Obtaining and keeping health insurance coverage can be a challenge for families who leave or are diverted from welfare. Until recently, most low-income families obtained health insurance through their eligibility for cash assistance programs, (e.g., the old Aid to Families with Dependent Children (AFDC) program). Since the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, eligibility for Medicaid and eligibility for cash assistance have been "delinked." That is, eligibility for Medicaid is not tied to eligibility or receipt of Temporary Assistance for Needy Families (TANF) benefits. Low-income children and families leaving or diverted from entering TANF often are eligible for Medicaid.
Children and families may qualify for Medicaid under several different categories. Under "section 1931, " established by PROWRA, families with dependent children are eligible for Medicaid on the basis of family income and state rules in effect under the old AFDC program or under new rules developed by the state that apply to all low-income families. Transitional Medical Assistance guarantees six to twelve months of coverage for families who lose Medicaid eligibility because of increased earnings or child support income. Poor children and pregnant women may qualify for Medicaid under poverty-related eligibility groups. Finally, children also may be covered under the State Children's Health Insurance Programs (SCHIP), which may be an expansion of a state Medicaid programs, a separate program, or a combination of the two, depending on the state.
Despite these numerous avenues of Medicaid eligibility, some families leaving or diverted from TANF have inappropriately lost out on Medicaid coverage. To address this issue, the Department of Health and Human Services (HHS) has issued substantial guidance to the states, conducted on-site reviews of all states' Medicaid/TANF eligibility and enrollment systems, and is working with states to identify promising strategies and procedures for ensuring Medicaid coverage to all eligible children and families. (See Related Links below). Research on families leaving or diverted from welfare has contributed to our understanding of programmatic issues and efforts to ensure that families and individuals are aware of their potential eligibility for Medicaid and have an opportunity to apply for the coverage to which they may be entitled.
The ASPE-funded studies are using both administrative and survey data to study Medicaid and other health insurance coverage of families leaving or diverted from welfare. Linkage of TANF administrative records with Medicaid enrollment data allows researchers to track Medicaid enrollment for twelve or more months after exit or diversion. This tracking task is simplified by the fact that both programs are often administered by the same state or local agency, with an integrated database. Studies generally track enrollment among the adult case head, with some studies also tracking enrollment of children and other members of the family.
All ASPE-funded studies include questions about health insurance on their surveys, typically asking whether the respondent is insured and about the type of insurance, with specific probes about Medicaid, and in some cases, employer-sponsored health insurance. Some of the surveys ask questions about coverage of the respondent's children, awareness of eligibility for Medicaid benefits, and reasons for lack of health care coverage.
Apart from real state-to-state differences, differences in measurement methodologies contribute to differences in Medicaid enrollment and health insurance coverage across studies. For example, some studies look at the adult as the unit of analysis, whereas others look at children or the whole family. The time period studied also is important. Coverage rates measured in a single month or point in time tend to be lower than rates over a calendar quarter or other multi-month time period. Coverage rates also may decline over time following exit from TANF, particularly for families receiving time-limited coverage under Transitional Medical Assistance. Finally, the wording of survey questions can influence responses. For example, unless questions are carefully worded, respondents may confuse questions about Medicaid enrollment with questions about actual receipt of medical services or may provide incomplete information about employer-sponsored coverage.
These measurement differences, combined with state variation in TANF and Medicaid eligibility rules and application policies and regional variations in private health insurance coverage, lead to sizable differences in Medicaid and overall health insurance coverage across the states.
- Cross-State Findings on Medicaid/Health Insurance. December 2001. From "Final Synthesis Report of Findings from ASPE's 'Leavers' Grants", by Gregory Acs and Pamela Loprest with Tracy Roberts, The Urban Institute (funded by ASPE).
- Medicaid and Health Insurance. July 2001. From "Findings from ASPE-Funded Leavers Studies (Appendix B)", by ASPE staff.
- Cross-State Findings on Medicaid/Health Insurance, based on Administrative and Survey Data. November 2000. From "A Cross-State Examination of Families Leaving Welfare: Findings from the ASPE-Funded Leavers Studies", by Julia B. Isaacs and Matthew R. Lyon, ASPE.
- Welfare Leavers and Medicaid Dynamics: Five States in 1995. April 2000.
- Welfare Leavers, Medicaid Coverage, and Private Health Insurance. March 2000. Issue brief from the Urban Institute's Assessing the New Federalism project.
- Access to and Participation in Medicaid and the Food Stamp Program. A Review of the Recent Literature. March 2000. Report by M. Robin Dion and LaDonna Pavetti, Mathematica Policy Research.
- See also: information on health insurance coverage and Medicaid enrollment in each grantee's reports.
- Review of Survey Instruments: Health Insurance Coverage
- Commonly Reported Administrative Data Measures
- DHHS/CMS web page on Medicaid and Welfare Reform.