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P1: vendor/GVM/GYQ Maternal and Child Health Journal (MACI)

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Style file version Nov. 07, 2000

C 2001) Maternal and Child Health Journal, Vol. 5, No. 3, September 2001 (°

State Welfare Reform Policies and Maternal and Child Health Services: A National Study Diana Romero, MPhil, MA,1,2,6 Wendy Chavkin, MD, MPH,3 Paul H. Wise, MD, MPH,4 Catherine A. Hess, MSW,5 and Karen VanLandeghem, MPH5

Objectives: Welfare reform (Personal Responsibility and Work Opportunity Reconciliation Act of 1996) resulted in dramatic policy changes, including health-related requirements and the administrative separation of cash assistance from Medicaid. We were interested in determining if changes in welfare and health policies had had an impact on state MCH services and programs. Methods: We conducted a survey in fall 1999 of state MCH Title V directors. Trained interviewers administered the telephone survey over a 3-month period. MCH directors from all 50 states, Washington, DC, and Puerto Rico participated (n = 52; response rate = 100%). Results: Among the most noteworthy findings is that similar proportions of respondents reported that welfare policy changes had either helped (46%) or hindered (42%) the agency’s work, with most of the positive impact attributed to increased funding. MCH data linkages with welfare and other social programs were low. Despite welfare reform’s emphasis on work, limited services and exemptions were available for mothers with CSHCN. Almost no efforts have been undertaken to specifically address the needs of substance abusers in the context of new welfare policies. Conclusions: Few MCH agencies have developed programs to address the special needs of women receiving TANF who either have health problems themselves or have children with health problems. Recommendations including increased MCH and family planning funding and improved coordination between TANF and MCH to facilitate linkages and services are put forth in light of reauthorization of PRWORA. KEY WORDS: PRWORA; TANF; maternal health; child health; workfare; family cap.

major change in welfare law created by the PRWORA was the replacement of the Aid to Families with Dependent Children (AFDC) program with the Temporary Assistance to Needy Families (TANF) state block-grant program. The most salient federal mandates included capping federal cash assistance to individuals at a 5-year lifetime benefit, requiring that recipients comply with job placements in order to work for their benefits (“workfare”) within 2 years of receiving assistance, prohibiting or delaying eligibility for cash assistance among certain groups of people (e.g., drug felons, noncitizens), and administratively separating (or “delinking”) cash assistance from Medicaid.7 As has been reviewed elsewhere (3),

The welfare reform law of 1996 (Personal Responsibility and Work Opportunity Reconciliation Act [PRWORA]) (1, 2) ended the longstanding federal entitlement to cash assistance for the poor. The 1

Center for Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York. 2 Division of Sociomedical Sciences, Graduate School of Arts and Sciences, Columbia University, New York, New York. 3 Mailman School of Public Health and College of Physicians & Surgeons, Columbia University, New York, New York. 4 Department of Pediatrics, Boston Medical Center, Boston, Massachusetts. 5 Association of Maternal and Child Health Programs, Washington, District of Columbia. 6 Correspondence should be addressed to Diana Romero, Center for Population and Family Health, Joseph L. Mailman School of Public Health, Columbia University, 60 Haven Avenue, B-3, New York, New York 10032; e-mail: [email protected].

7

Per Section 114 of the law (“Assuring Medicaid Coverage for Low-Income Families”), prewelfare reform eligibility criteria for

199 C 2001 Plenum Publishing Corporation 1092-7875/01/0900-0199$19.50/0 °


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200 other restrictions on TANF that states were allowed but not required to impose included requiring that children’s immunizations be up to date; that women identify the father of their child(ren) and cooperate with child support collection efforts; that teen mothers attend school and live with a relative or designated adult; that women participate in family planning counseling; and that the cash grant not be increased when a recipient has a baby (“family cap”). Failure to comply with any of these state welfare policies could lead to financial sanctions resulting in loss of part or all of the cash grant. We maintain that these sanctions could theoretically have an impact on the health of poor women and their children, as could the requirement that women who have health problems or sick children work. The change from AFDC to TANF clearly had an impact on other social programs. National analyses indicate that many eligible people inappropriately lost Medicaid (4–10). Some of this decline has been attributed to administrative or data system problems in some states (e.g., automatic disenrollment of Medicaid recipients when cash assistance and Medicaid computer systems were “delinked”). Elsewhere, we have shown that state policies to deter enrollment in TANF are statistically associated with Medicaid declines (11). The concurrent drop in Food Stamps over the past few years has also been attributed to confusion with new regulations and efforts to deter applicants from enrolling (12–15). We are concerned that poor mothers and their children may also forego health services offered by agencies such as maternal and child health (MCH) programs because of the mistaken impression that they are no longer eligible for these services, or that use of these programs may be applied to their lifetime TANF limit. The expressed goal of policymakers was to end dependency by promoting personal responsibility and self-sufficiency via employment, marriage, and discouraging out-of-wedlock births (1, 2). Many of these federal and state mandates extend to personal and health-related behaviors, and specifically to women in their role as mothers. We posited that state MCH Title V directors would be appropriate sources of information as to whether recent changes in welfare policies have had an impact on state MCH services and programs. This was a particularly relevant group to approach given the important role of the medical assistance are to be in effect, with the exception of a state option to terminate medical assistance due to failure to meet work requirements.


Romero, Chavkin, Wise, Hess, and VanLandeghem department of health as a safety-net provider for the poor. This paper reports the descriptive findings from a survey of state MCH Title V directors regarding the impact of welfare reform policies on various aspects of MCH Title V programs. Results are analyzed within the context of the stated goals of the federal and state policies to assess their potential impact on the health of poor women and children. We conclude with specific recommendations with an eye toward the upcoming Congressional reauthorization of the law.

METHOD In fall 1999 we completed a telephone survey of state MCH Title V directors in the 50 states, Washington, DC, and Puerto Rico (n = 52; 100% response rate). The survey instrument underwent several phases of development. First, we obtained input in response to five broad questions pertaining to welfare reform and MCH issues from several experts in state-level MCH programs. We then developed a draft of the survey instrument, which was reviewed by other experts, including colleagues at the Association of Maternal and Child Health Programs (AMCHP), the primary professional organization of MCH administrators. The instrument underwent extensive revision and pretesting. The final survey consisted of both close- and open-ended questions. The survey instrument contained eight domains specifically developed to document if recent welfare policy changes were having an impact on MCH services and/or demand, including 1) MCH interaction/coordination and data linkages with other social programs; 2) TANF policies; 3) maternal and women’s health; 4) adolescent health; 5) children’s health and child care; 6) health insurance and other benefits programs; 7) populations with special health needs; and 8) domestic violence. This paper presents selected findings addressing the main research objectives described above. AMCHP provided the database of state MCH Title V directors. An introductory letter printed on AMCHP stationery, co-signed by the study principal investigator and AMCHP executive director, was mailed to the MCH Title V directors requesting their participation in the study. Trained interviewers administered the survey by telephone (mean duration = 40 min) over a 3-month period. Eight of the 52 respondents requested a copy of the survey prior to the interview. Additional collaboration with AMCHP


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Welfare Reform Policies and Maternal and Child Health Services involved discussions concerning survey findings, their interpretation, and recommendations for subsequent investigation. Analysis of the quantitative data was performed with the Statistical Program for the Social Sciences (v10, SPSS, Chicago, IL) and consists of descriptive findings. In addition, we provide more in-depth, qualitative data for responses to select open-ended questions, for which the Ethnograph software program (v5.04, Qualis Research, London, UK) was utilized.

RESULTS Administrative Impact of Welfare Reform (TANF) Policies on MCH We first asked if demand for MCH services, outreach, and/or referrals had changed in the past year. Approximately 79% (n = 41) of respondents said demand for MCH services had changed, with 44% (n = 23) reporting an increase, 6% (n = 3) reporting a decrease, and 29% (n = 15) reporting that the change in demand had been mixed (i.e., both increased and decreased in different areas). Sixty percent (23 of 38) of those reporting an increase in demand attributed some or most of it to recent changes in welfare policies and specified increased demand in areas such as family planning and prenatal care; health insurance; child and adolescent health services; services for immigrant populations; and support services (e.g., transportation, child care, domestic violence). Approximately equal numbers reported that recent changes in welfare policy had either helped (46%; n = 24) or hindered (42%; n = 22) the agency’s ability to carry out its work. Most respondents stated that the positive impact was due to an increase in funds available to MCH from both the initial TANF block-grant allocation, as well as from reinvestment of funds saved from the declining TANF rolls. Increased collaborative opportunities, expansions in MCH programs, and an increased focus on preventive health services were other reasons cited. Conversely, the two major ways reported in which welfare reform had hindered MCH efforts were loss of health insurance among clients (predominantly Medicaid secondary to the delinking of the systems) and loss of clients because of misperceptions about eligibility (i.e., “given the impression they are not eligible for non-TANF services”) or because of TANF case closure. Respondents stated that the increased emphasis on sending poor mothers to work made it more difficult to reach

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them at home and led to missed appointments. Inadequate quality and quantity of child care for working mothers was noted, as was an increased work load and need for more training among case workers.

Coordination of Services and Data Linkage Two thirds (67%; n = 35) of respondents said that there was formal coordination of services or programs between MCH and TANF agencies. Twenty-nine percent (n = 15) reported interaction with TANF on a regular basis, 39% (n = 20) occasionally, 27% (n = 14) infrequently, and 4% (n = 2) not at all. The coordination between the two agencies was largely related to family planning initiatives and specific pregnancy-prevention programs, such as goals related to the out-of-wedlock bonus. Coordination also involved data sharing, referrals for home visits, and enrollment outreach for the State Child Health Insurance Program (SCHIP) and Medicaid. We asked respondents whether they had the technical ability to link their data systems with other social services agencies and, if so, if such linkage or data sharing occurred. These were general questions and therefore did not specify, for example, the exact type of data shared, nor the frequency with which such linkages might occur. Overall, the ability to link systems was low. Thus, in response to the question, “Does your agency have the technical or computer ability to link individuals served by MCH with clients served by other agencies, such as . . . ,” reported capability to link with the following agencies was as follows: TANF (29%; n = 15), Medicaid (52%; n = 27), SCHIP (27%; n = 14), Food Stamps (13%; n = 7), public child care (4%; n = 2), public housing (0%), child welfare (6%; n = 3), and WIC (60%; n = 31). Those respondents who reported the technical ability to link information systems said that actual interagency linkage occurred on average about 40% of the time and most commonly involved other healthrelated programs, such as Medicaid (n = 22), SCHIP (n = 11), and WIC (n = 20); linkage with other social programs, such as Food Stamps (n = 2), TANF (n = 5), child welfare (n = 2), child care (n = 0), and housing (n = 0), rarely occurred.

Maternal and Women’s Health Welfare reform addresses one aspect of women’s health—fertility—via state requirements that welfare


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202 recipients attend family planning counseling (13 states), family caps, or the prohibition of additional TANF funds for recipients who give birth (23 states), or the federal monetary incentive for states to reduce their out-of-wedlock birth rate. Thus, we asked respondents about reproductive-related services and funding. Most MCH programs (88%; n = 46) fund and/or administer family planning services (13 of these do not include sterilization). Sixty-one percent (n = 32) said funding for family planning had not changed, while 25% (n = 13) reported that their funding had increased, 2% (n = 1) reported a decrease in funding, and 11% (n = 6) did not know. Forty-two percent (n = 22) of MCH Title V directors reported that their states had set goals to reduce the out-of-wedlock birth rate in order to qualify for the federal “illegitimacy bonus” of $20 million (to be awarded to each of the top five states to achieve the greatest declines in this regard, without concomitant increases in the abortion rate) (16). Eighty-six percent (n = 19) of respondents from these states reported that specific programs to accomplish this goal had not been established. In fact, three of the five states that were awarded the bonus in 1999 either had not set a goal or had not established a special program to reduce its out-of-wedlock birth rate according to these state MCH Title V directors (17). Since welfare reform, 21% (n = 11) of state MCH agencies reported offering additional services to mothers of children with special health care needs (CSHCN) (e.g., outreach or expanded educational programs, increased case management, and expanded eligibility criteria), while 67% (n = 35) did not. Twenty-nine percent (n = 15) of respondents said their states allowed mothers of CSHCN to be exempted from TANF work requirements and 19% (n = 10) did not provide exemptions; just over half (n = 27) did not know if an exemption was allowed. Only one respondent reported helping mothers apply for exemption from TANF work requirements.


Romero, Chavkin, Wise, Hess, and VanLandeghem mance measures (an initiative not specifically related to welfare reform). The remaining 15 states were collecting new data regarding child care, health insurance, and select health issues (e.g., newborn hearing and dental sealants); only one respondent mentioned data collection specifically to assess the health effects of TANF. We asked if welfare reform policies had resulted in new initiatives for children’s health. Sixtyfive percent (n = 34) answered “yes” or “maybe” specifying SCHIP [13], child care [5], pregnancy prevention [5], immunizations/well-baby care [5], coordination of core services (i.e., care coordination) [4], and adolescent development [2]. Every respondent (n = 52) reported that his/her state had an unmet need for child care. Areas of greatest need included children with special health care needs (40%; n = 21), affordable/low-cost care (40%; n = 21), licensed sites/trained personnel (31%; n = 16), rural child care facilities (25%; n = 13), offhours care (23%; n = 12), infant care (20%; n = 10), care for sick children (15%; n = 8), pre-Kindergarten programs (15%; n = 8), and after-school programs (14%; n = 7). We then asked whether publicly subsidized child-care slots were specifically earmarked for (a) TANF recipients participating in workfare programs, (b) women leaving TANF for paid work or due to time limits, and (c) other working women. Although the majority did not know the answer to these questions, respondents reported that more slots are allocated for workfare participants (44%; n = 23) than for women leaving TANF for work (19%; n = 10), or for other working women (10%; n = 5). Respondents indicated that limited monitoring was being conducted to determine if mothers had to leave their children unattended at home: when sick (12%; n = 6), to fulfill TANF requirements (12%; n = 6), and to go to paid employment (10%; n = 5); however, 29– 40% of respondents did not know if monitoring efforts were in place.

Adolescent Health Child Health and Child Care Many states [27] now condition welfare receipt on compliance with immunization schedules and/or well-child medical visits (11). We asked, therefore, if any new child health indicators were being monitored by MCH departments. Although 57% (n = 30) responded “yes” or “maybe,” we found that half of these referred to the special initiative launched in 1998 by the MCH Bureau to collect data on Title V perfor-

All but one (n = 51) of the state MCH programs provide health services and/or programs for adolescents. The scope of services and programs described is wide, including drug and alcohol abuse programs, comprehensive school-based and primarycare clinics, abstinence education, family planning, STD clinics, health education, and injury prevention. Twenty-five percent (n = 13) of respondents said welfare reform policies had had an impact on the


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Welfare Reform Policies and Maternal and Child Health Services amount or types of services available to adolescents; 6% (n = 3) said maybe; 61% (n = 32) said there was no impact; and 8% (n = 4) did not know. Twelve reported abstinence education for pregnancy prevention. Two respondents noted a loss in funding both for programs for adolescents with children and for pregnant adolescents. Finally, some respondents noted that welfare reform policies either did (8%; n = 4) or may have (8%; n = 4) had an impact on requirements for parental consent for services they provide to adolescents (i.e., the issue of parental consent was under discussion or legislation was pending) (18). Populations With Special Health Needs The PRWORA allowed states to restrict assistance to individuals with certain drug-related convictions (2). The law did not prohibit states from testing TANF applicants for drug use, and sanctioning those who tested positive (2). Only 4% (n = 2) of respondents said their agencies had developed special substance abuse initiatives related to new welfare policies. Moreover, most respondents did not know if participation in drug treatment would avoid a sanction (79%; n = 41), counted toward fulfillment of work requirements (87%; n = 45), or could stop the TANF lifetime “clock” (89%; n = 46). The PRWORA drastically limited eligibility for welfare receipt by immigrants (19). Fifty two percent (n = 26) of respondents said that there had been changes in the amount or type of MCH services sought by immigrants since welfare reform. Thirty percent (n = 15) of states had set up special initiatives or programs for these groups and 48% (n = 24) had outreach programs to inform immigrants of their potential eligibility for programs other than TANF. The nature of the changes in MCH services sought by immigrants were as follows (n = 26): 23% (n = 6) increased demand and 4% (n = 1) decreased demand for reproductive health services, 46% (n = 12) increased demand for general health services, 10% (n = 2) unspecified, and 19% (n = 5) increased fear or hesitation in accessing services. DISCUSSION The majority of MCH Title V directors reported that between the summer/fall of 1998 and 1999 demand for MCH services had increased, which most attributed to welfare reform, and that welfare reform had had adverse effects on health insurance and


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MCH case load. Furthermore, the health areas specified most frequently—family planning and health insurance—coincide with two areas of emphasis of the PRWORA: pregnancy reduction and the delinking of cash assistance and Medicaid. More funds have been funneled into MCH budgets, whether allocated a priori from the TANF block grant or resulting from the large surpluses many states have recently reported (20–22). Yet, it is uncertain whether current federal block-grant funding levels will continue. Further, it is likely that the TANF surpluses resulting from the dramatic drop in caseloads will have been one-time windfalls and, therefore, may not be considered a routine source of income for MCH programs. MCH directors’ unanimous report that there is an unmet need for child care is consistent with numerous national reports (5, 23–27). The widespread lack of child care is a major impediment to employment, particularly for mothers of chronically ill children. In fact, MCH staff in the state of Washington reported having established a program of home visits by public health nurses to TANF recipients with chronically ill children, in order to assess their eligibility for work exemptions. The program was developed because many mothers of CSHCN had been sanctioned for noncompliance with workfare. That interaction between the MCH and TANF agencies is mostly related to pregnancy prevention reflects the focus of the PRWORA on fertility-related behaviors of poor women. Lack of information sharing was apparent given respondents’ low level of knowledge about state welfare policy requirements, sanctions, and deterrence activities (data not reported). In fact, MCH Title V directors’ lack of knowledge of the PRWORA is noteworthy given the fact that many state welfare reform policies relate to women’s and children’s health. We posit that this is more likely related to the longstanding fragmentation between health and welfare policies in this country, than disinterest on the part of MCH professionals. While sharing of information between service programs can benefit clients, care would have to be taken to maintain their confidentiality, particularly if sanctions or other punishments may be applied. Respondents from three of the five states that were awarded the federal “illegitimacy bonus” in 1999 reported that their states had either not set explicit goals to reduce the out-of-wedlock birth rate or had not established special programs toward this end. This casts doubt on the conclusion that state reductions in out-of-wedlock births directly resulted from their welfare reform policies. While many states


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204 have programs geared toward reducing teen pregnancy, the illegitimacy bonus focused specifically on out-of-wedlock births (at any age). Many have documented the numerous methodologic challenges to linking pregnancy trends to social policies (16, 28, 29). We remain critical of the conclusion that a policy implemented 2 years prior to the award has directly affected this complex longstanding demographic trend. Clearly, fertility trends are related to many factors, including economic and cultural ones, and cannot be ascribed solely to welfare policies (30). Several components of the PRWORA and state welfare policies have implications for child health. SCHIP is not directly related to welfare reform but was implemented around the same time (31, 32), offering the potential for compliance with TANF requirements and improved health for poor children. Yet, the requirements of paternity identification and biannual re-enrollment, as reported by almost a quarter of respondents (data not reported), may present continued barriers to SCHIP enrollment (10, 33–35). The PRWORA declared most drug users and immigrants to be ineligible for cash assistance. Among those who are eligible, the reported lack of programs specifically tailored to immigrants’ and substance abusers’ needs may be felt by safety-net providers, such as MCH departments. The PRWORA acknowledged that a certain segment (i.e., 20%) of the TANF population may not be able to comply with work requirements and thus require continued assistance. We expect that groups with special needs, such as these, may have to be considered for exemption. We acknowledge several limitations to this study. It was conducted shortly after passage of the PRWORA and therefore may not have detected effects that require more time to become manifest. Not all state MCH Title V directors have the same level of knowledge of or involvement with TANF policies in their states and, since most MCH programs and services are run at the local level, their knowledge of changes in services and impact of policies may be incomplete. Nonetheless, since most policy is decided at the state level and is communicated to local providers via state-level personnel, we decided that state directors remained an important source of information. Although most respondents did not have prior knowledge of the survey questions, eight requested the questionnaire in advance. This may have allowed them to obtain information for certain questions, thus biasing the survey results in the direction of providing more information (i.e., less “don’t know” responses) compared with the other 44 respondents. We considered


Romero, Chavkin, Wise, Hess, and VanLandeghem this against the possibility of nonparticipation, and decided that participation of as many respondents as possible was preferred. CONCLUSION AND RECOMMENDATIONS As we approach the end of the first 5 years of “welfare reform” many individuals are also approaching their 5-year lifetime limit for cash assistance (although many may have already reached their state’s shorter time limit). Yet, very few states have specific programs addressing the health needs of women in the context of their ability to work or comply with other TANF requirements. Reauthorization of the PRWORA in 2002 presents policymakers with an opportunity to reconsider some components of the legislation while fine-tuning others. Some women who have health problems themselves or have children with health problems may continue to need cash assistance after others have left the TANF rolls (36). Moreover, studies of those leaving TANF indicate that lack of health insurance may contribute to returns to welfare (37, 38). The findings from this study provide the basis for the following health-related recommendations in light of the forthcoming reauthorization of the law: • Given the increase in demand for MCH services, unspent TANF funds should be allocated to support the services of this important safetynet provider. • Improved coordination between MCH programs/services and other social programs (e.g., Medicaid, SCHIP, Food Stamps, child care) may increase clients’ awareness of and application for other services. • Increased funding and expanded eligibility for family planning services (such as Medicaid waivers providing for postpartum care) should be implemented given the importance placed on the fertility behaviors of poor women by the federal and state governments. • Mothers of CSHCN should be considered for exemption from TANF work requirements; if work is required, special arrangements such as paid leave for sickness and medical visits, as well as specialized child care may be needed. • Lack of affordable child care (including nontraditional hours) remains a nationwide problem, and must be provided for those leaving TANF if employment and self-sufficiency are to be maintained.


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Welfare Reform Policies and Maternal and Child Health Services The findings from this study of state MCH directors raise several questions. Since departments of health are important safety-net providers for the poor, we wonder about MCH departments’ ability to address TANF recipients’ health needs, including those of immigrants, substance abusers, mothers of CSHCN, and those suffering from problems with mental health and domestic violence—issues both addressed and not addressed by this study. Reauthorization provides us with an opportunity to adjust components of the legislation so that welfare reform does not adversely affect maternal and child health. Ideally, the concept of a maximum time limit for cash assistance would be replaced with a pragmatic approach to assisting the most disenfranchised groups. Safety-net providers such as MCH departments have been important service providers to these groups. Policymakers must ensure that they are adequately equipped to continue to provide services to the vulnerable populations that need them most.

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, and the Open Society Institute. We gratefully acknowledge the willingness of all the state MCH Title V directors to participate in this study. We are also grateful to Jennifer Ellis, BA, for her assistance with interviewing and data entry, Lynn Doxey, MPH, for her assistance with data cleaning and analysis, and Lauren Oshman, MPH, for her assistance with manuscript preparation.

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206 30. Chavkin W, Draut TA, Romero D, Wise PH. Sex, reproduction, and welfare reform. Georgetown J Poverty Law Policy 2000;11(2):379–93. 31. Ullman F, Hill I, Almeida R. CHIP: A look at emerging state programs. Washington, DC: The Urban Institute, 1999. 32. Robert Wood Johnson Foundation. State coverage initiatives. State of the states. Washington, DC: Robert Wood Johnson Foundation, 2000:25. 33. Pear R. 40 states forfeit health care funds for poor children. New York Times 2000; pp. 1, 26. 34. Families USA. Go directly to work, do not collect health insurance: Low-income parents lose Medicaid. Washington, DC: Families USA, 2000:43.


Romero, Chavkin, Wise, Hess, and VanLandeghem 35. Health Care Financing Administration. SCHIP annual enrollment report (fiscal year 1999). Washington, DC: Health Care Financing Administration, 1999. 36. Du J, Fogarty D, Hopps D, Hu J. A study of Washington state TANF leavers and TANF recipients. Olympia, WA: Department of Social and Health Services, 2000:59. 37. Guyer J. Health care after welfare: An update of findings from state-level leaver studies. Washington, DC: Center on Budget and Policy Priorities, 2000. 38. Garrett B, Holahan J. Welfare leavers, Medicaid coverage, and private health insurance. Washington, DC: Urban Inst 2000;B(13):6.