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FORUM ON WELFARE REFORM |
Paul H. Wise is with the Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, Mass. Nina S. Wampler is with the Division of American Indian and Alaska Native Programs, University of Colorado Health Science Center, Denver. Wendy Chavkin and Diana Romero are with the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City.
Correspondence: Requests for reprints should be sent to Paul H. Wise, MD, MPH, Boston Medical Center, Department of Pediatrics, Maternity-4, One Boston Medical Center Pl, Boston, MA 02118 (e-mail: pwise{at}bu.edu).
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ABSTRACT |
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Objectives. This study assessed chronic child illness among recipients of Temporary Assistance for Needy Families (TANF) benefits and poor families not receiving benefits.
Methods. Data from the 1998 National Health Interview Survey were used to examine chronic child illness, enrollment in TANF, health insurance status, and selected access indicators.
Results. One quarter of TANF-enrolled children had chronic illnesses. Unenrolled children were 3 times as likely as TANF-enrolled children to be uninsured. Among the chronically ill, 31.7% of unenrolled and 14.3% of enrolled children experienced gaps in insurance coverage that were associated with access barriers.
Conclusions. Welfare policies should consider the effects of chronic illness and gaps in insurance coverage on the health of poor children.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Despite considerable public debate over the impact of the Personal Responsibility and Work Opportunity Reconciliation Act and its reauthorization, there remains a striking paucity of information on the health status of families affected by this legislation.2,3 Of particular concern is whether current or proposed welfare provisions adequately account for the special requirements of families affected by serious chronic illness. Such illness in women or their children has been shown to influence the prospects of maternal employment and intensify the need for adequate health insurance.4–6
In the present study, we sought to provide some empirical context for public deliberation of the act’s reauthorization by examining patterns of TANF participation among a national sample of poor chronically ill children. Specifically, the analyses outlined here describe the extent to which children on TANF experience chronic illness, gaps in insurance coverage, and selected barriers to health care services. In addition, comparative analyses were conducted among children living in poverty but not enrolled in TANF, a group that may increasingly reflect those never enrolled in TANF or those who have lost TANF benefits but whose family income did not rise above the federal poverty level.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Income and age. The NHIS asks about household income for the year before the interview. We included children who were younger than 18 years and who were members of families at or below the official federal poverty level for the year 1997 only; a total of 1987 children met these criteria. Weighted national estimates are presented in the tabulations.
Welfare participation. Welfare program participation was confined to enrollment in TANF. The NHIS collects information on TANF enrollment by asking the adult respondent whether the child had received TANF or related public cash assistance payments during the year before the interview.
Health insurance. Information on health insurance coverage during the month before the interview was collected for each child. Types of public insurance coverage included Medicaid; state-based insurance programs such as those derived from the State Child Health Insurance Program; and other public programs offering coverage, such as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and the Indian Health Service. Children were considered to be privately insured if adults responded affirmatively to a specific question regarding private insurance plans. Gaps in health insurance coverage were considered to exist if children had experienced any time without health insurance during the 12 months before the interview.
Chronic conditions. Adult respondents provided information about children’s health status. A condition was considered to be present if a physician or other health care professional had ever told the respondent that the child had the condition in question. Chronic conditions included asthma, mental retardation, cerebral palsy, autism, attention deficit disorder, muscular dystrophy, cystic fibrosis, sickle-cell anemia, diabetes, arthritis, and congenital heart disease. Other conditions, including some that could be chronic, were not considered to be serious enough to mediate welfare effects and thus were excluded from the analysis.
Physician visits and access barriers. The survey collected information on the number of visits the child made in the preceding 12 months to a physician’s office, clinic, or other place for health care, excluding emergency departments and inpatient facilities. The survey also asked whether there was any time when the child needed care but did not receive it because the family could not afford the cost. We examined this issue specifically for prescribed medications, mental health services, and dental care. These variables were considered outcome variables and were analyzed in relation to insurance status and TANF enrollment.
Multivariate Analysis
Multivariate logistic regression models were constructed to measure the impact of TANF enrollment on physician visits and the selected access barriers. We assessed health insurance coverage by comparing public insurance coverage (Medicaid, state-based plans, CHAMPUS, Indian Health Service) and no insurance coverage with the referent private insurance group. Children with chronic illnesses were compared with children without such illnesses. Children’s age was also entered into the models. Models were constructed with SUDAAN8 statistical software, which accounted for the complex sampling framework of the NHIS.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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). The most prevalent of these conditions was asthma, accounting for almost 30% of the chronic illness reported. Twenty-eight percent of all children with chronic illness were reported to have more than 1 chronic condition, and 11% had more than 2 such conditions.
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also suggests that more than one quarter of the TANF-enrolled children were reported as having chronic illnesses. This prevalence rate proved to be significantly higher than the rate for the unenrolled group (21.5% vs 25.6%; P < .01). However, more than 1 in 5 poor children not enrolled in TANF also were reported to suffer from some form of chronic illness. There were no significant differences between the 2 groups in types of conditions reported.
Health Insurance Coverage
During the year under study, the majority of poor children were covered by Medicaid (Table 2). Eighteen percent of children had private insurance, primarily through employer-based plans; 3% were covered by state-based programs, including the State Child Health Insurance Program; and 3% had other public insurance. More than 23% of all studied children were reported to have had no insurance for the month before the interview.
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Importantly, poor children not enrolled in TANF were more than 3 times as likely as those enrolled in TANF to be uninsured (P < .001). Indeed, among the unenrolled children under study, 28.9% had been uninsured for at least part of the month before the interview. Nine percent of children enrolled in TANF were reported to have experienced a gap in insurance coverage over the previous month.
Gaps in Coverage and Chronic Illness
Data on parents’ reports of gaps in health insurance coverage of their children during the 12 months before the interview are presented in Table 3. These reports of insurance gaps were stratified by whether the child was reported to have a chronic illness. The data suggest that poor children without chronic illnesses were significantly more likely to have experienced a gap in insurance coverage than were children with chronic illnesses (P < .01). However, not being enrolled in TANF was strongly associated with a gap in coverage for children with and without chronic illnesses. Indeed, among unenrolled children with chronic disorders, almost one third experienced gaps in coverage, more than double the rate among enrolled chronically ill children (P < .001).
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As can be seen in Table 4, public insurance coverage (Medicaid, state-based, and other public plans) was associated with a significant increase in physician visitation relative to private insurance coverage (odds ratio [OR] = 2.24; 95% confidence interval [CI] = 1.70, 2.96; P < .001). Being uninsured, however, was not significantly related to physician visitation. The presence of a chronic illness was strongly related to physician visitation in this group of poor children (OR = 4.11; 95% CI = 2.66, 6.34; P < .001). Enrollment in TANF was associated with physician visitation even after insurance coverage and illness had been entered into the model (OR = 1.52; 95% CI = 1.08, 2.15; P < .05).
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Similarly, the presence of a chronic illness was strongly associated with being unable to afford the selected elements of care. This relationship was generally maintained for both asthma and developmental conditions, although the numbers available for study were too small to permit more refined, condition-specific analyses. Interestingly, TANF enrollment had no significant effect on the examined indicators of access once illness and insurance status had been entered into the model.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Although the Personal Responsibility and Work Opportunity Reconciliation Act eliminated the long-standing administrative linkage of cash assistance and Medicaid, the findings of this study suggest that TANF-enrolled children were far more likely to have had health insurance than were unenrolled poor children. We could not identify specific determinants of this disparity, including whether the unenrolled children were fully eligible for TANF, had been terminated from TANF, or had ever applied for TANF. However, enrollment in TANF may raise enrollees’ awareness of the Medicaid program and, in many settings, facilitate Medicaid enrollment. Nevertheless, the high rates of uninsured children among non-TANF poor families are of major concern. Accordingly, welfare policies that include strong efforts to enroll all eligible children in Medicaid programs or the State Child Health Insurance Program would be useful.
Newacheck et al.11,12 have clearly documented that the combination of chronic illness and lack of health insurance can result in serious unmet health care needs. Our study highlights the relevance of this fact to current welfare deliberations by documenting particularly serious gaps in health insurance coverage among poor chronically ill children not enrolled in TANF. Moreover, these gaps were associated with serious financial barriers to obtaining prescribed medications and other elements of comprehensive health services.
The present findings suggest that the main reason for this beneficial TANF effect was the association of TANF with higher rates of health insurance coverage. Indeed, families with public health insurance for their children, primarily Medicaid, experienced even fewer problems affording costs of the studied elements of care than did poor families covered by private insurance. The problems faced by the poor families not enrolled in TANF also raise questions regarding welfare policies that attempt to prevent families from enrolling in TANF even if they are eligible. These "diversion" programs may not make special provisions for families with chronically ill children or facilitate adequate health insurance coverage.
Our findings should be interpreted with some caution. The accuracy of parental reports of childhood illness and health care use should always be viewed critically. However, the parental report variables included in this study have been examined extensively and used constructively to assess child health care needs.11,12 Defining chronic illness in children can also be problematic, and prevalence estimates have varied accordingly.13,14 In addition, reduced contact with health care providers among children without health insurance could result in underestimations of the prevalence of chronic conditions. Our use of conditions that are likely to be both chronic and serious would tend to minimize, although not eliminate, this concern.
The NHIS has been used extensively to examine a variety of health issues, but it contains relatively little information about families’ experiences with TANF and other public benefit programs. Particularly because enrollment in such programs can be highly dynamic, the survey questions used in this study may not accurately reflect complex patterns of program participation over the course of any given year. Analysis of subsequent years is also essential. Given the important interactions between welfare policies and health, the lack of rich integrated data sets that include both welfare and health variables should be addressed urgently as part of the welfare reauthorization process.
In summary, our findings emphasize the importance of health concerns to the development of effective welfare policies. The requirements of clinical conditions among poor children and their parents remains a critical determinant of familial need as well as familial capacity. The present findings underscore the vulnerability of poor families with chronically ill children to welfare policies that preclude or terminate TANF benefits but do not adequately ensure access to health insurance or the necessities of life.
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Acknowledgments |
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The authors thank Madeline Howard for her assistance in preparing the manuscript.
Human Participant Protection
Ethical clearance for analysis of the National Health Interview Survey was provided by the institutional review board of the Boston University School of Medicine.
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Footnotes |
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P. H. Wise developed the analytic plan, interpreted the data, and wrote the manuscript. N. S. Wampler assisted in developing the analytic plan, conducted the computerized analyses, and edited the manuscript. W. Chavkin and D. Romero assisted in developing the analytic plan and in editing the manuscript.
Accepted for publication May 24, 2002.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Smith LA, Wise PH, Chavkin W, Romero D, Zuckerman B. Implications of welfare reform for child health: emerging challenges for clinical practice and policy. Pediatrics. 2000;106:1117–1125.
3. Chavkin W, Wise PH. The Data Are In: Health Matters in Welfare Policy Am J Public Health. 2002;92:1392–1395.
4. 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.
5. 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.
6. Smith LA, Hatcher JL, Wertheimer R. The association of childhood asthma with parental employment and welfare receipt. J Am Med Womens Assoc. 2002;57:11–15.
7. Data File Documentation. National Health Interview Survey, 1998. Hyattsville, Md: National Center for Health Statistics; 2000.
8. Shah B, Barnwell BG, Bieler GS. SUDAAN User’s Manual, Version 6.40. 2nd ed. Research Triangle Park, NC: Research Triangle Institute; 1996.
9. Romero D, Chavkin W, Wise PH, Smith LA, Wood PR. Welfare to work? Impact of maternal health on employment. Am J Public Health. 2002;92:1462–1468.
10. Smith LA, Romero D, Wood PR, Wampler NS, Chavkin W, Wise PH. Employment barriers among welfare recipients and applicants with chronically ill children. Am J Public Health. 2002;92:1453–1457
11. Newacheck PW, McManus M, Fox HB, Hung YY, Halfon N. Access to health care for children with special health care needs. Pediatrics. 2000;105:760–766.
12. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics. 2000;105:989–997.
13. McPherson M, Arango P, Fox HB, et al. A new definition of children with special health care needs. Pediatrics. 1998;102:130–147.
14. Newacheck PW, Strickland B, Shonkoff J, et al. An epidemiologic profile of children with special health care needs. Pediatrics. 1998;102:117–123.
This article has been cited by other articles:
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  E. W. Fleegler, T. A. Lieu, P. H. Wise, and S. Muret-Wagstaff Families' Health-Related Social Problems and Missed Referral Opportunities Pediatrics, June 1, 2007; 119(6): e1332 - e1341. [Abstract] [Full Text] [PDF]
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 K. Seccombe, H. Hartley, J. Newsom, K. Hoffman, G. C. Marchand, C. Albo, C. Gordon, T. Zaback, R. Lockwood, and C. Pope The Aftermath of Welfare Reform: Health, Health Insurance, and Access to Care Among Families Leaving TANF in Oregon Journal of Family Issues, February 1, 2007; 28(2): 151 - 181. [Abstract] [PDF]
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M. Satchell and S. Pati Insurance Gaps Among Vulnerable Children in the United States, 1999-2001 Pediatrics, November 1, 2005; 116(5): 1155 - 1161. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
