2000) Native American Children not reported on in Census statistics

9. 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 43% of non-citizen immigrants uninsured (2003, Center on Budget and Policy Priorities) �Low-income Medicaid Use�� (Wang & Holahan, 2003) Graph - Drop for noncitizens from 1996 to 2000 is from 11.5% to 9.1%. For citizens, drop is less from 12% to 10.6%. From Wang & Holahan, 2003)43% of non-citizen immigrants uninsured (2003, Center on Budget and Policy Priorities) �Low-income Medicaid Use�� (Wang & Holahan, 2003) Graph - Drop for noncitizens from 1996 to 2000 is from 11.5% to 9.1%. For citizens, drop is less from 12% to 10.6%. From Wang & Holahan, 2003)

10. 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 All from a Long & Kendall (2002) study, �Recent changes in health policy for low-income people in Minnesota� in Assessing the New Federalism: State Update (19). Urban InstituteAll from a Long & Kendall (2002) study, �Recent changes in health policy for low-income people in Minnesota� in Assessing the New Federalism: State Update (19). Urban Institute

11. 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 First bullet refers to those under 200% of FPL All from MN DHS (2002). ��Minnesota Family Investment Program Longitudinal Study: Special Report on Health Care Access Among Welfare Leavers 18 Months After Baseline�. First bullet refers to those under 200% of FPL All from MN DHS (2002). ��Minnesota Family Investment Program Longitudinal Study: Special Report on Health Care Access Among Welfare Leavers 18 Months After Baseline�.

12. 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 Second bullet cite is MN DHS (2002). ��Minnesota Family Investment Program Longitudinal Study: Special Report on Health Care Access Among Welfare Leavers 18 Months After Baseline Although the immigrant sample is small, the numbers for people of color were sizable with 82 out of 270. Second bullet cite is MN DHS (2002). ��Minnesota Family Investment Program Longitudinal Study: Special Report on Health Care Access Among Welfare Leavers 18 Months After Baseline Although the immigrant sample is small, the numbers for people of color were sizable with 82 out of 270.

13. 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 Manpower Demonstration Research Corporation (MDRC) did do a 3-year report when MFIP was an experimental program in 7 counties in MN, including Hennepin. When MFIP became a state-wide program, cash assistant became less (or the earned income disregard is less), and there were no time limitsManpower Demonstration Research Corporation (MDRC) did do a 3-year report when MFIP was an experimental program in 7 counties in MN, including Hennepin. When MFIP became a state-wide program, cash assistant became less (or the earned income disregard is less), and there were no time limits

14. 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?

15. 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

16. 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 For most of the report, pooled Hmong, Latino, and Somali into one �immigrant� group. For health care, however, looking closer at each group revealed substantive differences.For most of the report, pooled Hmong, Latino, and Somali into one �immigrant� group. For health care, however, looking closer at each group revealed substantive differences.

17. 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

18. 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 Work defined as paid full-time (35 hours or more a week) or part-time (more than 5 hours per week and less than 35 hours per week) in the paid labor force. Number of hours of work was not as important as status of paid worker, as an extensive worker could have worked 36 months of part-time employment.Work defined as paid full-time (35 hours or more a week) or part-time (more than 5 hours per week and less than 35 hours per week) in the paid labor force. Number of hours of work was not as important as status of paid worker, as an extensive worker could have worked 36 months of part-time employment.

19. 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 71% always had insurance was similar to the MDRC report of 69% of MFIP recipients.71% always had insurance was similar to the MDRC report of 69% of MFIP recipients.

20. Entire Sample (Parents): Coverage Statistics (3,528 months) Medicaid constituted nearly 75% of the months Medicaid + MNCare = 81% of all monthsMedicaid constituted nearly 75% of the months Medicaid + MNCare = 81% of all months

21. Number of Health Care Coverage Episodes For those who were insured the entire time, 43 out of 44 of them were on Medicaid. For the entire sample, Medicaid did the best job of providing continuous careFor those who were insured the entire time, 43 out of 44 of them were on Medicaid. For the entire sample, Medicaid did the best job of providing continuous care

22. Health Insurance Episodes and Uninsurance The more times participants changed health insurance, the more likely they were to have an episode of uninsuranceThe more times participants changed health insurance, the more likely they were to have an episode of uninsurance

23. Uninsurance (Parents) by Worker Type The more one worked, the more likely they were to be uninsured. Statistically significant at the .05 level. The more one worked, the more likely they were to be uninsured. Statistically significant at the .05 level.

24. Children: Uninsurance by Parents� Worker Type (42 month period)

25. Insurance Episodes (Parents) by Worker Type

26. Health Care Coverage by Worker Type (Parents) Medicaid = Medicaid + MNCare (publicly funded programs. MNCare covers only low-income working people). Extensive workers had MNCare 15% of the time (out of the 65% Medicaid presented here), Moderate workers had MNCare 3% of the time (out of the 83% Medicaid presented here), and Minimal workers had MNCare 0% of the time. �Other� category not present (includes SSI, coverage on spouse�s plan). Extensive workers had the most with 4% of coverage this way. Moderate workers had insurance 2% of the months this way, and Minimal workers had no months covered this way.Medicaid = Medicaid + MNCare (publicly funded programs. MNCare covers only low-income working people). Extensive workers had MNCare 15% of the time (out of the 65% Medicaid presented here), Moderate workers had MNCare 3% of the time (out of the 83% Medicaid presented here), and Minimal workers had MNCare 0% of the time. �Other� category not present (includes SSI, coverage on spouse�s plan). Extensive workers had the most with 4% of coverage this way. Moderate workers had insurance 2% of the months this way, and Minimal workers had no months covered this way.

27. 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 Difference among worker types receipt of MFIP are statistically significant at .o5 levelDifference among worker types receipt of MFIP are statistically significant at .o5 level

28. �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. Over time shows that people change insurance due to job changes, income changes, and life changes. May have been off TANF for a while. A year later, how can they be hooked back into Medicaid?Over time shows that people change insurance due to job changes, income changes, and life changes. May have been off TANF for a while. A year later, how can they be hooked back into Medicaid?

29. 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 This was not just the parent, but all four children as well. This respondent worked full-time every month and had another part-time job as well for a year during this time.This was not just the parent, but all four children as well. This respondent worked full-time every month and had another part-time job as well for a year during this time.

30. Uninsurance by Racial and Immigrant Status (Parents) All Hmong, Somali, and Latino participants were immigrantsAll Hmong, Somali, and Latino participants were immigrants

31. Uninsurance by Racial and Immigrant Status (Children)

32. Racial-Ethnic Groups (Parents) by Health Care Coverage Interesting to note that no African Americans had employer insurance. The majority of the 22 African Americans in the study were moderate workers (10) and extensive workers (6). Were also successful in acquiring MNCare. Low uninusurance rate. Whites had the largest percent of employer coverage over time and the largest percent of MNCare coverage. Had a fairly large proportion of the time uninsured. Native Americans were unique in this group of non-immigrants, in that they used no MNCare over the 31/2 years. Of these three groups they had the most months uninsured. Had a fairly high rate of employer insurance, nearly as high as whites. The vast majority of Native Americans were moderate workers (n=10). More successful than whites at using Medicaid.Interesting to note that no African Americans had employer insurance. The majority of the 22 African Americans in the study were moderate workers (10) and extensive workers (6). Were also successful in acquiring MNCare. Low uninusurance rate. Whites had the largest percent of employer coverage over time and the largest percent of MNCare coverage. Had a fairly large proportion of the time uninsured. Native Americans were unique in this group of non-immigrants, in that they used no MNCare over the 31/2 years. Of these three groups they had the most months uninsured. Had a fairly high rate of employer insurance, nearly as high as whites. The vast majority of Native Americans were moderate workers (n=10). More successful than whites at using Medicaid.

33. Immigrant and Racial Groups (Parents) by Health Care Coverage Hmong and Somali spent no time uninsured. Somali totally covered by Medicaid and Hmong covered by Medicaid and Employer insurance. Latinos were by far the most likely to be uninsured of all the racial-ethnic and immigrant groups. They were also the least likely to use Medicaid. The differences between Hmong and Latino employer coverage is striking in that the majority of Hmong respondents were minimal workers (6), with 3 moderate, and 2 extensive workers. Latinos, on the other hand, were extensive workers (5), and moderate workers (5), with only 1 minimal worker. Yet they are less likely to have employer insurance. Latinos and whites had some similarity in that both used all types of coverage and both were successful at using MNCare. Whites had the most employer insurance (followed closely by Native Americans). Latinos were similar in worker types with 5 extensive, 5 moderate, and 1 minimal worker, yet they were much more likely to be uninsured and much less likely to have employer health insurance. Hmong and Somali spent no time uninsured. Somali totally covered by Medicaid and Hmong covered by Medicaid and Employer insurance. Latinos were by far the most likely to be uninsured of all the racial-ethnic and immigrant groups. They were also the least likely to use Medicaid. The differences between Hmong and Latino employer coverage is striking in that the majority of Hmong respondents were minimal workers (6), with 3 moderate, and 2 extensive workers. Latinos, on the other hand, were extensive workers (5), and moderate workers (5), with only 1 minimal worker. Yet they are less likely to have employer insurance. Latinos and whites had some similarity in that both used all types of coverage and both were successful at using MNCare. Whites had the most employer insurance (followed closely by Native Americans). Latinos were similar in worker types with 5 extensive, 5 moderate, and 1 minimal worker, yet they were much more likely to be uninsured and much less likely to have employer health insurance.

34. 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 Worker Type: Our findings corroborated national and state-level findings that MFIP leavers (or extensive workers) are more likely to not have health insurance. Beyond this, though, each level of worker (minimal to moderate to extensive) had progressively less health insurance coverage. This may be linked to episodes of health insurance Our study also supported earlier findings that the delinkage of Medicaid from TANF is likely decreasing coverage for MFIP former, sometimes, and current recipients (especially the first two). However, our focus on work, rather than MFIP receipt demonstrates that low-income workers do not connect work and publicly-funded health care. Our findings might also demonstrate that state-induced lack of coverage periods (4 months to receive MNCare) may play a role. On the other hand, as a person moves from job to job and their incomes and families change, their health care provider often changes. These changes seem to be precarious for continuous health care coverage. Racial-Immigrant Groups distinct patterns not explained by amount worked. For example, African American respondents were constituted of a majority of moderate and extensive workers (16 of 22), but had no employer coverage, while Hmong had a much larger proportion of minimal workers, and yet had some employer coverage. Although Native Americans did successfully use Medicaid, they did not partake in MNCare.Worker Type: Our findings corroborated national and state-level findings that MFIP leavers (or extensive workers) are more likely to not have health insurance. Beyond this, though, each level of worker (minimal to moderate to extensive) had progressively less health insurance coverage. This may be linked to episodes of health insurance Our study also supported earlier findings that the delinkage of Medicaid from TANF is likely decreasing coverage for MFIP former, sometimes, and current recipients (especially the first two). However, our focus on work, rather than MFIP receipt demonstrates that low-income workers do not connect work and publicly-funded health care. Our findings might also demonstrate that state-induced lack of coverage periods (4 months to receive MNCare) may play a role. On the other hand, as a person moves from job to job and their incomes and families change, their health care provider often changes. These changes seem to be precarious for continuous health care coverage. Racial-Immigrant Groups distinct patterns not explained by amount worked. For example, African American respondents were constituted of a majority of moderate and extensive workers (16 of 22), but had no employer coverage, while Hmong had a much larger proportion of minimal workers, and yet had some employer coverage. Although Native Americans did successfully use Medicaid, they did not partake in MNCare.