Q&A with
Barbara Wolfe, Ph.D.
Barbara Wolfe, Professor in the departments of Population Health Sciences, Economics, and LaFollette School of Public Affairs at the University of Wisconsin-Madison, examines vulnerable populations such as those in poor families. Also an affiliate and past director of the Institute for Research on Poverty, Wolfe recently co-authored the paper, "Extending Health Care Coverage to the Low-Income Population: The Influence of the Wisconsin BadgerCare Program on Insurance Coverage."
Q: What was the aim of this research?
A: When we started, we were looking at the success or failure of expanding SCHIP to adults. We used research in one state, Wisconsin, to ask that question, then offer to other states the results to see if this is a policy they would like to adopt. We looked at a state's program to see if it should serve as a national model, or a model for other states.
Q: So did you determine BadgerCare's expansion to adults as a success or failure?
A: The impression is that it has been very successful. It's targeted at the low-income population and it has increased enrollment pretty dramatically. We estimate the introduction of this program increased the probability of women who left welfare having any health insurance coverage, public or private, by about 15 percentage points. The concern is that it has expanded so much that it has become quite expensive. I think everyone would agree that it has been quite successful in reducing the proportion of uninsured in the state.
Q: What's BadgerCare's biggest success?
A: It serves as a bridge for those who've left welfare and who have gone to work. It has been particularly important as women's earnings have increased and they've lost eligibility for Medicaid. So it has increased the proportion of low-income women who are eligible for any sort of public coverage, and thereby has increased their coverage. They have been able to work without the insecurity of losing coverage.
Q: Why did Wisconsin expand SCHIP coverage to adults?
A: To complement welfare reform. The design of welfare reform in Wisconsin was to provide all the resources individuals would need to make the transition. The state provided a lot of assistance early on so these women could move into the workforce and be productive and self sufficient. The idea was to make these investments - so the state was generous in terms of childcare, transportation assistance, employee assistance when they eliminated straight cash assistance - to make these women successful. Health care too was an important component of this.
Q: How many of these women remain uninsured? Why?
A: We do have substantial proportions that do remain uninsured.
Q: Most other states only expanded SCHIP coverage for kids, right?
A: Right. Only four states have generous programs available to adults, although a number of others increased coverage for adults up to 150% of the poverty line.
Q: How successful was BadgerCare in preserving health care coverage for people who left welfare?
A: Our best estimate is that BadgerCare increased the public health coverage of all leavers by about 17 percentage points.
Q: How many welfare-leaving women gained coverage as a result of BadgerCare versus those who remained eligible for Medicaid?
A: There's no easy answer, in part because the answer differs for every quarter and for each of the three cohorts. By the end of 2001, when we stopped tracking leavers, here was the situation by cohort in our sample:
- 1995 cohort--8,042 leavers: 15 percent were on Medicaid and another 15 percent were on BC at end of 2001.
- 1997 cohort--8,162 leavers: 33 percent were on Medicaid and another 22 percent were on BC at end of 2001.
- 1999 cohort--2,997 leavers: 52 percent were on Medicaid and another 19 percent were on BC at end of 2001.
Note it's not correct to say that BadgerCare increased participation in public insurance programs by 15, 22, and 19 percent for the three cohorts because other changes in policy and the economy were occurring simultaneously.
Q: At what rate, have all states reduced uninsured rates through CHIP programs?
A: This is a heavily studied question. Almost every study focuses on children and not adults, so it's not directly relevant to this research. However, the bulk of research suggests SCHIP accounts for increase in coverage of between 2 and 4 percentage points. It's hard to know for sure, as many of these children would have had coverage under the prior system.
Q: Big differences exist between take-up rates among women who left welfare in 1995 vs. those who left in 1997 group. Why?
A: The 1995 population left welfare at a time when they could have remained. They appear to be a group that is more able in terms of having more education, fewer children, perhaps more labor market experience prior to or while being on welfare. So there was a tremendous increase in eligible for the 1995 cohorts, compared to the 1997 cohorts. More of the 1997 cohorts remained eligible for Medicaid. So there were far fewer people who would be made eligible for public coverage in the 1997 cohort, compared to the 1995.
Q: You said while BadgerCare is viewed as a success, it's coming under pressure because of its costs. Does that have to do with more people qualifying for it?
A: It's certainly under a great deal of fiscal pressure. And the program overtime became more successful. The eligibility criteria really were not changed. Overtime, people become more aware of it and more and more people enroll in BadgerCare, so it's become a more expensive program. Also, health care in general has become more expensive. So each person who is covered is more expensive to cover than when the program was first introduced.
Q: What percentage of BadgerCare enrollment do adults comprise?
A: Two-thirds of BadgerCare enrollees are adults. It suggests that the individuals who are most likely to be uninsured and who would gain the most from an expansion in public insurance amongst the very low-income population, which is really a group of single parents and their children, were the adults. Because Medicaid was in place prior to SCHIP and these families are relatively low income so there wasn't much to gain. So the interesting part is that the group that really gained from BadgerCare seemed to be the adults.
Q: What relevance do the lessons from BadgerCare have for health care policymakers?
A: Our research shows BadgerCare was successful in increasing coverage for this group of vulnerable women as they left cash assistance and moved into the labor force. The take-up rate has been surprisingly high relative to take-up of other programs, although there are still a lot of individuals eligible who aren't enrolled. It's been successful in targeting this particular group and any state wanting to increase coverage in this group could do so by having a program similar to BadgerCare.
Q: What's the take-away for health care policymakers in other states and at the federal level of Wisconsin's experience?
A: If your goal is to decrease the proportion of low-income women who are uninsured, you can do so through a program such as BadgerCare. It gives you a tool to achieve a goal. But states have different goals.
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