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Factors that Influence Health Care Coverage for Low-Income .ppt

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									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)
    40.00%
    35.00%
    30.00%
    25.00%
    20.00%                    35.8%               32.8%
    15.00%
                 20.4%                                     18.6%
    10.00%                              17%
     5.00%
     0.00%
             All Children    African   White    Hispanic   Asian
                            American


                                  Medicaid Coverage
 Native Americans not reported on
     Uninsured Children in 2000
        (US Census Bureau)

25.00%

20.00%

15.00%
                            21.50%
10.00%
            11.60%                      Uninsured
5.00%

0.00%
         All Children   Poor Children
         Racial-Ethnic Disparities:
           Uninsurance in 2002
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
         White    African   Asians   Latinos
                 American
            Uninsured Children by Race
                 (US Census Bureau, 2000)

   25.00%


   20.00%

   15.00%
                                    24.9%
   10.00%                                                         Uninsured
               13.6%                           14.2%
                        10.9%
    5.00%

    0.00%
              African   White     Hispanic    Asian
             American

 Native American Children not reported on in Census statistics
           Medicaid and Immigrants

 43% of Non-Citizen
                                  14%
  Immigrants uninsured
                                  12%
 Low-income Medicaid
                                  10%
  Use in 2001 (< 200FPL)
                                  8%
      1/3 of citizens
                                  6%                      1996
      13.2% of non-citizens                              2000
                                  4%
      Substantial increase for
       citizens, but not non-     2%
       citizens                   0%
                                    Citizens    Non-
                                               Citizens
               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          Additional Interview
      42-month calendar          Questions
       (Sept. 1998-Feb. 2002)
                                      Type of provider most
      Work histories                  used
      MFIP receipt
                                      Problems with access
      Health care coverage
       (when and type)                Health condition
      Matched racial-ethnic          Missed care due to cost
       and immigrant groups           Citizenship status
       respondents and
       interviewers
                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)


           6%   2%
      8%
                                  Medicaid
9%                                Uninsured
                                  Employer
                                  MNCare
                                  Other
                        75%
      Number of Health Care
       Coverage Episodes

        4%   2% 1%
                             1 episode
14%
                             2 episodes
                             3 episodes
                             4 episodes
                             5 episodes
                       53%
                             7 episodes
26%
 Health Insurance Episodes and
          Uninsurance

100%      2%

80%               37%

60%                        78%
         98%
40%               63%
20%                                 Uninsured
                           22%
 0%                                 Insured
           1        2       3+
       episodes episodes episodes
      Uninsurance (Parents) by
           Worker Type
        45                            0
        40      7.6      2.83
        35
        30
M onths 25
  (42)  20              39.17        42
               34.4
        15                                  Uninsured
        10
         5                                  Insured
         0
             Extensive Moderate   Minimal
                   Worker Type
               Statistically Significant
                       *p < .05
    Children: Uninsurance by Parents’
     Worker Type (42 month period)

6
5
4
3      5.86
                                                Mean
                                                number of
2                                               months
                                        2.57
                   2.1                          uninsured
1                                0.01

0
    Extensive   Moderate     Minimal    Total

                      *p < .05
Insurance Episodes (Parents) by
         Worker Type

 2.5

  2

 1.5
                                        Insurance
          2.04                          Episodes
  1                   1.71
                                1.18
 0.5

  0
       Extensive   Moderate   Minimal
        Health Care Coverage by
         Worker Type (Parents)

           4%            2%              2%
100%                    7%    2%
 90%      18%           8%
 80%               3%
          13%
 70%                                          Other
 60%      15%                                 None
 50%                               96%        Employer
 40%
                      80%
                                              MNCare
 30%      50%                                 Medicaid
 20%
 10%
  0%
       Extensive   Moderate    Minimal
   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)
100%      4%       8%        9%
90%
                                                       35%
80%
70%
60%
50%      96%                         100%     100%             Uninsured
                   92%      91%
40%                                                            Insured
                                                       65%
30%
20%
10%
 0%
        African   White    Native    Hmong   Somali   Latino
       American           American
    Uninsurance by Racial and
   Immigrant Status (Children)

100%      1%
                    8%       7%
                                      25%
80%

60%
         99%       92%       93%               100%    100%
40%                                   75%

20%

 0%
        African   White    Native    Latino   Hmong   Somali
       American           American


                   Insured      Uninsured
 Racial-Ethnic Groups (Parents)
   by Health Care Coverage
             0%       4%         0%
100%        7%                  9%
       2%            11%
                     8%         16%
80%
                     17%                Other
60%                                     MNCare
            91%
40%                             75%     Uninsured
                     58%
                                        Employer
20%
                                        Medicaid
 0%
        African    Whites    Native
       Americans            Americans
         Immigrant and Racial Groups
       (Parents) by Health Care Coverage


                     4%
100%       6%
                    8%
                    11%
80%                                   Employer
                    35%               Other
60%                          100%
           94%                        MNCare
40%                                   Uninsured
                    42%               Medicaid
20%
 0%
         Hmong   Latinos   Somalis
        Conclusion: Worker Type and Racial-
     Immigrant Status Affect Health Care Coverage


Worker Type              Racial-Immigrant Groups
 The more one works,  Distinct patterns not
  more likely one and     successfully explained by
  ones’ family to be      amount worked
  uninsured              Certain racial-ethnic groups
 Although “delinkage”    use publicly-funded
  important, lack of      programs more successfully
  linkage of Medicaid
  and work may affect
  health care over time

								
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