Factors affecting declines in Texas Medicaid enrollment

The welfare reform bill of 1996 presents a degree of change in social policy not seen since the New Deal. One key policy of these reforms is the detachment of Medicaid from the federal cash assistance program, TANF (Temporary Assistance for Needy Families). Medicaid applicants have always had to meet the "income" eligibility guidelines of the TANF program to receive Medicaid, but now, an applicant need not be receiving cash assistance to qualify. Such a provision will drastically expand the Medicaid-eligible population and will provide temporary insurance coverage for those who leave the TANF program. Because insurance coverage has typically been correlated to health care receipt (Kammerman, 1996, Marquis and Long, 1996) this expanded eligibility might result in improving low income families' access to health care. But in Texas, as in many states, the certainty of the success of these policies is in question. Medicaid caseloads have been declining dramatically in Texas since early 1995, despite the fact that policy changes during this period have expanded, not tightened eligibility. Since July 1996, just before federal welfare reform, the Medicaid caseload of families with children has declined by 15%, or 185,000 children, and 62,000 eligible adults (CPPP, 1999). This project seeks to discover what factors might have affected the decline in Texas Medicaid enrollment. It investigates the relationship of familial characteristics, the politics of Medicaid policy design and policy implementation to Medicaid enrollment. The project is comprised of three interrelated components: survey data analysis, an ethnography of low-income families, and in-depth interviews with Department of Human Services personnel and state legislators. The survey and ethnographic data are drawn from "Welfare, Children and Families: a Three City Study", an existing research initiative based at Johns Hopkins University. This dissertation has potential to illuminate (1) what historical, political, and household issues are affecting Medicaid enrollment; (2) what applicants and state workers perceive to be barriers and facilitators to accessing Medicaid; (3) possible routes for community organizations and states to take to ensure better enrollment rates.