Eligible and Uninsured: Childless Adults Preliminary Results Funded by The United Hospital Fund through a grant to the National Center for Law and Economic Justice By Aviva Goldstein, Consultant

Profile of Target Population: 33% of uninsured adults are eligible for public health insurance; 650,000 adults are eligible for public programs and not enrolled; Uninsured eligible adults: –70% are childless –Over 50% are young adults (19-35) –57% have good or excellent health 57% of childless adults are men

Goals: Improve understanding of why this population is uninsured; Identify strategies that would improve enrollment; Identify policy changes that would improve enrollment; Identify areas for further research (both quantitative and qualitative).

Methodology 23 Key Informant Interviews:  17 case workers and/or case work supervisors who talk to target population about health insurance;  9 Facilitated Enrollers and/or FE supervisors (2 Plan- based);  4 Policy leaders who gather experiences of case workers for organization;  4 groups that serve homeless, 8 that serve low income and immigrants; 2 that serve ex-offenders; 1 that serves HIV+, 2 that serve students at community colleges. NB: not mutually exclusive categories

Methodology, cont. 8 Focus Groups (7 completed to date). Profile of Participants:  52 Total; all recruited through a CBO  11 had health insurance but were recently eligible and not enrolled; 31 did not have health insurance; information not available for 12  48 men; 4 women  8 did not speak English as a first language; 5 required a translator to Spanish  4 were homeless  12 were ex-offenders  19 were non-custodial fathers

Methodology, cont’ Consulted with: –Staff at United Hospital Fund –Advocates for Medicaid consumers –Representative of Prepaid Health Service Plans –Representatives of Facilitated Enrollers –Staff at National Center for Law and Economic Justice –Staff at NYS Department of Health, Division of Coverage and Enrollment

Results: slim range of eligibility Slim range of eligibility (confirmed in both FG and KI): Consumers are not aware of eligibility; assume ineligibility; Consumers assume program is for children and families (FHP);

Results: slim range of eligibility Fluctuating income actually makes them intermittently eligible; Fear of accusation of fraud and/or recoveries; Often in less formal employment and so documentation of income is difficult.

Focus Group Participants: “Ninety-nine point ninety-nine percent I’m going to be denied.” “I spend x amount of time attempting it and then I find out that either I don’t qualify or for some reason they feel that I’m not a good candidate for it. So after a while you just get jaded and you don’t want to deal with it unless it’s an emergency.” “Basically it’s because we’re individual males... I know that it seems like real humanitarian to go out and help the women and children first but when it comes down to it we can’t [work] because we’re sick. If I got diabetes and my teeth are falling out, eventually I’m not going to be able to work so guess who is going to be getting money for nothing – me…so basically you’re going to paying me for doing nothing when you could’ve just help me take care of my health.”

Results: Extremely low income Low income associated with eligibility (reported by both KI, FG): More likely to have other urgent priorities (housing, job, etc.) Closely associate enrollment with HRA offices (often eligible for other benefits and need to use these offices)

Results: Application barriers Other Barriers common for all consumers (mostly reported by KI): Complex process Documentation (income, birth certificates) Recertification letters go missing or misunderstood

Results: Attitudes Key Informants reported: Young prioritize health insurance less; Ability to use Emergency Dept. or get low- cost care may deter applications; Immigrants fear repercussions; Frustrations with the system; often after bad experiences

Results: Attitudes, cont. The complaints they get about the quality of care in Medicaid are minor and that most consumers consider Medicaid to be “golden;” Stigma only for people newly eligible (recently lost jobs).

Results: Attitudes Focus Group Participants Report that they: value health insurance; value it more as they get older and/or sick; feel discouraged by failed attempts to apply; avoid HRA offices, “the system;” fear repercussions (sponsor deeming, recovery, accusation of fraud); do feel a stigma; and do wonder about quality of Medicaid.

Focus group participants: "I think [health insurance] is very important. I’m in my forties. So I have to worry about prostate, high blood pressure. Diabetes runs in my family.” "It has a really big importance because one expense less you have to worry about if you get health insurance." “…and when they slip up and get caught out there then they got to pay it back.”

Focus Group Participants: “Waited for 6 hours. Staff (HRA office) can be rude. They're agitated, like they don't want to be there themselves. People are agitated. Snippy. You kind of figure that's how it's going to be at government offices. It's just going to be rude. Hostile. You don't want to take the time out to go and be in that environment.” “ Because it’s like being in court, being in jail and they’re giving you nothing. If you make something they’re going to tax you. So it’s not really helping you to lend you something so that when you get something they take it away … "

Focus Group Participants: “Now it’s almost embarrassing I need Food Stamps and Medicaid. You know. It’s a weird feeling because you don’t imagine yourself in that office.” “But you have to bite the bullet though.” “The card doesn't say Medicaid anymore. Does that make it, you feel better?"

Preliminary Recommendations Publicize that public health insurance is available to childless adults. Publicize the importance of health insurance (e.g,, similar to NYC’s anti-smoking campaign), specifically for adults. Enhance targeting of childless adults (location of FEs; mission of FEs); Make better use of available electronic documentation (such as New York City’s HHS Connect System’s Data Repository).

Prelim. Recommendations, cont. To address people’s fears (losing coverage; being pursued for fraud or recoveries; sponsor deeming): –Train FEs, case workers, social workers about how to identify and reach potentially eligible childless adults (clarify rules on income variation; sponsor deeming; recoveries; etc.); –Continue advocacy on the federal level for continuous eligibility for one year.

Prelim. Recommendations, cont. Create a buy-in option for Family Health Plus comparable to buy-in for Child Health Plus Aviva Goldstein Public Health and Nonprofit Consulting