Left Out: Women’s Life Changes Put Their Access to Health Insurance at Risk

This article is the third in Child and Family’s five-article series on the intersection of child and family policy and entitlement programs. For the rest of the series, click here.

Changes in health insurance systems over the last 20 years have significantly impacted low-income women in America. Research on health insurance coverage generally relies on snapshots of data from one moment in time, which cannot capture changes in life circumstances that low-income women often experience. In her September 2013 Sociological Forum article, “The Cost of Instability: The Effects of Family, Work, and Welfare Change on Low-Income Women’s Health Insurance Status,” Elizabeth Legerski argues that life changes for low-income women—such as moving onto welfare, gaining employment, or ending a marriage—are associated with a higher likelihood of using public health insurance programs.

In the paper, Legerski, a professor at the University of North Dakota, identifies key trends impacting low-income women between 1999 and 2005. The percentage of women below the poverty line decreased from 73 to 53 percent, and the percentage of women receiving welfare decreased from 36.7 to 14.6 percent. Along the goals of welfare reform, the percentage of women working full time increased 15 points (from 40 to 54.6 percent), and the percentage of women who married increased almost five points (from 14 to 19.6 percent).

Although many low-income women experienced life changes in the six years of the study, Legerski’s findings did not indicate a proportionate change in their health insurance status. According to the author, the percentage of uninsured women decreased by just two points (from 30 to 28 percent), and the percentage of women receiving Medicaid decreased by only four points (from 53 to 48.9 percent).  Merely looking at these broad numbers masks the actual correlations between life instability and health insurance status, which Legerski uncovers next.

Legerski finds that, compared to those with no access to welfare (these women may have never been eligible, may have exceeded their five year benefit cap, or may have failed to fulfill a permanent residency requirement), those who had a change in welfare status or who stayed on welfare were more likely to be on Medicaid than on private or employer-based insurance. Additionally, compared to those who stayed employed, those who experienced a change in full-time employment or were employed less than full-time were more likely to be on Medicaid than private or employer-based insurance. Surprisingly, those who gained full-time work were also found to be at risk of being uninsured.

With these findings, Legerski argues that gaining full-time employment is not a guarantee of access to health insurance, perhaps because women can be sandwiched between losing public health insurance and not being able to access private or employer-based insurance. Finally, Legerski finds that compared to those who stay married, those who had a change in marital status or who stayed single were more likely to be on Medicaid than private or employer-based insurance. In particular, staying single increased the likelihood of being uninsured.

Legerski emphasizes that even though the percentage of women below the poverty line decreased by 20 points between 1999 and 2005—a result of the rising proportion of low-income women in the labor force—the percentage of uninsured women decreased by only two points. This indicates that the current health insurance system is not meeting the needs of low-income women. As the Affordable Care Act continues to be implemented, the author is hopeful that expanded Medicaid coverage and subsidies will benefit low-income women currently ineligible for public health insurance. However, as long as instability in these women’s lives remains underappreciated in reforms, their needs may not be adequately addressed. Instead of narrowly defining eligibility and benefits in public health insurance systems, a more robust and flexible support network would yield improved health outcomes for low-income women, enabling a greater workforce and improved civic engagement.

Feature Photo: cc/(Contract Surfaces, Inc.)