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The programs in the NEWWS Evaluation were designed to move recipients from welfare to work, and the earlier chapters showed that many were successful in doing this. However, moving from welfare to work leads to a loss in health coverage for some recipients if they cannot replace their lost Medicaid with private coverage. Many low-wage workers do not have employer-provided coverage, either because their employers do not offer it or they cannot afford the high premiums.
This chapter examines how the NEWWS programs affected the health coverage of respondents and their children. Data on health coverage from the Five-Year Client Survey are available for 7 of the 11 programs. Health coverage status is an important aspect of family well-being, because it affects families' access to care and the quality of care they receive. Children who are uninsured, for example, are much less likely to see doctors than their insured counterparts, are less likely to have preventative care, and are more likely to have unmet health care needs.(1) Increasingly, families are without coverage: In 1997, for example, nearly half of all working poor parents were uninsured.(2)
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At random assignment, all sample members and their children had health care coverage because they were receiving AFDC and thus automatically covered under Medicaid. In general, Medicaid receipt should fall over time for both the program and control groups since most of them left welfare during the five-year follow-up period. By the last quarter, for example, welfare receipt ranged from 20 to 40 percent across the sites. Health care coverage in general should also fall over time if some sample members cannot replace their lost Medicaid coverage. Coverage might also fall more rapidly for parents than for their children. Most children under age 18 are now eligible for Medicaid if their family's income is less than 100 percent of the poverty level. They may also be eligible, depending on the state in which they live, for coverage through the Children's Health Insurance Program (CHIP). As a result, it is not uncommon for coverage status to vary within the same family. The mother might not have coverage or might be covered through her employer, while her children might be covered through CHIP or Medicaid.
The primary way that the programs might affect health coverage is through their effects on welfare receipt and employment. When people leave welfare for work, they run the risk of losing coverage because they will either immediately or eventually lose their public coverage and cannot often find private coverage to replace it. Transitional Medicaid is the main source of public coverage and is available to families for up to one year after leaving welfare.(3) However, recent research finds that its use has been slow to take hold: According to one study, over 600,000 recipients lost Medicaid coverage when their welfare case was closed, even though the majority still met Medicaid eligibility standards.(4) There are a number of possible reasons why individuals eligible for Medicaid do not receive it. One reason is that recently employed recipients, believing they are no longer eligible for welfare, often fail to respond to eligibility verification notices they receive from welfare caseworkers. Caseworkers typically close the cases of those who do not respond, which includes not only welfare but Medicaid and Food Stamps.(5)
Once Transitional Medicaid expires the family must find other insurance, mostly from private sources. This has become increasingly difficult for many low-income workers. There has been a decrease over the past decade in the number of workers with employer-sponsored coverage, especially among those in low-wage jobs.(6) With rising health care costs, many employers have been faced with the choice of dropping coverage for their employees or passing along the costs to them in the form of higher premiums. As a result, many former welfare recipients are either not offered insurance or cannot afford it.
In terms of program impacts, increases in employment and reductions in welfare receipt might lead to reductions in coverage, particularly in those sites with the largest reductions in welfare receipt. Because better jobs are more likely to come with employer-provided insurance, programs that may have encouraged recipients to take lower-quality jobs than they would have otherwise — particularly programs with an emphasis on quick employment — may have decreased coverage. In contrast, if program group members moved into better jobs than control group members over time, they may have increased coverage. Average wages, one measure of job quality, were higher for program group members in some sites (Atlanta LFA, Riverside HCD, and Riverside LFA all significantly increased hourly wages). Program impacts on earnings might also affect coverage, particularly coverage for children, since families with higher earnings may be less likely to qualify for public insurance programs.
The programs might also affect coverage in ways that are not related to their impacts on employment or welfare receipt. For example, program group members have more contact than control group members with program staff, making it more likely that they will be made aware of and receive help in obtaining Transitional Medicaid or other kinds of public coverage. Programs with a strictly enforced participation mandate might also affect coverage, probably reducing it, if they lead many individuals to leave welfare before they have found jobs.
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Data on health coverage come from the Five-Year Client Survey. Since coverage is measured at only one point, the month before the five-year survey, it is not possible to measure the continuity of coverage. Respondents were considered covered if they reported receiving Medicaid, if they were working and had accepted their employer's health insurance plan, or if they reported receiving coverage from another private source. If they were receiving welfare or SSI, they were assumed to be covered through Medicaid.
As discussed in Chapter 4, UI records data show that most of the programs began increasing employment within a year or two of random assignment, and the biggest effects were in Riverside LFA and HCD, Grand Rapids LFA, and Portland. The employment impacts also lessened over time. By the end of year 5, only Riverside LFA and HCD and Portland continued to show significant positive impacts. This pattern also holds with the survey data. The upper panel of Table 8.1 shows impacts on employment at the time of the five-year survey. In Riverside LFA, Riverside HCD, and Portland, more individuals in the program group than the control group were working at the five-year point, although the difference in Portland is not statistically significant.
The middle panel of Table 8.1 shows the percentage of program and control group members who were employed with health care coverage, either public or private. A comparison of this panel with the upper panel shows that a significant proportion of those working (ranging from 20 to 30 percent across sites) did not have health coverage. For example, 54 percent of control group members in Atlanta were employed, but only 37 percent were employed and had coverage, meaning that about 70 percent of those working had coverage. Control group rates were highest in Riverside and Portland. In Riverside, the high welfare benefit levels meant that more welfare recipients could work and still remain eligible for some welfare and, therefore, Medicaid.(7) In Portland, the high coverage rate may reflect the existence of the state's public health program — the Oregon Health Plan (OHP).(8)
The lower panel of Table 8.1 shows the percentage of program and control group members who were employed with employer-provided coverage. Between 15 and 30 percent of control group members were working and had employer-provided coverage. A comparison of these numbers with the upper and middle panels highlights several points. First, only about one-third to one-half of those who were employed had employer-provided coverage. In Atlanta, for example, 54 percent of the control group worked, but only 19 percent of the control group worked and had employer-provided coverage, meaning that only 35 percent of workers had coverage through their jobs. Second, 40 to 60 percent of workers with coverage had employer-provided coverage (compare the middle and lower panels), showing that other programs were an important source of coverage among low-wage workers. Other sources of coverage, for example, are Transitional Medicaid and coverage from a spouse (as shown in Chapter 9, from 10 to 20 percent of respondents were married at the five-year point). The percentage with employer-provided coverage is especially low in Riverside, where 40 percent of controls were working and had coverage, but only 15 percent had employer-provided coverage, meaning that 38 percent of insured workers had coverage through their jobs.
One reason for the relatively low rates of employer-provided coverage is that some respondents were offered but declined to enroll in their employer's plan. In Riverside and Atlanta, about 70 percent of those offered coverage accepted it compared with about 80 percent of those in Grand Rapids and Portland. The low employer-provided coverage rates in Riverside may reflect the fact that relatively more workers were still eligible for welfare and Medicaid. Individuals who have Medicaid are probably more likely to turn down an employer's offer of coverage.
Site and Program |
Sample Size | Program Group (%) | Control Group (%) | Difference (Impact) |
Percentage Change (%) |
|---|---|---|---|---|---|
Employed at interview |
|||||
| Atlanta Labor Force Attachment | 1,071 | 57.2 | 54.3 | 2.9 | 5.4 |
| Atlanta Human Capital Development | 1,146 | 52.9 | 54.3 | -1.4 | -2.5 |
| Grand Rapids Labor Force Attachment | 1,097 | 65.1 | 67.7 | -2.6 | -3.8 |
| Grand Rapids Human Capital Development | 1,109 | 66.2 | 67.7 | -1.5 | -2.2 |
| Riverside Labor Force Attachment | 1,219 | 55.0 | 48.9 | 6.1** | 12.4 |
| Lacked high school diploma or basic skills | 657 | 48.9 | 43.0 | 5.9 | 13.6 |
| Riverside Human Capital Development | 778 | 51.1 | 43.0 | 8.0** | 18.7 |
| Portland | 504 | 61.7 | 58.3 | 3.4 | 5.9 |
Employed with health care coverage at interview |
|||||
| Atlanta Labor Force Attachment | 1,071 | 39.1 | 36.9 | 2.2 | 6.0 |
| Atlanta Human Capital Development | 1,146 | 38.0 | 36.9 | 1.1 | 3.1 |
| Grand Rapids Labor Force Attachment | 1,097 | 49.4 | 51.8 | -2.4 | -4.6 |
| Grand Rapids Human Capital Development | 1,109 | 51.9 | 51.8 | 0.1 | 0.2 |
| Riverside Labor Force Attachment | 1,219 | 40.9 | 39.6 | 1.4 | 3.4 |
| Lacked high school diploma or basic skills | 657 | 38.5 | 33.8 | 4.6 | 13.7 |
| Riverside Human Capital Development | 778 | 40.6 | 33.8 | 6.8* | 20.0 |
| Portland | 504 | 47.8 | 47.7 | 0.1 | 0.2 |
Employed with employer-provided health care coverage at interview |
|||||
| Atlanta Labor Force Attachment | 1,071 | 22.2 | 19.0 | 3.2 | 16.6 |
| Atlanta Human Capital Development | 1,146 | 21.2 | 19.0 | 2.2 | 11.5 |
| Grand Rapids Labor Force Attachment | 1,097 | 30.5 | 30.0 | 0.5 | 1.7 |
| Grand Rapids Human Capital Development | 1,109 | 30.4 | 30.0 | 0.4 | 1.5 |
| Riverside Labor Force Attachment | 1,219 | 17.5 | 15.0 | 2.5 | 16.6 |
| Lacked high school diploma or basic skills | 657 | 12.0 | 10.9 | 1.1 | 9.8 |
| Riverside Human Capital Development | 778 | 14.8 | 10.9 | 3.9 | 35.5 |
| Portland | 504 | 31.6 | 27.3 | 4.4 | 16.0 |
| SOURCE: MDRC calculations
from the Five-Year Client Survey. NOTES: See Appendix A.2. |
|||||
Only Riverside HCD produced a statistically significant increase in the number of respondents who were employed and had coverage (of any type) at the end of year 5. None of the programs had a statistically significant impact on being employed and having employer-provided coverage. However, the impacts on employer-provided coverage are similar in size to the impacts on employment in Atlanta, Grand Rapids, and Portland, although somewhat smaller in Riverside. This suggests that the program group members who were encouraged to work had jobs at the end of year 5 that were at least as likely to have insurance as the jobs held by control group members.
Table 8.2 presents coverage more generally, not as it relates to employment status. Respondents were considered to be covered by public health insurance if they reported receiving Medicaid in the month prior to interview or if they were receiving welfare or SSI. They were considered to be covered by private health care if they had accepted their employer's plan or had coverage from another private source.
Site and Program |
Sample Size | Program Group (%) | Control Group (%) | Difference (Impact) | Percentage Change (%) |
|---|---|---|---|---|---|
Has health care coverage |
|||||
| Atlanta Labor Force Attachment | 1,071 | 71.0 | 72.4 | -1.4 | -1.9 |
| Atlanta Human Capital Development | 1,146 | 74.0 | 72.4 | 1.6 | 2.2 |
| Grand Rapids Labor Force Attachment | 1,097 | 75.1 | 77.7 | -2.6 | -3.3 |
| Grand Rapids Human Capital Development | 1,109 | 77.8 | 77.7 | 0.1 | 0.2 |
| Riverside Labor Force Attachment | 1,219 | 78.3 | 80.3 | -2.0 | -2.5 |
| Lacked high school diploma or basic skills | 657 | 82.7 | 80.0 | 2.7 | 3.4 |
| Riverside Human Capital Development | 778 | 80.3 | 80.0 | 0.3 | 0.4 |
| Portland | 504 | 74.7 | 80.6 | -6.0 | -7.4 |
Has public health care coverage |
|||||
| Atlanta Labor Force Attachment | 1,071 | 46.5 | 51.7 | -5.2* | -10.1 |
| Atlanta Human Capital Development | 1,146 | 50.3 | 51.7 | -1.4 | -2.7 |
| Grand Rapids Labor Force Attachment | 1,097 | 41.2 | 42.5 | -1.2 | -2.9 |
| Grand Rapids Human Capital Development | 1,109 | 43.2 | 42.5 | 0.7 | 1.7 |
| Riverside Labor Force Attachment | 1,219 | 55.8 | 59.4 | -3.6 | -6.1 |
| Lacked high school diploma or basic skills | 657 | 65.3 | 66.4 | -1.1 | -1.7 |
| Riverside Human Capital Development | 778 | 63.4 | 66.4 | -3.1 | -4.6 |
| Portland | 504 | 43.2 | 47.0 | -3.7 | -7.9 |
Has private health care coverage |
|||||
| Atlanta Labor Force Attachment | 1,071 | 28.6 | 24.1 | 4.5* | 18.5 |
| Atlanta Human Capital Development | 1,146 | 27.4 | 24.1 | 3.3 | 13.5 |
| Grand Rapids Labor Force Attachment | 1,097 | 41.8 | 40.7 | 1.1 | 2.7 |
| Grand Rapids Human Capital Development | 1,109 | 41.3 | 40.7 | 0.5 | 1.3 |
| Riverside Labor Force Attachment | 1,219 | 26.9 | 25.7 | 1.2 | 4.7 |
| Lacked high school diploma or basic skills | 657 | 20.9 | 18.0 | 2.9 | 16.4 |
| Riverside Human Capital Development | 778 | 23.9 | 18.0 | 5.9* | 33.1 |
| Portland | 504 | 39.0 | 37.8 | 1.2 | 3.2 |
| SOURCE: MDRC calculations
from the Five-Year Client Survey. NOTES: See Appendix A.2. |
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As the upper panel of Table 8.2 shows, coverage levels for the control group ranged from 72 percent in Atlanta to 81 percent in Portland, meaning that 20 to 30 percent of respondents were uninsured at the end of year 5. The percentage uninsured is higher than it is for the nation as a whole but lower than it is for low-income individuals. A recent study reported that 16 percent of all adults with children were uninsured; among those with incomes below poverty, 42 percent were uninsured.(9) A later section in this chapter will look more closely at the respondents who no longer had coverage at the time of the survey.
The middle and lower panels of Table 8.2 show that the majority of the coverage is from public sources. In Portland, for example, 80 percent of control group members had any coverage, 47 percent had public coverage, and 38 percent had private coverage. This extent of public coverage makes sense, considering that 20 to 40 percent of sample members were still on welfare at the five-year point and that those who left welfare shortly before that were probably still receiving Transitional Medicaid (data on the take-up of Transitional Medicaid are shown in a later section). In Riverside, for example, nearly 40 percent of control group members were still receiving welfare at the end of year 5, which explains why the extent of public coverage is relatively high in this site. In Portland, the extent of public coverage is also related to Oregon's OHP, since about 20 percent of control group members were receiving welfare at the five-year point.
None of the programs produced a statistically significant impact on coverage (upper panel of Table 8.2). Levels of coverage were about the same for program group members as for control group members. This result is encouraging since the expectation was that many welfare recipients would lose insurance as they went from welfare to work.
The impacts on types of coverage (middle and lower panels of Table 8.2) show that the programs may have led to a shift from public to private sources. Although few of the impacts are statistically significant, the general pattern is that program group members were less likely to have public coverage and more likely to have private coverage than control group members. For the Atlanta LFA program, this shift in coverage is statistically significant; the program reduced public health care coverage by 5 percentage points and increased private coverage by 5 percentage points. This is consistent with the program's moving more welfare recipients to work.
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Table 8.3 presents coverage for respondents' children. Respondents reported the coverage status of each of their children at the end of year 5. This analysis is limited to respondents' dependent children aged 18 or younger at the five-year interview date.(10) Children were considered to be covered if respondents reported that children had coverage from Medicaid or from a private insurer or if respondents reported receiving welfare or SSI benefits. Although data were collected for each child, the following analysis examines whether all children in the family were covered.(11)
Site and Program |
Sample Size | Program Group (%) | Control Group (%) | Difference (Impact) | Percentage Change (%) |
|---|---|---|---|---|---|
All dependent children have health care coverage |
|||||
| Atlanta Labor Force Attachment | 974 | 85.1 | 84.5 | 0.6 | 0.7 |
| Atlanta Human Capital Development | 1,057 | 83.4 | 84.5 | -1.1 | -1.3 |
| Grand Rapids Labor Force Attachment | 1,005 | 78.8 | 81.8 | -3.0 | -3.6 |
| Grand Rapids Human Capital Development | 1,026 | 79.3 | 81.8 | -2.5 | -3.1 |
| Riverside Labor Force Attachment | 1,120 | 81.9 | 83.2 | -1.3 | -1.6 |
| Lacked high school diploma or basic skills | 614 | 83.8 | 82.1 | 1.8 | 2.2 |
| Riverside Human Capital Development | 743 | 85.2 | 82.1 | 3.2 | 3.8 |
| Portland | 451 | 75.5 | 80.2 | -4.7 | -5.8 |
All dependent children have public health care coverage |
|||||
| Atlanta Labor Force Attachment | 974 | 63.7 | 69.1 | -5.3* | -7.7 |
| Atlanta Human Capital Development | 1,057 | 66.6 | 69.1 | -2.5 | -3.6 |
| Grand Rapids Labor Force Attachment | 1,005 | 49.7 | 51.3 | -1.6 | -3.2 |
| Grand Rapids Human Capital Development | 1,026 | 52.1 | 51.3 | 0.8 | 1.5 |
| Riverside Labor Force Attachment | 1,120 | 57.6 | 63.9 | -6.2** | -9.8 |
| Lacked high school diploma or basic skills | 614 | 66.0 | 70.9 | -4.9 | -6.9 |
| Riverside Human Capital Development | 743 | 67.8 | 70.9 | -3.1 | -4.4 |
| Portland | 451 | 44.1 | 52.1 | -8.0 | -15.3 |
All dependent children have private health care coverage |
|||||
| Atlanta Labor Force Attachment | 974 | 19.8 | 16.0 | 3.9* | 24.2 |
| Atlanta Human Capital Development | 1,057 | 16.0 | 16.0 | 0.0 | 0.1 |
| Grand Rapids Labor Force Attachment | 1,005 | 31.5 | 32.8 | -1.3 | -4.0 |
| Grand Rapids Human Capital Development | 1,026 | 29.2 | 32.8 | -3.6 | -10.8 |
| Riverside Labor Force Attachment | 1,120 | 22.9 | 19.9 | 3.1 | 15.5 |
| Lacked high school diploma or basic skills | 614 | 16.4 | 12.4 | 4.0 | 32.3 |
| Riverside Human Capital Development | 743 | 19.1 | 12.4 | 6.7** | 54.2 |
| Portland | 451 | 30.2 | 28.6 | 1.7 | 5.8 |
| SOURCE: MDRC calculations from the Five-Year
Client Survey. NOTES: See Appendix A.2. |
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A comparison of Table 8.3 with Table 8.2 shows that children were somewhat more likely than adults to have health care coverage at the end of year 5. In Grand Rapids, for example, 82 percent of control group children were covered compared with 78 percent of respondents. This is perhaps not surprising given the range of public programs that specifically cover low-income children. Nonetheless, the rates of noncoverage (15 to 20 percent) suggest that these programs are not serving all eligible children.
The greater number of public programs for children also is reflected in the fact that children were more likely than adults to be covered through public sources and less likely through private sources. Only 33 percent of control group children in Grand Rapids, for example, had private insurance compared with 41 percent of adults. Employers may not have offered to cover children or the adults may have turned down this coverage if it was too expensive.
Finally, none of the programs had statistically significant effects on coverage for children. They did lead to a slight shift from public to private sources, which mirrors the effects found for adults. It is encouraging that the programs, by leading more families from welfare to work, did not negatively affect children's health care coverage.
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For many welfare recipients, the potential loss of health coverage can create a disincentive to leave welfare and go to work. Transitional Medicaid reduces this disincentive by allowing working individuals to continue coverage, for themselves and their children, for up to one year after leaving welfare.(12) Receipt of this benefit is not automatic, however, and eligible recipients must request it and receive caseworker approval.(13) Data on the receipt of Transitional Medicaid are available from the survey: Respondents were asked whether they had ever received this benefit during the five-year follow-up period.
Table 8.4 shows the percentage of respondents who were eligible for and used Transitional Medicaid. The upper panel shows the percentage of program and control group members who worked and were off welfare at some point during the follow-up period and indicates the number of respondents who would have been eligible to receive Transitional Medicaid. Between 56 and 68 percent of control group members worked and left welfare during the follow-up period in Atlanta, Grand Rapids, and Portland. A much smaller percentage of controls (40 percent) were eligible for Transitional Medicaid in Riverside, probably because fewer in this site worked and when they did many were still eligible for welfare. Both programs in Riverside produced a significant increase in the percentage working and off welfare.
Site and Program |
Sample Size | Program Group (%) | Control Group (%) | Difference (Impact) | Percentage Change (%) |
|---|---|---|---|---|---|
Ever employed and off welfare during follow-up |
|||||
| Atlanta Labor Force Attachment | 1,071 | 59.7 | 56.2 | 3.5 | 6.2 |
| Atlanta Human Capital Development | 1,146 | 59.6 | 56.2 | 3.3 | 5.9 |
| Grand Rapids Labor Force Attachment | 1,097 | 71.3 | 67.7 | 3.6 | 5.4 |
| Grand Rapids Human Capital Development | 1,109 | 67.9 | 67.7 | 0.3 | 0.4 |
| Riverside Labor Force Attachment | 1,219 | 46.9 | 39.6 | 7.2*** | 18.3 |
| Lacked high school diploma or basic skills | 657 | 37.7 | 28.3 | 9.4*** | 33.3 |
| Riverside Human Capital Development | 778 | 36.6 | 28.3 | 8.2** | 29.1 |
| Portland | 504 | 67.8 | 66.8 | 1.0 | 1.6 |
Ever covered by Transitional Medicaid during follow-up |
|||||
| Atlanta Labor Force Attachment | 1,071 | 42.0 | 38.1 | 3.8 | 10.1 |
| Atlanta Human Capital Development | 1,146 | 42.7 | 38.1 | 4.6 | 12.1 |
| Grand Rapids Labor Force Attachment | 1,097 | 53.5 | 50.8 | 2.7 | 5.3 |
| Grand Rapids Human Capital Development | 1,109 | 50.2 | 50.8 | -0.6 | -1.2 |
| Riverside Labor Force Attachment | 1,219 | 32.3 | 25.8 | 6.5** | 25.3 |
| Lacked high school diploma or basic skills | 657 | 25.6 | 17.9 | 7.7** | 42.8 |
| Riverside Human Capital Development | 778 | 26.2 | 17.9 | 8.2** | 45.9 |
| Portland | 504 | 55.5 | 50.8 | 4.6 | 9.1 |
For those ever off welfare and employed,ever covered by Transitional Medicaid |
|||||
| Atlanta Labor Force Attachment | 70.3 | 67.8 | 2.5 | 3.6 | |
| Atlanta Human Capital Development | 71.7 | 67.8 | 4.0 | 5.8 | |
| Grand Rapids Labor Force Attachment | 75.0 | 75.1 | -0.1 | -0.1 | |
| Grand Rapids Human Capital Development | 73.9 | 75.1 | -1.2 | -1.6 | |
| Riverside Labor Force Attachment | 68.8 | 65.0 | 3.9 | 6.0 | |
| Lacked high school diploma or basic skills | 67.9 | 63.3 | 4.6 | 7.2 | |
| Riverside Human Capital Development | 71.6 | 63.3 | 8.2 | 13.0 | |
| Portland | 81.8 | 76.2 | 5.7 | 7.4 | |
SOURCE: MDRC calculations from the Five-Year Client Survey.
|
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The middle panel of Table 8.4 shows that not all who were eligible received Transitional Medicaid. This can be seen more easily in the lower panel, which shows receipt of Transitional Medicaid by those who were eligible (this is a nonexperimental comparison). Data for the control groups show that about 65 to 76 percent of eligible respondents received this benefit. In Atlanta, for example, 56 percent of control group members were eligible for Transitional Medicaid and 38 percent received it, meaning that only 68 percent of eligible respondents received it. Data from the two-year survey (not shown) indicate that the use of this benefit increased over time, probably as more families became eligible. At the two-year point, between 10 and 25 percent of control group members reported having used Transitional Medicaid compared with a much higher percentage at the end of year 5.
The programs generally increased Transitional Medicaid use — although only Riverside LFA and Riverside HCD produced statistically significant increases — because they increased the percentage who were eligible to receive it, but also because they increased its use among those eligible. The similarity of the impacts on the number of respondents who were employed and off welfare and on the number who used Transitional Medicaid suggests that most of those individuals who were induced by the program to work and leave welfare did, in fact, receive Transitional Medicaid at some point. This is also reflected in the nonexperimental numbers in the lower panel of Table 8.4. Of program group members who were eligible in Portland, for example, 82 percent received the benefit compared with only 76 percent of control group members. This finding is consistent with one of the hypotheses raised earlier that more involvement by caseworkers would lead to greater use of available benefits.
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Section III of this chapter showed that 20 to 30 percent of respondents no longer had health coverage at the end of year 5. Were these families less likely to work, did they work in lower-quality jobs, or did they earn too much to qualify for public programs? Although an extensive analysis of the uninsured is beyond the scope of the chapter, this section presents a comparison of adults who had coverage and those who did not have coverage at the end of the five-year follow-up.
Figure 8.1 presents coverage status for respondents at the end of year 2 and at the end of year 5.(14) The figure shows that between 70 and 80 percent of respondents had coverage at the end of year 5. Also, among those who were uninsured at that point, most had lost coverage after year 2.
Figure 8.1
Health Care Coverage for Respondents Over Five Years
SOURCES: MDRC calculations from the Two-Year Client Survey and Five-Year
Client Survey.
NOTES: See Appendix A.2.
Table 8.5 compares uninsured and insured control group members. The first two rows show that the uninsured were equally if not more likely to have been working at the end of the five-year follow-up than the insured, but they were much less likely to have been offered coverage by their employers. In Grand Rapids, for example, 69 percent of the uninsured were working at the end of the follow-up, but only 20 percent were working and were offered employer-provided coverage. In contrast, 66 percent of insured control group members were working at the end of the follow-up and 43 percent of them were offered coverage through their jobs.
| Site | Respondent Covered at End of Year 5 | Respondent Not Covered at End of Year 5 |
|---|---|---|
Atlanta |
||
| Employed at end of year 5 (%) | 54.4 | 67.8 |
| Employed and offered coverage from employer (%) | 36.5 | 19.9 |
| Earnings in last quarter ($) | 1,729 | 1,597 |
| Ever received Transitional Medicaid (%) | 39.4 | 50.7 |
| Covered at end of year 2 (%) | 92.1 | 83.8 |
| All children covered at end of year 5 (%) | 95.5 | 54.3 |
| Sample size | 406 | 146 |
Grand Rapids |
||
| Employed at end of year 5 (%) | 65.7 | 68.9 |
| Employed and offered coverage from employer (%) | 42.7 | 19.7 |
| Earnings in last quarter ($) | 2076.5 | 1364.6 |
| Ever received Transitional Medicaid (%) | 48.2 | 54.1 |
| Covered at end of year 2 (%) | 89.2 | 77.7 |
| All children covered at end of year 5 (%) | 90.9 | 48.2 |
| Sample size | 440 | 122 |
Riverside |
||
| Employed at end of year 5 (%) | 49.4 | 47.5 |
| Employed and offered coverage from employer (%) | 25.4 | 9.2 |
| Earnings in last quarter ($) | 1,181 | 1058.9 |
| Ever received Transitional Medicaid (%) | 26.4 | 22.7 |
| Covered at end of year 2 (%) | 92.2 | 76.5 |
| All children covered at end of year 5 (%) | 94.2 | 32.5 |
| Sample size | 579 | 141 |
Portland |
||
| Employed at end of year 5 (%) | 60.8 | 59.5 |
| Employed and offered coverage from employer (%) | 43.1 | 9.5 |
| Earnings in last quarter ($) | 1745.0 | 1165.1 |
| Ever received Transitional Medicaid (%) | 50.3 | 50 |
| Covered at end of year 2 (%) | 92.1 | 85 |
| All children covered at end of year 5 (%) | 86.5 | 43.2 |
| Sample size | 181 | 42 |
| SOURCE: MDRC calculations from the Five-Year
Client Survey. NOTES: See Appendix A.2. |
||
The uninsured on average earned less than the insured in the last quarter of follow-up. This difference is consistent with the lower rate of employer-provided coverage and suggests that the uninsured may have been working in lower-quality jobs, including more part-time work. The lower earnings also suggest that the lack of coverage is not due to the fact that these workers were earning too much to qualify for public programs serving low-income families. In Portland, for example, average earnings in the last quarter of year 5 were $1,165 for the uninsured, which is less than $5,000 on an annual basis. The OHP provides coverage to families who are not eligible for Medicaid but have incomes below the poverty line. Although coverage rates were generally higher in Portland than in the other sites (see Table 8.2), many eligible people probably did not receive benefits. The low earnings also suggest that the children of uninsured respondents were probably eligible for Medicaid or other public health programs. Nonetheless, only between one-third and one-half of them were covered. In Riverside, for example, only 33 percent of uninsured adults had coverage for their children.
Finally, the uninsured were at least as likely as the insured to have received Transitional Medicaid during the follow-up period. This suggests that they were not more likely to immediately lose coverage when they made the transition from welfare to work, but that they were unable to replace Medicaid when their transitional benefits expired.
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A potential effect of the NEWWS programs was the loss of health coverage for participants as they moved from welfare to work. Many low-wage workers either are not offered or do not accept employer-provided insurance, making it difficult to replace their lost Medicaid with private coverage. It is encouraging that the programs did not lead to a loss in coverage for the adults or their children.
As expected, levels of health care coverage decreased for both program and control group members over time, though a large majority of respondents and their children were still insured at the end of the five-year follow-up. Since the evaluation started, states have continued to address the issue of coverage for low-income families by creating or expanding public programs. These additional benefits were not a program component and were available to members of both research groups. The findings presented in this chapter indicate that the sites were generally successful in continuing to provide coverage for families who left welfare. Nonetheless, 20 to 30 percent of adults were not covered, suggesting that states should continue in their efforts to reach the uninsured. Because access to health care has been expanding, the findings presented here on the effects of the programs might have been different had the evaluation taken place in more recent years.
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1. Mullahy and Wolfe, 2000.
2. Guyer and Mann, 1999.
3. Kaplan, 1997.
4. Families USA Foundation, 1999.
5. Quint and Widom, 2001.
6. Farber and Levy, 2000.
7. In Riverside, about 16 percent of control group respondents (and one-third of those employed) combined work and welfare at the end of year 5, compared with less than 10 percent of control group members in the other three sites.
8. The OHP provides publicly financed health care coverage to residents of the state of Oregon who do not qualify for Medicaid but whose income is below the poverty level.
9. See Holahan and Brennan, 2000.
10. About 8 percent of respondents were excluded from this analysis either because none of their children was 18 or under at interview or because they reported having no children.
11. In very few families — between 3 and 7 percent of control group families — were only some (but not all) of the children in the family covered.
12. In 1998 the State of California increased Transitional Medicaid coverage for up to two years. This change would have affected only the sample members in Riverside who entered the program near the end of the random assignment period.
13. Recipients who find jobs and stop communicating with caseworkers might lose transitional coverage, since caseworkers might close their cases.
14. For more detailed information about health care coverage at the end of year 2, see Freedman et al., 2000a, Chapter 8.
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