While Congress is focusing on health insurance for low-income children, this survey highlights the vulnerability of low-income adults as well.

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1 Insurance Matters For Low-Income Adults: Results From A Five-State Survey While Congress is focusing on health insurance for low-income children, this survey highlights the vulnerability of low-income adults as well. by Cathy Schoen, Barbara Lyons, Diane Rowland, Karen Davis, and Elaine Puleo ABSTRACT: Using survey data from 2,000 low-income adult respondents in each of five states, this DataWatch assesses how uninsured, low-income adults differ from low-income adults who have public or private insurance and how Medicaid expansions have affected insurance coverage patterns across states with different eligibility policies. Findings show that the proportion of low-income uninsured adults is two to three times higher in states that have not expanded Medicaid eligibility beyond relatively low welfare levels. Compared with persons who have either Medicaid or private insurance, uninsured persons report more difficulties getting needed care, are less likely to have a regular provider, and rate the care they do receive as lower quality. DATAWATCH 163 The more than forty million uninsured persons and the consequent problems in access to care continue to be major policy issues in the United States. 1 At the same time, budget constraints on public funds and competition in the health care marketplace are squeezing the funds that historically have helped to pay for the care of uninsured persons. The low-income population is often at the crux of these changes in health care coverage, delivery, and financing because they have a greater likelihood of being uninsured and are often dependent on public financing through Medicaid. In the late 1980s Medicaid was expanded to cover additional groups of low-income children and pregnant women; by 1995 it provided coverage to thirty-six million Cathy Schoen is director of research and evaluation at The Commonwealth Fund, in New York City. Barbara Lyons is senior program officer and Diane Rowland is executive vice-president at The Henry J. Kaiser Family Foundation, in Washington, D.C. Karen Davis is president of The Commonwealth Fund. Elaine Puleo is a member of the research faculty at The University of Massachusetts at Amherst, School of Public Health ThePeople-to-PeopleHealth Foundation, Inc.

2 D a t a W a t c h 164 INSURANCE COVERAGE beneficiaries. More recently a few states have received Medicaid waivers that provide federal matching funds for extending coverage to low-income adults and children, in combination with greater flexibility in implementing managed care. 2 As federal and state policies change the basic structure of the Medicaid program and competitive forces continue to influence the availability, affordability, and benefits provided by private insurance, state-level data are needed to answer basic questions about how the low-income population is faring in terms of insurance coverage and access to care. To address these issues, The Henry J. Kaiser Family Foundation and The Commonwealth Fund are engaged in a multipart analytic effort to gain early insights and timely information about the changes taking place in key states. In this DataWatch we examine data from the Kaiser/Commonwealth Five-State Low-Income Survey of 2,000 low-income adults in each of five states Florida, Minnesota, Oregon, Tennessee, and Texas to assess how uninsured, low-income adults differ from low-income adults who have public or private insurance and how the expansions of Medicaid coverage have affected insurance coverage patterns of low-income adults across states with different eligibility policies. The five survey states were selected to include examples of innovative expansions of Medicaid to low-income persons, maintenance of more traditional eligibility standards, and variations in the pace of managed care implementation. Expansions in Oregon and Tennessee provide full coverage to the uninsured up to the federal poverty level, without categorical restrictions. In Tennessee uninsured families with incomes up to 0 percent of poverty may buy into Medicaid on a sliding scale or pay full premiums at higher incomes. 3 Subsequently, Tennessee closed and then partially reopened new enrollment. Minnesota expanded coverage to persons otherwise ineligible for Medicaid with MinnesotaCare, a new, publicly subsidized program that provides premium subsidies for families with children with incomes up to 275 percent of the federal poverty level and childless adults with incomes up to 5 percent of poverty. In contrast, Florida and Texas link Medicaid eligibility for adults to Aid to Families with Dependent Children (AFDC) and welfare rules. As of 1996 Florida s AFDC standard was 28 percent of the federal poverty level for a family of three, and Texas s was 17 percent, substantially below the AFDC standards prevailing in the other three study states before the expansions. 4 Methodology The five-state survey consisted of twenty-minute telephone in- H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 5

3 terviews with,0 (2,000 per state) low-income adults ages eighteen to sixty-four who had household incomes that were 2 percent of poverty or less. Each adult was asked a series of questions on insurance coverage, health status, access to and use of health care services, and basic demographic characteristics. In the analysis, the data were weighted by sex, age, race, education, number of adults in the household, and urbanization. Weights were based on the twoyear averages of the March 1994 and 1995 Current Population Surveys. The interviews were conducted in fall 1995 for Minnesota, Oregon, and Tennessee, more than one year after these states had expanded public coverage to adults and children with family incomes up to or beyond the federal poverty level. 5 The Florida and Texas interviews took place in early Since the survey did not include households without telephones, which are likely to be poorer and more disadvantaged in gaining access to care, the survey results are likely to understate the rates of uninsurance and the difficulties of getting care. Overall, 54 percent of adults who are likely to be eligible based on screening criteria completed interviews. The full sample has a margin of error of 1 percent, at a 95 percent confidence level. The margin of error increases for subgroups (2 percent for 2,000; 4 percent for 0.) DATAWATCH 165 Insurance Coverage Of Low-Income Adults This survey confirms the importance of Medicaid policy for coverage of the low-income population and documents the extensive health problems of the uninsured. Economic status and insurance. Within the low-income population, uninsured adults are generally better-off economically than are those with Medicaid but less well-off than the privately insured. Half of the uninsured are poor, compared with 71 percent of Medicaid beneficiaries and 24 percent of those with private insurance (Exhibit 1). Persons with private coverage are more likely than both the uninsured and those receiving Medicaid to be employed and working full time. Reflecting Medicaid s role in covering poor families, adults without children comprise a larger share of the uninsured population than the Medicaid or privately insured population. Health status and insurance. Medicaid beneficiaries are more likely than the privately insured or uninsured to have health problems: Two out of five Medicaid enrollees said that their health is fair or poor, compared with 19 percent of the privately insured and 32 percent of the uninsured. Nearly one-third of persons with Medicaid have had a serious illness, chronic disease, or injury that has required a lot of care in the past year, compared with percent of

4 D a t a W a t c h EXHIBIT 1 Socioeconomic Characteristics, Health Status, And Access To Care Among Low-Income Adults In Five States, By Insurance Status, Insurance status Insured Uninsured Medicaid Private Total N 2,438 2,025 5,248,0 Socioeconomic characteristics Income relative to federal poverty standards Up to 0% of poverty 1 0% of poverty 1 2% of poverty Current employment status Employed Full time Part time Self-employed Not working Family composition Single, with children Couple, with children Adults, without children Health status (self-reported) Fair or poor Serious illness, chronic disease, or injury in past year Access to care (self-reported) Needed care in past year but did not receive it No regular doctor No usual source of care No physician visit in past year Fair/poor rating of overall health care services a 51% % % % SOURCE: Kaiser/Commonwealth Five-State Low-Income Survey, NOTES: Total population includes 302 adults with Medicare or other insurance who are not included in Medicaid or private categories. Individual categories may not add to 0% because of rounding or missing answers. a Of those receiving care in the past year those who are privately insured or uninsured (Exhibit 1). Access to care and insurance. Health insurance matters for lowincome adults because it influences how one gains access to the health care system. Previous studies have shown that the uninsured get care later, get less care, and often suffer adverse consequences because of delayed or forgone care. 6 This survey confirms that uninsured low-income adults can encounter significant barriers to care. The uninsured are consistently more likely to report access prob- H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 5

5 Without Medicaid it is likely that half of all low-income adults and two-thirds of poor adults would be uninsured. lems than are those who are insured by Medicaid or private insurance. Twenty-two percent of the uninsured said that they did not get needed care in the past year, which is three times the rate reported by those who are privately insured and slightly less than twice the rate for those with Medicaid (Exhibit 1). A comparable portion of low-income uninsured adults in each state reported not getting needed care in the past year: 24 percent in Florida, 19 percent in Minnesota, 22 percent in Oregon, 24 percent in Tennessee, and 22 percent in Texas. The perception by some observers that persons who are sick get the care they need, regardless of insurance status, is not accurate for many low-income uninsured adults. Past studies have found that having a regular provider or source of primary care is instrumental in providing preventive services and timely care and in preventing unnecessary hospitalization. 7 Yet 58 percent of uninsured adults reported not having a regular physician, and nearly one-quarter have no usual source of care (Exhibit 1). In each of the study states, more than half of the uninsured have no regular provider: 62 percent in Florida, 54 percent in Minnesota, 52 percent in Oregon, 58 percent in Tennessee, and 59 percent in Texas. Forty percent of the uninsured reported no visits to a physician in the past year, compared with less than a quarter of low-income adults with private insurance, a healthier subgroup based on perceived health status. Within the Medicaid population, which had poorer health status according to the survey, only percent reported no physician visits. Based on ratings of care received, the uninsured reported worse care experiences than the insured reported. Of persons receiving any care in the past year, 31 percent of the uninsured rated services as fair or poor compared with percent of persons with private or Medicaid coverage. Thus, even when the uninsured get care, the process of obtaining care and the care they receive often are not satisfactory. Coverage Variations Across The States Impact of Medicaid expansions. When examining health insurance coverage variations in the five states, the role of Medicaid emerges. Almost one-quarter of low-income adults in the five study states are uninsured, but the proportion that is uninsured is two to three times higher in states with more traditional Medicaid pro- DATAWATCH 167

6 D a t a W a t c h EXHIBIT 2 State Distribution Of Low-Income, Nonelderly Adults, By Insurance And Poverty Status, Insurance and poverty status Minnesota Oregon Tennessee Florida Texas Total N 2,003 2,004 2,003 2,002 2,001,0 Poor (up to 0% of poverty) Uninsured Medicaid Private Near-poor (1 0% of poverty) Uninsured Medicaid Private Moderate (1 2% of poverty) Uninsured Medicaid Private Total Uninsured Medicaid Private 19% % % % % SOURCE: Kaiser/Commonwealth Five-State Low-Income Survey, NOTE: The coverage distributions include the 1 4% of low-income, nonelderly adults in these states covered by Medicare or coverage other than private insurance or Medicaid % grams (Florida and Texas) than it is in states with recent Medicaid and other coverage expansions (Minnesota and Tennessee) (Exhibit 2). The proportion of low-income adults covered by Medicaid is highest in the states that have expanded coverage, reaching 34 percent in Tennessee, and lowest in Florida ( percent) and Texas (11 percent), where eligibility is largely dependent on receipt of welfare. Without Medicaid it is likely that half of all low-income adults and two-thirds of poor adults would be uninsured. State-initiated expansions in Medicaid appear to be making a major difference in the extent to which low-income adults are uninsured. At the time of their surveys, Minnesota, Oregon, and Tennessee had opened new programs or expanded Medicaid to enroll previously uninsured low-income adults into public coverage. Fewer restrictions and the use of higher income-eligibility criteria have enabled Medicaid to reach a larger proportion of low-income adults in these states than it has in Florida and Texas, where the proportion of uninsured is up to three times higher. Poverty and uninsurance. Despite the role of Medicaid, the risk H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 5

7 of being uninsured remains greatest for those who are poorer. On average, 31 percent of persons with incomes below 0 percent of poverty are uninsured, compared with percent of those with incomes between 1 percent and 2 percent of poverty. However, there is substantial variation across the states (Exhibit 2). Poor adults are two to three times more likely to be uninsured in Texas and Florida than they are in Minnesota, Oregon, or Tennessee. In all five states, the likelihood of being uninsured for the 1 0 percent of poverty group is at least percent higher than it is for those with incomes in the 1 2 percent of poverty range. Private coverage. Overall, private insurance covers about half of low-income adults in the five states, but private coverage is strikingly low among the poor. Private insurance covers fewer than onethird of poor adults (31 percent), ranging from 27 percent to 38 percent across the five states. Even among full-time poor workers living in poverty, fewer than half are covered by employer plans. The likelihood of having private insurance increases with income, with 56 percent of those with incomes between 1 percent and 0 percent of poverty and 77 percent of those with incomes between 1 percent and 2 percent of poverty privately insured (Exhibit 2). Given the wide variation in Medicaid policies and differing industry structures, the extent of private coverage among low-income adults is remarkably similar across the five study states: 59 percent in Minnesota, 54 percent in Oregon, percent in Tennessee, percent in Florida, and 49 percent in Texas. No clear pattern is evident between Medicaid expansions and the likelihood that lowincome adults will have private insurance. In particular, there is no evidence that Medicaid is crowding out employer-financed health insurance, since the extent of private insurance for low-income adults is remarkably similar across states despite wide variations in Medicaid coverage. Gaps in coverage. The low-income population also experiences gaps in coverage and long spells without insurance. Of those with any lapse in coverage, half said that they were without coverage for more than eighteen months, whereas only percent reported that they were uninsured for three months or less (Exhibit 3). Threequarters of the currently uninsured reported being uninsured for the past twenty-four months. The length of time without insurance varies by state. A much higher proportion of those who have been uninsured in Florida and Texas said that they were without insurance for more than eighteen months than was the case in Tennessee, Oregon, or Minnesota (Exhibit 3). Expansions of public insurance programs in the latter three states, as of fall 1995, may have decreased the likelihood that DATAWATCH 169

8 D a t a W a t c h E X H IB IT 3 Length Of Time Without Insurance: Number Of Months Uninsured In Past Two Years, Percent uninsured 70 Less than 3 months More than 18 months Minnesota Oregon Tennessee Florida Texas Total SOURCE: Kaiser/Commonwealth Five-State Low-Income Survey, INSURANCE COVERAGE low-income adults will have to endure being uninsured for periods of time. Conclusion Our survey findings show that the risk of being uninsured is greatest for adults at the lowest income levels and is closely related to state Medicaid eligibility policy. The proportion of uninsured adults is two to three times higher in states that have relatively limited Medicaid eligibility levels. Although the states in our study that expanded Medicaid coverage have not eliminated uninsurance among low-income adults, considerable headway is evident. Whether or not states will be able to sustain the forward momentum on their own, coupled with the simultaneous conversion of Medicaid to managed care, remains to be seen. If savings from managed care fall short or state budgetary pressures emerge, states may curtail expanded Medicaid coverage. Federal policy efforts to expand health insurance that are currently under discussion focus primarily on children, not low-income adults. Although improving the coverage of children is warranted, the findings from this survey show that low-income adults are vulnerable as well. Having insurance affects access to care. In the total sample and in all five states, the uninsured reported more difficulties in getting needed care, are less likely to have a regular provider, and rated the care they do receive as lower quality than those respon- H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 5

9 dents with either Medicaid or private insurance. In sum, the Kaiser/Commonwealth Five-State Low-Income Survey provides insight into the plight of highly vulnerable subpopulations, constitutes a baseline for assessing change in the future, and indicates a need to continue to move forward on expanding subsidized coverage for low-income families. Given the dynamic changes taking place in public programs and private insurance markets, lowincome adults are likely to be at increasing risk of being uninsured. Monitoring the impact of federal and state policies on those who are most vulnerable because of low incomes and poor health will be particularly important as states adopt major changes in health and welfare coverage. The authors acknowledge the assistance of Patricia Seliger Keenan and Maureen Vickers-Lahti. NOTES 1. Employee Benefit Research Institute, Analysis of the March 1996 Current Population Survey, Issue Brief 179 (Washington: EBRI, November 1996); and K. Davis et al., Health Insurance: The Size and Shape of the Problem, Inquiry (Summer 1995): S. Rosenbaum and J. Darnell, Statewide Medicaid Managed Care Demonstrations under Section 11 of the Social Security Act: A Review of the Waiver Applications, Letters of Approval, and Special Terms and Conditions (Report to the Kaiser Commission on the Future of Medicaid, May 1997). 3. Mathematica Policy Research, Inc., Managed Care and Low Income Populations: A Case Study of Tennessee, 1996 Update (Prepared for the Kaiser/Commonwealth Low-Income Coverage and Access Project, January 1997). 4. AFDC standards: Minnesota, percent; Oregon, 43 percent; and Tennessee, 54 percent of poverty. National Governors Association, State Medicaid Coverage of Pregnant Women and Children Summer 1996 (Washington: NGA, August 1996), Table See M. Gold, M. Sparer, and K. Chu, Medicaid Managed Care: Lessons from Five States, Health Affairs (Fall 1996): K. Davis, The Uninsured in an Era of Managed Care, Health Services Research (February 1997): ; and D. Rowland et al., A Profile of the Uninsured in America, Health Affairs (Spring II 1994): See, for example, J. Lambrew et al., The Effects of Having a Regular Doctor on Access to Primary Care, Medical Care 34, no. 2 (1996): 8 1; A. Bindman et al., Preventable Hospitalizations and Access to Health Care, Journal of the American Medical Association (26 July 1995): ; and E. Moy, B.A. Bartman, and M.R. Weir, Access to Hypertensive Care: Effects of Income, Insurance, and Source of Care, Archives of Internal Medicine (24 July 1995): DATAWATCH 171

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