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Unprecedented and Unequal: Racial Inequities in the COVID-19 Pandemic

Posted on October 14, 2020December 14, 2020 by Brittany Holom-Trundy

Published on Oct 14, 2020 in COVID-19, Health

Health disparities in the COVID-19 pandemic spotlight the long-standing inequities that permeate the health care system. Though the pandemic has been undeniably devastating throughout the country, the impact on Black and Latinx communities outpaces that on other populations.^[i] Nationally, Black and Latinx residents have been three times more likely than white residents to contract COVID-19 and nearly twice as likely to die from it.^[ii] These patterns are also reflected at the state level. This report examines racial disparities in New Jersey throughout the COVID-19 pandemic and suggests policy solutions to alleviate these problems and build more equitable conditions for the future.

Black and Latinx Cases, Hospitalization Rates, and Mortality Rates Outpace Others

The Garden State’s population, while increasingly diverse, still sees the impact of structural racism in its housing and occupational divides.^[iii] Past redlining practices have resulted in the segregation of neighborhoods and schools, with many Black and Latinx families living in densely populated metro areas with segregated school districts.^[iv] Residents of color make up over half of employees in essential, or “frontline” industries, including grocery stores and pharmacies; trucking, warehouse, and postal services; cleaning services; public transportation; health care; and child care and social services.^[v] These vulnerabilities, in addition to the need for many to commute into New York City or Philadelphia for work, put these residents at greater risk for exposure to the virus. The results of that structural risk are seen in the data, with Black and Latinx populations disproportionately represented in COVID-19 case, hospitalization, and mortality rates.

Age-adjusted case, hospitalization, and mortality rates also show that New Jersey’s Black and Latinx residents have suffered directly from the disease at double to triple the rates of the state’s white and Asian residents.^[vi] Due to poor socioeconomic conditions and systemic racism in the health care system, Black and Latinx communities often die at younger ages and have proportionally more young residents than white populations. This means that, amongst the elderly, there are regularly more white than Black or Latinx individuals. The elderly are the most vulnerable age group to COVID-19, which is a possible reason that the white death rate is proportionally higher than the case rate — because there are more white, as opposed to Black or Latinx, elderly residents to suffer from age vulnerability. However, Black and Latinx residents are more likely to contract, be hospitalized, and die from COVID-19 than white residents of the same age group. The age-adjusted rates, then, allow us to better compare relatively incomparable populations, by assessing what the rates would look like if the age structures (proportion in each age group) of these populations were the same. In the case of New Jersey, this shows that Black and Latinx residents have been significantly more likely to suffer from COVID-19 in every way than white or Asian residents.

The state data remains consistent with patterns seen at the national level. In the COVIDView Surveillance Summary published weekly by the Centers for Disease Control and Prevention, nationally reported hospitalization rates amongst Latinx, Black, and American Indian or Alaska Native residents are higher than those of white residents in every age group. The highest rates by age group in the national data range from 3.7 (for non-Latinx Black residents, age 65+) to 8.2 (for Latinx residents, ages 18-49 years old) times those of white residents for that age group.^[vii]

Black and Latinx people are more likely to contract COVID-19 than would be expected based on their representation in most counties. Black residents have been particularly overrepresented amongst cases in Atlantic, Burlington, Camden, Essex, Gloucester, Mercer, Somerset, and Union Counties. This means that, even in places where the outbreak and surge began later and general protective measures were already put in place when the disease arrived, residents of color were still more vulnerable than others; their high numbers of deaths and cases were not just due to initial outbreak conditions. In Salem County, for example, Latinx residents made up approximately 40 percent of cases by the end of May, while only accounting for roughly 9 percent of the county population. This means that Latinx residents are between 4 and 5 times overrepresented in the county case count as compared to their representation in the population.^[viii] Like with the state-level data, there is a clear divide between Latinx and Black health outcomes and white and Asian health outcomes.

Addressing racial inequities in health will take more than a quick infusion of money or testing during the public health crisis, however. Success in tackling these inequities will include not only improvements in access and quality in the health care system itself, but improvements in conditions shaped by social determinants of health that exacerbate vulnerabilities to outbreaks, such as inadequate housing,^[ix] limited access to nutritious foods,^[x] and low-paying jobs in unsafe environments that prove to be essential during historic pandemics.^[xi]

The COVID-19 pandemic has highlighted these broader trends in socioeconomic vulnerabilities. Residents of color have seen the greatest unemployment rates throughout the crisis in New Jersey, putting them at greater risk for financial insolvency.^[xii] In the Household Pulse Survey from the Census Bureau, Black and Latinx households in New Jersey were approximately three times more likely than white households to report not having enough to eat in the past seven days.^[xiii] Black and Latinx residents, as well as residents identifying as multiracial, were more likely to report being behind on rental payments than white or Asian residents: Latinx residents were twice as likely as white residents to report this, while Black and multiracial residents were between 3.5 and 4 times more likely to do so.^[xiv] Latinx residents were three times more likely than white residents to report lacking health insurance, in addition to being the most likely residents to experience feelings of nervousness, anxiety, and being on edge.^[xv] Black residents were twice as likely as white residents to report lacking health insurance;^[xvi] they were also most likely (nearly 1.5 times more likely than white residents) to report both delaying medical care and needing medical care for something other than COVID-19, but not getting it, in the past four weeks.^[xvii] As a result, there are dual crises: residents of color have a greater likelihood of contracting the virus due to unhealthy conditions beyond their control, while they also face the devastating impact of the virus on long-term health and finances. This will create even greater inequities of health and well-being outcomes in the post-COVID-19 world.^[xviii]

Lack of Adequate Planning and Prevention has Led to Greater Suffering

State and local lawmakers’ efforts to address racial disparities and prevent devastation that exacerbates inequities have been inadequate. New Jersey’s county leaders did not anticipate a pandemic sweeping through the state so violently; only Mercer County identified a pandemic as a hazard of concern in mitigation plans in 2018.^[xix] Given this, during the early stages of the crisis, counties were less prepared, hospitals were overwhelmed, and, without known treatments and overflowing hospital beds, providers were required to ration treatments, meaning that patients were more likely to die.^[xx]

This lack of preparation was not inevitable. In New Jersey, past disease outbreaks have shown that certain counties and populations are regularly vulnerable to these early stages of epidemics.^[xxi] With COVID-19, the first case was identified in Bergen County, near New York City, on March 4, 2020.^[xxii] The outbreak quickly spread to the neighboring counties outside of New York City, the same counties that have been vulnerable to outbreaks in the past.^[xxiii] Of the state’s seven counties with majority communities of color — that is, counties with over 50 percent of the population identifying as Latinx, Asian, Black, Alaska Native, American Indian, Native Hawaiian or Other Pacific Islander, or another race outside of the white population in the 2019 American Community Survey data (Cumberland, Essex, Hudson, Mercer, Middlesex, Passaic, and Union) — five (Essex, Hudson, Middlesex, Passaic, and Union) were among those hit the hardest by the pandemic during its early stages.^[xxiv] Even within counties, communities of color suffered more than white populations, as access to resources became a determining factor in the number of cases and deaths, creating disparities between neighboring zip codes.^[xxv]

This means that the harms of COVID-19 in New Jersey have been two-fold. First, the counties to initially get hit — and therefore, are most vulnerable to a surge beyond their hospitals’ capacities — were largely communities of color, resulting in many cases and deaths among residents of color. Then, in counties not hit by the early surge, Black and Latinx populations have been more vulnerable, likely due to the effects of structural racism that have created unhealthy environments and living conditions, limited access to care, and discrimination in care.^[xxvi]

This lack of planning can be seen in health statistics beyond the COVID-19 data. This is because the toll of COVID-19 comes not only from cases related to the disease itself, but also from its consequences. Excess death data, which compares the deaths counted during a specific time period to average deaths during that period in previous years, can help to show a picture of the true impact of an event by accounting for not only deaths directly from COVID, but also those that may have resulted from the indirect effects of the outbreak, such as depression and other mental health challenges due to hardships or an unwillingness or fear of seeking care for other medical issues.^[xxvii]

Like with the confirmed cases data, New Jersey’s most diverse communities have significant representation when examining excess deaths. Essex County, in which approximately 70 percent of residents are people of color, saw nearly 1,900 excess deaths at the peak of the pandemic in April 2020, an approximately 400 percent increase over the average April death count for the county.^[xxviii] Essex County has also experienced the highest number of deaths overall from COVID-19, counting 1,901 confirmed deaths as of October 7, 2020. Additionally, there have been an estimated 229 probable COVID deaths in the county that have not been confirmed.^[xxix]

While Essex County’s number of excess deaths comes close to its number of confirmed and probable COVID-19 deaths, the hundreds of additional deaths included in the data may be unconfirmed deaths due to COVID-19.^[xxx] These can result from lack of access to testing, avoidance of or lack of access to care for other medical issues, or “deaths of despair” — deaths due to drugs, suicide, or alcohol — that can be connected to the stress of the COVID-19 pandemic.^[xxxi] Amongst communities of color, deaths both directly from COVID-19 and deaths caused indirectly by the pandemic’s conditions are also exacerbated by “weathering,” the effect on health and well-being of living long term with inequitable socioeconomic conditions.^[xxxii]

The impact of the COVID-19 pandemic does not end with hospitalizations and deaths, or even with possible unconfirmed deaths or deaths caused indirectly from the pandemic’s conditions. Differences in trust in the medical system across racial groups will cause these disparities to diverge even further. A long history of systematic racism in health care remains fresh for many Black residents, and many still experience this racism today. This has led to a distrust among Black communities, in particular, of doctors, vaccines, and other paths that will be necessary tools in containing the outbreak.^[xxxiii] If people most at risk for the virus and long-term damaging effects or death are also more likely than others to either not have access to or to be unwilling to get the vaccine, then disparities will become even greater as the outbreak rages on amongst our most vulnerable populations. The more the virus continues to spread, the more that neighbors, friends, classmates, and co-workers also continue to risk contracting COVID-19, and the worse the long-term economic impact of the pandemic.

The lack of extensive data collection and transparency makes all of the efforts to address issues of inequity and build better preparedness systems more difficult. Lawmakers have been slow to initiate the collection of racial and ethnic data during both COVID-19 and previous public health emergencies, resulting in partial data and a need to try to backtrack in order to add this data to previously collected information.^[xxxiv] When data is collected, the categories often used for race and ethnicity, including those used by the New Jersey Department of Health (DOH) cited here, are broad. In being so broad, they do not accurately depict the many varied experiences of residents within each race or Latinx category. They do not, for instance, differentiate between residents identifying as East Asian (such as Japanese) versus South or Southeast Asian (such as Indian). They also do not account for the different experiences of residents who are first-generation immigrants as compared to residents who identify with a racial or ethnic group but have grown up in the United States. This can be an important factor in understanding the full picture of residents’ experiences with racism in the healthcare system and therefore needs to be examined more in-depth than the data currently provides.^[xxxv]

Greater Investment in the Future Health of New Jersey is Necessary

Budget choices reveal lawmakers’ values, especially when choices about access to health programs can literally be the difference between life and death. Overall, funding for DOH has significantly decreased over the past 15 years, standing 61 percent lower than its Fiscal Year (FY) 2005 levels. Funding relative to the size of the population has been reduced from $287.62 per resident in FY 2005 to $178.46 per resident in FY 2019.^[xxxvi]

Some of this funding decline was due to structural changes, such as the moving of programs outside of DOH. For instance, the Division of Aging (formerly known as Senior Services) — which funds programs like the Pharmaceutical Assistance to the Aged and Disabled (PAAD) and Senior Gold programs that provide prescription drug benefits to low-income seniors and individuals with disabilities — moved to the Department of Human Services (DHS) in FY 2013.^[xxxvii] In addition, the state has not increased funding for DOH to reflect increases in New Jersey’s population.

While DHS directs many services related to health (such as Medicaid) and other anti-poverty initiatives that address social determinants of health, the overall decline in direct DOH funding has resulted in diminishing support for many key divisions and programs addressing health inequities. These include the Office of Minority and Multicultural Health as well as the Communicable Disease Service, which are meant to strengthen New Jersey’s health care system and better protect New Jersey residents.

The Office of Minority and Multicultural Health, the mission of which is to “promote health equity for all and reduce health disparities,” has received the same special purpose funding ($1.5 million) from the early 2000s up until the fiscal year 2021 budget, when a slight cut was made in response to the COVID-19 crisis.^[xxxviii] Because the funding was maintained at the same dollar amount, the value of those dollars has decreased over the years due to inflation.

Attention given to newer initiatives to address racial disparities, such as the Nurture NJ multi-agency campaign to address New Jersey’s abysmal Black maternal and infant mortality rates, has provided some promise of improvements in the future.^[xxxix]These programs cannot be short-lived or one-off promotions, however, to truly impact the long-term health landscape for New Jersey’s populations. In order to both permanently and effectively address racial disparities in health outcomes, New Jersey lawmakers should consider prioritizing the following:

Build data collection capacity and transparency.
Much of the data presented in this brief does not cover all cases, hospitalizations, or deaths. Some only cover around 50 to 60 percent of cases because racial and ethnic data was not directed to be collected until the end of April, a month after Governor Murphy instituted his stay-at-home order.^[xl] The need for this data should not have been a surprise — there were many calls for better collection efforts after the 2009 H1N1 outbreak in the United States, which appear to have gone unheeded.^[xli] Without data — and particularly data collected on cases, rather than just during hospitalization or post-mortem — it is impossible to determine how to most effectively and efficiently fund and design programs meant to address racial inequities.A federal initiative to regulate these types of actions across states would produce more uniform data and a clearer picture than current efforts, since states have differing practices in both the decisions to collect data and how they collect the data.^[xlii] However, until federal-level initiatives are pursued, New Jersey can take its own steps to become a leader in these efforts. Regulations that automatically trigger this data collection during crises and permanent directives to collect this data would move the state forward in better understanding the consequences of outbreaks like COVID-19. Additionally, greater efforts to coordinate and support systematic population health work in the state is needed: New Jersey is currently one of only 15 states without a public health institute or participation in the National Network of Public Health Institutes.^[xliii]
Require regular state health racial equity impact assessments for policy proposals.
In addition to greater data transparency during crises, New Jersey should require systematic analysis of the racial impacts of policy proposals. This would both aid in providing a picture of the long-term impact a policy would have on New Jersey’s population, as well as develop a stronger understanding of policy designs that work.^[xliv] Having improved data collection efforts, as mentioned in the section above, is crucial for this work.
Increase support for initiatives that improve trust in the medical system.
While cultural competency training will aid in the communication between doctors and patients and therefore should be continued, it does not guarantee overall greater health outcomes unless residents of the at-risk populations come to a medical professional in the first place.^[xlv] Programs that work to understand the causes of distrust and identify trusted sources of information can help to create better systems for disseminating facts about medical care and encourage take-up. Increased funding and support for New Jersey’s Office of Minority and Multicultural Health, initially established in 1991, can provide a foundation for these efforts.^[xlvi]
Encourage policies that diversify the medical field and improve access to culturally sensitive resources.
While steps have been made in recent years to bring more diversity to medical education and, in turn, the medical field, even more can be done to encourage the building of a medical profession that reflects the population it is serving.^[xlvii]Continuing to build programs that provide support for medical professionals who come from vulnerable populations, better encourage practice in areas of greatest need, and remove barriers to providers and services to improve cultural competence of the available resources, will be necessary. New Jersey has recently taken steps in this direction by working to improve access to doula services and removing barriers to professional licenses for immigrant populations.^[xlviii] The state should continue in this direction by supporting initiatives focused on greater diversity in the medical field, such as Graduate Medical Education (GME) programs, and by exploring the creation of programs that provide financial support for those serving in areas of critical need.^[xlix]
Build racial impact results into future public health crisis preparedness plans.
While the current New Jersey preparedness plan does provide an in-depth look into the possible severity of an outbreak, its economic costs, and environmental and structural factors that may exacerbate certain types of outbreaks, there is no discussion of the fact that certain racial and ethnic groups are more subject to those factors than others, and that the combined impact of the inequities can exacerbate the poor outcomes even further.^[l]

Building on these efforts with additional policies that address housing, food insecurity, schooling, workers’ safety, and other areas that impact health will further lessen the inequities in health outcomes that we see in New Jersey. While New Jersey’s challenges in these areas seem daunting, systematic investment in programs that promote equity will lead to healthier lives for all — both during normal times and especially during future health crises.

^[i] This brief refers to residents who identify as having ethnic roots in Spain or Latin America with the term “Latinx.” While this term is not used by all residents identifying with this ethnicity (see Noe-Bustamante, Luis, Lauren Mora, and Mark Hugo Lopez (2020). “About One-in-Four U.S. Hispanics Have Heard of Latinx, but Just 3% Use It.” Pew Research Center. Online: https://www.pewresearch.org/hispanic/2020/08/11/about-one-in-four-u-s-hispanics-have-heard-of-latinx-but-just-3-use-it/), this term is more inclusive of all populations with this ethnic identity, including those who may not identify as native Spanish speakers. Also, utilizing “Latinx” rather than “Latino” or “Latina” is more gender-inclusive. All of these considerations help to create more inclusivity for the population considered here, something that is particularly important in addressing structural racism in health care, which does not, in many ways, differentiate between a first-generation immigrant and later generations with these familial roots.

^[ii] Oppel Jr., Richard A., Robert Gebeloff, K.K. Rebecca Lai, Will Wright, and Mitch Smith (2020). “The Fullest Look Yet at the Racial Inequity of Coronavirus.” New York Times. 5 July 2020. Online: https://www.nytimes.com/interactive/2020/07/05/us/coronavirus-latinos-african-americans-cdc-data.html

^[iii] Raychaudhuri, Disha (2020). “N.J. is more diverse than ever. See how your town has changed.” NJ Advance Media for NJ.com. 19 February 2020. Online: https://www.nj.com/data/2020/02/nj-is-more-diverse-than-ever-see-how-your-town-has-changed.html

^[iv] Orfield, Gary, Jongyeon Ee, and Ryan Coughlann (2017). “New Jersey’s Segregated Schools: Trends and Paths Forward.” UCLA: The Civil Rights Project. November 2017. Online: https://www.civilrightsproject.ucla.edu/research/k-12-education/integration-and-diversity/new-jerseys-segregated-schools-trends-and-paths-forward/New-Jersey-report-final-110917.pdf?_ga=2.105008256.2029930253.1598600934-536607244.1597420044; Petenko, Erin, and Disha Raychaudhuri (2018). “Why Minorities in N.J. are More Likely to be Denied Mortgages, Explained.” NJ.com. Posted 16 February 2018. Updated 30 January 2019. Online: https://www.nj.com/data/2018/02/modern-day_redlining_how_some_nj_residents_are_bei.html

^[v] Center for Economic and Policy Research (2020). “A Basic Demographic Profile of Workers in Frontline Industries.” 7 April 2020. Online: https://cepr.net/a-basic-demographic-profile-of-workers-in-frontline-industries/. State-level data available in linked spreadsheet.

^[vi] An important note to make about all this data from the Department of Health is that the categories for race and ethnicity are broad and, in being so broad, do not accurately depict the many varied experiences of residents within each race or Latinx category. This can be an important factor in understanding the full picture of residents’ experiences with racism in the healthcare system and therefore needs to be examined more in-depth than the data currently provides.

^[vii] Centers for Disease Control and Prevention (2020). COVIDView. Weekly Summary for Week 39, ending September 26, 2020. Online: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. Hospitalization rates for each age group can be found on page 10.

^[viii] Salem County’s first confirmed COVID-19 case was reported on March 21, 2020, approximately 17 days after officials confirmed the first case in New Jersey. This was also the day that Governor Murphy announced the state lockdown of all non-essential businesses. See Salem County Department of Health and Human Services (2020). “Salem County Health Department Confirms First Positive Case of Coronavirus.” 21 March 2020. Online: https://health.salemcountynj.gov/salem-county-health-department-confirms-first-positive-case-of-coronavirus/; Erminio, Vinessa (2020). “Coronavirus in New Jersey: A Timeline of the Outbreak.” NJ Advance Media for NJ.com. Last updated on 12 June 2020. Online: https://www.nj.com/coronavirus/2020/03/coronavirus-in-new-jersey-a-timeline-of-the-outbreak.html

^[ix] Taylor, Lauren (2018). "Housing and Health: An Overview of the Literature." Health Affairs Health Policy Brief 10. Online: https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/full/

^[x] Gundersen, Craig, and James P. Ziliak (2015). "Food Insecurity and Health Outcomes." Health Affairs 34 (11): 1830-1839. Online: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.0645

^[xi] McCormack, Grace, Christopher Avery, Ariella Kahn-Lang Spitzer, and Amitabh Chandra (2020). Economic Vulnerability of Households With Essential Workers. JAMA. 2020;324(4):388–390. doi:10.1001/jama.2020.11366. Online: https://jamanetwork.com/journals/jama/fullarticle/2767630; Yearby, Ruqaiijah, and Seema Mohapatra (2020). "Law, Structural Racism, and the COVID-19 Pandemic." Journal of Law and the Biosciences (Forthcoming). No. 2020-8. Online: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3612824

^[xii] Kapahi, Vineeta (2020). “Labor Day Snapshot: How New Jersey Can Honor Workers and Improve Economic Security.” New Jersey Policy Perspective. 7 September 2020. Online: https://www.njpp.org/reports/labor-day-snapshot-how-new-jersey-can-honor-workers-and-improve-economic-security

^[xiii] U.S. Census Bureau (2020). Week 15 Household Pulse Survey: September 16-28. “Food Table 2b. Food Sufficiency for Households, in the Last 7 Days, by Select Characteristics: New Jersey.” https://www.census.gov/data/tables/2020/demo/hhp/hhp15.html At the time of writing, this was the most recent release.

^[xiv] U.S. Census Bureau (2020). Week 15 Household Pulse Survey: September 16-28. “Housing Table 1b. Last Month’s Payment Status for Renter-Occupied Housing Units, by Select Characteristics: New Jersey” https://www.census.gov/data/tables/2020/demo/hhp/hhp15.html At the time of writing, this was the most recent release.

^[xv] U.S. Census Bureau (2020). Week 15 Household Pulse Survey: September 16-28. “Health Table 3. Current Health Insurance Status, by Select Characteristics: New Jersey” and “Health Table 2a. Symptoms of Anxiety Experienced in the Last 7 days, by Select Characteristics: New Jersey.”https://www.census.gov/data/tables/2020/demo/hhp/hhp15.html At the time of writing, this was the most recent release.

^[xvi] U.S. Census Bureau (2020). Week 15 Household Pulse Survey: September 16-28. “Health Table 3. Current Health Insurance Status, by Select Characteristics: New Jersey.” https://www.census.gov/data/tables/2020/demo/hhp/hhp15.html At the time of writing, this was the most recent release.

^[xvii] U.S. Census Bureau (2020). Week 15 Household Pulse Survey: September 16-28. “Health Table 1. Coronavirus Pandemic Related Problems with Access to Medical Care, in Last 4 weeks, by Select Characteristics: New Jersey.” https://www.census.gov/data/tables/2020/demo/hhp/hhp15.html At the time of writing, this was the most recent release.

^[xviii] Tolbert, Jennifer Kendal Orgera, Natalie Singer, and Anthony Damico (2020). “Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19.” Kaiser Family Foundation. 7 April 2020. Online: https://www.kff.org/coronavirus-covid-19/issue-brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/

^[xix] New Jersey Office of Emergency Management (2018). “5.1 Identification of Hazards.” 2019 New Jersey State Hazard Mitigation Plan. Online: http://ready.nj.gov/mitigation/2019-mitigation-plan.shtml Specific chapter: http://ready.nj.gov/mitigation/pdf/2019/mit2019_section5-1_Id_Hazards.pdf. Pg. 5.

^[xx] Cavallo, Joseph J., Daniel A. Donoho, and Howard P. Forman (2020). "Hospital Capacity and Operations in the Coronavirus Disease 2019 (COVID-19) Pandemic—Planning for the Nth Patient." In JAMA Health Forum 1 (3): e200345-e200345. American Medical Association. Online: https://jamanetwork.com/channels/health-forum/fullarticle/2763353; Some groups worked to build tools for building better hospital surge capacity as the pandemic developed. See, for example: Abir, Mahshid, Christopher Nelson, Edward W. Chan, Hamad Al-Ibrahim, Christina Cutter, Karishma Patel, and Andy Bogart (2020). “Critical Care Surge Response Strategies for the 2020 COVID-19 Outbreak in the United States.” Santa Monica, CA: RAND Corporation. Online: https://www.rand.org/pubs/research_reports/RRA164-1.html. See also New Jersey’s response to the surge: New Jersey Department of Health (2020). “Allocation of Critical Care Resources During a Public Health Emergency.” 11 April 2020. Online: https://nj.gov/health/legal/covid19/FinalAllocationPolicy4.11.20v2%20.pdf

^[xxi] Kaulessar, Ricardo (2018). “100 years ago, Spanish flu pandemic brought dread to New Jersey.” NorthJersey.com. Online: https://www.northjersey.com/story/news/local/2018/10/09/1918-spanish-flu-pandemic-killed-thousands-new-jersey/1222214002/; Influenza Encyclopedia (n.d.) “Newark, New Jersey.” Published by University of Michigan Center for the History of Medicine and Michigan Publishing and University of Michigan Library. Online: https://www.influenzaarchive.org/cities/city-newark.html; New Jersey Office of Emergency Management (2018). “5.21 Pandemic.” 2019 New Jersey State Hazard Mitigation Plan. Online: http://ready.nj.gov/mitigation/2019-mitigation-plan.shtml Specific chapter: http://ready.nj.gov/mitigation/pdf/2019/mit2019_section5-21_Pandemics.pdf

^[xxii] Office of Governor Phil Murphy (2020). “Governor Murphy, Acting Governor Oliver, and Commissioner Persichilli Announce First Presumptive Positive Case of Novel Coronavirus in New Jersey.” 4 March 2020. Online: https://www.nj.gov/governor/news/news/562020/20200304e.shtml

^[xxiii] Kaulessar, Ricardo (2018). “100 years ago, Spanish flu pandemic brought dread to New Jersey.” NorthJersey.com. Online: https://www.northjersey.com/story/news/local/2018/10/09/1918-spanish-flu-pandemic-killed-thousands-new-jersey/1222214002/; Influenza Encyclopedia (n.d.) “Newark, New Jersey.” Published by University of Michigan Center for the History of Medicine and Michigan Publishing and University of Michigan Library. Online: https://www.influenzaarchive.org/cities/city-newark.html; New Jersey Office of Emergency Management (2018). “5.21 Pandemic.” 2019 New Jersey State Hazard Mitigation Plan. Online: http://ready.nj.gov/mitigation/2019-mitigation-plan.shtml Specific chapter: http://ready.nj.gov/mitigation/pdf/2019/mit2019_section5-21_Pandemics.pdf

^[xxiv] NJPP Analysis of New Jersey Department of Health (DOH), Communicable Disease Service - COVID-19 Dashboard data and Census data. DOH data online at: https://covid19.nj.gov/. Estimated population data found through the American Community Survey through the Census Bureau. 2019 1-Year Estimates. Table DP05, Demographic and Housing Estimates. This can be found online at: https://data.census.gov

^[xxv] Balcerzak, Ashley and Stacey Barchenger (2020). “COVID-19 in your ZIP code: Race, income can double your chance of getting sick in NJ.” NorthJersey.com. 13 July 2020. Online: https://www.northjersey.com/story/news/coronavirus/2020/07/13/coronavirus-nj-race-income-can-double-your-chance-getting-sick/5404947002/

^[xxvi] Rubin-Miller, Lily Christopher Alban, Samantha Artiga, and Sean Sullivan (2020). “COVID-19 Racial Disparities in Testing, Infection, Hospitalization, and Death: Analysis of Epic Patient Data.” Kaiser Family Foundation. 16 September 2020. Online: https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-racial-disparities-testing-infection-hospitalization-death-analysis-epic-patient-data/

^[xxvii] Centers for Disease Control and Prevention (2020). “Excess Deaths Associated with COVID-19.” Online: https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm

^[xxviii] NJPP Analysis of Census Bureau data. American Community Survey, 2019 1-Year Estimates. Table DP05, Demographic and Housing Estimates. Online: https://data.census.gov

^[xxix] New Jersey Department of Health, Communicable Disease Service (2020). COVID-19 Dashboard. Online: https://covid19.nj.gov/. Accessed 7 October 2020. Probable deaths are updated every week, with the latest update on 29 September 2020.

^[xxx] It is important to note here that the excess deaths data only covers up until July, and so does not total deaths up until October as the COVID deaths update includes. This means that the total will likely go up for the number of excess deaths, though the later months were not the peak months of the pandemic.

^[xxxi] Petterson, Steve et al (2020). “Projected Deaths of Despair During the Coronavirus Recession,” Well Being Trust. 8 May 2020. WellBeingTrust.org. Online: https://wellbeingtrust.org/areas-of-focus/policy-and-advocacy/reports/projected-deaths-of-despair-during-covid-19/

^[xxxii] Forde, Allana T., Danielle M. Crookes, Shakira F. Suglia, and Ryan T. Demmer (2019). "The weathering hypothesis as an explanation for racial disparities in health: a systematic review." Annals of epidemiology 33: 1-18.

^[xxxiii] Gramlich, John and Cary Funk (2020). “Black Americans Face Higher COVID-19 Risks, are More Hesitant to Trust Medical Scientists, Get Vaccinated.” Pew Research Center. 4 June 2020. Online: https://www.pewresearch.org/fact-tank/2020/06/04/black-americans-face-higher-covid-19-risks-are-more-hesitant-to-trust-medical-scientists-get-vaccinated/

^[xxxiv] Kim, Soo Rin and Matthew Vann (2020). “Many States Are Reporting Race Data For Only Some COVID-19 Cases And Deaths.” FiveThirtyEight. 7 May 2020. Online: https://fivethirtyeight.com/features/many-states-are-reporting-race-data-for-only-some-covid-19-cases-and-deaths/; National Academy for State Health Policy (2020). “How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities.” Online: https://www.nashp.org/how-states-report-covid-19-data-by-race-and-ethnicity/

^[xxxv] Hummer, Robert A. and Iliya Gutin (2018). "Racial/ethnic and Nativity Disparities in the Health of Older US Men and Women." In Future Directions for the Demography of Aging: Proceedings of a Workshop. Washington, D.C.: The National Academies Press, Washington, DC. Pages 31-66; Enchautegui, María E. (2014). “Immigrant Youth Outcomes: Patterns by Generation and Race and Ethnicity.” Urban Institute. Online: https://www.urban.org/sites/default/files/publication/22991/413239-Immigrant-Youth-Outcomes-Patterns-by-Generation-and-Race-and-Ethnicity.PDF; Teruya, Stacey A. and Shahrzad Bazargan-Hejazi (2013). "The Immigrant and Hispanic Paradoxes: A Systematic Review of Their Predictions and Effects." Hispanic Journal of Behavioral Sciences 35 (4): 486-509.

^[xxxvi] Calculated using NJPP analysis of Budget Data and Census Data from 2019 estimates (latest available). Intercensal data tables can be found at: https://www.census.gov/data/tables/time-series/demo/popest/intercensal-2000-2010-state.html. Data estimates for the 2019 population can be found at: https://www.census.gov/quickfacts/NJ. Budget information can be found at: https://www.njleg.state.nj.us/legislativepub/finance.asp

^[xxxvii] This is now titled the “Division of Aging Services.”

^[xxxviii] New Jersey Department of Health, Office of Minority and Multicultural Health (2020). “About Us.” Last Reviewed: 11/23/2018. Online: http://www.nj.gov/health/ommh/about-us; Budget analysis completed by author using Departmental Appropriations information on the New Jersey Office of Management and Budget (OMB) website.

^[xxxix] Office of Governor Phil Murphy. “Nurture NJ.” Online: https://www.nj.gov/governor/admin/fl/nurturenj.shtml

^[xl] Office of Governor Phil Murphy. “Governor Murphy Announces Actions to Require Reporting of COVID-19 Demographic Data.” 22 April 2020. Online: https://nj.gov/governor/news/news/562020/approved/20200422b.shtml

^[xli] Gibbons, Ann (2020). “How can We Save Black and Brown Lives During a Pandemic? Data from Past Studies can Point the Way.” Science. 10 April 2020. Online: https://www.sciencemag.org/news/2020/04/how-can-we-save-black-and-brown-lives-during-pandemic-data-past-studies-can-point-way

^[xlii] National Academy for State Health Policy (2020). “How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities.” Online: https://www.nashp.org/how-states-report-covid-19-data-by-race-and-ethnicity/

^[xliii] National Network of Public Health Institutes (2020). Website: https://nnphi.org/about-nnphi/. Last accessed: 9 September 2020.

^[xliv] Race Forward (n.d.). Racial Equity Impact Assessment Toolkit. Online: https://www.raceforward.org/practice/tools/racial-equity-impact-assessment-toolkit; Center for the Study of Social Policy (2018). “Racial Equity Impact Assessment.” Online: https://cssp.org/wp-content/uploads/2018/08/Race-Equity-Impact-Assessment-Tool.pdf

^[xlv] County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation Program (2020). “Cultural Competence Training for Health Care Professionals.” Updated 27 January 2020. Online: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/cultural-competence-training-for-health-care-professionals

^[xlvi] New Jersey Department of Health. Office of Minority and Multicultural Health. Online: https://www.nj.gov/health/ommh/

^[xlvii] Boatright, Dowin H., Elizabeth A. Samuels, Laura Cramer, Jeremiah Cross, Mayur Desai, Darin Latimore, and Cary P. Gross (2018). "Association between the Liaison Committee on Medical Education’s Diversity Standards and Changes in Percentage of Medical Student Sex, Race, and Ethnicity." JAMA 320 (21): 2267-2269.

^[xlviii] Office of Governor Phil Murphy (2020). “Governor Murphy Signs Legislative Package to Combat New Jersey’s Maternal and Infant Health Crisis.” 8 May 2019. Online: https://www.nj.gov/governor/news/news/562019/20190508a.shtml; Office of Governor Phil Murphy (2020). “Governor Murphy Signs Legislation Expanding Access to Professional and Occupational Licenses.” 1 September 2020. Online: https://www.nj.gov/governor/news/news/562020/approved/20200901c.shtml

^[xlix] A good example of these efforts is the Washington Health Corps, established in 2019. See information here: https://wsac.wa.gov/washington-health-corps

^[l] New Jersey Office of Emergency Management (2018). “5.21 Pandemic.” 2019 New Jersey State Hazard Mitigation Plan. Online: http://ready.nj.gov/mitigation/2019-mitigation-plan.shtml Specific chapter: http://ready.nj.gov/mitigation/pdf/2019/mit2019_section5-21_Pandemics.pdf

Brittany L. Holom-Trundy, Ph.D., Senior Policy Analyst, is a researcher and lecturer whose interests include health care system reform, the differential impact of health policies across socioeconomic groups, and the role of social and cultural factors in the access to and use of health care services.

Census 2019: New Jersey’s Uninsured Rate Increased for the First Time in Years

Posted on September 22, 2020October 12, 2020 by Brittany Holom-Trundy

As the COVID-19 pandemic has taught the country, access to health care is essential for all residents to lead a healthy life, protect public health, and build an economically and racially just future. While New Jersey outpaces other states in prioritizing access for all, newly released data on health insurance coverage from the United States Census Bureau show that the Garden State still has a long way to go in guaranteeing a healthy and equitable future.

New Jersey’s Uninsured Rate Increased for the First Time Since 2013

The number of uninsured New Jersey residents increased in 2019 from the year prior, according to newly released American Community Survey data. This represents the first increase in the state’s uninsured rate since the Affordable Care Act (ACA) was fully implemented, and is likely due to the Trump administration’s ongoing efforts to sabotage the landmark health law. Approximately 692,000 New Jerseyans were uninsured in 2019, representing a 6.8 percent increase in the uninsured rate from 2018. Residents under the age of 19 made up 88,000 of those uninsured in the state, representing a 10.3 percent increase in the uninsured rate for this age group.

These increases were not spread equally among all New Jerseyans. A hostile national environment toward people of color and immigrants, including the fear and uncertainty caused by the Trump administration’s public charge rule, have made it increasingly difficult to boost health care enrollment. In New Jersey, approximately 343,000 Latinx residents were uninsured in 2019, an increase of 7.5 percent in the uninsured rate from 2018. Residents identifying as Latinx, Black, or American Indian/Alaska Native remained the most likely to be uninsured.

Despite these challenges, New Jersey is still out-performing many other states in getting more residents covered. Nationally, 9.2 percent of people remained uninsured in 2019, a continuation of the increases experienced every year since 2016. While the Garden State’s uninsured rate (7.9 percent) crept closer to the national rate between 2018 and 2019, it remained well below that national average — and far below the state’s 2010 uninsured rate of 13.2 percent. New Jersey was able to expand health coverage thanks in great part to the implementation of the ACA. The state’s decisions to adopt many of the health law’s key provisions, particularly the expansion of Medicaid in 2014, have helped the state provide affordable coverage options. Similarly, New Jersey’s proactive decisions to codify key ACA provisions in state law — including the establishment of a reinsurance fund, banning junk plans, and restoring the individual mandate — helped protect these gains amidst the Trump administration’s ongoing efforts to undermine the ACA.

The COVID-19 Pandemic Promises Hardship … and New Jersey Needs to Prepare

New Jersey’s increasing uninsured rate must be viewed with careful consideration of the extraordinary conditions of 2020 that have yet to be captured by census data. With the COVID-19 pandemic, more individuals and families have been losing employer-based coverage, facing not only threats to their health but also to their economic well-being. This has been particularly true for people of color, who have fought the effects of structural racism that put them at greater risk for contracting, being hospitalized, and dying from the virus, in addition to facing more devastating and long-term economic repercussions.

In the Census Bureau’s most recent Household Pulse Survey — with data gathered between August 19th and 31st — over 8 percent of New Jersey respondents reported being uninsured, indicating a concerning increase from the 2019 estimates due to the pandemic. Without health coverage, people are unable to access needed care, a dilemma faced disproportionately by Black and Latinx residents in the state, according to the survey. The long-term health consequences of this lack of coverage will further exacerbate the overarching social and economic consequences of COVID-19 in the coming months and years.

There is hope, however. New Jersey has already seen that strong state action to protect the ACA and prioritize health care access improves outcomes. The 2014 Medicaid expansion in New Jersey has played a key role in dampening the overall effects of the COVID-19 crisis, as enrollment numbers have shown that the program has served as an important safety net for many residents who have lost employer-based coverage. Furthermore, Get Covered New Jersey, the new state-based health insurance exchange, opens for enrollment on November 1, 2020. With state subsidies available for those with incomes below 400 percent of the federal poverty level (annual income up to $51,040 for an individual or $104,800 for a family of four), the exchange will increase affordable coverage options for many of New Jersey’s populations who have suffered most during the pandemic.

Click here for the latest Census data on economic security in New Jersey.

COVID-19 Job Loss Leaves More Than 100,000 New Jerseyans Uninsured

Posted on August 6, 2020September 3, 2021 by Brittany Holom-Trundy

The COVID-19 pandemic has exposed the many weaknesses of a health care system that ties coverage tightly to employment. Two recent reports by Families USA underscore the catastrophic result: an estimated 124,000 New Jerseyans lost access to their health insurancedue to loss of employment in the first months of 2020 and were not able to enroll in coverage under Medicaid, a spouse’s coverage, or the individual insurance market. This means that a total of approximately 701,000, or 13 percent, of all non-elderly adults in the state were uninsured as of May 2020.^[i] Alarmingly, this loss of insurance could lead to additional job losses: as revenue for health care decreases, another 86,000 jobs could be lost in New Jersey’s health care industry alone.

These striking numbers, while historic, could have been much worse if not for state and federal policies that have expanded access to health care. If New Jersey had not expanded Medicaid, as allowed by the Affordable Care Act (ACA), many more individuals would currently be uninsured. By expanding eligibility to previously excluded individuals — including childless adults with income below 138 percent of the federal poverty level ($1,468 per month for a single adult in 2020) — the Garden State has a lower share of adults who are uninsured during the crisis than states that have not expanded Medicaid.^[ii] The Families USA reports estimate that uninsurance rates for non-elderly adults in non-expansion states have reached levels as high as 29 percent (Texas), which could result in 362,000 additional job losses in the health care sector.^[iii] With Census Bureau data showing that, nationwide, communities of color and low-wage workers have been most likely to lose insurance during the pandemic, Medicaid eligibility for these vulnerable populations has proven crucial to better addressing the fallout of the crisis.

During New Jersey’s pandemic lockdown, increases in NJ FamilyCare enrollment — New Jersey’s Medicaid and Children’s Health Insurance Program (CHIP) — show that the program serves as critical relief for many experiencing a loss of income. After an overall decline in enrollment in previous months, the COVID-19 pandemic led to a quick and significant surge in Medicaid enrollment numbers as disenrollment was frozen and hundreds of thousands of residents faced unemployment.^[iv] From February to July 2020, total enrollment in NJ FamilyCare increased by 118,622 individuals, a jump of 7 percent. Enrollment in all non-Aged, Blind, and Disabled eligibility groups increased during the crisis as well. Most notably, enrollment for adult groups that became newly eligible under the Medicaid expansion rose significantly during the crisis, demonstrating that this safety net has successfully protected thousands of New Jerseyans that otherwise would have been uninsured after losing insurance through their employers.

How do we move forward?

Pandemics necessitate strong governmental responses. Leaders need to both support the health care system through crisis conditions and protect residents by slowing the spread of the outbreak. Viruses do not discriminate in whom they infect, but they do thrive on discriminatory structures within a country, feeding off of the disparities and shortcomings in our institutions and furthering the inequities present. Strengthening affordable health care options outside of employment, providing safe working conditions, improving access to basic needs like healthy foods, and increasing resources to deal with emergencies that low- and moderate-income families face should be prioritized.

By supporting the ACA, building more options for affordable coverage, avoiding cuts to critical services for vulnerable populations, and establishing guarantees of job retention in the midst of unsafe conditions, state lawmakers can demonstrate their commitment to a more equitable New Jersey. This is not the first crisis to challenge our existing social and economic systems, nor will it be the last. It is time for Garden State leaders to recognize the lessons of COVID-19 and to make sure that when another outbreak inevitably arrives, we are ready.

Appendix

ABD = Aged, Blind, and Disabled.
M-CHIP = Children under an extended income eligibility group in Medicaid that is funded by CHIP funds.
ABP = Alternative Benefit Plan. New Jersey’s adoption of Medicaid expansion introduced eligibility for all non-Medicare eligible individuals under age 65 (children, pregnant women, parents and adults without dependent children) with incomes up to 138 percent of federal poverty level (FPL) based on modified adjusted gross income.

End Notes

^[i] It is important to note here that some of the individuals who were furloughed or who elected to move into COBRA coverage after losing employment may be delayed in their self-reported loss of coverage as they maintain benefits for a few to several months after employment. However, for low-income households, coverage under such programs as COBRA is often unaffordable.

^[ii] While the ACA officially introduced eligibility for households below 133 percent of the federal poverty level (FPL), it was doing so for “modified adjusted gross income” (MAGI). In another part of the act, one modification introduced was a further five-point deduction from the FPL, effectively making the eligibility level 138 percent. More information on this distinction can be found here: https://www.shadac.org/news/aca-note-when-133-equals-138-fpl-calculations-affordable-care-act

^[iii] This calculation does not cover the recent spikes in COVID-19 cases in many of the non-expansion states.

^[iv] With the Families First Coronavirus Response Act, a Federal Medical Assistance Percentage (FMAP) bump was provided for states, given that they met particular requirements. One of these Maintenance of Effort (MOE) provisions required that Medicaid enrollees who might have otherwise lost eligibility due to “issues such as non-response to redetermination requests or changes in income” remain enrolled during the course of the crisis. Maintaining these enrollees while also taking in new enrollees accounts for a significant amount of the growth, as noted in the above linked New Jersey Department of Human Services monthly enrollment report. This helps to protect many who may have struggled to attend to redetermination requests or faced uncertain income levels during this time, in addition to those who have recently lost employment.

NJPP Applauds Passage of State-Level Health Insurance Assessment

Posted on July 30, 2020September 18, 2020 by Brittany Holom-Trundy

Earlier today, the New Jersey Assembly and Senate passed S2676/A4389, which would establish a state-level Health Insurance Assessment (HIA). With a state-level HIA, New Jersey will raise over $200 million in annual revenue — at no new cost to insurance companies — to invest in initiatives to make health care more affordable in the state’s new health care exchange. In response to the passage of this bill, New Jersey Policy Perspective (NJPP) releases the following statement.

Brittany Holom, Senior Policy Analyst, New Jersey Policy Perspective:

“With the passage of this bill, New Jersey is solidifying itself as a national leader in protecting the Affordable Care Act and keeping health coverage affordable. The Health Insurance Assessment will provide ample resources for New Jersey to expand health coverage, lower the number of people who are uninsured, and address racial disparities in access to care. These are necessary steps to build a stronger and more equitable state where all residents can lead healthy lives. If the COVID-19 pandemic has taught us anything, it’s that improving access to care will improve public health for all. We sincerely thank Senator Joe Vitale and Assemblyman John McKeon for their leadership on this critical issue.”

For more information on the state-level HIA, read NJPP’s explainer: New Jersey Can Act Now to Make Health Care More Affordable: The Health Insurance Assessment Explained

New Jersey Policy Perspective (NJPP) is a nonpartisan think tank that drives policy change to advance economic, social, and racial justice through evidence-based, independent research, analysis, and advocacy.

# # #

The Health Insurance Assessment Will Make Coverage More Affordable and Accessible

Posted on July 27, 2020November 11, 2020 by Brittany Holom-Trundy

The following testimony, on A4389, was delivered to the Assembly Appropriations Committee on July 27, 2020.

Good morning Chairman Burzichelli and members of the Appropriations Committee. Thank you for this opportunity to provide my testimony on the Health Insurance Assessment. My name is Dr. Brittany Holom, and I am a senior policy analyst at New Jersey Policy Perspective (NJPP). NJPP is a non-partisan, non-profit research institution that focuses on policies that can improve the lives of low- and middle-income people, strengthen our state’s economy, and enhance the quality of life in New Jersey.

New Jersey stands at a critical juncture for our health care system. The full impact of the COVID-19 pandemic is still to be seen, but we know one thing for sure: the virus has taken a historic toll on the families, economy, and future of New Jersey. The measures needed to protect our residents and contain the virus’ outbreak have resulted not only in lost income, but also a lack of insurance coverage, rising distrust in and fear of the health care system, and uncertainty about a vast array of activities for the foreseeable future. This is a moment when New Jerseyans need to see that their leaders are not just reacting to the crisis in the short term, but are committed to protecting them in the long term.

In order to maintain the state’s vital services and build a system better able to handle these crises going forward, we need to be creative. The proposed Health Insurance Assessment (HIA) provides a golden opportunity to do just that. With the federal government giving up this source of income, New Jersey has the chance to absorb those funds without having to introduce changes to current fees.

This is why NJPP strongly supports the proposed legislation to collect an assessment on certain health insurance providers and direct those resources toward making health coverage more affordable and accessible. We understand the need for revenue to not only support current programs, but also to support new initiatives to ensure that New Jersey’s health care landscape is more equitable.

The legislation’s dedication of funds to health care gives New Jersey long-term resources to keep health care affordable. Estimates of a state HIA’s revenue come in just above $300 million. This revenue can be put toward initiatives that provide subsidies to our low- and moderately-paid working families, create more affordable coverage opportunities for our most vulnerable populations, support the reinsurance program, help small businesses with the costs of care, and much more. This is more than a simple cut of costs — this is an investment in a sustainable and affordable health care system for New Jersey’s residents for the future.

This is New Jersey’s moment to make that investment. The federal fee expires after December 31st of this year. This means that, by establishing a state fee now, we are maintaining a system that already exists and are not introducing a new fee for health insurance providers. Only by establishing the fee this year do we have the opportunity to capture this revenue without seeing an increase in rates from the previous year.

Some groups may argue that this would raise rates. This is simply not true. New Jersey would be replacing an existing fee — not introducing a new one — and, because that money is being invested back in the health care system, the state would be committing to sustainable decreases in rates. Further, by supporting increases in enrollment and improving the health insurance risk pool, the state would be directly aiding in cost decreases for New Jersey residents. In other words, this is not a one-and-done situation; rates would not just decrease for one year before increasing again. Instead, measures would support lower rates in the long term.

Again, the opportunity to establish this source of revenue and commit funds to affordability is only available this year. If we let this fee expire without replacing it, the actions needed to build this revenue in later years will face significant obstacles, and residents will be faced with greater instability in their health insurance options. Leaders need to show that they are willing to invest in their residents’ future, because if the COVID-19 pandemic has not been a strong enough lesson on the necessity for that investment, then it is clear that nothing ever will be.

Thank you for your time.

New Jersey Can Act Now to Make Health Care More Affordable: The Health Insurance Assessment Explained

Posted on July 13, 2020November 20, 2020 by Brittany Holom-Trundy

The COVID-19 pandemic is revealing the fragility of our health system: from disparities in providing care to people of color to budget shortfalls that threaten the state’s social safety net. In the midst of these concurrent health and budget crises, New Jersey has the opportunity to expand health coverage by picking up revenue that the federal government is leaving behind through the Health Insurance Assessment (HIA). The HIA would bring in more funding for health care programs, increasing coverage and affordability amongst children and low- and moderate-income families across the state. This explainer answers frequently asked questions about the HIA and how it can improve health care in New Jersey.

What is a Health Insurance Assessment (HIA)?
How much revenue would a state-level HIA bring into New Jersey?
Who would benefit from a state-level HIA?
How would a state-level HIA improve public health and increase affordability?
How would a state-level HIA impact insurance providers, and what types of insurance plans would be included?
Would a state-level HIA lead to increases in premiums?
Have other states introduced state-level HIAs?

What is a Health Insurance Assessment (HIA)?

The Health Insurance Assessment (HIA) is a federal fee on health insurance companies that was established in 2014 to help fund the Affordable Care Act (ACA). This fee is set to expire on January 1, 2021, giving states the opportunity to take on the assessment on insurance providers and capture funding all without raising insurers’ payments.^[1] States that implement their own HIA have the ability to spend the funds however they see fit, providing them the flexibility necessary to meet their own unique health care needs. Governor Phil Murphy first proposed the HIA for New Jersey in his Fiscal Year 2021 Budget.^[2]

How much revenue would a state-level HIA bring into New Jersey?

The HIA proposed in S2676/A4389 (as amended in committee on Monday, July 27, 2020) is projected to bring in over $224 million in revenue for New Jersey in calendar year 2021.^[3] Because the state HIA proposal differs from the existing federal HIA, it will bring in less revenue than if the state had mirrored the federal fee, which would have net the state $567 million in revenue. This lower revenue figure is a result of the state HIA proposal not applying to Medicaid, Medicare Advantage and prescription plans, federal employee and retiree coverage, dental plans, Multiple Employer WelfareArrangements (MEWAs) established before the enactment of the bill, or small-group plans which were included in the federal fee.^[4]

Who would benefit from a state-level HIA?

With funds directed toward health care, New Jersey’s children, working families, and low- to moderate-income households would benefit from a state-level HIA. Unlike the federal fee, which was not directed toward specific health care costs, a state-level HIA can help provide the funding needed to expand coverage and address existing inequities in access to quality care.^[5] This can be accomplished by using the funds to: provide health coverage for all kids; provide subsidies to low-income residents; create a public plan on the ACA market for families with income of less than 400% of the federal poverty level (FPL), which, in 2020, is $68,960 for a family of two or $104,800 for a family of four.^[6] The state could also offset high claims through the reinsurance program, which partially reimburses insurance providers for high-cost claims, helping to stabilize the market and decrease plan prices.

As we have learned during the COVID-19 pandemic, improving access to health care helps to improve public health for all New Jerseyans. By getting more people covered and giving them greater access to quality care, we can reduce the spread and fatalities from infectious diseases like COVID-19 that occur when residents are unable or reluctant to seek health care when needed.

How would a state-level HIA improve public health and increase affordability?

In New Jersey, the state-level HIA would generate revenue to improve health care access and affordability through a variety of mechanisms, including subsidies, reinsurance, tax policies, outreach and enrollment efforts, and other efforts to extend coverage to and improve affordability of health insurance for low- and moderate-income families and the uninsured. The funds can only be used for these purposes, as outlined in S2676/A4389.

The revenue collected could fund initiatives like enrollment efforts for children, so that more affordable coverage options are available to the approximately 80,000 uninsured kids in New Jersey.^[7] Revenues could also be used to improve affordability and coverage options for working families, particularly low- and moderate-income families. With revenue from a state-level HIA, New Jersey could provide subsidies to individuals so they can better afford their insurance, create a public plan on the ACA market that will benefit families with income of less than 400% of the federal poverty level (FPL), and/or offset high claims through the reinsurance program. New Jersey should determine how to most effectively use this revenue based on forthcoming affordability studies by the state Department of Banking and Insurance, as mandated by legislation passed in 2019.^[8]

How would a state-level HIA impact insurance providers, and what types of insurance plans would be included?

For insurance providers, a state-level HIA would not be a new fee. The federal HIA came into effect in 2014.^[9] While it was suspended temporarily in 2017 and 2019, the federal HIA is in place for 2020 and was included in the calculations for the 2020 premium rates. By taking action in 2020, New Jersey would be preserving the current assessment, rather than allowing it to lapse.

The state would redirect the assessment funds currently paid to the federal government by individual insurance and large-group coverage plans back to the state. Medicaid Managed Care Organizations (MCOs) — which contract with the state to provide Medicaid benefits in exchange for payments from the state — small-group plans, MEWAs, and dental plans are currently subject to the expiring federal fee. However, under the proposed state-level assessment, these plans would not be included.

The state also cannot legally collect this assessment from Medicare plans or federal employee or retiree coverage, which are included in the federal HIA. Finally, the fee will not be collected from self-funded plans, which were exempted from the federal HIA.

Would a state-level HIA lead to increases in premiums?

Based on the experiences of other states with their own HIA, New Jersey should not see an overall increase in premiums due to the assessment. This is because it continues the structure of fees that is already in place. Further, increasing affordability and coverage would strengthen and improve New Jersey’s State-Based Health Exchange, which is set to launch in November 2020.^[10] An increase in enrollment would help to lower premiums by improving the risk pool; it would also bring more federal money into the state through premium tax credits, a tax credit that the federal government provides to help lower the cost of monthly premiums on the Marketplace for low- and moderate-income individuals.

Have other states introduced state-level HIAs?

Other states have shown that a state-level HIA can generate funds to help improve affordability of health insurance for state residents. Maryland and Delaware both enacted state-level HIAs when the federal fee was temporarily suspended in 2019 to provide funds for market stabilization efforts.^[11] Delaware’s and Maryland’s programs partially reimburse insurance providers for high-cost claims, which helps to keep plan costs down.^[12] New Jersey currently has a reinsurance program in place that could similarly benefit from a portion of the funding through a state-level HIA.

At least two more states have sought to take advantage of this opportunity for funding affordability measures this year. In June 2020, Colorado became the latest state to enact its own Health Insurance Assessment, which will fund critical measures to make health coverage more affordable. Specifically, the Colorado HIA will provide additional funding for state-subsidized plans for those who are not eligible for premium tax credits or public assistance health care programs, payments to carriers to help lower premiums for those who already receive a premium tax credit, and their reinsurance program. The legislation will particularly help those families who receive assistance but still find health insurance unaffordable, as well as those who are ineligible for premium tax credits under federal law, including those without sufficient documentation.^[13] New Mexico introduced a similar bill in February. This legislation proposed creating a Health Care Affordability Fund and using the revenue to decrease premiums for residents across the state.^[14]

Over the last several years, New Jersey has emerged as a national leader in expanding health coverage and keeping insurance affordable amidst ongoing attacks on the Affordable Care Act by the federal government. Establishing a state-level HIA is the natural next step for New Jersey to improve public health and ensure all residents can lead healthy lives.

End Notes

^[1] Internal Revenue Service, Treasury. 2020. “Affordable Care Act Provision 9010 – Health Insurance Providers Fee.” Online: https://www.irs.gov/businesses/corporations/affordable-care-act-provision-9010. The fee is repealed for all calendar years after December 31, 2020.

^[2] Office of Governor Philip Murphy. 2020. 2021 Budget in Brief. Pg. 26. Can be read online here: http://d31hzlhk6di2h5.cloudfront.net/20200225/ce/30/5e/26/39c12d44bf1af2b6bd2ab34a/BIB_FY2021.pdf

^[3] State of New Jersey, 219th Legislature. 2020. “An Act concerning an assessment on entities authorized to issue health benefits plans and supplementing Title 17B of the New Jersey Statutes.” Online: https://www.njleg.state.nj.us/2020/Bills/S3000/2676_R2.PDF. Note that this estimate was provided by the Department of Banking and Insurance (DOBI). The Office of Legislative Services wrote a fiscal impact note on the bill that estimates $390 million in revenue. This appears to be a possible error, as it is significantly higher than previous estimates that had included the now exempted small-group plans, MEWAS, and dental plans.

^[4] Dorn, Stan. 2020. “A Golden Opportunity for States to Make Health Insurance More Affordable: Rapid Action Required.” The National Center for Coverage Innovation. Families USA. Online: https://familiesusa.org/resources/a-golden-opportunity-for-states-to-make-health-insurance-more-affordable-rapid-action-required/

^[5] The revenues from the federal fee were used to help cover costs of the establishment and expansion of the ACA, but their specific use for affordability purposes is not legally required.

^[6] Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. 2020. “HHS Poverty Guidelines for 2020.” 8 January 2020. Online: https://aspe.hhs.gov/poverty-guidelines. See “A chart with percentages (e.g., 125 percent) of the guidelines (PDF)” on the right of the page.

^[7] Castro, Raymond. 2019. “It’s Time for All Kids Health Coverage.” New Jersey Policy Perspective. Online: https://www.njpp.org/wp-content/uploads/2019/04/NJPP-All-Kids-Coverage-Report-Final-Draft-1.pdf

^[8] The data could come from a study on methods of improving affordability of coverage that was commissioned through New Jersey’s Department of Banking and Insurance (DOBI), which regulates the insurance market in the state. This study was commissioned in the FY 2020 Appropriations Act, which can be found here: https://www.njleg.state.nj.us/2018/Bills/AL19/150_.PDF Please see pg. 28, beginning at line 20: “[T]he Commissioner of Banking and Insurance shall commission an actuarial and/or microsimulation analysis of options for the State to provide more affordable health coverage in the individual market for both consumers who are currently eligible for federal financial assistance and those who are not, while reducing disruptions in coverage affordability for consumers who become ineligible for Medicaid due to an increase in the minimum wage or who will lose federal subsidies in the Marketplace or exceed the income limits for federal subsidies in the Marketplace for other reasons.”

^[9] Internal Revenue Service, Treasury. 2013. “Health Insurance Providers Fee.” Federal Register 78 (230): 71476. Document number 2013-28412, Available online: https://www.federalregister.gov/documents/2013/11/29/2013-28412/health-insurance-providers-fee

^[10] Office of Governor Philip Murphy. 2019. “Governor Murphy Announces New Jersey to Transition to State-Based Exchange.” Online: https://www.nj.gov/governor/news/news/562019/20190628a.shtml

^[11] Levitis, Jason, John-Pierre Cardenas, Steven Costantino. 2020. “Considerations for a State Health Insurer Fee Following Repeal of the Federal 9010 Fee.” State Health & Value Strategies. Available online: https://www.shvs.org/wp-content/uploads/2020/01/FINAL-State-Health-Insurer-Fee-Slide-Deck.pdf

^[12] Delaware’s “The Delaware Health Insurance Individual Market Stabilization Reinsurance Program” (Delaware Code, Title 18, Chapter 87, § 8703) can be found here: https://delcode.delaware.gov/title18/c087/index.shtml. Maryland’s (Insurance Article, §6-. 102.1 Annotated Code of Maryland) can be found here: http://mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin&section=6-102.1&enactments=False&archived=False

^[13] Colorado’s SB20-215 can be found here: https://leg.colorado.gov/bills/sb20-215

^[14] New Mexico’s House Bill 278 can be found here: https://www.nmlegis.gov/Legislation/Legislation?Chamber=H&LegType=B&LegNo=278&year=20

Promoting Equal Opportunities for Children Living in Poverty

Posted on April 13, 2020August 19, 2021 by Raymond Castro

To read a PDF version of the full report, click here.

Temporary Assistance for Needy Families (TANF) is New Jersey’s only program designed to protect low-income families with children during their times of greatest need, acting as a critical bridge to stability and a shield against the harms of deep poverty. Programs like TANF that help stabilize the take home pay of low-income families have long-lasting effects on a child’s ability to succeed in school, get a high school or college degree, and find work as an adult. By increasing the state’s inadequate TANF grant levels, lawmakers could improve maternal and child health, which will have major short- and long-term benefits for families in every corner of the state.

TANF does not provide the full supports that parents need to obtain the jobs that will permanently lift their families out of poverty. In fact, the ability to protect families in deep poverty has been undercut by many state and federal policies. This can be traced back to 1996 when Congress replaced the New Deal-era Aid to Families with Dependent Children (AFDC) program with TANF block grants. Intended to drastically limit basic assistance to struggling families, the federal TANF law set fixed federal funding, placed a five-year lifetime limit on TANF benefits, implemented punitive and ineffective work requirements, and included other harmful policies that further impoverish children and place enormous stress on families.

Making matters worse, New Jersey established its own enabling legislation in 1997 (P.L.1997, c.13) with harsher restrictions than required under federal law, resulting in an incredible 91 percent drop in enrollment from 102,000 families in 1996 to 13,000 in 2018. Prior to TANF, New Jersey assisted 93 out of 100 families below the federal poverty level compared to the national average of 72 families out of 100. In 2017-2018, the state was only assisting 15 out of 100 families living below the federal poverty level, which was below the national average of 22 families out of 100. In other words, New Jersey fell from one of the top performers in helping low-income families to one of the worst. The table in the appendix shows the incredible harm that TANF has caused in eliminating basic assistance to 180,000 children by county through 2019.

Despite recent increases in TANF benefits, they remain woefully inadequate for families living in poverty, especially since New Jersey has one of the highest costs of living in the nation. In fact, New Jersey ranks only 32nd in TANF benefits as compared with all states when housing costs are considered.^[1] While this is a significant improvement as compared to the rank of 43rd in 2017 before the most recent increases in TANF benefits, New Jersey still has far to go.^[2]

By reinvesting in TANF, state lawmakers choose healthier kids, safer families, and stronger communities where everyone has what they need to contribute and thrive. This report describes commonsense changes that would correct some of the flaws in the state TANF program and extend the reach of TANF to help many more families in New Jersey climb out of
poverty.

The good news is that TANF allows states considerable flexibility to make changes in the program. The Legislature and governor have recently started to make improvements in TANF by increasing the assistance levels by 32 percent over the last year through 2020. This is the first increase in three decades and progress that can be built upon. The current administration, under Governor Murphy, is also emphasizing more education and training (E&T) in TANF instead of placing parents in dead-end work activities that lack opportunities to secure employment and long-term economic success. However, much more than that will be needed to turn around a program that was neglected for decades and made worse at the federal level.

The Importance of Reducing Child Poverty

Surprisingly, there is no state statutory goal in TANF to lift families out of poverty. Historically, the practice has been to get families off TANF as soon possible, which often forces enrollees to take any job, even if the pay is inadequate to support a family. Because of this narrow goal, the state has viewed a reduction in the TANF caseload as a success even when child poverty was increasing. This means that families often remain in poverty or even cycle back onto TANF. Research shows that kids who spend most of their childhood in poverty are 45 percent more likely to live in poverty at age 35 than children who live in poverty for only one year.^[3] In other words, the less time in poverty, the more likely the cycle of poverty can be broken.

Although New Jersey has increased TANF benefits over the last two years, the state’s historic TANF policy of discouraging full economic opportunity is cruel, shortsighted, and discriminatory. It also does not make any economic sense because the best investment a state can make is in its children. The following are some of the benefits of reducing child poverty:

Reduces public costs in the long run

Chronic poverty causes devastating and long-term harm to children that costs the nation an estimated $1 trillion in economic activity, health, and crime.^[4] The National Academies of Science, Engineering, and Medicine’s 2019 report, “A Roadmap to Reducing Child Poverty,” provides the first consensus declaration by the scientific community on the causal connection between growing up with adequate family income and positive outcomes for children that lay the foundation for better health and higher earnings in adulthood.^[5] We either invest in our children now or pay much more later on.

Improves maternal and child health

Extensive research has conclusively shown the strong link between family income and infant mortality and children’s health.^[6] Children born to low-income mothers have the highest rate of low birth weight. Children in poor families are four times more likely to be in poor or fair health compared to higher income kids. By directly giving pregnant mothers cash assistance, they have the flexibility to spend more of their limited income on things that lead to better health such as transportation to doctor appointments, safer housing, over the counter medications, diapers, and better nutrition. Improving health for families is especially important in New Jersey given that the state has consistently scored poorly in maternal and child health, especially for Black families. As long as pregnant mothers and parents of newborns suffer the stress of extreme poverty, New Jersey’s efforts to reduce infant mortality will be limited.

Reduces racial and ethnic income disparities.

New Jersey is a wealthy state, but wealth is not shared equally or fairly. This is especially true for kids in poverty. Due to historic discrimination, such as in housing, employment, and education, Black and Hispanic kids do not have the same opportunities white kids do. In fact, about two-thirds of all New Jersey children in poverty are Black or Hispanic, as Black and Hispanic children are more than three times more likely to live in poverty than white kids.^[7] As a result, 8 out of 10 children on TANF, the poorest of the poor, are either Black or Hispanic. Failure to improve TANF means continuing to discriminate against these kids of color and robbing them of their birthright to equal opportunity. Addressing this problem would also help to reduce major income inequality, where New Jersey is ranked the seventh worst in the nation.^[8]

Improves the economy

Child poverty is a drag on New Jersey’s economy and makes the state less competitive because parents are not working or do not have opportunities for good paying jobs. There are also employers who do not want to train their employees because they do not want to invest in them to only have them leave for other jobs, which is also problematic. This could be reduced by improving TANF so it better provides the E&T that parents need. In addition, increasing TANF benefits would stimulate local economies where it is needed the most. Research shows that providing direct assistance to low-income people is one of the most effective ways to stimulate the economy because the money is spent quickly and directly in local communities.^[9] State expenditures have decreased by over $5 billion since TANF was established, which has not only harmed thousands of poor families but the economies of low-income communities as well.^[10]

Common Sense Measures to Improve TANF

1. Ensure that no families on TANF remain in deep poverty

The current level of NJ TANF benefits ($559 a month for a family of three) is only one-third of the federal poverty level, guaranteeing that families continue to live in deep poverty, defined as below half of the federal poverty level. This remains true despite the state increasing TANF benefits by 32 percent over the last two years. The low benefit level also costs the state more for many families because they cannot afford any housing and end up receiving much more expensive emergency assistance in a shelter or other arrangements to avert homelessness.

Solution: Require a set annual increase in TANF benefits so it reaches 50 percent of the federal poverty level within three years for each household size. For every year after, automatically adjust the TANF benefit for inflation.

2. Get families off the caseload and out of poverty

Historically, the goal of TANF has been to get a family off TANF as soon as possible, regardless of the outcome. As a result, parents are pressured to take jobs that are so low paying or temporary that the family remains in poverty and may be forced to return to TANF. Previous governors, therefore, have measured the success of TANF not by how many families in poverty have been helped but rather how quickly the caseload can be reduced regardless of the number of families that need assistance. This goal has resulted in punitive policies and practices in TANF that can make it a bureaucratic nightmare. The state also does not follow employment or earnings outcomes for families who left TANF to determine if TANF was successful in promoting economic independence.

Solution: In addition to federal TANF goals, the state should add the goal of lifting families out of poverty. To measure that goal, the state should be required to monitor the employment rates and earnings of families that leave TANF, including identifying where TANF leavers fall with respect to various percentages of the federal poverty level.

3. Provide better supports for children

Historically, TANF has focused on parents rather than the whole family. In fact, TANF often punishes children to get their parents to comply with the many TANF rules. For example, if a parent does not meet the rigid work requirements, the parent loses his or her assistance in the second month and the child loses assistance by the third month if the parent is still non-compliant or cannot find suitable employment. Further, if a parent is denied assistance because they have reached the five-year limit, the child is also denied assistance as long as the child lives with the parent. In 2017, benefits were taken away from 328 families who reached the arbitrary time limit.^[11] This increases stress and homelessness, which threatens family stability. Continuing to provide benefits to children will increase costs, which could be from state or federal TANF funds, but it is one of the best investments the state can make.

Solutions:

Only end TANF benefits for the parent when the parent is not in compliance with work activity but continue to provide them to the child.

Restore parents’ reduced TANF benefits due to a sanction if the parent becomes in compliance within 60 days.

Allow children to continue to be eligible for TANF even when their parents have reached the five-year TANF limit, encouraging home and family stability. The state can use federal funds so long as no more than 20 percent of caseloads are over the five-year limit. The state can also use existing state funds for these kids.

Exclude parents from the five-year TANF limit if they have followed all the TANF rules and continue to do so.

Expand quality childcare and provide adequate information to parents to ensure they can identify such care.

4. Increase child support payments

Currently New Jersey and the federal government keep all the child support that is paid to a family on TANF except for the first $100 a month regardless of how many kids are in the family. In 2020, the state and federal government estimates that they will collect $24 million in child support whereas kids will only receive $2 million in New Jersey.^[12] This not only shortchanges the kids who live in deep poverty, it also means that the non-custodial parent is less likely to pay the full support because they know most of it would not go to their child. Recent research shows that when children on TANF are allowed to receive their full child support payments, those payments increase.^[13] Therefore, New Jersey should accept the federal government’s offer to waive its share of the child support collected for up to $200 a month (when there are two or more children) when the support is passed through to the family and disregarded as income. This waiver of the federal share of collected support makes increasing the amount of child support passed through to the family at essentially half-price to the state.

Solution: Increase this child support pass through to $200 for families with two or more children, which will benefit the children and encourage non-custodial parents to pay more in child support.

5. Provide the education and training parents need for better jobs

Historically, in order to meet TANF’s work requirements, more parents have been placed by the state, sometimes without pay, in job search activities or the Community Work Experience Program (CWEP) than in education and training programs. This policy too often results in “make work” placements that perpetuate poverty and creates enormous stress for the parents who in some cases have little or nothing to do in their CWEP placement. Unfortunately, because of the declining caseloads due to harsher requirements and greater reliance on CWEP, fewer parents are receiving E&T in TANF.

Solutions:

Prioritize education and training with the goal of getting parents to qualify for livable wage jobs that lift families out of poverty.

Expand existing options for E&T to provide parents with the skills that are needed for growing New Jersey industries, such as through apprenticeships, internships, work study programs and other opportunities as well as greater utilization of community colleges. A large body of research has shown that sectoral-based skills training programs can result in major gains in employment and wages for low-income adults who have the most difficulty finding jobs.[14]

Restrict the time period in CWEP placements to 6 months within any 12-month period.

Allow placements with for-profit entities to satisfy “alternative work experience,” provided that they are limited to 6 months and will likely lead to full-time employment with the employer.

Require businesses that receive state tax incentives to collaborate with local community organizations that provide support to TANF participants in the form of work-study, apprenticeships, internships, sector-based contextualized literacy training, skills-based training in growing New Jersey industries, and/or job-retention and advancement services.

6. Eliminating work requirement provisions that are much harsher than required by federal law

Federal rules require a parent to participate in a work activity for 30 hours a week, or 20 hours if their child is under six, but the state goes beyond that by requiring between 35 and 40 hours in unpaid work placements.^[15] This higher hourly requirement is not always realistic for parents; for example, a parent who must also take their children on a bus to childcare then take another bus to participate in a work activity. Also, while federal policy allows a state to exempt parents of infants from work activities for up to 12 months, New Jersey only allows three months. The current state requirements often set up parents for failure and make it impossible for them to support and bond with their children, which is critical for their development. TANF sanctions historically have been the leading cause of case closures.^[16]

Solution: Consistent with federal rules, allow parents with infants to be exempt from work requirements for up to 12 months, and reduce the current 35-hour week work requirement to 30 hours, and 20 hours if their child is below age 6.

7. Improving case management

Because of the five-year lifetime limit on TANF, it is critical that families receive supportive case management to ensure that the parents have all the resources they need to find good jobs before that limit is reached. Currently, participants who reach their 48th month of assistance must participate in the Supportive Assistance to Individuals and Families (SAIF) program. This program provides intensive case management for families who have been unable to become independent due to multiple barriers to employment.^[17] While this has helped some families, it has been reported that it starts too late, and can sometimes mean parents have to meet even more requirements, which can cause them to just give up in frustration.

Solution: Offer additional case management and supportive services, based on an assessment of their barriers to securing employment, once a parent reaches a total of 36 months of enrollment.

8. Broadening TANF eligibility for lawfully present immigrant families

The New Jersey law sharply limits which immigrant children or parents that are lawfully present in this country are eligible for TANF. For example, immigrant children and parents who have been in the U.S. for five years or less are ineligible for TANF. People who were born outside the U.S. have the same needs as native-born people from New Jersey who live in poverty and should not be discriminated against. Excluding immigrants is also antithetical to the state’s public message that it welcomes them. Moreover, studies have shown that immigrants strongly contribute to the state’s economy.

Solution: Make all immigrant children and their parents who are lawfully present in this country eligible for TANF and who otherwise meet TANF eligibility standards.States can use state funds but not federal TANF funds for those immigrants who were made ineligible or excluded for five years under the 1996 law.

9. Improving the exit ramp off of public assistance to support work

It is important that a family’s TANF benefits be reduced gradually once the parent obtains a job to avoid a “cliff,” which is when a small increase in income from a job causes a disproportionate drop in TANF benefits, causing the family to be worse off financially. This cliff also becomes a disincentive to increasing hours or accepting potential raises. The current policy allows the parent to keep their full TANF benefits in the first month of employment, which is then phased down in subsequent months. The phase down rules differ for part-time and full-time workers, which is confusing for the parents and even the case workers. Simpler policies that also do not start grant reduction until after two months of earnings will allow TANF families time to stabilize their family budget after getting a new job.

Solutions:

Increase the current incentive for employment by allowing the employed family to receive their full TANF benefits for two months.

Remove some of the limits on how many times the earnings disregards can be applied.

No longer count the time receiving TANF due to earnings disregards towards the five-year time limit on TANF. While the federal TANF rules do not have a “stop the clock” provision, a state can choose when to run time or stop time clocks so long as not more than 20 percent of the caseload receive federal TANF funds beyond 60 months. Most working families do not stay on TANF for five years, but if the state chose, it also could simply use state funds to serve families whose clocks are stopped.

Conclusion

Collectively, these policies would provide a boost in basic assistance that gives families needed flexibility to use the income in the ways that best help their household live in a high cost of living state like New Jersey. This means diapers, medicine, clothing, bus fare, school supplies, rent and utility payments, car repairs, and more. Income matters: when Black, Brown, and white families struggling to meet their basic needs get more income, their children have a better chance of growing up healthy and with an opportunity to thrive.

TANF is the main income assistance program for families experiencing extreme financial hardship, and it can play a key role in ensuring that they are able to climb up and out of poverty. When we support the well-being of our neighbors, we make sure that everyone can reach their full potential and contribute to our communities.

Appendix

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End Notes

^[1] Ashley Burnside, Ife Floyd, More States Raising TANF Benefits To Boost Families’ Economic Security, December 9, 2019, https://www.cbpp.org/research/family-income-support/more-states-raising-tanf-benefits-to-boost-families-economic-security

^[2] Center on Budget and Policy Priorities, TANF Cash Benefits Have Fallen By More Than 20% In Most States And Continue To Erode, October 13,2017 https://www.publicnow.com/view/71F8C9CD6D0CC646ABAF4FF08EB28C609F63ABC9

^[3] Department of workforce services, Inter-Generational Poverty In Utah 2012, Department of workforce services, Inter-Generational Poverty In Utah 2012, https://jobs.utah.gov/edo/intergenerational/igp12.pdf

^[4] Michael McLaughlin, Marc Rank, Estimating The Economic Cost Of Childhood Poverty In the United States, March 30, 2018, https://academic.oup.com/swr/article-abstract/42/2/73/4956930?redirectedFrom=fulltext

^[5] The National Association of Sciences, Engineering, Medicine; Consensus Study Report, A Roadmap To Reducing Child Poverty, 2019, https://www.nap.edu/catalog/25246/a-roadmap-to-reducing-child-poverty

^[6] Stephen Woolf, et al, How Are Income and Wealth Linked To Health And Longevity, April, 2015, wealth https://www.urban.org/sites/default/files/publication/49116/2000178-How-are-Income-and-Wealth-Linked-to-Health-and-Longevity.pdf

^[7] The Annie E. Casey Foundation, Children In Poverty By Race And Ethnicity In New Jersey, 2018, Richard Barrington, Moneyrates, States with the Lowest And Highest Income Inequality, April 3, 2019, https://datacenter.kidscount.org/data/tables/44-children-in-poverty-by-race-and-ethnicity?loc=32&loct=2#detailed/2/32/false/37,871,870,573,869,36,868,867,133,38/10,11,9,12,1,185,13/324,323

^[8] Elizabeth McNichol, How State Tax Policies Can Stop Increasing Inequality and Start Reducing It, December 15, 2016, https://www.cbpp.org/research/state-budget-and-tax/how-state-tax-policies-can-stop-increasing-inequality-and-start

^[9] Sarah Rinehart, SNAP Is A Boon To Urban And Rural Economies. Proposed Farm Bill Changes Could Cripple Them, July 5, 2018, https://civileats.com/2018/07/05/snap-is-a-boon-to-urban-and-rural-economies-proposed-farm-bill-changes-could-cripple-them/

^[10]Raymond Castro, Lost Opportunities For New Jersey Children, February 11, 2016, https://www.njpp.org/reports/lost-opportunities-for-new-jerseys-children

^[11] New Jersey Division of Family Development, WorkFirst NJ, Quarterly Progress Update, December 2017, https://www.state.nj.us/humanservices/dfd/news/wfnj_%20dec17.pdf,

Development, WorkFirst NJ, Quarterly Progress Update, September 2017, https://www.state.nj.us/humanservices/dfd/news/wfnj_sept17.pdf, https://www.state.nj.us/humanservices/dfd/news/wfnj_june17.pdf , New Jersey Division of Family Development, WorkFirst NJ, Quarterly Progress, June, 2017, https://www.state.nj.us/humanservices/dfd/news/wfnj_mar17.pdf

^[12] Governor’s FY 2020 Budget.

^[13] Colorado Office of Performance and Strategic Outcomes, Evaluating the Effect Of Colorado’s For Support Pass-Through Policy, 2019-2019, https://drive.google.com/file/d/1lh2NsnwZP27eoZEjOPpHtUKMs2qOUW65/view

[14] Tazra Mitchell, Research Note: Sectoral Skills Training Programs For Low Income Workers Can Yield Sustained Earnings and Employment Gains, New Evaluation Finds, June 20, 2017, https://www.cbpp.org/research/family-income-support/research-note-sectoral-skills-training-programs-for-low-income

^[15] New Jersey Division of Family Development, New Jersey State Plan For Temporary Assistance For Needy Families, FFY 2015 To FFY 2017, https://www.nj.gov/humanservices/dfd/programs/workfirstnj/tanf_state_plan_15-17.pdf, p. 14

^[16] In the last quarter alone in 2017 1057 parents were sanctioned, New Jersey Division Of Family Development, WorkFirst NJ, Quarterly Progress Update, December 2017, sanctioned. https://www.state.nj.us/humanservices/dfd/news/wfnj_%20dec17.pdf

^[17] New Jersey Division of Family Development, New Jersey State Plan For Temporary Assistance For Needy Families, FFY 2015 To FFY 2017, https://www.nj.gov/humanservices/dfd/programs/workfirstnj/tanf_state_plan_15-17.pdf, .p.21

NJPP: Trump Budget Proposes Devastating Cuts to Health and Social Programs

Posted on February 10, 2020 by Raymond Castro

Earlier today President Trump unveiled a $4.8 trillion budget for 2021, including major cuts to the social safety net. In response to the budget proposal, New Jersey Policy Perspective (NJPP) releases the following statement.

Raymond Castro, Health Policy Director, NJPP:

“President Trump’s budget represents yet another massive redistribution of wealth from low-income and working class families to the top 1 percent. His budget proposes devastating cuts to health and social programs — possibly the largest cuts proposed by a president in the nation’s history — and threatens to push far too many families into poverty. Meanwhile, wealthy individuals would receive a windfall as the budget makes the 2017 tax cuts permanent. If signed into law, this will widen growing inequities and pull the safety net out from under families struggling to make ends meet.

“The budget calls for $1 trillion in cuts over ten years in Medicaid and the marketplace which would result in billions of dollars lost for New Jersey and reverse the major progress that has been made in expanding health coverage across the state. The proposed cuts to Medicaid expansion endanger the health care of 500,0000 New Jerseyans currently in Medicaid. The health care of an additional 300,000 New Jerseyans is also at risk from a sharp reduction in marketplace premium assistance.

“Further, the budget would cut food assistance in New Jersey by $1.5 billion over five years. The budget would also fully eliminate the social services block grant, Community Services Block Grant, and Low-Income Home Energy Assistance Program, resulting in a total loss of federal funds of $1.3 billion over five years and the complete loss of these supportive services at the community level. In addition, Temporary Assistance for Needy Families, which has not received an increase at the federal level in 20 years, would be cut by over $200 million in New Jersey over five years, further impoverishing these families that live well below the poverty level. Simply put, these cuts would be catastrophic for New Jersey and would directly harm our families, friends, and neighbors in every corner of the state.”

# # #

Protecting Roe v. Wade is Not Enough

Posted on January 22, 2020October 9, 2020 by Sheila Reynertson

Today, Americans commemorate the 47th anniversary of Roe v. Wade, the 1973 U.S. Supreme Court decision that struck down statewide bans on abortion, thereby allowing people to make decisions about whether and when to have a family. Thankfully, New Jersey has consistently upheld the right to abortion care since the procedure was legalized.

New Jersey is one of just twelve states that uses state funds to support Medicaid access to abortion services to mitigate the impact of the Hyde Amendment, which blocks all federal funds from paying for abortion information, referrals, or care. Equally important, the state has largely remained outside the national trend of state-level abortion restrictions like waiting periods and mandatory ultrasound exams.

Though the right to abortion exists in theory, for many people in New Jersey and around the nation, it is inaccessible in practice. The leader of Yellowhammer Fund, an abortion fund and reproductive justice organization in Alabama, describes this reality in a thoughtful refection of this day. In a post-Roe world, Amanda Reyes asserts, access to abortion care requires a person have the financial ability to travel to and obtain the service; it requires a doctor or clinic savvy enough to remain in business despite chronically low Medicaid reimbursement rates; it requires a new generation of abortion providers to replace those who retire. When one or more of these are absent, the harm falls hardest on lower income communities and the under- and uninsured, people who are transgender and non-binary, and people who may face significant barriers to health care more generally.

New Jersey can do better.

In his State of the State address, Governor Murphy detailed an agenda for the year ahead that includes passing legislation to enshrine the right to abortion access and reproductive health care in state law. That makes sense, as it recognizes that reproductive health care is inextricably linked to racial and economic justice. With Roe v. Wade under threat by the U.S. Supreme Court, it’s more important than ever that New Jersey build on its strong track record of supporting reproductive health.

But the legislation must go further to show that New Jersey won’t back down in the face of ongoing attacks. Lawmakers must ensure that everyone has equitable access to care regardless of a person’s income, zip code, age, race, or immigration status. When everyone can make decisions that are best for their own lives, families thrive and communities grow stronger.

At NJPP, we know that ensuring access to comprehensive reproductive health care is critical to reducing poverty, ensuring racial equity, and advancing economic justice. But access to these services should not depend on how wealthy you are or which zip code you happen to live in. The governor and legislature have a unique opportunity this legislative session to not only affirm these rights, but ensure that the state is taking an active role in breaking down harmful barriers so all New Jerseyans can decide what’s best for them and their families.

NJPP: New Jersey Takes Major Step to Codify ACA Protections

Posted on January 9, 2020 by Raymond Castro

Earlier today, the New Jersey Senate passed a package of bills to codify core provisions of the Affordable Care Act (ACA) in state law. Should a federal court strike down the ACA, these protections would remain in place if signed into law by Governor Murphy. In response to the passage of these bills, New Jersey Policy Perspective (NJPP) releases the following statement.

Raymond Castro, Health Policy Director, NJPP:

“With the passage of these bills, New Jersey is solidifying its place as a national leader in protecting the health coverage of its residents. If signed by Governor Murphy, key provisions of the ACA will stay in place should a federal court strike down the landmark health care law. Most of these protections — such as prohibiting insurers from denying coverage for preexisting conditions, requiring essential benefits, providing free preventive services, and allowing parents to keep their dependents on their plan until age 26 — have been in effect for six years; it is hard to imagine a health care system without them.

“These bills, however, do not remedy the biggest problem New Jersey would face if the federal courts overturn the ACA: the loss of billions of federal dollars that are essential to provide Medicaid expansion coverage to a half-million New Jerseyans and keep premiums in the individual market affordable for another 300,000 adults and children. To avoid such a catastrophe, the state’s congressional delegation must continue to fight back against the Trump administration’s sabotage of the ACA.”

# # #

Topic Category: Health

Unprecedented and Unequal: Racial Inequities in the COVID-19 Pandemic

Black and Latinx Cases, Hospitalization Rates, and Mortality Rates Outpace Others

Lack of Adequate Planning and Prevention has Led to Greater Suffering

Greater Investment in the Future Health of New Jersey is Necessary

Census 2019: New Jersey’s Uninsured Rate Increased for the First Time in Years

New Jersey’s Uninsured Rate Increased for the First Time Since 2013

The COVID-19 Pandemic Promises Hardship … and New Jersey Needs to Prepare

COVID-19 Job Loss Leaves More Than 100,000 New Jerseyans Uninsured

How do we move forward?

NJPP Applauds Passage of State-Level Health Insurance Assessment

The Health Insurance Assessment Will Make Coverage More Affordable and Accessible

New Jersey Can Act Now to Make Health Care More Affordable: The Health Insurance Assessment Explained

What is a Health Insurance Assessment (HIA)?

How much revenue would a state-level HIA bring into New Jersey?

Who would benefit from a state-level HIA?

How would a state-level HIA improve public health and increase affordability?

How would a state-level HIA impact insurance providers, and what types of insurance plans would be included?

Would a state-level HIA lead to increases in premiums?

Have other states introduced state-level HIAs?

End Notes

Promoting Equal Opportunities for Children Living in Poverty

The Importance of Reducing Child Poverty

Common Sense Measures to Improve TANF

Protecting Roe v. Wade is Not Enough

NJPP: New Jersey Takes Major Step to Codify ACA Protections

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