IICommunity Pediatrics:Community Pediatrics:

Welfare Reform and the Health of Welfare Reform and the Health of Women and ChildrenWomen and Children

Wendy Chavkin, MD, MPH Wendy Chavkin, MD, MPH **Paul H. Wise, MD, MPH Paul H. Wise, MD, MPH ††

Diana Romero, PhD, MADiana Romero, PhD, MA * *Barbara Pastrana Pahud, MD Barbara Pastrana Pahud, MD **

* Department of Population and Family Health, Mailman* Department of Population and Family Health, Mailman School of Public School of Public

Health, Columbia University Health, Columbia University

† † Department of Pediatrics, Boston UniversityDepartment of Pediatrics, Boston University School of MedicineSchool of Medicine

History of Welfare in the US: IHistory of Welfare in the US: I

• 1935: Social Security Act -- Aid to Dependent Children, like 1935: Social Security Act -- Aid to Dependent Children, like Mother’s Pensions, promoted concept that maternal employment Mother’s Pensions, promoted concept that maternal employment negatively affected negatively affected childchild development and that ‘deserving’ development and that ‘deserving’ women belonged in the home.women belonged in the home.

• 1962: Aid to1962: Aid to Families Families with Dependent Children with Dependent Children - goals were to - goals were to strengthen strengthen familyfamily life and foster self-sufficiency. life and foster self-sufficiency.

• 1967: expanding welfare rolls and rising numbers of unwed 1967: expanding welfare rolls and rising numbers of unwed mothers receiving aid led to ‘welfare crisis’.mothers receiving aid led to ‘welfare crisis’.

Abramovitz, M. Regulating the Lives of Women, South End Press, 1988.

History of Welfare in the US: IIHistory of Welfare in the US: II

• 1987-1995: Most states had received waivers1987-1995: Most states had received waivers• 1996: PRWORA passed (P.L. 104-193)1996: PRWORA passed (P.L. 104-193)

– AFDC AFDC TANF TANF– Entitlement Entitlement block grants with time limits block grants with time limits– Devolution to states Devolution to states – Separation from Medicaid, food stampsSeparation from Medicaid, food stamps– Emphasis on workEmphasis on work– Family life obligationsFamily life obligations

• 1997: Creation of CHIP1997: Creation of CHIP

1996 Welfare Reform: 1996 Welfare Reform: Congress’ FindingsCongress’ Findings

““The Congress makes the following findings:The Congress makes the following findings:

1. Marriage is the foundation of a successful society.1. Marriage is the foundation of a successful society.

2. Marriage is an essential institution of a successful 2. Marriage is an essential institution of a successful society which promotes the interests of children.society which promotes the interests of children.

3. Promotion of responsible fatherhood and 3. Promotion of responsible fatherhood and motherhood is integral to successful child rearing motherhood is integral to successful child rearing and the well-being of children.”and the well-being of children.”

Personal Responsibility and Work Opportunity Reconciliation Act, Pub L No. 104-193 (1996).

1996 Welfare Reform:1996 Welfare Reform: Purpose Purpose

““Increase the flexibility of states in operating a Increase the flexibility of states in operating a program designed to:program designed to:

1. Provide assistance to needy families so that 1. Provide assistance to needy families so that children could be cared for in their own homes or children could be cared for in their own homes or in the homes of relativesin the homes of relatives

2. End dependence of needy parents on government 2. End dependence of needy parents on government benefits by promoting job preparation, work, and benefits by promoting job preparation, work, and marriage”marriage”

Personal Responsibility and Work Opportunity Reconciliation Act, Pub L No. 104-193 (1996).

1996 Welfare Reform: 1996 Welfare Reform: PurposePurpose

““Increase the flexibility of states in operating a Increase the flexibility of states in operating a program designed to:program designed to:

3. Prevent and reduce the incidence of out-of-3. Prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual wedlock pregnancies and establish annual numerical goals toward these goalsnumerical goals toward these goals

4. Encourage the formation and maintenance of two-4. Encourage the formation and maintenance of two-parent families”parent families”

Personal Responsibility and Work Opportunity Reconciliation Act, Pub L No. 104-193 (1996).

TANF Policies and TANF Policies and “Family Life Obligations”“Family Life Obligations”

• WorkfareWorkfare

• ImmunizationsImmunizations

• Other health visits Other health visits (pediatric, family planning)(pediatric, family planning)

• School attendanceSchool attendance

• Child exclusion/family capChild exclusion/family cap

• Paternity identificationPaternity identification

• Child support enforcementChild support enforcement

• Teen residency requirementsTeen residency requirements

• Drug screensDrug screens

• Noncitizens, including legal Noncitizens, including legal residentsresidents

Health InsuranceHealth Insurance

• Medicaid drop (Families USA, AGI, Kaiser)Medicaid drop (Families USA, AGI, Kaiser)

– 21% in women of reproductive age between 1994-1998 (R. Gold. 21% in women of reproductive age between 1994-1998 (R. Gold. AGI report, 12/99)AGI report, 12/99)

– 30.7% (10,093) of the US population was uninsured in 2001 (US 30.7% (10,093) of the US population was uninsured in 2001 (US Census, Annual Demographic Survey, 2001)Census, Annual Demographic Survey, 2001)

• CHIP enrollment slow and lowCHIP enrollment slow and low

– By 1999, only 2 million had been enrolled in the past year andBy 1999, only 2 million had been enrolled in the past year and

– 11 million children remained uninsured11 million children remained uninsured

– Currently, CHIP covers 3.5 million children (Kaiser Commission, Currently, CHIP covers 3.5 million children (Kaiser Commission, December 2001) in addition to the 22 million covered by December 2001) in addition to the 22 million covered by Medicaid.Medicaid.

Family CapFamily Cap• 23 states (19 received pre-PRWORA waivers)23 states (19 received pre-PRWORA waivers)• Only NJ and AR completed evaluationsOnly NJ and AR completed evaluations• ArkansasArkansas

– no effect on birth rate, paternity ID, income, exits or no effect on birth rate, paternity ID, income, exits or entrances to AFDC; half of the women not fertileentrances to AFDC; half of the women not fertile

• New JerseyNew Jersey– decreased birth rate, increased family planning and decreased birth rate, increased family planning and

abortion (esp. among new cases)abortion (esp. among new cases)

• 5 states surveyed caseworkers and recipients5 states surveyed caseworkers and recipients– concur that grant not a factor in childbearing decisionsconcur that grant not a factor in childbearing decisions

• As of 1999, 83,000 children in 16 states were As of 1999, 83,000 children in 16 states were “capped”“capped”

Illegitimacy BonusIllegitimacy BonusIllegitimacy Bonus Winners: 1999, 2000 and 2001

1999 2000 2001

Rank State % change out-of-wedlock

births

State % change out-of-wedlock

births

State % change out-of-wedlock

births

1

2

3

4

5

CA

DC

MI

AL

MA

-5.7

-3.7

-3.4

-2.0

-1.5

DC

AZ

MI

AL

IL

-4.1

-1.4

-1.3

-0.3

-0.02

DC

AL

MI

--

--

-3.98

-0.25

-0.009

Data for 1999 represent the % change in out-of-wedlock births from 1994-95 to 1996-97; 2000, % change from 1995-96 to 1997-98; 2001, % change from 1996-97 to 1998-99. National Center for Health Statistics. State Rankings, 1999, 2000, and 2001.

IIIIWIC, Medicaid, Welfare:WIC, Medicaid, Welfare:

Understanding Government Assistance Understanding Government Assistance in NYCin NYC

Developed by:Developed by:

Anouk Amzel, M.D.Anouk Amzel, M.D.

Hetty Cunningham, M.D.Hetty Cunningham, M.D.

Conditions of TANF:NYC

• Lifetime limit of 60 months• Work Activities requirement

– Education

– ESL

– Job search

– Work (non-subsidized or Work Experience Program)

• Must comply with Child Support Services• School attendance requirement

Work Requirement ExemptionWork Requirement Exemption

• Caring for a child younger than 12 monthsCaring for a child younger than 12 months– No more than 12 months of a caretakers life may be No more than 12 months of a caretakers life may be

exempted for child careexempted for child care– No more than 3 months for any one childNo more than 3 months for any one child

• Social service official may extend to 12 monthsSocial service official may extend to 12 months

• Not job readyNot job ready• Fleeing domestic violenceFleeing domestic violence• Ill or incapacitated person or person caring for an Ill or incapacitated person or person caring for an

ill or incapacitated person.ill or incapacitated person.

NYC’s Version: “NYC WAY”

• March 1998: converts welfare offices into “Job Centers”

• Core components:– Work experience program (WEP)

– Eligibility verification review

– Finger printing

– Substance abuse program

– SSI

– Intensive case control

Who Qualifies for Family Assistance?

• Income of <185% of federal poverty level

• $2,138 per month for a family of 3

= $25,666 per year

Food Stamps

• Average monthly allotment• $73 per person

• Uses• Food or food products• Seeds or food-producing plants

• Exemptions• Alcohol and tobacco• Food to be eaten in the store• Vitamins and medicines• Pet foods• Any non-food items

Food StampsFood Stamps

• Who is eligible?Who is eligible?

– U.S citizensU.S citizens

– Many child and elderly legal immigrantsMany child and elderly legal immigrants

– <<130% federal poverty limit 130% federal poverty limit

WICWIC

• Federal grants to states to provideFederal grants to states to provide– Supplemental foodsSupplemental foods– Health care referralsHealth care referrals– Nutrition educationNutrition education

• Works through vouchers for use in storesWorks through vouchers for use in stores1.1. Get essential foods: milk, eggs,cheese, etc.Get essential foods: milk, eggs,cheese, etc.2.2. Formula Allotment: The equivalent of 403 fluid Formula Allotment: The equivalent of 403 fluid

ounces per month: about 12 cans of concentrated ounces per month: about 12 cans of concentrated formula.formula.

WICWIC

• EligibilityEligibility– Low-incomeLow-income ((<<180% FPL)180% FPL)

• Pregnant womenPregnant women

• Postpartum womenPostpartum women

• Infants and children to age 5 years ”found to be at Infants and children to age 5 years ”found to be at

nutritional risk”nutritional risk”

– Automatic eligibility with MedicaidAutomatic eligibility with Medicaid

– Illegal immigrants can get WICIllegal immigrants can get WIC

Other NYC Assistance Programs Other NYC Assistance Programs **

• Safety Net AssistanceSafety Net Assistance• Emergency Assistance to FamiliesEmergency Assistance to Families• Home Energy Assistance ProgramHome Energy Assistance Program• Child Care SubsidiesChild Care Subsidies• Housing ServicesHousing Services• Refugee and Immigration ServicesRefugee and Immigration Services• Discount Telephone ServiceDiscount Telephone Service

*Limited eligibility*Limited eligibility

Child CareChild Care

• Transitional Child CareTransitional Child Care

– PartialPartial reimbursement of child care costs for up to one reimbursement of child care costs for up to one

year.year.

• Low Cost Child Care: Low Cost Child Care:

– Group or family day care available through another Group or family day care available through another

NYC agency. The cost is based on income and family NYC agency. The cost is based on income and family

size.size.

SSIBackground:• Supplemental Security Income• Enacted 1972 to care for elderly or disabled Americans

with limited resources• 1997 - 965,000 people receiving SSI

Eligibility:• Low-income people > 65 years of age• Low-income people who are blind or disabled (includes

children)• Does not include most immigrants• Asset limitations

SSI

Definition of Disability in ChildrenDefinition of Disability in Children

• Changed under welfare reform of 1996

• Must have a medically-proven physical and/or

mental condition resulting in marked and severe

functional limitations

• Must be expected to last >12 months or result in

death

SSI

How Do Parents Get SSI?

• Social Security office has specific guidelines

• Paperwork sent to the Disabilities Determination

Service for decision

• Must bring information about child’s medical and

day-to-day care to the appointment

SSI - Time to Benefits

• Review process takes several months

• Provision for presumed disability– HIV infection

– Blindness

– Deafness (in some cases)

– CP (in some cases)

– Down’s syndrome

– Muscular dystrophy

– Significant mental deficiency

– DM (with foot amputation)

– Amputation of 2 limbs or the leg at the hip

Continuing Disability ReviewContinuing Disability Review

• Reviewing disabilityReviewing disability– If improvement is expected -- case review q6-18 If improvement is expected -- case review q6-18

monthsmonths– If improvement is possible but not predicted -- case If improvement is possible but not predicted -- case

review q3 yearsreview q3 years– If improvement is not expected -- case review q5 - If improvement is not expected -- case review q5 -

7 years7 years

• Must present evidence of compliance with Must present evidence of compliance with medical treatmentmedical treatment

Major Developments Since 1996Major Developments Since 1996

• Biggest drop in welfare rolls since inceptionBiggest drop in welfare rolls since inception• Racial disparity in those leaving the rollsRacial disparity in those leaving the rolls• Varied employment and income experiencesVaried employment and income experiences• Drop in Medicaid, Food Stamps, WICDrop in Medicaid, Food Stamps, WIC• Increased lack of health insuranceIncreased lack of health insurance• Increased reports of hunger and homelessnessIncreased reports of hunger and homelessness• Privatization of servicesPrivatization of services• Widespread lack of child careWidespread lack of child care

Finding Common Ground:Overall Conclusions

• Dramatic declines in benefit programs; mixed findings regarding income, job retention, poverty status

• Limited evaluations of behavior-related TANF policies

• State health personnel largely uninvolved in welfare policies and report welfare policymakers not focused on health

• Association between uninsurance and state TANF policies

• Association between maternal health problems and ability to work, and child chronic illness and mothers’ ability to work

• Need more health-related data to contribute usefully to post-welfare reform programs