文章基本信息

标题：Welfare Reform and Health Insurance: Consequences for Parents
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作者：Jane L. Holl ; Kristen Shook Slack ; Amy Bush Stevens 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2005
卷号：95
期号：2
页码：279-285
DOI：10.2105/AJPH.2003.025882
语种：English
出版社：American Public Health Association
摘要：Objectives. We assessed the relation between the work promotion, welfare reduction, and marriage goals of welfare reform and the stability of health insurance of parents in transition from welfare to work. Methods. We analyzed a panel survey (1999–2002) of a stratified random sample of Illinois families receiving welfare in 1998 (n=1363). Results. Medicaid remains the foremost source of health insurance despite a significant decline in the proportion of parents with Medicaid. Regardless of work/welfare status in year 1, transitioning to work only or no work/no welfare increased the likelihood of having unstable health insurance in years 2 and 3 compared with those who remained on welfare only. Conclusions. Parents who meet the welfare reform goals of work promotion and reduction of welfare dependence experience significant loss and instability of health insurance. The past decade has seen dramatic changes in both welfare policy and expansions of publicly funded health insurance programs in the United States. 1 In 1996, the US Congress enacted the Personal Responsibility and Work Opportunity Reconciliation Act, 2 replacing the entitlement program Aid to Families with Dependent Children with a block grant program, Temporary Assistance for Needy Families (TANF). TANF, popularly known as welfare reform, seeks to promote work and marriage and to decrease welfare dependence. A key feature of the TANF legislation was the separation of eligibility for welfare and for Medicaid. Initially, Medicaid administrative difficulties for eligible families 3– 5 and increasing uninsured rates 6– 10 were documented. Many studies and reports focus on those who leave welfare completely (“leaver” studies) 11– 13 or use Medicaid administrative data that report on Medicaid recipients only. 14, 15 Considerably less is known about the stability of different types of health insurance, over time, for families transitioning from welfare to work, perhaps because longitudinal data are necessary to assess the dynamic relations between the key goals of welfare reform—work promotion, welfare reduction, and marriage—and the stability of health insurance. Recent reports show that for working-age adults, being uninsured and not having continuous health insurance coverage leads to unfavorable health outcomes. 16, 17 Low-income and minority populations, which encompass many parents involved in the transition from welfare to work, experience worse health status and have a greater number of chronic health conditions. 18 Furthermore, welfare recipients have considerable rates of mental (35%) and physical (20%) health problems that are significant barriers to employment, 19 and former welfare recipients with a self-reported health limitation are at increased risk for job loss. 20 There is also evidence that many common conditions (i.e., diabetes, 21 allergy, 22 depression 23 ) affect worker absenteeism and reduce job performance, situations that may contribute to job loss. Lack of health insurance and poor access to health care, by limiting timely and optimal treatment of health conditions, illnesses, and injuries, are likely to lead to greater worker absenteeism. 24 In addition, the uninsured limit their use of nonacute (e.g., preventive or chronic disease care) health care to avoid out-of-pocket costs. 25 Health insurance coverage of parents also has implications for the health care of their children because parents’ use of any physician services is a potent predictor of any physician visit by their children. 26 The TANF legislation included some provisions to preserve Medicaid eligibility by maintaining state Aid to Families with Dependent Children levels of eligibility and by requiring states to provide at least 6 months of Medicaid through Transitional Medical Assistance to families leaving welfare for work. 27 In addition, some states have expanded Medicaid eligibility above low-income levels or used federal waivers to expand the State Children’s Health Insurance Program to include adult family members. 28 In this study, we examined the relations between changes in work, welfare, and marriage status and the stability of health insurance coverage for parents in transition from welfare to work. During a 3-year period (1999–2002), we followed a representative sample of families who were receiving welfare in late 1998. As welfare reform evolves, it is particularly important for policymakers to consider the important role that health insurance coverage may play in enabling parents to achieve and sustain the work promotion, welfare reduction, and marriage goals of welfare reform. The Illinois TANF program, implemented in July 1997, has a 60-month lifetime limit on assistance, although the “clock stops” for parents who qualify for and receive welfare while working at least 30 to 35 hours per week. With the exception of denial of cash assistance for a child born 10 months or more after enrollment, the Illinois TANF program does not have any of the policies associated with decreased Medicaid enrollment and increased uninsured rates. 29 Illinois TANF recipients can receive up to 12 months of Transitional Medical Assistance. However, Illinois, like many other states, has had difficulties with the state’s automated eligibility system, resulting in families not being offered Transitional Medical Assistance. 30 An estimated 38.5% of low-income nonelderly Illinois adults had no health insurance in 1999–2000, 31 and an early study of Illinois welfare leavers showed that 6 to 8 months after leaving welfare, 36% had no health insurance. 32 Medicaid enrollment of families, children, and pregnant women in Illinois declined in 1997–1998 but overall has increased by 13% between 1997 and 2001. 33