Welfare Reform and Elderly Immigrants' Health Insurance Coverage: The Roles of Federal and State Medicaid Eligibility Rules

Immigrants' access to federally-funded Medicaid became limited after welfare reform imposed restrictive noncitizen eligibility rules. This study used a representative sample from the Current Population Survey (N?=?105,873) and state-level data to examine the effects of these policy changes on elderly immigrants. Triple difference-in-differences analyses show that federal restriction of eligibility had a significantly negative association with elderly immigrants' Medicaid coverage, and generous state eligibility had significantly positive relationships with Medicaid and any health insurance coverage. Findings indicate the important role of eligibility on elderly immigrants' health insurance coverage. Results call for social workers' actions to expand elderly immigrants' Medicaid eligibility.     

Effects of Placement Changes on Health Insurance Stability Among a National Sample of Children in the Child Welfare System

ABSTRACT

Children in the child welfare system have entitlements to health insurance coverage—critical because of their considerable physical and mental health needs—based largely on their placement status. This study conducted path and transitions analyses on data from the National Survey of Child and Adolescent Well-Being (3,801 children followed-up for 3 years) to examine the interplay between placement changes and insurance stability. Children maintained in-home at Wave 1 had significantly lower odds of being insured (OR = 0.7); children transitioning from out-of-home placement to in-home care had significantly lower odds of maintaining insurance coverage (OR = 0.6). Child welfare workers working with children maintained in-home and those being reunified should safeguard the children's insurance status. Policy makers should consider extension of categorical eligibility to all children presenting to child welfare agencies in order to assure access to needed services for these vulnerable children.     

The State Children's Health Insurance Program: Participation and Substitution

We examine the effects of SCHIP enactment by focusing on two policy concerns: take-up and crowd-out. The literature has examined how income eligibility expansions affect the type of children's insurance coverage. However, states jointly implemented various policy instruments. The results in previous works do not control for this variety. We analyze how changes in several SCHIP factors affected decisions regarding health insurance coverage. Our analysis indicates that the estimates in the literature may have combined the effects of various policy factors. In distinguishing individual policy factors, our results provide useful information for designing effective public health insurance programs.     

Obamacare and the Politics of Universal Health Insurance Coverage in the United States

In the USA, universal coverage has long been a key objective of liberal reformers. Yet, despite the enactment of the Patient Protection and Affordable Care Act (PPACA) (commonly known as ‘Obamacare’) in 2010, the USA is not set to provide health care coverage to all, even if and when that reform is fully implemented. This article explores this issue by asking the following question: Why was a clear commitment to universal coverage, the norm in other industrialized countries, excluded as a core objective of the PPACA and how has post‐enactment politics at both the federal and the state level further shaped coverage issues? The analysis traces the issue of universal coverage prior to the debate over the PPACA, during the 2008 presidential race, and during consideration of the bill. The article then looks at the post‐enactment politics of coverage, with a particular focus on how states have responded to the planned use of the Medicaid programme to expand access to care. The article concludes by discussing how an explanation of the limits of the PPACA, in terms of both its commitment to universal coverage and, more importantly, the failure to provide comprehensive health insurance to all, requires an understanding of complex institutional and policy dynamics.     

Adverse Selection,Bequests, Crowding Out,and Private Demand for Insurance: Evidence from the Long-term Care Insurance Market

Adverse selection, moral hazard, and crowding out by public insurance have all been proposed as theoretical reasons for why the market for private long-term care insurance has been slow to evolve in the U.S. Using national samples of the elderly and near elderly, this study investigates which is most important. The data contain direct measures of risk aversion, expectations of future nursing home use and living to old age, and the bequest motive. For both groups, we find evidence of adverse selection, and, for the elderly, crowding out of private long-term care insurance by Medicaid. However, we do not find that demand for such insurance is motivated either by bequest or exchange motives.     

Health insurance coverage of Hispanic adults: An assessment of subgroup difference and the impact of immigration

This research explores the health insurance coverage of various Hispanic subgroups in comparison to non-Hispanic whites and blacks. The impact of immigration status is also considered as we hypothesize that nativity, duration, and naturalization tap a possible process of structural acculturation that increases access to insurance coverage for Hispanic groups. We find that the immigration variables impact the type of insurance reported. However, race/ethnic disparities continue to exist, with the various Hispanic subgroups more likely to report miscellaneous government health insurance or no health insurance coverage as compared to non-Hispanic whites.     

The impact of tax-financed pensions on poverty reduction in Latin America: Evidence from Argentina, Brazil, Chile, Costa Rica and Uruguay

In many Latin American countries, tax-financed pensions (TFPs) have expanded, mainly resulting from growing informalization of employment and stagnating or declining pension insurance coverage. In the five countries examined in this article, TFPs have generally been effective in reducing poverty and indigence. In Brazil rural social assistance pensions cut the incidence of destitution among poor older people by 95 per cent. In Chile TFPs considerably improved their poverty reduction effectiveness between 1990 and 2000. Tax-financed pensions have therefore been seen as an instrument to supplement contributory pension coverage and boost overall social security coverage. A key challenge is to increase pension insurance coverage through existing statutory pension insurance or special contributory schemes targeted on workers in the informal economy. Otherwise, TFPs could become financially and socially unsustainable in the future. There are also various ways to improve the financing, administration and eligibility criteria of TFPs, particularly because it is necessary to define consistent structure and benefit policies between these and contributory schemes.     

Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage

Mongolia achieved high population coverage under mandatory health insurance relatively quickly. This fact was viewed by policy‐ and decision‐makers as a central issue for health financing reform in Mongolia. Health insurance brought many new features for health service planning, provision, funding and resource management. Based on initial achievements, health insurance came to be strategically considered as the vehicle for achieving universal coverage. The article analyses developments in Mongolia's health insurance over the last decade along with the core policy dimensions of Universal Health Coverage. It examines various reform approaches and the numerous amendments to laws that have been implemented during this period and discusses new opportunities as well as challenges. The analytical review and findings discussed suggest that Mongolia has a need for evidence‐based policy decisions and informed political support, with health insurance backed by robust institutional and administrative capacities. More generally, it also emphasizes that health policy goals and objectives can be attained by strengthening and making transparent and publicly‐accountable all health system financing functions and arrangements. The policy analysis, experiences, lessons and proposed strategies presented with regard to Mongolia intend to stimulate wider discussions on health insurance development as well as promote continuing focused research on specific aspects of health insurance and public financing reform.     

Chapter 17. Rural Mental Health

SUMMARY

Mental health services available in many rural communities are too limited in scope and availability to meet the needs of rural citizens. The future of mental health services for the rural poor will be impacted by state government decisions about Medicaid funding priorities. It is important that rural practitioners, especially those that work in the fields of mental health, health, and aging services, engage in advocacy for better coverage of the rural poor and low-income elderly persons. This chapter discusses issues of advocacy related to improving the provision of mental health services to older rural citizens as an important goal in the larger effort to expand and improve rural mental health service delivery throughout the nation.     

Development of Social Health Insurance in Mongolia: Successes, Challenges and Lessons

This paper examines the process of developing social health insurance in Mongolia, and its successes, challenges and lessons. The government of Mongolia introduced social health insurance in 1994, which is compulsory for all public and private sector employees and low-income and vulnerable population groups. The scheme also provided voluntary insurance for unemployed people of working age. About 95 per cent of the population was covered by health insurance within the first two years thanks to a high level of government subsidy for vulnerable population groups. The insurance benefit initially covered nearly all inpatient services except the treatment of some specified chronic and infectious diseases, which were directly funded by the government. The scheme not only had many successes but also faced challenges in maintaining universal coverage. The new financing arrangement has provided little financial incentive for healthcare providers to contain health expenditure, contributing to rapid health cost inflation. In addition to reforming the payment system for providers, there has been an increasing need to expand benefits into ambulatory care. The development of compulsory health insurance in Mongolia shows that a prepaid health insurance mechanism based on risk sharing and fund pooling is feasible in low-income countries given political commitment and government financial support for vulnerable population groups.     

Ensuring equitable access to public health care: Two steps forward,one step back

Advancements by the federal government to extend access to health care to Medicaid eligible populations have been countered by state government efforts to curtail program benefits and eligibility. Fiscally and philosophically-based legislation and Medicaid waivers have created a patchwork of state policies that contradict the original civil rights orientation of the program. This examination of equitable access to Medicaid programs and services reviews individual and community factors and fiscal and institutional barriers that contribute to discriminatory practices and then explores ways in which the Patient Protection and Affordable Care Act (ACA) addresses those issues. We find that the ACA funding authorizations for numerous innovative programs strives to substantially redress issues of discriminatory and inequitable service provision.     

Social Insurance and Older Adults in China: Effect of Education and Household Income on Coverage Following the 2009 Health Reform

Abstract

Education and income have been considered two primary determinants to affect individuals’ health outcomes. China initiated a comprehensive health reform in 2009, with the goals to provide equal access yet sufficient healthcare to all residents. However, social disparities continue to persist following this large reform. This research hypothesized that older adults’ years of education and income are determinants of participation in each social insurance scheme following the 2009 health reform. Multilevel logistic regression models were used with a nationally representative sample (n?=?5,274) to investigate the education and income disparities in each social insurance scheme for older adults, with random effects among provinces at the national level. The analyses show that years of education was not associated with enrollment in three social insurances, with the exception of the association between 11?years of formal education or above and the rural coverage. Participants with higher levels of household income had greater odds of having urban social insurances, but had lower odds of having the rural scheme. Further research should continue to investigate the disparities of enrollment of each social insurance. Chinese policy makers should consider these social factors carefully to reach a true universal coverage.     

Determinants of Household Insurance Coverage Among Low‐Income Families from Boston,Chicago, and San Antonio: Evidence from the Three‐City Study*

Objectives. In this article we examine correlates of health insurance coverage for low‐income households. Methods. Using data from the Welfare, Children, and Families Project (1999–2001), a sample of 2,402 low‐income families from Boston, Chicago, and San Antonio, we estimate two logistic regressions, one that predicts health insurance coverage for one focal child in each household and another that assesses the odds that all children in the household have coverage. Results. The children of poorly‐educated, immigrant, and Mexican‐origin parents are at an elevated risk of lacking insurance. These characteristics also increase the risk of incomplete household coverage. Mexican‐origin children and households are at particularly high risk of lacking complete coverage, a fact partially reflecting their residential concentration in states with high uninsurance rates, such as Texas. Conclusions. Serious holes in the health‐care safety net affect poor Americans differently based on their state of residence, race, ethnicity, and household structure.     

Health care as a social security benefit: Institutional approaches to extending coverage

Reaching universal health‐care coverage requires an appropriate mix of compulsory contributory social insurance schemes, with mechanisms to include the informal‐economy population, and tax‐based social assistance for those whose incomes preclude their own contributions. This article urges a reversal of the trend that favours the separate development of social health insurance by separate health authorities and makes the case for the extension of health‐care coverage using existing formal‐sector social security schemes, not least because they have the necessary political backing and institutional structures. The article reviews reasons for the slow pace of coverage extension to date, and stresses the added value of incorporating health care as a social security benefit while also acknowledging the importance of retaining linkages between statutory and well‐regulated community‐based or micro health‐insurance schemes.     

Party control, policy reforms, and the impact on health insurance coverage in the U.S. states

Objectives. One of the major policy concerns at the federal and state level is the rising number of individuals without health insurance. The purpose of this article is to investigate whether party control of government and various state reforms impact the percentage of the state population without health insurance.Methods. Using data from 1987–2007, I empirically examine whether party control and five state policy reforms reduce the uninsured population.Results. The results show that Republicans are more effective than Democrats at the state level at reducing insurance gaps and that three of five policy reforms explored appear to significantly expand insurance coverage.Conclusions. The results provide valuable insight into which components of health-care reform at the national level may help address the health insurance problem.     

Immigrant households and hardships after welfare reform: a case study of the Miami-Dade Haitian community

Compared with other nations such as Canada and Australia, the US experiment with welfare reform has yielded steeper and more immediate caseload declines. These declines have been especially pronounced for immigrants who have been subject to a new set of service restrictions implemented under the 1996 Welfare Reform Act. This article examines service access for Haitian immigrants in Miami, Florida since the onset of these reforms. The data presented here are derived from a series of qualitative interviews with Haitian service professionals and a quantitative survey of Haitian immigrant households. The survey data indicate that many Haitians who are living in poverty and qualified to access services are not enrolled for government services. Confusion over eligibility guidelines explains some of the variation of these low enrolments for specific services (such as child health insurance and childcare) but not for services most commonly used by immigrant adults such as food stamps and Medicaid. The survey also demonstrates that qualified immigrants living in households with unqualified persons are less likely to access services than are other qualified immigrants and are more likely to experience hardships that impede their ability to find stable employment. The concluding discussion highlights the significance of using a household unit of measure in assessing immigrant enrolments and hardships.     

社会医疗保险对老年人健康水平的影响：基于浙江省的实证研究

本研究根据2010年浙江省城乡老年人口生活状况调查的数据认为,对于老年人的社会医疗保险问题,不仅要关注保险覆盖面的扩大,更应关注不同保险项目参保老人之间的健康平等。在揭示医疗服务使用与健康水平负向关系这一主效应的基础上,研究发现,职工医保作为moderator可以改善使用较多医疗服务老人的健康水平,新农合的作用则相反。研究希望对医疗保险的改革思路进行反思,全民医保的改革思路不仅是医疗服务可及性的提高,更应该是不同社群享有平等的医疗福利,并最终促进健康结果的平等。     

Extension of social insurance coverage to informal economy workers in China: An administrative and institutional perspective

This article reviews administrative issues in the context of decentralized social protection in China. In particular, what are the main obstacles to expanding social insurance coverage for workers in the informal economy? Over the last two decades, China has achieved remarkable progress toward universal social protection when this target was set as a national policy priority. However, the social insurance enrolment of informal economy workers still lags significantly behind. This article reviews the application of the International Labour Organization’s definition of informality in the Chinese context and overviews existing pension and health insurances in China. This article discusses the impact of China’s inter‐governmental fiscal relations and decentralized social protection in the multilevel government system. The article highlights that under a system of decentralized managed social insurance many informal economy workers choose to opt out of the system because of low benefits and high compliance costs. This result in deficits in social insurance coverage amongst informal economy workers.     

The Patient Protection and Affordable Care Act Meets the ‘Persistently Uninsured’

Under the Patient Protection and Affordable Care Act (commonly known as ‘Obamacare’), the national uninsured rate has fallen from 17.3 per cent in 2013 to 11.7 per cent in the first half of 2015. While this is a substantial drop, even accounting for the states that did not expand Medicaid, the remaining double‐digit national rate, as well as higher rates in some states, indicates that a significant minority of Americans are not buying insurance. Researchers have identified a segment of the population with weak or uncertain preferences for health insurance. This article explores how such individuals are unevenly distributed across states and whether cultural preferences relating to time preference and risk aversion underlie the geographic distribution of the ‘persistently uninsured’. It concludes by reviewing the policy implications presented by the presence of numerous health insurance sceptics in certain jurisdictions.