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Wendy Chavkin, MD, MPH and Paul H. Wise, MD, MPH

Wendy Chavkin and Diana Romero are with the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY. Paul Wise is with the Department of Pediatrics, School of Medicine, Boston University, Boston, Mass.

Correspondence: Requests for reprints should be sent to Wendy Chavkin, MD, MPH, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B-2, New York, NY 10032 (e-mail: wc9{at}columbia.edu).

	INTRODUCTION

TOP INTRODUCTION THE BURDEN OF CHRONIC... BENEFIT LOSS AND FAMILY... HEALTH-RELATED RECOMMENDATIONS CONCLUSION References

 
Social policies are expressed physically in individuals and in patterns of health in populations. Yet the authors of a major policy change in the United States—welfare reform—did not consider the health consequences of this change to be outcomes of critical importance. This is particularly striking since the foundation of public assistance in this country, the 1935 Social Security Act, was intended, in the words of President Franklin D. Roosevelt, "for the protection of children and the prevention of ill health."¹

Five years ago, the Personal Responsibility Work Opportunity and Reconciliation Act (PRWORA)² was passed to "end welfare as we know it." The act converted cash assistance for parents (generally mothers) caring for children from an entitlement based on income to a temporary benefit, available for a maximum of 5 years. The new cash assistance program, Temporary Assistance for Needy Families (TANF), was uncoupled ("delinked") from other benefit programs, such as Medicaid and the food stamp program, and conditioned receipt of benefits on a host of behavioral requirements, of which paid maternal employment was the centerpiece. In recognition of the likelihood that women might become uninsured, the State Children’s Health Insurance Program (SCHIP), included in the Balanced Budget Act of 1997, was intended to provide health insurance for children even if their parents were not covered. Regulatory and programmatic authority was "devolved" from the federal government to the states, which has generated broad variation in state welfare programs and reduced federal oversight.

Although the federal government has collected limited data on the impact of the PRWORA experience, it is clear that the number of families receiving TANF has declined dramatically—by 56% from the 1996 figures.³ There have been independent efforts to evaluate the consequences of the PRWORA, most of which have focused on the legislation’s expressed central goal: maternal employment. Many of these studies have reported that the majority of women leaving TANF have found paid employment, but often only temporarily, which did not generally raise incomes. Concurrently, various national and state studies have reported large declines in Medicaid and food stamp enrollment.^4–8

It has been 5 years since the PRWORA was passed and it must now be reauthorized. This reauthorization process provides a crucial opportunity for the clinical and public health communities to elevate health as an important element in these deliberations. It is now a fact of social history that health concerns were largely ignored in the original construction of the welfare reform legislation. To permit a continued disregard for health issues during the reauthorization process would be unconscionable.

The work presented in this issue of the Journal helps document the association between welfare reform and health; it frames for public discourse the human cost of welfare policies that do not reflect the underlying epidemiology of familial capacity and need. The research methods used vary considerably, but all attempt to provide insight into the ways in which welfare reform has affected the health of women and children and how health influences the ability of women to move into the workforce and maintain steady employment. Some of the analyses presented attempt to glean lessons from extant data sets that were not expressly developed to link welfare and health variables.^9,10 However, several of the studies offer the first empirical insights into the effects of welfare reform derived from clinical and community settings, with analyses based on interviews with mothers of chronically ill children. Together these articles begin to outline the complex relationship between welfare and health and, in so doing, challenge directly those current welfare proposals that continue to disregard and may be damaging to health.

	THE BURDEN OF CHRONIC ILLNESS

TOP INTRODUCTION THE BURDEN OF CHRONIC... BENEFIT LOSS AND FAMILY... HEALTH-RELATED RECOMMENDATIONS CONCLUSION References

 
A significant proportion of poor families are affected by chronic illness in the mother, the children, or both. Moreover, data suggest that poor families with chronic illness are more likely to enroll in welfare programs. Children of such families appear to miss more school than do other poor children¹¹ and to suffer from more severe symptoms,¹² and their families have greater difficulty affording care.¹¹

Not surprisingly, children’s illness interferes with their mothers’ ability to maintain employment.^13,14 In our work and that of others,^15,16 mothers have consistently reported that their children’s illnesses caused them to miss work and to lose jobs. These problems were even more severe for those who had left TANF and for those whose children had more emergency room visits and hospitalizations. Conversely, maternal work requirements also impeded these mothers’ ability to bring their children to health facilities for medical care.

Too often, these women themselves face illness and hardships. It is important to recognize that the population of women on welfare is heterogeneous. For example, 500 mothers interviewed in San Antonio, Tex, tended to fall into 4 categories with different social characteristics. The first group comprised women who had never received welfare and who were better educated, had higher incomes, and were least likely to have chronic health problems. The second group included women currently receiving TANF and who had completed the fewest years of schooling, had very low incomes, had a host of physical and mental health problems, and were more likely than women in the other groups to be receiving benefits such as food stamps, housing, and Medicaid. The third group consisted of women who had left TANF, were more educated than those who remained in the program, and were slightly less likely to have had chronic health problems but had much lower rates of benefit receipt. The fourth group included women who had applied for TANF, who had the most concentrated cluster of problems, and who fared worse than others on every parameter examined. These mothers were most likely to report that their child’s illness interfered with their ability to hold jobs.

	BENEFIT LOSS AND FAMILY HARDSHIP

TOP INTRODUCTION THE BURDEN OF CHRONIC... BENEFIT LOSS AND FAMILY... HEALTH-RELATED RECOMMENDATIONS CONCLUSION References

 
Several other major investigations have demonstrated declines in food stamp and Medicaid enrollment across the nation and indicated that women leaving TANF were particularly likely to experience loss of these benefits.^17–19 Nor has enrollment in the SCHIP compensated for reduced Medicaid coverage among children of TANF leavers.¹⁹ Our data confirm these observations and suggest that TANF families are more likely to have children with health insurance than non-TANF poor families, and that this latter group, consequently, was less able to afford prescriptions and dental and mental health care and was less likely to have had medical visits in the past year. In San Antonio, those who had left TANF or were TANF applicants were most likely to have experienced hardships such as food insecurity.

It is also important to recognize that major obstacles to the receipt of needed benefits are the application and recertification processes themselves. Many states have implemented "diversion" policies whereby TANF applicants are told to provide proof of failed job searches, are urged to seek resources from family or charities, or are provided with a lump sum payment in exchange for a promise not to apply for TANF for a specified time period.^20,21 Our previous state-level analysis²¹ showed that declines in Medicaid receipt and increases in numbers of the uninsured, including among children, were associated with such diversion policies. TANF leavers are supposed to receive transitional Medicaid, but the higher numbers of uninsured families in this group suggest either that this is not occurring or that transitional Medicaid coverage is not followed by employer-based health insurance.

In the course of conducting a survey of state maternal and child health directors, we documented the fact that many states require frequent recertification of eligibility, using forms and procedures that are burdensome or confusing.²³ In addition, many states have imposed other demands as part of the application process, such as paternity identification for SCHIP. Current administrative procedures appear to have erected unnecessary barriers to the provision of benefits for many who are both eligible and in need.

	HEALTH-RELATED RECOMMENDATIONS

TOP INTRODUCTION THE BURDEN OF CHRONIC... BENEFIT LOSS AND FAMILY... HEALTH-RELATED RECOMMENDATIONS CONCLUSION References

 
Administrative systems should be revised to reduce barriers to enrollment in social programs. Congress must ensure that state efforts to deter applicants from enrolling in TANF and other benefit programs result in improved life conditions for applicant families and not just reduced numbers of program participants. This will require restrictions in the methods employed by deterrence programs and intensified monitoring of deterred families. In addition, current recertification procedures for TANF, Medicaid, SCHIP, and food stamps must be simplified and made far more responsive to families erroneously cut off from the programs. Current procedures in no way recognize that the loss of benefits for stilleligible families affected by chronic illness can be catastrophic.

The reauthorization legislation must also support improved state efforts to enroll eligible children and families in Medicaid and food stamp programs. It is a disgrace that children eligible for Medicaid or SCHIP go uninsured, a status that is expressed daily in preventable illness. Legislative revisions should address the well-documented administrative barriers and redress the lack of outreach that have contributed to the increase in numbers of uninsured women and children over the past 5 years.

Expand and modify criteria for waivers and exemptions for families with serious chronic illness. Chronic illness, in both children and mothers, will limit the ability of many women to maintain regular employment. Inflexible welfare employment rules and working conditions may also impede access to necessary health care. Some individuals may not be able to work at all and will need exemptions both from the work requirements and from the 5-year (or shorter in some states) lifetime limit for benefits. Therefore, the reauthorization legislation should modify current waiver and exemption mechanisms so that they provide greater flexibility to address the needs of families affected by serious chronic illness.

In addition, the shortage of competent child care confronting all poor working women is aggravated for those whose children need medicines administered, special regimens, or recognition of symptoms needing medical attention. Sufficient resources should be provided for child care for children with special needs, and guidelines should be developed for states and businesses to support protected leave policies, expand medical hours for health care delivery, and explore other innovative approaches to ensure access to care for families struggling with chronic maternal or child illness and the requirements of subsistence.

Data should be gathered on the impact of welfare reform on maternal and child health. Indicators of maternal and child health must be included as outcomes of concern in revised welfare policies. The revised legislation should include data collection mandates and the necessary support to permit meaningful evaluation of the impact of new welfare policies and programs on health. Currently, the paucity of data that link welfare and health is striking. The reauthorized legislation should provide support for the development of such data sets at the national level as well as fund innovative efforts, such as those that exist in South Carolina and Washington, to link relevant data sets at the state level. In addition, we urge the exploration of innovative, policyrelevant approaches that monitor sentinel geographic areas, populations of children with special health care needs, and safety net providers, as such monitoring efforts may offer rapid and efficient means of obtaining information or detecting developing trends.

	CONCLUSION

TOP INTRODUCTION THE BURDEN OF CHRONIC... BENEFIT LOSS AND FAMILY... HEALTH-RELATED RECOMMENDATIONS CONCLUSION References

 
It is essential that welfare reform legislation not continue to ignore the requirements of maternal and child health. No responsible voice, regardless of political ideology, would urge the deprivation and suffering of ill women and children. Yet without attention, current proposals for reauthorization of the PRWORA may produce just such a result. The development of programmatic goals and procedures with little sense of the underlying epidemiology of chronic illness among poor families in America is likely to undermine an effective safety net and deepen the mismatch of services to needs.

Responding to this epidemiology of need does not require major alterations in current legislation or funding levels. Rather, it requires concern for the impact of ill health on family capacity and an awareness of the flexibility and resources states and local programs need in order to respond. The public health community, through research and advocacy, can give voice to the experiences of those families most affected by welfare reform and inform the public deliberation of the reauthorized legislation so that it may emerge as both effective and just.

	Acknowledgments

 
This research was supported in part by funding from the Ford Foundation, the General Service Foundation, the Maternal and Child Health Bureau, the Moriah Fund, the National Institute of Allergy and Infectious Diseases, the Office of Population Affairs, the Open Society Institute, and the Robert Wood Johnson Foundation.

Thanks to all members of the research team and specifically to Diana Romero, PhD, MA, for her insightful contributions to the themes presented in this paper and her overall role in directing this multipronged research effort. We gratefully acknowledge Fernando Guerra, MD, MPH; William Parry, MD; James Alexander, MD; Steven Enders, and the administrators at the San Antonio Texas Works offices, without whose assistance we would not have been able to conduct this research. We would also like to express our appreciation to Monica Trevino, the San Antonio site coordinator; Tammy Draut, Lauren Oshmon, Naomi Lince, and Julia Choe for overall study coordination; the various clinical and agency site personnel; our dedicated interviewers; and the families and children who so generously agreed to participate in this important project. Thanks to the many reviewers for their thoughtful and expeditious suggestions, to Rebecca Shoai for her assistance with background research, and to Ann Gavaghan for coordinating the review and submission of the cluster of related articles in this issue of the Journal.

Accepted for publication May 2, 2002.

	References

TOP INTRODUCTION THE BURDEN OF CHRONIC... BENEFIT LOSS AND FAMILY... HEALTH-RELATED RECOMMENDATIONS CONCLUSION References

 
1. Social Security Administration. Presidential statement signing the Social Security Act, August 14, 1935. Available at: http://www.ssa.gov/history/fdrstmts.html#signing. Accessed July 9, 2002.

2. Personal Responsibility and Work Opportunity Reconciliation Act, Pub L No 104-193, 110 Stat 2105 (1996) (codified as amended at 42 USC: 601–617).

3. Administration for Children and Families. Statistics. Available at: http://www.acf.dhhs.gov/news/stats/recipients.htm. Accessed July 9, 2002.

4. Health Care Financing Administration. Medicaid eligibles. Available (in PDF format) at: http://www.hcfa.gov/medicaid/msis/2082-99.htm. Accessed July 9, 2002.

5. Medicaid Enrollment: Amid Declines, State Efforts to Ensure Coverage After Welfare Reform Vary. Washington, DC: Health, Education, and Human Services Division, US General Accounting Office; 1999.

6. Food Stamp Program Actual Participation, December. Washington, DC: Food and Nutrition Services Budget Division, US Dept of Agriculture; 1999:2.

7. Dion M, Pavetti L. Access to and Participation in Medicaid and the Food Stamp Program. Washington, DC: Administration for Children and Families, US Dept of Health and Human Services; 2000.

8. Go Directly to Work, Do Not Collect Health Insurance: Low–Income Parents Lose Medicaid. Washington, DC: Families, USA; 2000:43.

9. Wise PH, Wampler N, Chavkin W, Romero D. Chronic Illness Among Poor Children Enrolled in the Temporary Assistance for Needy Families Program. Am J Public Health. 2002;9:1458–1461.

10. Pati S, Romero D, Chavkin W. Changes in Use of Health Insurance and Food Assistance Programs in Medically Underserved Communities in the Era of Welfare Reform: An Urban Study. Am J Public Health. 2002;9:1441–1445.

11. Wise P, Chavkin W, Wampler N, Romero D, Howard M, Hartman N. Assessing the Impact of Welfare Reform on Chronically Ill Children. Abstract submitted to the 2002 National Association for Welfare Research and Statistics (NAWRS) conference; August 25-28, 2002; Albuquerque, NM.

12. Wood P, Smith LA, Romero D, Bradshaw P, Wise PH, Chavkin W. Relationships Between Welfare Status, Health Insurance Status, and Health and Medical Care Among Children With Asthma. Am J Public Health. 2002;9:1446–1452.

13. Smith LA, Romero D, Wood P, Wampler N, Chavkin W, Wise PH. Employment Barriers Among Welfare Recipients and Applicants With Chronically Ill Children. Am J Public Health. 2002;9:1453–1457.

14. Romero D, Chavkin W, Wise PH, Smith LA, Wood P. Welfare to Work? Impact of Maternal Health on Employment. Am J Public Health. 2002;9:1462–1468.

15. Earle A, Heymann SJ. What causes job loss among former welfare recipients: the role of family health problems. J Am Med Womens Assoc. 2002;57: 5–10.

16. Heymann SJ, Earle A. The impact of welfare reform on parents’ ability to care for their children’s health. Am J Public Health. 1999;89:502–505.[Abstract/Free Full Text]

17. Zedlewski S. Leaving welfare often severs families’ connections to the food stamp program. J Am Med Womens Assoc. 2002;57:23–26.

18. Zedlewski S, Brauner S. Declines in Food Stamp and Welfare Participation: Is There a Connection? Washington, DC: The Urban Institute; October 2001. Also available (in PDF format) at: http://www.urban.org/news/focus/focus_welfare.html. Accessed July 9, 2002.

19. Mann C, Hudman J, Salganicoff A, Folsom A. Five years later: poor women’s health care coverage after welfare reform. J Am Med Women’s Assoc. 2002;57:16–22.

20. Maloy KA, Pavetti LA, Shin P, Darnell J, Scarpulla-Nolan L. A Description and Assessment of State Approaches to Diversion Programs and Activities Under Welfare Reform. Washington, DC: Center for Health Policy Research, The George Washington University Medical Center; August 1998.

21. State Policy Documentation Project. Available at: http://www.spdp.org. Accessed July 10, 2002.

22. Chavkin W, Romero D, Wise PH. State welfare reform policies and declines in health insurance. Am J Public Health. 2000;90:900–908.[Abstract/Free Full Text]

23. Romero D, Chavkin W, Wise PH, Hess CA, Van Landeghem K. State welfare reform policies and maternal and child health services: a national study. Mat Child Health J. 2001;5(3):199–206.

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