Restrictiveness of Eligibility Determination and Medicaid Enrollment by Low-Income Seniors

Medicaid is an important source of supplemental health care coverage for low-income seniors, yet little is known about the effect of state policy on Medicaid enrollment by eligible elderly. Data from a nationally representative survey were used to examine Medicaid enrollment by elderly, low-income Medicare beneficiaries living in states that liberalize or restrict Medicaid eligibility criteria using the 1986 Omnibus Budget Reconciliation Act or provision 209(b) of the 1972 Social Security Act Amendment, respectively. Controlling for demographics and health status, residence in states applying these laws was significantly, though modestly, associated with Medicaid enrollment. Additionally, 73% of eligible elderly Medicare beneficiaries were not enrolled in Medicaid, and most have serious chronic health problems. These findings suggest that a significant number of eligible elderly are not enrolled in Medicaid and that liberalizing or tightening Medicaid eligibility criteria can have an impact on Medicaid enrollment by low-income elderly patients.     

ENHANCED CITIZENSHIP VERIFICATION AND CHILDREN'S MEDICAID COVERAGE

This article examines a potential unintended consequence of the mandated Medicaid citizenship verification requirements of the 2005 Deficit Reduction Act (DRA). We investigate whether or not these new rules led to an increase in the Medicaid exit rate among enrollees using state administrative data from Georgia. We do this by comparing the exit rate for children enrolled in Medicaid whose first coverage recertification occurs just after implementation of the DRA (which we refer to as a “high impact” first recertification) with those whose first recertification occurs just prior (which we refer to as a “low impact” first recertification). Our analysis suggests that children in the high‐impact first recertification group were about 2 percentage points more likely to exit Medicaid than those in the low‐impact group. Furthermore, these additional exits occurred in racial and ethnic groups more likely to be citizens than noncitizens and prereform estimates suggest that there were very few (roughly 0.10%) noncitizen Medicaid enrollees to begin with. Taken together, our results suggest that the DRA‐enhanced citizenship verification rules led to an increase in Medicaid disenrollment, and thus a reduction in coverage, among citizens. (JEL I18, I38, J13)     

Social Capital and Community Supportsfor Low Income Families

Abstract

The Personal Responsibility, Work Opportunity and Medicaid Restructuring Act of 1996 changed welfare dramatically. This article explores the concept of social capital, illustrating how social and cultural capital are important factors that make the difference between persistent and temporary poverty. Through research in Wisconsin and Philadelphia, this article shows that social capital provides both barrier and bridge to families trying to survive in a changed policy context. However, just as programs focusing exclusively on work experience, developing human capital, or providing additional income fail to produce results for everyone on public assistance, programs concentrating exclusively on social or cultural capital are also doomed to failure.     

Stuck in a Loop: Individual and System Barriers for Job Seekers With Disabilities

Research conducted within Temporary Assistance to Needy Families (Personal Responsibility and Work Opportunity Reconciliation Act of 1996) and Workforce Investment Act of 1998 systems indicates pervasive issues hindering program effectiveness for job seekers with disabilities. This population frequently experiences employment barriers beyond those of able‐bodied job seekers, including significantly lower self‐esteem. Service providers need and want information about disability but do not know how to obtain it. Program staff and job seekers with disabilities get stuck in a loop wherein each questions their ability and neither feels empowered to make meaningful changes to improve outcomes. Career counselors may need to expand their role to be more culturally relevant for these clients.     

Explaining the Decline in Women's Household Labor: Individual Change and Cohort Differences

Women's hours of housework have declined, but does this change represent shifts in the behavior of individuals or differences across cohorts? Using data from the National Longitudinal Surveys, individual and cohort change in housework are examined over a 13‐year period. Responsibility for household tasks declined 10% from 1974–75 to 1987–88. For individual women, changes in housework are associated with life course shifts in time availability as well as with changes in gender attitudes and marital status, but are not related to changes in relative earnings. Cohort differences exist in responsibility for housework in the mid‐1970s and they persist over the 13‐year period. Overall, these findings suggest that aggregate changes in women's household labor reflect both individual change and cohort differences.     

The Affordable Care Act,Dependent Health Insurance Coverage,and Young Adults' Health

This study examines the consequences of the Patient Protection and Affordable Care Act (ACA) dependent coverage provision for the health of U.S. young adults aged\–25. Using data from the Current Population Survey—March Supplement for the years 2007–2012 and ordered logistic regression analyses, we examine self‐rated health and its association with dependent health insurance coverage for 19‐ to 25‐year‐olds and a comparison group of 28‐ to 34‐year‐olds before and after implementation of the ACA. Compared to 28‐ to 34‐year‐olds, results indicate the post‐ACA period (2010–2011) is associated with increased access to dependent health insurance coverage and improved health for young adults aged 19–25 relative to the period before implementation (2008–2009). More than half of the difference in health improvement across age groups can be attributed to changes in dependent coverage. These results are the first to demonstrate a positive health benefit resulting from the implementation of the ACA.     

Elders with Serious Mental Illness: Lost Opportunities and New Policy Options

This article reviews key federal Medicaid policies affecting older adults with serious, long-term mental illness: (a) the Medicaid exclusion of coverage for Institutions for Mental Diseases, (b) the Preadmission Screening and Resident Review Process, and (c) the Medicaid Home and Community Based Services waiver policy. Documenting the incentives and restrictions in these policies provides an historical context for understanding the current gaps in treatment for elders with mental illness. New federal options under the Deficit Reduction Act may provide opportunities for reducing the institutional bias for older adults with mental illness and for improving mental health services for elders under Medicaid.     

Modeling the Impact of the Affordable Care Act and the Individual Mandate on Californians

The Patient Protection and Affordable Care Act (ACA) was designed to provide health insurance to uninsured or underinsured individuals. We used the California Simulation of Insurance Markets (CalSIM) model to predict the experience of consumers in California, who will be faced with new insurance options through Medicaid, employer-sponsored insurance, and the individual market in 2014 and beyond. We explored the response and characteristics of Californians who will and will not secure insurance coverage, with and without the “individual mandate” or minimum coverage requirement (MCR). We found 1.8 million Californians (38 %) of the 4.7 million eligible uninsured will secure coverage by 2019 with the MCR, while only 839,000 (18 % of the eligible uninsured) would obtain coverage without it.     

VA Staff Perceptions of Barriers and Facilitators to Home-and Community-Based Placement Post–Hospital Discharge

This study identifies factors U.S. Department of Veterans Affairs (VA) staff perceived to promote or impede home- and community-based services (HCBS) placement post–hospital discharge among Veterans cared for within the VA. Data derive from 35 semi-structured interviews with staff from 12 VA medical centers from around the country. VA staff reported that Veteran’s care needs and social and financial resources influence HCBS placement. They also reported prerequisites for successful placement, including housing, unpaid informal care, and non-VA services funded privately and by public programs such as Medicaid and the Older Americans Act. Lack of staffing and failure to offer the specific types of services needed limit referral to and use of HCBS. Budgetary imperatives influence the relative availability of HCBS across VA medical centers. Findings highlight patient-, provider-, and system-level constraints that impede successful placement at home and in the community of Veterans in need of long-term services and supports after hospitalization.     

The More Things Change the More They Stay the Same: Mexican Naturalization before and after Welfare Reform1

During the last decade there has been a dramatic increase in the both the number and the rate of Mexican naturalization. Some have interpreted this increase as a response to changes in welfare and immigration policy surrounding the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), which limited public assistance to non‐citizens, and the 1996 Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA), which may have increased the incentive to naturalize by making it more difficult for legal immigrants to sponsor their relatives for entry to the United States. This article uses Current Population Survey data from 1994/95 and 2000/01 to examine how the social and economic determinants of naturalization may have changed in order to provide insight into which explanation for the increase in naturalizations is most relevant. We find that while the proportion of Mexican immigrants who are naturalized increased during the 1990s, their determinants have remained largely the same with the exception that those with noncitizen spouses have become more likely to be naturalized in the post‐reform period. This suggests that a more cautious interpretation be taken about the relationship between the increase in naturalizations and welfare and sponsorship restrictions, particularly when regarding Mexican immigrants.     

Sources of health insurance and characteristics of the uninsured: analysis of the March 2000 Current Population Survey

This Issue Brief provides summary data on the insured and uninsured populations in the nation and in each state. It discusses the characteristics most closely related to an individual's health insurance status. Based on EBRI estimates from the March 2000 Current Population Survey (CPS), it represents 1999 data--the most recent available. In 1999, for the first time since at least 1987, the percentage of Americans with health insurance increased: 82.5 percent of nonelderly Americans (under age 65) were covered by some form of health insurance, up from 81.6 percent in 1998. The percentage of nonelderly Americans without health insurance coverage declined from 18.4 percent in 1998 to 17.5 percent in 1999. The main reason for the decline in the number of uninsured Americans is the strong economy and low unemployment. Between 1998 and 1999, the percentage of nonelderly Americans covered by employment-based health insurance increased from 64.9 percent to 65.8 percent, continuing a longer-term trend that started between 1993 and 1994. In 1999, 34.1 million Americans received health insurance from public programs, and an additional 15.8 million purchased it directly from an insurer. Twenty-five million Americans participated in the Medicaid program, and 6.5 million received their health insurance through the Tricare and CHAMPVA programs and other government programs designed to provide coverage for retired military members and their families. Despite expansions in the State Children's Health Insurance Program (S-CHIP), public health insurance coverage did not increase overall between 1998 and 1999. The percentage of nonelderly Americans covered by Medicaid and other government-sponsored health insurance coverage did not change between 1998 and 1999, though some children benefited from expansions in government-funded programs. The percentage of children in families just above the poverty level without health insurance coverage declined dramatically, from 27.2 percent uninsured in 1998 to 19.7 percent uninsured in 1999. Some of the decline can be attributed to expansions in Medicaid and S-CHIP, but it appears that expansions in employment-based health insurance and individually purchased coverage had an even larger effect than expansion of S-CHIP. Even though the number and percentage of uninsured declined substantially between 1998 and 1999, more than 42 million Americans remain uninsured. As long as the economy is strong and unemployment is low, employment-based health insurance coverage will expand and the uninsured will decline gradually. If the economy continues to soften or comes close to a recession, the number of uninsured would easily and quickly start to increase again as unemployment rises. Should a severe downturn in the economy occur, causing the uninsured to represent 25 percent of the nonelderly population, 63 million Americans would be uninsured.     

The courts and elective abortions under Medicaid.

Although therapeutic or elective abortions are among the most frequently performed medical procedures for women throughout the world, indigent American women are now denied coverage under the Medicaid program because of the Hyde Amendment, which prohibits the use of federal funds for the termination of pregnancies except in narrowly defined cases. The vast majority of states, left free to choose as to the expenditure of their own funds for abortion coverage, have also denied this type of welfare assistance to economically eligible women. The discriminatory effect of the refusal to subsume abortions as part of the Medicaid mandate has been the subject of various legal actions. The constitutionality of that denial is at issue and now awaits Supreme Court determination.     

Welfare‐to‐Work Reform and Intergenerational Support: Grandmothers' Response to the 1996 PRWORA

The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA; Pub. L. 104‐193) in the United States aimed at encouraging work among low‐income mothers with children below age 18. In this study, the author used a sample of 2,843 intergenerational family observations from the Health and Retirement Study to estimate the effects of the reform on single grandmothers who are related to those mothers. The results suggest that the reform decreased time transfers but increased money transfers from grandmothers. The results are consistent with an intergenerational family support network where higher child care subsidies motivated the family to shift away from grandmother provided child care and where grandmothers increased money transfers to either help cover the remaining cost of formal care or to partly compensate for the loss in benefits of welfare leavers.     

Orphanhood and Completion of Compulsory School Education Among Young People in South Africa: Findings From a National Representative Survey

We examined the association of orphanhood and completion of compulsory school education among young people in South Africa. In South Africa, school attendance is compulsory through grade 9, which should be completed before age 16. However, family and social factors such as orphanhood and poverty can hinder educational attainment. Participants were 10,452 16–24‐year‐olds who completed a South African national representative household survey. Overall, 23% had not completed compulsory school levels. In univariate analyses, school completion was lower among those who had experienced orphanhood during school‐age years, males, and those who reported household poverty. In multivariate analyses controlling for household poverty, females who had experienced maternal or paternal orphanhood were less likely to have completed school; orphanhood was not independently associated with males' school completion. Findings highlight the need for evidence‐informed policies to address the education and social welfare needs of orphans and vulnerable youth, particularly females, in South Africa.     

Family structure and child health outcomes in the United States

We use categorical and logistic regression models to investigate the extent that family structure affects children’s health outcomes at age five (i.e., child’s type of health insurance coverage, the use of a routine medical doctor, and report of being in excellent health) using a sample of 4,898 children from the "Fragile Families and Child Well-Being Study." We find that children with married biological parents are most likely to have private health insurance compared with each of three other relationship statuses. With each additional child in the home, a child is less likely to have private insurance compared with no insurance and Medicaid insurance. Children with cohabiting biological parents are less likely to have a routine doctor compared with children of married biological parents, yet having additional children in the household is not associated with having a routine doctor. Children with biological parents who are not romantically involved and those with additional children in the household are less likely to be in excellent health, all else being equal.     

Expanding health insurance for children: examining the alternatives

This Issue Brief examines the issue of uninsured children. The budget reconciliation legislation currently under congressional consideration earmarks $16 billion for new initiatives to provide health insurance coverage to approximately 5 million of the 10 million uninsured children during the next five years. Proposals to expand coverage among children include the use of tax credits, subsidies, vouchers, Medicaid program expansion, and expansion of state programs. However, these proposals do not address the decline in employment-based health insurance coverage--the underlying cause of the lack of coverage, to the extent that a cause can be identified. What is worse, some proposals to expand health insurance among children may discourage employers from offering coverage. Between 1987 and 1995, the percentage of children with employment-based health insurance declined from 66.7 percent to 58.6 percent. Despite this trend, the percentage of children without any form of health insurance coverage barely increased. In 1987, 13.1 percent were uninsured, compared with 13.8 percent in 1995. Medicaid program expansions helped to alleviate the effects of the decline in employment-based health insurance coverage among children and the potential increase in the number of uninsured children. Between 1987 and 1995, the percentage of children enrolled in the Medicaid program increased from 15.5 percent to 23.2 percent. Some questions to consider in assessing approaches to improving children's health insurance coverage include the following: If the government intervenes, should it do so through a compulsory mechanism or a voluntary system? Is the employment-based system "worth saving" for children? In other words, are the market interventions necessary to keep this system functioning for children too regulatory, too intrusive, and too cumbersome to be practical? In addition to reforming the employment-based system, what reforms are necessary in order to reach those families who have no coverage through the work place? Which approaches are both efficient and politically acceptable? Employment-based coverage of children will likely continue. The challenge for lawmakers is to find a way to cover more uninsured children without eroding employment-based coverage. Several current legislative proposals attempt to avoid this problem by excluding children who have access to employment-based coverage. Without such a requirement, the opportunity to purchase coverage at a discount would create incentives for some low-income employees to drop dependent/family coverage, which in turn could lead some employers to drop their health plans.     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.