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

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

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

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

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

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

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

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

14. Research Questions H as amount of work over time affected health care coverage for low-income populations in Hennepin County, Minnesota? H ow 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

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

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

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

21. Number of Health Care Coverage Episodes

22. Health Insurance Episodes and Uninsurance

23. Uninsurance (Parents) by Worker Type

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)

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

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.

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

30. Uninsurance by Racial and Immigrant Status (Parents)

31. Uninsurance by Racial and Immigrant Status (Children)

32. Racial-Ethnic Groups (Parents) by Health Care Coverage

33. Immigrant and Racial Groups (Parents) by Health Care Coverage

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