Many Working Parents and Families in Georgia Would Benefit from Extending Medicaid Coverage Key Points Georgia is one of the 19 states that have elected not to accept federal funding under the ACA to extend Medicaid 1. Georgia is one of 19 states that has coverage to parents and other low-income adults and is elected not to accept federal funding not actively considering plans for coverage.1 Consequently, under the ACA to extend Medicaid parents in Georgia are not eligible for Medicaid or premium coverage to parents and other low- tax credits if their incomes exceed 39 percent of the income adults and is not currently poverty line ($7,835 annually, or $653 per month, for a exploring coverage options. family of three in 2015) but remain below 100 percent of 2. Georgia has high rates and numbers of the poverty line ($20,090 annually, or $1,674 per month for uninsured children and parents. Nearly a family of three).2, 3 As a result, there are about 300,000 three-in-ten Georgians potentially Georgians (including childless adults) who fall into this eligible for coverage should Georgia coverage gap and at least 500,000 adults excluded from choose to extend Medicaid are Medicaid coverage due to Georgia’s decision not to expand parents with dependent children Medicaid.4 residing in their home. Providing health coverage to Georgia’s parents would reduce children’s uninsurance rate and Figure 1. enhance families’ financial security. Georgia Medicaid Coverage Gap Experience from other states shows that an extremely effective way to reduce the uninsured rate for children is to extend 300,000 Medicaid Georgians Healthcare.gov coverage to parents so the entire family eligible currently excluded eligible can get covered. families from health families coverage 3. Of those parents that could benefit from extended Medicaid eligibility, nearly two- Families Families thirds (57 percent) are employed. Nearly earn less than earn more than half of all uninsured parents (46 percent) $7,835 annually* $20,090 annually work in restaurants, retail, or professional service occupations. * Up to 23 hours at minimum wage for family of three in 2015. September 2015 CCF.GEORGETOWN.EDU GEORGIA MEDICAID EXPANSION 1 Should Georgia choose to extend Medicaid Georgia has some of the highest rates and coverage to adults with incomes up to 138 numbers of uninsured children, parents, percent of FPL, federal funding will be available and adults in the nation. Research based to cover 100 percent of the costs for the on the experience of other states shows newly covered through 2016. Georgia has the that insurance rates for children improve Georgia has some option to join six other states in creating its when coverage is available to the whole of the highest rates own plan to extend coverage through a waiver family. In Georgia, uninsured parents with of certain Medicaid provisions. All six of the children present in the home account for over and numbers of states that have proposed Medicaid waivers one quarter (29 percent) of the population uninsured children, so far have come to agreement with the federal potentially eligible for health coverage if the parents, and adults government and extended coverage.5 Georgia state expands Medicaid.9 The population of in the nation. law currently requires the General Assembly low-income uninsured parents in Georgia most approve any Medicaid expansion.6 likely to be helped by Medicaid expansion in Georgia are white, employed, and have one to According to a study by the Urban Institute, two children. Georgia is foregoing $3 billion annually in federal funds and hospitals will lose $13 billion between 2013 and 2022 from Medicaid funding originally intended to increase care reimbursement funds.7 In addition, between 2014 and 2023 Medicaid expansion would help create 56,000 jobs in Georgia.8 Figure 2. Rates of Uninsurance in Georgia and the U.S., 2013 30.0% 25.8% 25.9% 25.0% Georgia ranks 44th 20.3% for highest rate 19.8% of uninsured 20.0% children 46th 15.0% for highest rate of uninsured 9.6% parents and 10.0% 7.1% 48th for highest rate 5.0% of uninsured adults 0.0% Children Parents Adults (under 18 years old) (18-64 years old) (18-64 years old) Georgia U.S. Source: CCF analysis of 2013 Public Use Microdata Sample (PUMS) from the American Community Survey (ACS). 2 GEORGIA MEDICAID EXPANSION CCF.GEORGETOWN.EDU September 2015 Who Are the Uninsured in Family Demographics Georgia? zz Two-thirds (67 percent) of potentially eligible uninsured parents are in young to middle Data reported here is from 2013 and does not adulthood, between ages 26 and 49 years of reflect the impact of the ACA’s major provisions age. that took effect on January 1, 2014. Full implementation of the ACA will likely improve zz The vast majority of families eligible for an coverage rates and will be reflected in 2014 extension of Medicaid (71 percent) are parents data when it becomes available.10 to one or two children living in the home. zz More than half of families (57 percent) have Employment school-aged children (those ages 6 to 17 zz Of those uninsured parents who could years old). potentially benefit from expanded Medicaid eligibility, the majority (57 Figure 3: percent) are employed outside of the Uninsured Georgia Parents Potentially home, nearly one-third (30 percent) Eligible for Medicaid of parents are not in labor force by Race and Ethnicity (meaning they are most likely students, homemakers, or otherwise retired By Race workers), and only 14 percent are unemployed. zz Nearly one-fifth (19 percent) of potentially Black 40% eligible parents are from families with two working parents in the home. White 49% zz Georgia’s Medicaid expansion would lead to greater health coverage for the working poor. More than half (57 percent) of potentially eligible uninsured parents live below the poverty line (39 to 100 percent Other/Multiracial/ Asian/ FPL). In Georgia, minimum wage workers Hawaiian/API American Indian/ Alaska Native make the federal minimum wage of $7.25 4% 7% per hour. This means that minimum wage workers in a family of three who By Ethnicity work more than 23 hours per week have incomes too high to qualify for Medicaid (39 percent of the FPL is $163 per week). Hispanic Employees earning the minimum wage 13% who work more than 23 hours per week but earn less than $419 per week (100 percent of the FPL) have incomes too high Non-Hispanic for Medicaid and too low for premium 87% assistance through the exchanges. September 2015 CCF.GEORGETOWN.EDU GEORGIA MEDICAID EXPANSION 3 Figure 4. Top 10 Industry Sectors for Potentially Eligible Uninsured Parents in Georgia Retail Restaurant/Food Services Professional Services Construction Of the uninsured parents that Manufacturing could benefit from Medicaid expansion, Medical almost three-fifths or 57% are Service ? employed outside the home. Education Social Services Transportation 0%4% 8% 12% 16% 20% 4 GEORGIA MEDICAID EXPANSION CCF.GEORGETOWN.EDU September 2015 Children Benefit When Their it also leads to better long-term outcomes including lower rates of mortality, improved Parents Have Coverage educational attainment, and government Extending Medicaid coverage to more parents savings. A growing body of research directly helps children by reducing the number documents later-life outcomes improve with Not only does of uninsured children, boosting a family’s childhood access to Medicaid coverage. Medicaid expansion financial security, and enabling children to get better care from healthier parents. One study found that Medicaid eligible children for parents and were more likely to attend college and had Medicaid coverage Covering parents increases the likelihood of lower rates of mortality than their non-Medicaid for children lead children being enrolled in health coverage. A eligible counterparts.16 Expanding Medicaid number of studies find that when parents are eligibility improved the economic outcomes for to better health insured, children are more likely to have health low-income children who experienced positive outcomes in the coverage.11 This is because most uninsured economic mobility in adulthood.17 In addition, short-term, but it children are already eligible for Medicaid or children enrolled in Medicaid had higher wages also leads to better CHIP but not enrolled. A recently published and, because they contributed more taxes later study in Oregon showed the odds of eligible in life, led the government to recoup most of long-term outcomes. children receiving Medicaid or CHIP coverage the dollars spent on Medicaid for children.18 doubled if their parents enrolled in Medicaid.12 When parents are covered, their health Extending Medicaid coverage for parents and status improves along with the well-being of other low-income adults has proven to be an their children. Uninsured parents have more effective strategy to boost children’s enrollment difficulty accessing needed care, potentially rates. Arkansas enrolled significant numbers compromising their ability to work, support of already eligible children when the state their families, and care for their children.19 expanded coverage to their parents. In just one Medicaid coverage improves access to month, Arkansas’s enrollment effort resulted necessary health care and decreases out- in 58,000 new enrollees, including 2,500 of-pocket spending for low-income adults, children.13 improving financial stability for the whole family. Recent research shows that children with For example, more than half of all infants Medicaid coverage and Medicaid-eligible living in poverty have a mother suffering from parents have improved physical well-being, depression.20 Untreated maternal depression earning potential, and educational attainment. can be damaging to a child’s cognitive, social Children enrolled in Medicaid are more likely and emotional development. While depression to receive well-child care and are significantly is treatable, many poor mothers do not receive less likely to have unmet or delayed needs for care. In Oregon, rates of depression decreased medical care, dental care, and prescription by 30 percent as a result of new Medicaid drug use due to cost.14 Expanding Medicaid coverage.21 eligibility to children and parents reduces States choosing to extend Medicaid coverage hospitalizations and leads to fewer emergency to parents directly help children by reducing department visits later in life.15 the number of uninsured children, boosting a Not only does Medicaid expansion for parents family’s financial security, and enabling children and Medicaid coverage for children lead to to get better care from healthier parents. better health outcomes in the short-term, but September 2015 CCF.GEORGETOWN.EDU GEORGIA MEDICAID EXPANSION 5 Appendix: Profile of Uninsured Parents in Georgia Potentially Eligible for Medicaid Age Age of Children 18-25 25% Presence of young children (under 6 years only) 18% 26-34 33% Presence of school-aged children 35-49 35% (6-17 years only) 57% 50-64 7% Presence of both young and school-aged children (under 6 and 6-17 years) 25% Federal Poverty Level 39-100% of FPL 57% Employment Status Employed (Civilian) 65% 101-138% of FPL 43% Unemployed 15% Race Not in Labor Force 20% White 49% Top 10 Industry Sectors Black 40% Retail 18% Asian/Hawaiian/API 4% Restaurants/Food Services 16% Other/Multiracial/ American Indian/ Alaska Native 7% Professional Services (accounting, architecture business support, etc.) 11% Ethnicity Construction 9% Hispanic 13% Manufacturing 8% Non-Hispanic 87% Medical (hospitals, dentist, outpatient care) 7% Number of Children Service (beauty, car wash, maintenance, other) 7% 1 39% Education 5% 2 32% Social Services (child care) 4% 3 20% Transportation 4% 4 5% 5 to 7 4% Note: Due to rounding, percentages may not add to 100 percent. 6 GEORGIA MEDICAID EXPANSION CCF.GEORGETOWN.EDU September 2015 Methodology Data Source he ACS provides one-year health insurance This brief analyzes 2013 Public Use Microdata coverage estimates. The U.S. Census Bureau Sample (PUMS) from the U.S. Census Bureau recognizes and reports race and Hispanic origin American Community Survey (ACS) and applies (i.e., ethnicity) as separate and distinct concepts. the PUMS person weight. The U.S. Census To report on an individual’s race, we merge the Bureau publishes PUMS data on Data Ferrett. data for “Asian alone” and “Native Hawaiian or Parents other Pacific Islander alone.” In addition, we The estimates presented here focus on parents report the ACS category “some other race alone” defined as civilian non-institutionalized adults and “two or more races” as “Other.” Except age 18 to 64 living with a biological, adoptive, or for “Other,” all other racial categories refer to step child under the age of 18 (“own” children). respondents who indicated belonging to only one Note that the definition of “own” children excludes race. foster children since they are not related to the We report “Hispanic or Latino,” as “Hispanic.” As householder. We did not adjust the family unit this refers to a person’s ethnicity, these individuals definition to analyze health insurance units (HIUs), may be of any race. We report data for both most likely resulting in an undercount of the total “white” parents and “white non-Hispanic parents.” number of individuals. The former refers to all parents whose race is Health Coverage reported as white, without regard to their ethnicity; the latter category refers to parents who reported Data on health insurance coverage are point-in- their race as white and do not report their ethnicity time estimates that convey whether a person does as Hispanic. For more detail on how the ACS not have coverage at the time of the survey. The defines racial and ethnic groups see “American estimates are not adjusted to address the Medicaid Community Survey and Puerto Rico Community undercount often found in surveys, which may Survey 2013 Subject Definitions.” be accentuated by the absence of state-specific health insurance program names in the ACS. Employment Medicaid Eligibility Under Current Rules This brief reports those who are employed as those who had a job or business and those who Data on poverty levels includes only those are unemployed as those who do not work or individuals for whom the poverty status can are actively looking for work. The labor force is be determined for the last year. Therefore, everyone classified as employed or unemployed. this population is lightly smaller than the total People who are not in the labor force are mostly non-institutionalized population of the U.S. We students, homemakers, retired workers, seasonal include only those parents whose income-to- workers, institutionalized people, and people poverty status is determined to be 39 percent to doing unpaid family work. As defined by the U.S. 138 percent of Federal Poverty Level ($7,835 to Department of Labor Bureau of Labor Statistics, $27,724 for a family of three in 2015). working part-time is working between 1 and 34 The ACS does not contain sufficient information to hours per week and full time work is 35 hours or determine whether an individual is an authorized more per week. immigrant and therefore potentially eligible for Limitations of Data Medicaid coverage, thus we only include those who are classified as citizens (those who are Data provided in this brief should be noted as born in the U.S.; Born in Puerto Rico, Guam, the an estimate. Variables presented are defined U.S. Virgin Islands, or the Northern Marina; Born using only the information provided on the PUMS abroad of American parent(s); U.S. citizen by and do not include adjustments for possible naturalization). measurement problems. We did not use statistical models to impute for various socio-demographic Demographic and Socio-economic factors (e.g., authorized immigration status and Characteristics health insurance unit). In this brief we report data for all seven race categories and two ethnicity categories for which September 2015 CCF.GEORGETOWN.EDU GEORGIA MEDICAID EXPANSION 7 Endnotes 1 Kaiser Commission on Medicaid and the Uninsured, 10 For examples of preliminary data on uninsurance rates in “Status of state Action on the Medicaid Expansion Debate,” 2014, see federal data from the CDC in “Health Insurance Kaiser Family Foundation (September 1, 2015), available Coverage: Early Release of Estimates From the National at http://kff.org/health-reform/state-indicator/state-activity- Health Interview Survey, January-September 2014”; policy around-expanding-medicaid-under-the-affordable-care-act/. briefs from the Urban Institute’s Health Reform Monitoring 2 Georgia, as in some other states, determines eligibility Survey including “A First Look at Children’s Health limits for Section 1931 parents based on a dollar amount. Insurance Coverage under the ACA in 2014” and “Taking The exact Federal Poverty limit may vary based on Stock: Health Insurance Coverage for Parents under the calculations from the dollar limit. ACA in 2014.” 3 T. Brooks, et al., “Modern Era Medicaid: Findings from 11 Georgetown Center for Children and Families, “Medicaid a 50-State Survey of Eligibility, Enrollment, Renewal, and Expansion: Good for Parents and Children,” (January Cost-Sharing Policies in Medicaid and CHIP as of January 2014), available at http://ccf. georgetown.edu/wp-content/ 2015,” Kaiser Commission on Medicaid and the Uninsured uploads/2013/12/ Expanding-Coverage-for-Parents-Helps- (January 2015). Children-2013.pdf. 4 R. Garfield, et al.,” “The Coverage Gap: Uninsured 12 J. DeVoe, et al., “Effect of Expanding Medicaid for Poor Adults in States that Do Not Expand Medicaid – Parents on Children’s Health Insurance Coverage: Lessons An Update,” Kaiser Commission on Medicaid and the From the Oregon Experiment,” JAMA Pediatrics 169 Uninsured (April 17, 2015), available at http://kff.org/ (January 2015). health-reform/issue-brief/the-coverage-gap-uninsured- 13 A. Strong, “Early Results in Arkansas Show ACA is poor-adults-in-states-that-do-not-expand-medicaid-an- Reaching Uninsured Children and Families,” Say Ahh! update/; G.M. Kenney, et al., “Opting Out of the Medicaid Blog (October 6, 2013), available at http://ccf. georgetown. Expansion under the ACA: How Many Uninsured Adults edu/all/early-results-in-arkansas-show- aca-is-reaching- Would not Be Eligible for Medicaid,” Urban Institute (July uninsured-children-and-families/. 2012); State of Georgia Medicaid Enrollment Forecast – 14 J. Paradise and R. Garfield, “What is Medicaid’s Impact 2012 Estimate. on Access to Care Outcomes, and Quality of Care? Setting 5 The six states with approved Medicaid expansion waivers the Record Straight on the Evidence,” Kaiser Commission are Arkansas, Indiana, Iowa, Michigan, New Hampshire, and on Medicaid and the Uninsured (August 2013). Pennsylvania. 15 L. Wherry, et al., “Childhood Medicaid Coverage and 6 G. Bluestein and M. Williams, “Georgia Weighs Medicaid Later Life Health Care Utilizations,” National Bureau of Experiment (But Not Expansion),” Kaiser Health News and Economic Research, Working Paper 20929 (February 2015). Atlanta Journal-Constitution (May 7, 2015), available at 16 S. Cohodes, et al., “The Effect of Child Health Insurance http://khn.org/news/georgia-weighs-medicaid-experiment- Access on Schooling: Evidence from Public Health but-not-expansion/. Insurance Expansion,” National Bureau of Economic 7 S. Dorn, et al., “What Is the Result of States Not Expanding Research, Working Paper 20178 (May 2014). Medicaid?: Timely Analysis of Immediate Health Policy 17 R. O’Brien, et al., “Medicaid and Intergenerational Issues,” Urban Institute (August 2014), available at http:// Economic Mobility,” University of Wisconsin-Madison www.urban.org/sites/default/files/alfresco/publication- Institute for Research on Poverty, No. 1428- 15 (April 2015). pdfs/413192-What-is-the-Result-of-States-Not-Expanding- 18 D. Brown, et al., “Medicaid as an Investment in Children: Medicaid.PDF. What is the Long-Term Impact on Tax Receipts?,” National 8 W. S. Custer, “The Economic Impact of Medicaid Bureau of Economic Research, Working Paper 20835 Expansion in Georgia,” Health Georgia Foundation (February (January 2015). 2013), available at http://www.healthcaregeorgia.org/ 19 C. Lowenstein, et al., “Linking Depressed Mothers to uploads/file/Georgia_Medicaid_Economic_Impact.pdf. Effective Services and Supports: A Policy and Systems 9 Based on a Georgetown CCF analysis of U.S. Census Agenda to Enhance Children’s Development and Prevent Bureau American Community Survey (ACS) data, 2013 Child Abuse and Neglect: Summary of May 2013 single year estimates. Georgetown CCF estimated that there Culminating Roundtable,” Urban Institute (October 2013). are about 151,000 uninsured parents potentially eligible 20 T. Vericker, et al., “Infants of Depressed Mothers Living for Medicaid if Georgia expands eligibility, accounting for in Poverty: Opportunities to Identify and Service,” Urban 29 percent of the total newly eligible adult population. Institute (August 2010). We believe this likely underestimates the full number and should be used as an approximation for the population 21 K. Baicker, et al., “The Oregon Health Insurance profile of uninsured parents potentially eligible for Medicaid Experiment – Effects of Medicaid and on Clinical expansion. Outcomes,” New England Journal of Medicine 368:1713- 1722 (May 2, 2013). 8 GEORGIA MEDICAID EXPANSION CCF.GEORGETOWN.EDU September 2015 For more information about the research and data presented in this brief, contact Alisa Chester or Adam Searing at the Georgetown University Center for Children and Families. Design and layout assistance provided by Nancy Magill. The Center for Children and Families (CCF) is an independent, nonpartisan policy and Alisa Chester research center whose mission is to expand Alisa.Chester@georgetown.edu and improve health coverage for America’s (202) 687-4917 children and families. CCF is based at Adam Searing Georgetown University’s Health Policy Institute. ags68@georgetown.edu Visit ccf.georgetown.edu (202) 740-1744 Center for Children and Families Health Policy Institute Georgetown University Box 571444 3300 Whitehaven Street, NW, Suite 5000 Washington, DC 20057-1485 Phone (202) 687-0880 Georgians for a Healthy Future is a nonprofit Email childhealth@georgetown.edu consumer health advocacy organization with a mission to build and mobilize a unified ccf.georgetown.edu/blog/ voice, vision, and leadership to achieve a healthy future for all Georgians. facebook.com/georgetownccf Visit healthyfuturega.org. twitter.com/georgetownccf September 2015 CCF.GEORGETOWN.EDU GEORGIA MEDICAID EXPANSION 9