«Co-Principal Investigators Jerome Seliger, Ph.D. & Carl A. Maida, Ph.D. Department of Health Sciences California State University, Northridge August ...»
Policy Options in Transitional Health Insurance Coverage
Faculty Fellows Program
Center for California Studies
California State University, Sacramento
in cooperation with
California Legislature -- Senate Office of Research, Sacramento
Jerome Seliger, Ph.D. & Carl A. Maida, Ph.D.
Department of Health Sciences
California State University, Northridge
August 1, 1998
We would like to thank Judy Cohen, MPH (Westside Women’s Health Center) for her work in assembling and facilitating the focus groups, and in providing skilled translation and transcription of the focus group interview; Roberto Belloso, MPH (County of Los Angeles, Department of Health Services) for his work in conducting the cognitive interviews, in field testing the survey, and in providing skilled translation of the survey questionnaire; and Jorge Lara and Gloria Martinez (Pacoima Urban Village), Tom Boczan (Plaza Community Center), Joanne Rojas (St. Mary’s Hospital Medical Center), Kimberly McLay (Flossie Lewis Center), and Pastor Leonel Robaina (Temple Baptist Church/Hispanic Congregation, Los Angeles). We would like to thank Hal Hunter (California State University, Long Beach), for his invaluable assistance in framing the policy issues, and Linda Fidell (California State University, Northridge) for her assistance in assessing respondent answers to the research-developed questionnaire. We would also like to thank the following for their support of the study: Frank Martucci, Tom Welch and Marlene Ratner (California Department of Health Services), Jan DeSilva (California Department of Social Services), Peter Hansel (California Legislature - Senate Office of Research), Ingrid Aguirre Happoldt (Medi-Cal Policy Institute), Lucy Quacinella (Western Center on Law and Poverty), and Robert Wassmer (California State University, Sacramento - Center for California Studies).
TABLE OF CONTENTS
TABLE OF CONTENTS 3
LIST OF TABLES 4
EXECUTIVE SUMMARY 5
POLICY RECOMMENDATIONS 6
INTRODUCTION 7STUDY DESIGN 10 Defining the Study 10 Field Research 11 Respondent Universe 12
ATTACHMENT C: Transitional Medi-Cal Questionnaire: English Language 46 Version ATTACHMENT D: Transitional Medi-Cal Questionnaire: Spanish Language 47 Version
Table Number 1 Demographic Profile of Field Test Respondents 2 Self reported Health Status 3 Length of Time as AFDC Recipient 4 Current Medi-Cal consumer 5 Respondents leaving Cash Assistance but Retaining Medi-Cal 6 Dropped from Medi-Cal After Leaving Cash Assistance 7 Best Ways to Help Eligible Persons Retain Medi-Cal after Cash Assistance
Medi-Cal is a crucial component of the CalWORKs safety net for eligible parents and children. The data nationally and in California suggest that parents, the vast majority of whom are single head of household and women, generally fail to apply for or continue Medi-Cal coverage when they leave cash assistance for work. A number of variables impact this behavior. Out-of-pocket charges during the first half of the CalWORKs Medi-Cal transitional insurance period may be a limiting factor. However cost alone cannot explain the relative low enrollment rates in the Medi-Cal program following an end to cash assistance or the low continuation rates as these former beneficiaries encounter a work place in which many employers do not make arrangements for or subsidize group health insurance. This report describes an initial study of factors that CalWORKs eligible persons felt may impede persons such as themselves from enrolling in Transitional Medi-Cal (TMC) coverage.
The project had dual aims. The first aim was to develop information about health insurance and TMC held by persons formally or currently receiving cash assistance. The second aim was to involve respondents representative of the cash assistance population in development of a questionnaire that assesses respondent (1) knowledge of the TMC entitlement, (2) interest in obtaining TMC, and (3) the extent to which they have or value other health insurance.
We developed baseline information about TMC and health insurance held by respondents demographically representative of the CalWORKs participant universe. Working collaboratively with community-based family and child welfare agencies in Los Angeles county we assembled four focus groups of former cash assistance recipients. Focus groups were conducted at host agency sites convenient to respondents in Pacoima in the northeast San Fernando Valley of Los Angeles county, East Los Angeles, and Long Beach. A total of 50 persons participated. The aim of the focus groups was to gather information about respondent (1) knowledge of TMC, (2) barriers to accessing TMC, (3) verbalized satisfaction with prior and current experiences as a Medi-Cal consumer, (4) knowledge of health insurance and perceived valuing of health insurance, and (5) suggestions for improving communication with Medi-Cal consumers.
Drawing on the results of the four focus groups, we constructed a draft survey questionnaire with items intended to assess respondent knowledge, attitudes and practices related to TMC. We exposed 32 individuals as a group to a “cognitive interview” to determine how respondents interpret the items. With their feedback we revised the questionnaire and field tested it with 24 individual respondents. The participants in both the cognitive interviews and the field test with individuals were Spanish-speaking MediCal insured and medically indigent women. This cohort was selected because Spanishspeaking persons are the cultural and linguistic population least benefiting from TMC.
Results of the field test were used to develop a recommended future survey process and methodology, and to construct a recommended TMC Survey Questionnaire.
We make seven policy recommendations. They are to:
Validate and test the reliability of the TMC Survey Questionnaire across CalWORKs sub-populations statewide (See Attachments C and D).
Assess the use of church-based outreach for its potential in recruiting and motivating eligible persons to enroll in TMC, Healthy Families, and other entitlements.
Evaluate various interventions in current practice used to recruit and motivate eligible persons to enroll in TMC, Healthy Families, and other entitlements.
Evaluate the use of non-traditional outreach methods that reduce applicant fear of authority, the INS, legal sanction, and disclosure of status and need, particularly among immigrant populations.
Use clear, straightforward messages delivered in writing and interpersonally to communicate with eligible persons about TMC.
Communicate with clients individually, in non-group settings, with sensitivity to time, culture, language, and support factors such as transportation and child respite care.
Examine institutional requirements that may impede eligible persons from accessing and enrolling in TMC or Healthy Families programs.
Medi-Cal is a crucial component of the CalWORKs safety net for eligible parents and children. The data nationally and in California suggest that parents, the vast majority of whom are single head of household and women, generally fail to apply for or continue Medi-Cal coverage when they leave cash assistance for work. A number of variables impact this behavior. Out-of-pocket charges during the first half of the CalWORKs MediCal transitional insurance period may be a limiting factor. However cost alone cannot explain the relative low enrollment rates in the Medi-Cal program following an end to cash assistance or the low continuation rates as these former beneficiaries encounter a work place in which many employers do not make arrangements for or subsidize group health insurance. This report describes an initial study of factors that CalWORKs eligible persons felt may impede persons such as themselves from enrolling in Transitional Medi-Cal (TMC) coverage.
The clear majority of women entering the workforce from the CalWORKs entitlement have very low literacy levels and marketable skills. The point-of-entry, or reentry for most of these workers is into service sector jobs or assembly jobs not requiring much prior know-how. Also, the majority come to the work place with relatively skewed perceptions of work accountability, employer expectations, norms of behavior, hygiene, dress, and lack of sensitivity to time and collaboration expectations. Jobsuccess failure rates are high, especially for first-time workers although the reality is that all of these persons face considerable barriers which seem to proscribe their long term success.
The California GAIN Employment and Training programs found that only 25 percent of persons entering employment had health insurance or prepaid health care after 2 or 3 years on the job. But these data do not account for the many unable to obtain or keep their jobs for a variety of inter-related reasons including inadequate child care, care demands in their home, inability to adjust to the culture of the workplace, loss of MediCal coverage, and other reasons. It would seem that Medicaid/Medi-Cal transitional coverage would lessen work failure due to loss of insurance but the fact that relatively few transitioning workers avail themselves of this resource may be because they may give more importance to insurance coverage for their children than for themselves. With Medi-Cal expansion and California’s new Healthy Families program now operational coverage for children in these families probably will become less of an issue although the consistently large number of uninsured children statewide is an issue policy makers must ponder.
As former welfare recipients meet with success in employment and their earnings move them above means-test thresholds for Medi-Cal or Healthy Families we are likely to see an increase in job turnover as workers seek employment that has affordable health insurance benefits for dependents. In the absence of reasonable employer-arranged insurance and dependent coverage many may consider returning to the “safety net” of cash assistance.
Former recipients do not access the TMC coverage for many reasons. Lack of knowledge contributes as does perceived stigma associating Medi-Cal with “welfare” social ascription. The failure during the first weeks of eligibility to follow required registration and other procedures probably keeps many from the program. Lack of understanding of health insurance and health insurance products is also a likely reason many do not register. We know that younger persons, particularly those new to the workforce, have little understanding of the market price of health insurance, employer sentiment about and willingness to make health insurance and other benefits available to employees, or about potential cost of health insurance or dependent health insurance coverage.
TMC enables families to segue into employment while retaining full Medi-Cal coverage for all eligible family members. This resource is potentially quite valuable to the many taking entry level jobs that do not include an affordable health insurance benefit. Premium costs and out-of-pocket charges for commercial insurance or managed care products are beyond the reach of most whose net earnings hover above poverty levels. It is problematic too whether these entry level workers have sufficient discretionary income to purchase Healthy Families coverage. As health needs require professional care services persons without TMC or other forms of insurance will be forced to leave the workforce and return to cash assistance for the health insurance protection it provides.