The data are in: health matters in welfare policy.

Abstract

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.