اصلاحات رفاهی و پوشش بیمه سلامت از خانواده های کم درآمد

We study whether welfare reform adversely affected the health insurance coverage of low-educated single mothers and their children. Specifically, we investigate whether changes in the welfare caseload during the 1990s were associated with changes in Medicaid participation, private insurance coverage, and the number of uninsured among single mothers and their children. Estimates suggest that between 1996 and 1999, the 42% decrease in the welfare caseload was associated with the following changes in insurance coverage among low-educated, single mothers: a 7–9% decrease in Medicaid coverage; an increase in employer-sponsored, private insurance coverage of 6%; and a 2–9% increase in the proportion uninsured. Among children of low-educated, single mothers, effects were somewhat smaller. Since welfare policy was responsible for only part (e.g. one-third) of the decline in the caseload, welfare reform per se had significantly smaller effects on the health insurance status of low-income families. However, we found limited evidence that changes in the caseload due to state and federal welfare policy had fewer adverse consequences on insurance status than changes in the caseload due to other factors. This implies even smaller effects of welfare reform.

The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) eliminated entitlement to cash assistance, required recipients to meet new work requirements, and instituted lifetime time limits on participation. One of the main goals of the program was to move recipients of cash assistance (i.e. welfare), who are mostly women with children, off public assistance and into the workforce as quickly as possible. Many state welfare reform efforts that preceded PRWORA shared this emphasis on employment as a means to leaving public assistance. Partly as a consequence of these efforts, the number of welfare recipients dropped 62% between January 1993 and March 2001, from about 14.1 million recipients in 1993 to 5.4 million recipients in 2001. A decline in the welfare caseload of this magnitude has the potential to reduce significantly the prevalence of health insurance among low-income families, particularly those headed by unmarried women. Health insurance coverage of these families may be adversely affected because those who leave, or are deterred from entering, the welfare program may find it difficult to obtain Medicaid coverage due to administrative hurdles, and because many of the jobs that low-skilled women typically obtain after leaving welfare do not offer private health insurance. This scenario is consistent with evidence from studies of former welfare recipients, which show that many women and children who left welfare are without insurance (Guyer, 2000). If welfare reform led to loss of health insurance coverage, it would most likely reduce low-income families’ health care utilization and possibly adversely affect the health of persons in these families (Currie and Grogger, 2002). Knowledge of such unintended consequences would almost certainly influence the debate over the efficacy of current welfare policy. In fact, the original Congressional deliberations over welfare reform led to bipartisan support to insure, through provisions in the legislation, that welfare reform did not affect health insurance coverage. In sum, the effect of welfare reform on health insurance coverage is an important and timely public policy issue that is under-researched. In spite of the relatively sparse scientific literature on the subject, it is widely believed that welfare reform has adversely affected the health insurance coverage of low-income families. However, much of the information that is available on the issue has been produced by advocacy groups and is of questionable scientific value. Moreover, the few studies of this problem by social scientists have not reached a consensus on this issue underscoring the need for additional research. In this article, we study whether welfare reform adversely affected the health insurance coverage of low-educated women and their children. Specifically, we obtain estimates of the effect of the welfare caseload and state and federal welfare reform policies on Medicaid participation, private insurance coverage, and the number of uninsured among low-income families. To obtain these estimates we use multivariate regression methods that control for the influence of the economy and other measured factors on health insurance coverage. To bolster the causal interpretation of our estimates, we use a pre- and post-test with a comparison group research design. For this procedure, we obtain regression estimates of the effect of the welfare caseload and welfare reform policy on insurance coverage for low-income families likely to be affected by welfare reform, and similar estimates for low-income families unlikely to be affected by welfare reform. The difference in these estimates is the effect of the welfare caseload and welfare reform policy on health insurance coverage of the affected group.

There is a widespread belief that an unintended consequence of welfare reform was loss of health insurance coverage among low-income families. This belief is supported by findings from “leaver” studies, which show that a significant number, perhaps 40–50%, of women and children who leave welfare are uninsured in the year after leaving welfare, and descriptive statistics from national data sources that show a significant decrease in Medicaid enrollment during the period of welfare reform. Moreover, the low rates of employer-sponsored insurance on jobs typically obtained by low-educated women, and the administrative hurdles associated with Medicaid enrollment, are consistent with the above belief. In this study, we investigated the empirical evidence to substantiate this belief. Results from our study indicate that changes in the welfare caseload were associated with an increase in the proportion of low-educated women and their children who are without health insurance. However, the increase in the proportion uninsured is significantly less than that implied by “leaver” studies and approximately half of the actual decrease in Medicaid coverage. Estimates from our analysis suggest that the 42% decrease in the caseload between 1996 and 1999 were associated with the following changes in the insurance status of low-educated single mothers: • a decrease in Medicaid participation of between three and four percentage points (between 7 and 9%); • an increase in employer-sponsored insurance coverage of two percentage points (6%); • an increase in the proportion uninsured of between 0.5 and 2.5 percentage points (2–9%). For children in these families, the decline in the caseload between 1996 and 1999 was associated with the following: • a decrease in Medicaid participation of between two to three percentage points (3–5%); • an increase in private insurance coverage of between zero and two percentage points (0–9%); • an increase in the proportion uninsured of between one and two percentage points (6 and 11%). A few points are worth noting. First, the increase in the proportion uninsured is less than the decline in Medicaid coverage; there is clear evidence that changes in the caseload and the resulting greater work effort of low-educated single mothers resulted in some increase in employer-sponsored coverage. Second, the increase in the proportion of low-educated, single mothers without health insurance is less than that implied by “leaver” studies. To see why, note that between 1996 and 1999, the proportion of low-educated single mothers receiving cash assistance in our sample decreased by 13.6 percentage points (40%). If 40% of these women were uninsured, as suggested by “leaver” studies, the proportion of all low-educated, single mothers that are uninsured would have increased by 5.4 (0.4×13.6) percentage points. Our estimates suggest that it increased by between 0.5 and 2.5 percentage points, which is only 10–50% of the increase in uninsured implied by “leaver” studies. One possible reason for the difference between estimates is that “leaver” studies ignore entry effects; there may be significant heterogeneity in the health insurance coverage of women deterred from entering welfare and those induced to leave welfare. We also obtained estimates of the effect of changes in the caseload due to state and federal welfare reform policy on the health insurance status of low-income families. On the one hand, these estimates indicated that changes in the caseload due to welfare policy had the same effect on insurance status as did changes in caseload due to other factors. This implies that the effect of welfare reform on insurance status was about one-third the size of the effects listed above, assuming that welfare policy was responsible for one-third of the decline in the caseload. On the other hand, these estimates suggest, albeit with significant qualification, that decreases in the caseload caused by government policy had less adverse effects on health insurance coverage than did decreases in the caseload due to other factors. This is a reasonable result. Women induced to leave, or not enter, welfare because of government policy may be much more likely to take advantage of transitional Medicaid benefits and to find jobs that provide health insurance than women induced to leave the program because of a strong economy. The latter women may have better labor market opportunities and better long range economic prospects that include obtaining private health insurance. They also may be healthier and have healthier children and less likely to need Medicaid and therefore less likely to enroll in Medicaid. Further study is required to sort out these possibilities. What are the implications of these findings? Mostly, the significantly smaller adverse consequences found here as compared to other studies weaken the argument that PRWORA and Medicaid has failed to provide insurance to low-educated women who have exited welfare. For example, Kronebusch (2001) states: “The evidence … indicates that the states have largely failed in the task of protecting Medicaid coverage of low-income children (p. 110).” In light of our findings, this appears to be somewhat of an overstatement. It is true that declines in the welfare caseload have adversely affected health insurance coverage of low-income women and children, but the effects are not as large as previously thought and they do not suggest a general failure of the Medicaid program, as implied by Kronebusch (2001). Moreover, they are apparently not solely due to changes in government policy, but also because of declines in the caseload related to other factors such as better economic conditions. The relatively small effects also suggest that welfare reform and the declines in the welfare caseload has not led to a significant decrease in access to health care that may adversely impact the health of low-income families. Of course, some families who have become uninsured as a result of not being on welfare will suffer some financial hardship and possibly some adverse health consequences. However, the relatively small increase in the proportion of low-income families without insurance associated with welfare reform does not suggest that there was a fundamental problem with the safeguards provided in PRWORA to protect health insurance coverage of former welfare recipients. This is particularly true since some portion of uninsured persons is eligible for Medicaid and will enroll in the program at the time medical services are required. Similarly, the results of this study weaken the argument that cite the loss of health insurance as a consequence of welfare reform as justification for an expansion of Medicaid and the State Children’s Health Insurance Program (SCHIP) to adults (Holahan and Weil, 2001). Proponents of this argument suggest that the large number of uninsured welfare “leavers” illustrates the problem of relying on the labor market to provide health insurance coverage. But the smaller effects found in this study suggest that many women who were deterred from entering or who left welfare remained insured, particularly those induced to leave welfare because of government policies, either by using their transitional Medicaid benefits, or by obtaining employer-sponsored insurance. Indeed, some may argue that these findings show that low-income workers may have more opportunity to obtain employer-sponsored insurance than was previously thought possible. Currie and Yellowitz (2000) show that among working single mothers, over 60% were covered by private insurance in 1996, a figure that has undoubtedly increased because of welfare reform. Currie and Yellowitz (2000) also show that over 75% of low-educated workers are offered employer-sponsored health insurance. So an alternative to expanding Medicaid to near-poor adults is to help low-income workers buy into employer-sponsored insurance. This may be a more cost effective way to increase health insurance coverage and protect health than expanding Medicaid and SCHIP, which basically provide a voucher for free and unlimited health care that results in a significant amount of over utilization (i.e. moral hazard), and which risks causing many families with employer-sponsored insurance to drop such insurance (Cutler and Gruber, 1996).