INTERVIEW / Stan Dorn, Director-Health Division, Childrens Defense Fund
Welfare changes could sharply increase number of Medicaid-eligible children who dont enroll
INTERVIEW / Stan Dorn, Director-Health Division, Children’s Defense Fund
Welfare changes could sharply increase number of Medicaid-eligible children who don’t enroll
Dorn: 52% of children get on Medicaid through AFDC.More than half of the 20 million children covered by Medicaid have been receiving it automatically because their families get cash welfare. Under the new welfare law signed by President Clinton Aug. 22, children and parents who would qualify for Aid to Families with Dependent Children (AFDC) under existing law are supposed to receive Medicaid even if they lose cash assistance. But many experts, including Bruce Vladeck, chief of the Health Care Financing Administration, have warned that, if families are required to go through a separate application process, large numbers of people could end up losing benefits because the "take-up" rate of people joining Medicaid is lower when eligibility is not automatic. Stan Dorn, director-health division, of the Children's Defense Fund, talks about ways states could ensure eligibles receive benefits and about some of the positive steps states have taken to improve health coverage for children.
Before the welfare reform law was passed, a General Accounting Office (GAO) report estimated that 2.9 million children who were eligible for Medicaid in 1994, did not receive it. Now with the "delinking" of cash welfare and Medicaid eligibility, isn’t there a concern that children will be even harder to reach?
The Children’s Defense Fund just took a look at some more recent census data and came up with something similar to the GAO estimate—2.5 million children. A few years ago, the Urban Institute looked beyond the federally mandated categories of Medicaid eligibility and concluded that, altogether, 5.6 million children in the early 1990s were eligible for Medicaid, but not enrolled in the program. Regardless of which numbers you use, there are clearly millions of children who are eligible for Medicaid, but not receiving it.
Even without the new welfare law, the procedural barriers that exist are a huge barrier. About half of all Medicaid denials for children are for procedural reasons—for failure to complete the application, failure to turn in required pay stubs, etc. One study, which looked at case files in two Georgia counties, found that most people who didn’t complete the application process or were turned down for procedural reasons were eligible for Medicaid. If you were to look today, you would find, certainly among children in families applying for cash assistance, that the vast majority are eligible for Medicaid. Medicaid coverage is now guaranteed for children through age 13 in households up to the poverty level and most children in AFDC-applicant households are younger children.
Exactly what are the obstacles to obtaining Medicaid coverage?
The Aid to Families With Dependent Children (AFDC)/Medicaid application process is often very difficult, both for those who automatically qualify for Medicaid because they get AFDC and for those who don’t. It can be a 20-page form, more complicated than an IRS form. You have to provide all kinds of documentation that is difficult to obtain. The welfare worker may tell you to go get pay stubs from your employer, and your employer may not want to give you those pay stubs.
What are some successful strategies that have been used by states to reduce or eliminate these obstacles?
One page application forms or self-verification in appropriate cases are some strategies. Self-verification is where you don’t need to bring in pay stubs, but it is made clear that you are completing the application under penalty of perjury if it turns out, through the IRS or other computer records, that you were wrong.
In your view, how has welfare reform added to the challenge?
When lots of families lose their cash welfare benefits, which we know is going to happen, many of those children will not get picked up by Medicaid, though they are supposed to be. That’s because cash assistance is the most secure route to Medicaid. The most recent HCFA data suggest that 52% of children on Medicaid get on that program through AFDC. Many of those children will not get Medicaid, even though they have a theoretical right to the program, if their parents have to fill out a second application to qualify.
Today there is just one application form that serves for both AFDC and Medicaid. That won’t be the case any more. It will be a matter of state option whether to have a single application or separate applications. If there are separate application forms it will be a disaster because families coming in to apply for welfare may or may not be told about the possibility of applying for Medicaid with a separate form.
Is there a danger that people on Medicaid could face a gap in their coverage as a result of welfare reform?
If beneficiaries currently receiving cash assistance are terminated from the program, they are supposed to be kept on the Medicaid program while a redetermination of their potential eligibility for Medicaid on other grounds is evaluated. (The danger is that) there are all kinds of procedural requirements that states are supposed to follow, but sometimes don’t. Families could lose their cash assistance and be required to reapply for Medicaid. It can take months to process an application. If you are sick in the meantime, you don’t get health care, and many families may not reapply because they are not able to run that procedural gauntlet.
Despite these recent developments, the Children’s Defense Fund cites several areas in which there have been significant improvements in child health care. What are some of the most notable?
There has been substantial improvement in immunization rates over the last couple of years, and that seems to reflect vigorous action by literally every component of society, including federal action, state action, physicians, parent education. The 1993 federal Childhood Immunization Initiative has played a major role. One piece of it is the federal Vaccine for Children Program, which provides free vaccines for uninsured children and Medicaid-eligible children. It has just been up and running since October 1994 and it has been extraordinary. These children can receive their immunizations in a physician’s office. In the past, they were typically referred to public health clinics that were overwhelmed by their workloads. You would have parents showing up at 6 a.m. to take advantage of the morning immunization clinic.
Because free vaccines are now provided to the states, state matching money that previously went to pay for Medicaid vaccinations and for vaccines for uninsured children is now freed up for other purposes.
How are states using the money they ordinarily spent on
vaccinations?
All kinds of things. Expanded clinic hours, an increase in general public outreach, i.e. targeting high-risk populations, sometimes door-to-door, or tying into other public programs such as Women, Infants and Children (WIC.) A number have used WIC sites to educate parents.
Some states are developing immunization registries so that providers have the ability to find out whether a particular child has gotten all his or her shots. They also are increasing physician education to make sure that there are not missed opportunities for vaccines. In the past, a child might come in with some illness and the physician or nurse might not think to give the child a shot. Some physicians were under the mistaken impression that a sick child should not be given a shot. There also have been attempts to get hospitals to ensure that a child has all his or her shots, either during emergency room visits or when the child is hospitalized.
Over the governor’s veto, Massachusetts is expanding insurance coverage to an additional 125,000 children who are not currently covered by Medicaid or the state’s Children’s Medical Security Plan. Do you see expanding coverage to children as a growing trend?
The Massachusetts program (paid for by a 25 cent increase in the cigarette tax) is terrific in that the state will probably have one of the country’s lowest rates of uninsured children. What’s exciting about it is not just the policy itself, but the way the legislature passed the bill. It was an incredibly broad bipartisan coalition that included the business community, insurance companies, health-care providers, seniors, people with disabilities and children’s advocates, overriding the opposition of the governor of Massachusetts. The children’s coverage was front and center, but the bill also improves prescription drug coverage for seniors and expands health coverage for people with disabilities.
There have been major expansions of insurance for children in some other states as well. New York has Child Health Plus, a state-only program which tripled in size this past year with the support of the governor. Enrollment is expected to more than double over the next two to three years from 104,000 to 251,000.
The New York program will now cover children up to the age of 18 (previously children through the age of 14 were covered) and will also cover inpatient hospital care. New Mexico covers all children under age 18, up to 185% of poverty. Washington State has coverage for children up to 200% of poverty through Medicaid, with adults covered through the Basic Health Plan.
Do you think this is a trend that will continue?
I think this is a terrific opportunity at the state level to take the initiative, when the economy is good and there are surpluses in state treasuries. When you look at the demographics of the uninsured population, it’s a group that is easy to gather support for. Nine out of 10 uninsured children have parents that work and six out of 10 have parents that work full time during the entire year. There was polling data in Massachusetts that showed that 80% of Republican voters in the state supported the recent expansion of coverage there, as did 90% of the Democratic voters.
Contact Mr. Dorn at 202-662-3595.
A recent General Accounting Office report, based on 1994 statistics, shows that:
• ten million children were uninsured, 14.2% of all children under 18;
• the percentage of children with private insurance
coverage reached the lowest level in eight years—65.6%;
• among children with a parent working full-time during the entire year, approximately 25% lacked private health insurance and nearly 12% were uninsured;
• 62% of children covered by Medicaid had a working
parent; and
• 50% of the children covered by Medicaid did not receive AFDC or other public assistance
"Health Insurance for Children: Private Insurance Coverage Continues to Decline" is available from the U.S. General Accounting Office by calling 202-512-6000. Specify document GAO/HEHS-96-129.
INTERVIEW / Stan Dorn, Director-Health Division, Childrens Defense Fund
Welfare changes could sharply increase number of Medicaid-eligible children who dont enroll
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