Health Coverage Instability for Mothers in Working Families

As women have entered the labor force in large numbers, they increasingly have gained access to the employer-based coverage that dominates the U.S. health care system (Mishel, Bernstein, & Schmitt, 2001). Yet, several studies have shown that many working women lack access to employer-based coverage (Currie & Yelowitz, 2000; Hoffman & Scholbohm, 2000; Van Loon, Borkin, & Steffen, 2002), and public health coverage options are limited by rigid income eligibility restrictions (Guyer, Broaddus, & Dude, 2002). The implementation of welfare reforms may have exacerbated this problem, as both work requirements and lifetime limits on welfare receipt have contributed to many women leaving welfare for low-paying jobs and then quickly exhausting transitional Medicaid benefits (Anderson & Gryzlak, 2002; Garrett & Holahan, 2000a). Globalization of the marketplace, increasing use of contingent and contractual labor, and rising health care premiums cast doubt on the future adequacy of employer-based coverage for working women (Davis, Aguilar, & Jackson, 1998; Keigher & Lowery, 1998; Kuttner, 1999). In these dynamic economic and social policy environments, the extent to which mothers have access to either private or public health care coverage requires continuing scrutiny. We examined health insurance stability for a sample of mothers not receiving welfare when TANF programs were being implemented to determine prevalent health insurance coverage patterns for mothers as they experience varying employment and income scenarios. This was useful in ascertaining the health care situations of mothers in working families generally and in predicting coverage prospects for women less able to obtain Medicaid as welfare reform programs mature. We used a measure of health coverage stability, as opposed to coverage estimates at a single point in time, to provide a fuller picture of the health coverage disruptions experienced by women over time. Background In 2001 an estimated 41 million Americans lacked health insurance, and about three-fourths of the uninsured were in working families (Holahan & Kim, 2000; U.S. Census Bureau, 2002). Largely because they often obtain coverage through spouses, uninsurance rates for women were slightly lower than for men (U.S. Census Bureau, 2000). However, women are less likely to obtain coverage through their own employment, which leaves unmarried women particularly vulnerable to being uninsured (Currie & Yelowitz, 2000; Mishel et al., 2001). The implications of these coverage problems are substantial. Research has demonstrated that health insurance coverage improves health care for low-income adults and their children (Almeida, Dubay, & Ko, 2001; Lillie-Blanton, 1999; Salganicoff & Wyn, 1999). In addition, the Medicaid program has been shown to have significantly narrowed socioeconomic differences in health care access and outcomes for nonelderly people (Andrulis, 1998; Berk & Schur, 1998; Currie & Gruber, 1996). Being uninsured is much more prevalent among low-income groups, so poor single mothers who have been the focus of welfare reform are particularly likely to lack coverage in the absence of public health insurance programs. The Family Support Act of 1988 (P.L. 100-485) attempted to alleviate health coverage problems for those leaving welfare by establishing time-limited transitional Medicaid coverage (Garrett & Holahan, 2000b). This coverage continued with the devolution of welfare programs to the states under TANF, and some states have extended coverage beyond the one-year period allowed under federal regulations (Ellwood, 1999; Guyer et al., 2002). Transitional Medicaid assistance is based on a philosophy of providing low-income workers a period of coverage while they gain the job experience needed to gain access to employer-based health care coverage. However, Garrett and Holahan (2000a) found that nearly half the people who leave TANF lack health care coverage one year later. …