Karen Seccombe

The Aftermath of Welfare Reform: Health, Health Insurance, and Access to Care Among Families Leaving TANF in Oregon

This research reports the initial findings of a statewide study that looks at health, insurance, and access to health care among families leaving Temporary Assistance to Needy Families (TANF) for work. Most national and state-level evaluation projects focus primarily on the employment characteristics of TANF leavers and pay little or no attention to health and access to health care. The quantitative data are from a sample of 637 adults in Oregon leaving TANF for work, and they are personalized by qualitative data from a subsample of 90 respondents. Our findings reveal significant barriers to accessing the health care system, even at a time when Medicaid enrollment is considered automatic, in a state with a relatively generous expanded Medicaid program.

Planning for and Securing Health Insurance in the Context of Welfare Reform

Previous research indicates that 25% to 50% of former Temporary Assistance to Needy Families (TANF) recipients and approximately 15% to 30% of their children become uninsured after the expiration of the one-year transitional Medicaid coverage they receive when leaving welfare. Using data from 90 face-to-face interviews, this paper explores the expectations, plans, and coping strategies of TANF leavers in Oregon who are in the middle of this year of transitional coverage. The paper examines (1) the information available to these individuals, (2) their planning and expectations about securing health insurance, and (3) their perceptions of opportunities for obtaining jobs that provide insurance. The paper shows that while TANF leavers often assume their Medicaid coverage will continue after the transitional year, many lack complete information about this. Many respondents have no active plans for securing health insurance. Even those who do have sufficient information to plan for the end of the transitional year may find themselves having to make stark choices (e.g., sacrificing income in order to keep coverage). Policy recommendations are presented.

The impact of expanded health system reform on governmental contributions and individual copayments in the new Chinese rural cooperative medical system

In 2002, the Chinese central government created a new rural cooperative medical system (NCMS), ensuring that both central and local governments partner with rural residents to reduce their copayments, thus making healthcare more affordable. Yet, significant gaps in health status and healthcare utilization persisted between urban and rural communities. Therefore, in 2009, healthcare reform was expanded, with (i) increased government financing and (ii) sharply reduced individual copayments for outpatient and inpatient care. Analyzing data from Chinas Ministry of Health, the Rural Cooperative Information Network, and Statistical Yearbooks, our findings suggest that healthcare reform has reached its preliminary objectives-government financing has grown significantly in most rural provinces, especially those in poorer western and central China, and copayments in most rural provinces have been reduced. Significant intraprovincial inequality of support remains. The central government contributes more money for poor provinces than for rich ones; however, NCMS schemes operate at the county level, which vary significantly in their level of economic development and per capital gross domestic products (GDP) within a province. Data reveal that the compensation ratios for both outpatient and inpatient care are not adjusted to compensate for a rural countys level of economic development or per capita GDP. Consequently, a greater financial burden for healthcare persists among persons in the poorest rural regions. A recommendation for next step in healthcare reform is to pool resources at prefectural/municipal level and also adjust central government contributions according to the GDP level at prefectural/municipal level.

Access to Health Care after Welfare Reform

This research uses data from a longitudinal statewide study of Oregon families leaving Temporary Assistance to Needy Families (TANF) to identify: 1) the trends in insurance coverage over time; 2) the role of health insurance coverage in predicting whether respondents received needed medical care; and 3) the relationship between access to care and physical and mental health. Data were obtained from 637 families seven months after leaving welfare for work; 552 of these families were re-interviewed one year later. The data reveal that 40% of TANF leavers were uninsured at wave 2 and suggest that significant access barriers exist, which may be associated with poor health outcomes.

LIFE AFTER WELFARE IN RURAL COMMUNITIES AND SMALL TOWNS: PLANNING FOR HEALTH INSURANCE

This research explores how families coming off of Temporary Assistance to Needy Families (TANF), the national cash welfare program, plan for their health insurance after their automatic benefits expire. Data were collected in focus groups in rural communities and small towns in Oregon. Respondents reported that topics related to health insurance or planning for health insurance are not components of any welfare-to work curriculum, nor are they part of routine conversations with caseworkers. Many respondents reported that we were the first ones to raise these issues with them. Consequently, they had done virtually no planning for when their transitional Medicaid expires despite their serious concerns about access to health care and their previous negative experiences with being uninsured.

Literacy: Influence on Access and Use of the Health Care System

The striking number of persons with low levels of literacy in the United States is a major public-health concern. This study examines the relationship between literacy levels and both (1) access to health care and (2) use of specific health care services among adults. The data are collected from in-person interviews with a representative sample of adults aged 18–44 in Portland, Oregon, who are proficient English speakers, and have not completed high school nor have a GED. Adults with lower levels of literacy are less likely to have a usual provider, to have health insurance, and they have trouble understanding written medical directions, more difficulty getting needed care, and poorer health. They also use physician services, overnight hospital stays, and emergency rooms more frequently, controlling for education, access, health, and sociodemographic characteristics. Literacy is conceptually distinct from education and independently affects the way in which adults seek health care.