MEDICAID ELIGIBLE, BUT UNINSURED: THE NEW YORK STATE EXPERIENCE Kenneth E. Thorpe Curtis Florence Emory University October 2000 This working paper was prepared by the authors with support from the United Hospital Fund as part of the Fund s efforts to explore the growing problem of New Yorkers without health insurance, and to stimulate discussions on practical strategies to increase health insurance coverage. Address all correspondence to the United Hospital Fund, 350 Fifth Avenue, 23 rd Floor, New York, NY 10118-2399.
OVERVIEW During 1998, approximately 3.1 million New Yorkers received health care through the Medicaid program. During the same year, however, a slightly higher number of New Yorkers, some 3.2 million, were uninsured. Previous studies have found that a substantial number of uninsured New Yorkers meet Medicaid's eligibility guidelines but remain uninsured. 1 This paper examines the magnitude of the number of uninsured New Yorkers eligible for Medicaid and other public programs. Adults and children may receive Medicaid through several channels. These estimates focus on several, though not all, categories of Medicaid eligibility (Table 1). 2 Table 1. Categories of Medicaid Eligibility Based on Income as a Percent of Poverty, New York State, 1998 Category Income* Pregnant women and infants 185% Children aged 1-5 133% Children aged 6-14 100% Children aged 15-18 87% Children aged 19-21 87% Single and unemployed parents 87% Single adults, childless couples, and 55%** adults in two-parent families *Based on net income. New York disregards some income for Medicaid eligibility; therefore, higher income families may be eligible for Medicaid. **Income eligibility varies by county. 1 United Hospital Fund, Taking Steps, Losing Ground: The Challenge of New Yorkers without Health Insurance (New York, 1998). 2 For example, we do not examine Medicaid eligibility among those with SSI eligibility, the medically needy, or the aged. UNITED HOSPITAL FUND 1
METHODS AND DATA We estimate the number of adults and children eligible for Medicaid using the income eligibility guidelines in Table 1. We examine gross income, and model the income disregards (e.g., child care expenses) used by the state for determining Medicaid eligibility. We use similar methods to estimate the number of persons eligible for other public programs. Our analysis relies on the March supplement to the Current Population Survey (CPS). The CPS provides estimates of health insurance coverage, as well as detailed income, employment, and demographic information for each of approximately 60,000 households nationally. For several states, such as New York, the CPS has a sufficient sample to produce state-based estimates. The survey sampling structure relies on the household. Households include immediate and extended families, and may also include unrelated individuals. However, the relevant unit used by Medicaid for determining income and categorical eligibility is a Medicaid standard filing unit (SFU). The SFU is a more restricted group of individuals, such as the mother and child and not the household. We take the household structure of the CPS and create sub-units based on the SFU concept. We then link income to the newly created SFU. Our determination of Medicaid eligibility compares net income within each SFU to the income eligibility guidelines outlined in Table 1. We limit our estimates to adults and children eligible for Medicaid and other public programs. Among those deemed eligible, we examine each person s health insurance status (including uninsured). The number of uninsured, Medicaid-eligible adults and children is the primary focus of our study. UNITED HOSPITAL FUND 2
RESULTS Children and Young Adults Eligible for Medicaid We estimate that 2.2 million children within the income eligibility guidelines outlined in Table 1 were potentially eligible for Medicaid during 1998 (Table 2). Of this total, approximately 54 percent, or 1.15 million, were enrolled in Medicaid at some point during the year. More than one in five children eligible for Medicaid had some form of private health insurance. Finally, more than 540,000 children eligible for Medicaid, over one in four children, were uninsured. Young adults were the most likely and children aged 1 to 5 were the least likely to lack health insurance while they were eligible for Medicaid. Nearly 35 percent of young adults aged 15 to 21, more than 228,000, were eligible for Medicaid but uninsured. Approximately 20 percent aged 1 to 5 more than 122,000 children were uninsured. Medicaid participation was the lowest among young adults aged 15 to 21, with only 40 percent of eligible young adults enrolled, and highest (nearly 63 percent) among children aged 6 to 14. Adults Eligible for Medicaid Certain groups of adults are also eligible for Medicaid in New York. Under the state s old Home Relief program, single adults and childless couples with incomes of approximately 55 percent of the federal poverty level (this varies by county in New York) were eligible for Medicaid. In addition, single adults and two-parent families (with an unemployed parent at home) with incomes at or below 87 percent of poverty were also eligible for Medicaid. UNITED HOSPITAL FUND 3
Table 2. Number of Children and Young Adults Eligible for and Enrolled in Medicaid (000), New York State, 1998 Source of Insurance Age Medicaid Uninsured Other* Total** Under 1 48.4 28.6 38.2 115.3 42.0% 24.8% 33.2% 100% 1-5 355.9 122.2 120.9 599.0 59.4% 20.4% 20.2% 100% 6-14 486.7 164.7 124.0 775.4 62.8% 21.2% 16% 100% 15-21 264.0 228.3 169.7 662.1 40.0% 34.5% 25.3% 100% Total 1,154.9 543.8 452.8 2,151.5 53.7% 25.3% 21% 100% *Some children with Medicaid also have other insurance during the year. These children are included under "Medicaid." **Totals include only those children eligible for "Medicaid." Table 3. Number of Adults Eligible for and Enrolled in Medicaid (000), New York State, 1998 Source of Insurance Category Medicaid* Uninsured Other Total** Single Parents 302.1 109.7 62.5 474.2 and Unemployed 63.7% 23.1% 13.2 100% Parents Single Adults and 132.0 337.6 141.0 610.6 Childless Couples 21.6% 55.3% 23.1% 100% Total 434.1 447.3 203.5 1,084.8 40.0% 41.2% 18.8% 100% SOURCE: Author's tabulations from the March 1999 Supplement to the Current Population Survey * Covered by Medicaid at any time during the year. Medicaid recipients may also have other forms of insurance, or be uninsured during the year. **Totals included only those eligible for Medicaid. UNITED HOSPITAL FUND 4
Table 3 examines the number of adults eligible for Medicaid, as well as the distribution of their actual source of insurance. Approximately 474,000 single and unemployed parents were eligible for Medicaid during 1998. Of this number, more than 60 percent were enrolled in the Medicaid program. At the same time, however, 23 percent of this population was uninsured. Single adults and childless couples comprised the largest group of Medicaideligible adults, as nearly 611,000 were Medicaid eligible. Only 22 percent of this group ever enrolled in the Medicaid program. More than half of such adults some 337,000 were uninsured during 1998. The remaining 23 percent received some form of private health insurance coverage. ESTIMATED NUMBER OF PEOPLE ELIGIBLE UNDER NEW YORK S CHILD HEALTH PLUS AND FAMILIES HEALTH PLUS PROGRAMS New York s Child Health Plus (CHP) program covers children aged 1 through 18 up to 208 percent of the federal poverty level (or 250 percent of the gross federal poverty level). CHP eligibility begins where Medicaid eligibility ends children are eligible for CHP if their family income is above Medicaid levels, but below 208 percent of the federal poverty level. As of June 2000, there were 522,000 children enrolled in CHP (New York State Department of Health, June 2000). We estimate that 147,200 uninsured children are eligible for this program but unenrolled. The Family Health Plus (FHP) program is a Medicaid expansion targeted toward low-income adults. FHP extends (upon federal approval) insurance to the following groups of adults: UNITED HOSPITAL FUND 5
Group Percent of Poverty* Single adults and childless couples 84% Parents 100% by 1/1/2001 111% by 10/1/2001 125% by 10/1/2002 *Based on net income. Table 4 presents an estimate of the number of uninsured adults who will become eligible for insurance under FHP by 2002. CONCLUSIONS During 1998, approximately 3.2 million New Yorkers were uninsured. Our analysis indicates that almost one-third of the uninsured, some 991,000, are currently eligible for Medicaid (Table 5). In addition, nearly 150,000 children are eligible for CHP and nearly 400,000 adults will be eligible for FHP. Adults account for almost half of all uninsured people eligible for Medicaid. However, more than 41 percent of adults eligible for Medicaid were uninsured. In contrast, approximately 25 percent of all children eligible for Medicaid were uninsured. Among those Medicaid eligible, single adults and childless couples are the most likely to be uninsured. They account for over one-third of all Medicaid-eligible and uninsured New Yorkers. Among children, young adults aged 15 to 21 were most likely to be uninsured, accounting for over 40 percent of all uninsured Medicaid-eligible children. The results presented above provide guidance for state and local policymakers for increasing Medicaid enrollment. Substantial attention has recently focused on enrolling uninsured children eligible for either the Medicaid program or the State-Children's Health Insurance Program (S-CHIP). These strategies include enrolling children in schools, as UNITED HOSPITAL FUND 6
Table 4. Number of Uninsured Adults Eligible under Family Health Plus (000), New York State, 1998 Group Number Eligible Single parents and uninsured parents 337.6 Single adults and childless couples 40.7 SOURCE: Tabulations from the March 1999 Supplement to the Current Population Survey. Table 5. Number of Uninsured Children and Adults Currently Eligible for Medicaid (000), New York State, 1998 Category Uninsured Percent of Total Total Eligible Adults 447.3 41.2% 1,084.8 Children 543.8 25.3% 2,151.5 Total 991.1 30.6% 3,236.3 SOURCE: Tabulations from the March 1999 Supplement to the Current Population Survey. well as relying on other government programs (e.g., Head Start) for identifying eligible children. In contrast, strategies for identifying and enrolling adults eligible for Medicaid have received relatively little attention. Indeed, outreach strategies targeting adults may differ from those developing for identifying eligible children. While several programs have recently been adopted in New York to continue to reduce the number of uninsured, a key factor in determining their ultimate success is the ability to enroll those eligible. Our analysis suggests that an important part of the overall strategy for reducing the number of uninsured is the development of outreach and enrollment strategies targeting both uninsured children and adults. UNITED HOSPITAL FUND 7