Monitoring Outcomes for Former Welfare Recipients: A Review of 11 Survey Instruments. Health Insurance Coverage

08/11/1999

Grantees ask many more questions about health insurance coverage than about food stamp receipt, reflecting the greater complexity of the subject.  As shown in Table III, grantees are asking between five and ten questions about health insurance, with the questions falling into five general areas:

  1. Do you have health insurance coverage?
  2. What type of coverage do you have?
  3. Are you enrolled in Medicaid?
  4. Do you participate in an employer health plan?  and
  5. Why don’t you have ... [Medicaid/employer/any health insurance]?

Most of these health insurance questions are asked twice, both with regard to the leaver herself, and with regard to her children (denoted with a “C” in Table III).  Though not shown in the table, one survey (Cuyahoga/L.A.) also asks about coverage for the leaver’s spouse/partner, and another (Wisconsin) asks all health insurance questions about each member of the household, allowing different responses for various adults and children (see Appendix III for detailed wording of health insurance questions).

  • Coverage and Type of Care.  The first two types of questions are the most common, with eight of the eleven instruments specifically asking whether the respondent has health insurance coverage (now or last month), and all but one asking about type of coverage (see Table III).  Note that this latter question, “type of coverage” question overlaps with the other questions, since Medicaid, employer health plans, and in some cases, no insurance, are among the eight or so types of care listed as possible responses.  One grantee, the District of Columbia, specifically probes, “So are you/all your children uninsured?” if the respondent replies “No,” to the question about whether she has any health insurance coverage.  Another grantee (Florida) asks what type of health insurance is used to pay for most of the respondent’s medical care, taking into account the possibility of more than one health plan.
  • Medicaid Receipt.  Seven grantees ask specific questions about Medicaid receipt, in addition to listing “Medicaid” as one response to the question about health insurance coverage.  Questions focus on current Medicaid receipt, or receipt after exit from cash assistance, with two grantees (Arizona and Cuyahoga/L.A.) asking about receipt in both time periods.  Grantees generally ask about Medicaid coverage separately for the adult and for the children in the household, with some grantees (e.g., Cuyahoga/L.A., South Carolina, Wisconsin) allowing for situations where some children are covered by Medicaid and others are not covered.

Table III:  Health Insurance

Questions
What type of health care coverage?  (Choices include... Medicaid, employer, etc) X
C
  X
C
  X
C
X
C
X
C
X
C
X
C
X
C
X
C
9
Any current health care insurance? X
C
X
C
X
C
X
C
X     X
C
X
C
  X 8
Currently enrolled in/receive Medicaid?   X
C
  X
C
X           X
C
4
Continue to receive Medicaid after left cash assistance?   X
C
  X
C
  X
C
  X   X
C
  5
Does your employer OFFER...health plan? X   X       X         3
Do you ENROLL/PARTICIPATE IN employer health plan? X
C
X
C
X
C
    X
C
X         5
Do you GET a health plan or medical insurance from your employer?       X
C
X
C
    X
C
      3
Why (main reason) not covered?     X
C
C X
C
      X
C
    4
Why not enrolled/continue to get Medicaid? X
C
X
C
      X
C
          3
Why not participating in employer health plan? X           X         2
Other Questions (see below)           X
C
X
C
  X C   4
Total Number of Questions 10 10 9 9 8 8 7 7 7 6 5  

Notes:
X = Question asked of adult;  C = Question asked about children in household.

Other Questions:

  • Illinois:  Have you applied for a Medicaid card for yourself?  For your children?
  • Missouri:  Since left AFDC, any periods when children were without medical coverage, including Medicaid?  When you?
  • Georgia:
    1. When did you last have health insurance for the children?  What was it?
    2. Has child's absent father paid for ... dental or mental expenses?  Child's medical insurance?
  • Wisconsin:  If private insurance, who pays premium?

 

The wording of questions about Medicaid receipt may be quite important, given the fact that Medicaid coverage is a less tangible benefit than receipt of a monthly cash grant or a monthly food stamp allotment.  Medicaid receipt may be under reported, if a recipient does not think of herself as “receiving Medicaid benefits” in months where no one in the family uses the health care system or if a Medicaid­paid HMO is not correctly identified as a Medicaid plan.  On the other hand, she may over report Medicaid coverage, if her Medicaid coverage expires without her knowledge.

To probe for Medicaid coverage, surveys try different approaches.  Surveys typically ask about Medicaid in the context of health insurance coverage, although a few ask about receipt of Medicaid benefits along with receipt of WIC, food stamps, and other government benefits/services.  In Illinois, Medicaid coverage is tied to the tangible card itself, “Do you have a Medicaid card for yourself now?”  The Georgia survey asks, “are you enrolled in Medicaid, Medicare, an employer­provided plan, or one you pay for on your own?”  In Missouri, the interviewer lists “Medicaid or Medicaid­paid HMO” as one of the eight types of health insurance plans a person may have.  There may some opportunities to analyze the effects of various wording differences as researchers compare answers to specific questions about Medicaid benefits with responses to the more general question about type of coverage and with data from administrative records.

Employer health plans.  Eight surveys ask questions about employer health plans. These questions can be classified as falling into three categories:

  • Does your employer offer a health plan?  (three grantees);
  • Are you enrolled in or participating in your employer’s health plan (same three grantees as above), or, a somewhat similar question, is your health insurance coverage through your employer?  (two grantees); and
  • Do you get or are you provided with any of the following benefits [... sick leave, a health plan or medical insurance for you, etc.] from your employer?  (three grantees).

I created a separate category for this third set of questions, because I was not sure whether “getting” health insurance benefits from an employer was more analogous to being offered health insurance, or actually enrolling in the employer­offered plan.  I probably would have interpreted it as closer to “enrollment,” except that the Florida survey explicitly states to the interviewer that they “want to know if offered, not what employee is taking advantage of.”

Why not covered.  Several instruments include additional questions to probe why a former recipient does not have health insurance coverage (four surveys); is not enrolled in Medicaid (three surveys), or is not participating in an employer health plan (two surveys).

Four grantees ask additional questions, not found on other state surveys.  Illinois asks whether the leaver has applied for a Medicaid card.  Missouri asks whether the children have been without medical coverage for any period since the family left cash assistance.  If the family is covered by private insurance, Wisconsin asks who pays the premium.  And Georgia asks a set of additional questions about child health coverage:  When did you last have health insurance for the children?  What was it?  Has the child’s absent father paid for dental or medical expenses?  For medical insurance?

The first two sets of survey items explored in this paper — questions about food stamp receipt and health insurance coverage — gather information about the family’s participation in programs other than TANF, and more generally, about work supports.  Grantees also ask about many other types of program participation and work supports, most notably, child care assistance, but these are not included in the scope of this paper.  The next two sections of the paper examine another important topical area covered by grantees, that of experiences of material hardship, deprivation, or insecurity.  Most grantees ask questions about difficulty paying the rent or other bills, experiences with homelessness, use of emergency services, and the two sub­topics examined below, food insecurity and lack of health care.