IV. Other Medicaid Policies Favor a Disproportionately White Population

      Pennsylvania's long-term care reimbursement system offers clearly contrasting examples of how Medicaid policy decisions can facilitate or impede access to care for blacks or African Americans. But recent history reveals other instances in which choices by the Medicaid agency have benefited different racial and ethnic classes of recipients. Because race is so closely tied to economic status, decisions to expand Medicaid eligibility stand out, but more subtle decisions, such as whether to contract with “poor people only” managed care plans, can also impact access to care.

      In the late 1980s and early 1990s, Congress expanded Medicaid eligibility for women and children, which resulted in increased enrollments nationally of almost seven million between 1989 and 1995. The federal expansion came in the form of a mandate with which states had to comply. In Pennsylvania, the expansion was termed “Healthy Beginnings.” Today, Healthy Beginnings extends Medicaid eligibility for pregnant women and children up to age one to families with income up to 185% of the federal poverty income guidelines (“FPIG” or “poverty level”). Children ages one through five qualify with family income of 133% of the poverty level, and children ages six through eighteen qualify at 100% of the poverty level. In 2009, an infant in a family of three qualified if the family income was at or below $2,823 per month, a one-*1172 year-old qualified if the monthly family income was at or below $2,030, and a six-year-old qualified at or below $1,526 per month.

      As a program serving families of modest means, Healthy Beginnings predictably enrolls a significant percentage of black or African American women or children. As of May, 2009, between 21.2% and 24.4% of Pennsylvania's Healthy Beginnings enrollees were black or African American.

      By contrast, in the mid 1990s, Pennsylvania became the only state in the country to extend coverage to children under age 18 with severe disabilities who did not qualify for Supplemental Security Income (and automatic Medicaid entitlement) because their parents' income was too high. Pennsylvania did so by disregarding the income of the parents. Other states extended Medicaid to these special needs children only if they otherwise qualified for nursing home services. Despite a 2005 change to the state welfare code that imposed premiums for children in families with income above 200% of the FPIG, the program is very expensive, and serves an overwhelmingly white population. During 2006, the total number of children enrolled at least sometime was 47,632, at a total cost (state and federal matching funds) of $140,260,140.91.

      The six counties with the highest number of enrolled children were Allegheny, Montgomery, Bucks, York, Delaware, and Chester, respectively. Five of these (all but York) rank among the top six Pennsylvania counties in per capita income. Predictably, Medicaid enrollment of white children in this category of eligibility is between 93.8% and 94.1%. Black or African American children comprise between 4.3% and 5.1% of the enrolled population. As in its long-term care programs, Pennsylvania has established policies which steer funding to a disproportionately white population.