In 1996, President Clinton signed the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) into law. PRWORA replaced existing AID to Families with Dependent Children (AFDC), Job Opportunities and Basic Skills Training (JOBS), and Emergency Assistance programs. In their stead, PRWORA established cash welfare block grants for Temporary Assistance for Needy Families (TANF) and made significant changes in programs dealing with supplemental security income, food stamps, and public assistance benefits for noncitizens.

In response, the American Psychological Association's Division of the Psychology of Women formed a Task Force on Women, Poverty, and Public Assistance. The division was concerned with the psychological, social, and economic effects of welfare reform on the lives and futures of poor women and their families. Everyone, including recipients, agreed that reforms were needed. However, turning a federal program that entitles assistance to those who qualify into a program that gives states a set sum of money does not necessarily constitute reform. Reform is not reform when assistance is denied to needy individuals or families, including mothers and their children fleeing domestic violence. These policy changes were based on the mistaken premise that welfare is the problem. Welfare is not the problem-poverty is the problem. The economic gap between poor and rich is now larger than it has ever been. In 1993, the top 20 percent of U.S. households received 48.9 percent of the total income, but those households in the bottom 20 percent shared only 3.6 percent. Yet the national debate continues to focus on the "welfare problem" rather than on the "income distribution problem" or the "wealth concentration" problem.

Children and single mothers, especially those of color, have suffered the most. The National Women's Law Center reported in 1995 that almost 70 percent of U.S. working women earn less than $20,000 yearly, and nearly 40 percent earn less than $10,000. More than 10 million women are the sole support for their children and families (National Women's Law Center, 1996). The expansion of a service economy, fewer jobs in government, and curtailment of civil rights has significantly limited job opportunities for poor women and people of color. Economists and historians have long noted how the gender-based division of labor and the corresponding low wages paid for women's work have made many women poor (Feldberg, 1986). Comprehensive welfare reform must take into account the larger economic and social biases that cause women's poverty.

In this report we take aim at some common myths about welfare. We look at the real causes of poverty among women and what the scientific research tells us about issues such as domestic violence, education and training, the structure of work and workplace benefits, child care, and physical and mental health care. All of these issues must be successfully addressed before women can move out of poverty. We include specific recommendations policymakers can use today to build programs that work. Our recommendations, which are highlighted at the end of each topic, deal with obstacles faced by poor women that are not acknowledged in the welfare reform legislation. It is our hope we can work together with policymakers towards helping women move out of poverty into the national workforce, and succeed in staying there.

Psychology has a critical role to play in the reform of welfare

Psychology's particular advantage among health care professions is that it is both a scientifically grounded academic discipline and a service-oriented health care service profession. Indeed, the direct link and integration of science and practice is a primary strength of psychologists. Moreover, it is becoming evident that many welfare recipients suffer from mental health problems that could interfere with their abilities to obtain and maintain a job (DeParle, 1997).

In this report, the task force disseminates critical scientific research about women and welfare and recommends key supportive structures that must be in place for women to move out of poverty and into real work. Throughout this report we highlight this critical research-the data on which our recommendations are based. This data has been accumulated with the help of many organizations very active in collecting and analyzing research on the impact of poverty and welfare reform on poor women and their families. For additional information on women and welfare reform, we refer readers to the organizations and sources cited.

"Human capital" versus "work first"

The data we cite herein support recommendations based on a human capital approach, that is, an approach that emphasizes investment in the education, training, and productive skills of a national workforce that includes poor women. In the rush to get more mothers on welfare employed, little attention has been paid to the impact of the welfare-to-work transition for poor families. To encourage work among current welfare recipients, significant resources must be amassed to promote employability and retention.

Work success for mothers on welfare cannot be accomplished without concomitant services such as quality child care, education and relevant job skills training, available jobs that pay more than welfare and provide family friendly benefits, and support services that promote retention such as transportation, appropriate attire, and encouragement from the home environment (Lerman, 1995). For women, obstacles such as violence from partners and mental and physical health problems must also be addressed.

Historically, it was believed that mothers, especially if the children were young, should stay home and care for their children. More recently, however, policymakers and citizens have come to believe that the welfare system prevented long-term economic self-sufficiency and that mothers on welfare should be required to participate in work and employment activities rather than stay at home (Wilson, Ellwood, & Brooks-Gunn, 1995). However, the many barriers to successful welfare-to-work transition for poor women are considerable and formidable.

The new welfare law, by contrast, emphasizes a "work first" approach. This approach assumes a lack of personal responsibility as the principal cause of poverty and unemployment among welfare mothers, which disregards the very real larger economic and social biases at work-many women are poor in part because they are women. The "work first" approach also ignores individual variation; that is, although many welfare recipients will be able to get and maintain paying jobs, others will be so significantly disadvantaged, medically, personally, and/or socially, that they have very little hope of being placed in what most would consider an adequate, paying job (R.K. Weaver & Dickens, 1995). Officials in Oregon, which has had one of the nation's sharpest caseload declines (50 percent in 3 years), estimate that 75 percent of those left on the rolls suffer from mental health problems that could interfere with a job (DeParle, 1997).

Despite widespread debate with respect to whether welfare fosters dependency, very little data have been collected that explain why women remain on welfare or how psychosocial factors such as violence, abuse, poor housing, dangerous neighborhoods, and limited support affect welfare-to-work transitions (Salomon, Bassuk, & Brooks, 1996). There is only limited literature on what attitudes and social structures may support welfare-to-work transition. For example, recent research has shown that having other adults in the home and having a support system reinforces expectations about working and increases work participation for mothers on welfare (Wolfe & Hull, 1993). This finding suggests that far more psychological research needs to be directed toward identifying women's personal strength and resiliency factors as well as the well-known structural factors such as adequate child care and meaningful education and job training that help mothers on welfare succeed in the workplace.

PRWORA does not focus on solving the critical problems poor women face but emphasizes instead short-term savings by denying and reducing welfare benefits, setting strict time limits, and focusing only on strategies to quickly immerse welfare recipients into the labor market. The failure to include in successful welfare-to-work strategies such factors as transportation, child care, clothing, and other structural supports often perpetuates a cycle of poor job preparation and a return to a need for public assistance (Handler, 1995). A long-term macro approach is critical.

The human capital approach sees addressing education and skill deficits as ultimately a more successful means of reducing poverty and unemployment, and underscores the country's need for investment in a well-trained and educated workforce. The human capital approach is not antithetical to an emphasis on work; in fact, success in the workplace is more likely if needs are acknowledged and addressed appropriately, that is, if flexible and comprehensive services, supportive infrastructure, and opportunities for continuing education and training are made an integral part of the package.

Misperceptions About Welfare Recipients

Ambivalence about the benefits of welfare programs, modest gains in income for recipients of Aid to Families With Dependent Children (AFDC), and negative myths and stereotypes about AFDC recipients have been cited as reasons for the recent shift in public policy, which was codified in PRWORA. These popular prejudices hold firm in the face of research that clearly documents the fallacy of these perceptions. Despite the well-known failures of welfare, the lives of poor women would have been significantly worse without income assistance. While the social welfare programs prior to 1981 had not eliminated poverty, they had gradually increased the income for poor persons. The recessions of the 1980s, however, were devastating to poor families, and the massive AFDC reductions under the Reagan administration unfortunately reversed the decline in poverty rates (Bassuk, Browne, & Buckner, 1996b; Cloward, 1994; Haverman & Scholz, 1994; K. Phillips, 1990).

The general public views poverty as the result of personal failures and deficiencies. This perception rests on several myths. The most prevalent are that poverty results from a lack of responsibility; welfare leads to chronic dependency; African American women make up the largest group of welfare recipients; welfare promotes single parenthood and out-of-wedlock births; welfare provides a disincentive to work; welfare creates a "culture of poverty" because recipients share and hand down to their children a set of defective behaviors, values, and personality traits; and welfare funds extravagant spending by welfare recipients (Ehrenreich, 1987; Katz, 1989). These myths of pathology translate directly to the debate of who deserves help. They also fuel powerful stereotypical racial and gender messages. It is mothers, especially African American and single mothers, who are viewed as undeserving. Unwed mothers are thought to have the choice of marriage and do not obtain the sympathy that widows have. Other groups that are perceived as undeserving are immigrants, especially if they are not fluent in English.

Even the term "welfare" has been pejorative, and distortions of facts about welfare perpetuate myths about public assistance and those who receive it. These negative myths and stereotypes reinforced the government's agenda in cutting welfare spending to those recipients viewed as undeserving. Reform will continue to be ineffective if those implementing it do not separate myth from fact.

Strategies for alleviating poverty and decisions about government spending continue to be closely linked to the perceived causes of poverty, as well as the extent to which these causes are perceived to be modifiable (Furnham, 1982). Poverty is seen as an individual problem or a social issue (such as education or crime) rather than an economic issue (such as unemployment and the economy)(Gallup, 1992). Consequently, solutions are geared toward fixing or punishing those individuals with the "problem." Little attention is focused on societal factors that may perpetuate under- and unemployment, such as inadequate education, transportation, child care, and mental health problems.

Myth: Poverty Results From a Lack of Responsibility

Fact: Poverty Results From Low Wages

Welfare programs have been our country's response to poverty, and everyone agrees that those programs have not solved the problem. Jared Bernstein (1996) of the Economic Policy Institute identifies wage decline as the crucial economic factor that has had the largest impact on poverty rates in the 1980s and 1990s. While hourly rates of pay have fallen for the majority of the workforce since the late 1970s, by far the largest losses have been for the lowest paid workers. According to Bernstein (1996), between 1979 and 1989, the male worker, for example, at the 10th percentile (meaning 90 percent of the male workforce earns more) saw his hourly wage decline 13 percent, and since 1989 he lost another 6 percent. For women workers at the 10th percentile, the decline over the 1980s was 18 percent. The low-wage female worker gained slightly since 1989, but by 1995, her hourly wage rate was $4.84, down from $5.82 in 1979 (all dollars are in 1995 inflation-adjusted terms).

Myth: A Huge Chunk of My Tax Dollars Supports Welfare Recipients

Fact: Welfare Costs 1 Percent of the Federal Budget

Widespread misperception about the extent of welfare exacerbate the problems of poverty. The actual cost of welfare programs-about 1 percent of the federal budget and 2 percent of state budgets (McLaughlin, 1997)-is proportionally less than generally believed. During the 104th Congress, more than 93 percent of the budget reductions in welfare entitlements came from programs for low-income people (Center on Budget and Policy Priorities, 1996). Ironically, middle-class and wealthy Americans also receive "welfare" in the form of tax deductions for home mortgages, corporate and farm subsidies, capital gains tax limits, Social Security, Medicare, and a multitude of other tax benefits. Yet these types of assistance carry no stigma and are rarely considered "welfare" (Goodgame, 1993). Anti-welfare sentiment appears to be related to attitudes about class and widely shared and socially sanctioned stereotypes about the poor. Racism also fuels negative attitudes toward welfare programs (Quadagno, 1994).

Myth: People on Welfare Become Permanently Dependent on the Support

Fact: Movement off Welfare Rolls Is Frequent

A prevalent welfare myth is that women who received AFDC became permanently dependent on public assistance. Analyses indicate that 56 percent of AFDC support ended within 12 months, 70 percent within 24 months, and almost 85 percent within 4 years (Staff of House Committee on Ways and Means, 1996). These exit rates clearly contradict the widespread myth that AFDC recipients wanted to remain on public assistance or that welfare dependency was permanent. Unfortunately, return rates were also high, with 45 percent of ex-recipients returning to AFDC within 1 year. Persons who were likely to use AFDC longer than the average time had less than 12 years of education, no recent work experience, were never married, had a child below age 3 or had three or more children, were Latina or African American, and were under age 24 (Staff of House Committee on Ways and Means, 1996). These risk factors illustrate the importance of structural barriers, such as inadequate child care, racism, and lack of education.

Myth: Most Welfare Recipients Are African American Women

Fact: Most Welfare Recipients Are Children–Most Women on Welfare Are White

Children, not women, are the largest group of people receiving public assistance. Less than 5 million of the 14 million public assistance recipients are adults, and 90 percent of those adults are women (U.S. Bureau of Census, 1995). The majority of the recipients are White (38 percent), followed by 37 percent African Americans, and 25 percent other minority groups (Latinos, Native Americans, and Asian Americans) (McLaughlin, 1997). However, African Americans are disproportionately represented on public assistance because they are only 12 percent of the population (O'Hare, Pollard, Mann, & Kent, 1991).

Myth: Welfare Encourages Out-of-Wedlock Births and Large Families

Fact: The Average Welfare Family Is No Bigger Than the Average Nonwelfare Family

The belief that single women are promiscuous and have large families to receive increased benefits has no basis in extant research, and single-parent families are not only a phenomenon of the poor (McFate, 1995). In fact, the average family size of welfare recipients has decreased from four in 1969 to 2.8 in 1994 (Staff of House Committee on Ways and Means, 1996). In 1994, 43 percent of welfare families consisted of one child, and 30 percent consisted of two children. Thus, the average welfare family is no larger than the average nonrecipient's family, and despite considerable public concern that welfare encourages out-of-wedlock births, a growing body of empirical evidence indicates that welfare benefits are not a significant incentive for childbearing (Wilcox, Robbennolt, O'Keeffe, & Pynchon, 1997).

Myth: Welfare Families Use Their Benefits to Fund Extravagance

Fact: Welfare Families Live Far Below the Poverty Line

The belief that welfare provides a disincentive to work by providing a well-paying "free ride" that enables recipients, stereotyped as "Cadillac queens," to purchase extravagant items with their benefits is another myth. In reality, recipients live considerably below the poverty threshold. Despite increased program spending, the average monthly family benefit, measured in 1995 dollars, fell from $713 in 1970 to $377 in 1995, a 47 percent drop. In 26 states, AFDC benefits alone fell 64 percent short of the 1996 poverty guidelines, and the addition of food stamps only reduced this gap to 35 percent (Staff of House Committee on Ways and Means, 1996).

Despite the ready availability of facts, myths about welfare continue to be widespread. The media contributes to this lack of information. The media helps shape public perceptions about welfare recipients. The way in which a topic is reported can turn a neutral reader into an opinionated reader and can greatly influence public opinion. Although in an analysis of articles published in 10 major newspapers from January 1997 to April 1997, the tone was generally sympathetic to the poor, actual research and facts to counter myths were generally lacking (Wyche & Mattern, 1997).

Recommendations

1. Federal and state agencies should provide newspapers and other media with accurate information about welfare recipients and programs, including information on welfare reform.

2. Jobs need to pay better than welfare. Rather than focusing on welfare time limits, policy action at the state and federal levels must address reforming the low-wage labor market by raising wages and increasing the ability of low-wage workers to join unions and bargain collectively.

3. Public and private agencies should collaborate more effectively to promote and increase employment opportunities for women, especially of hard-to-place women.

4. States should provide training for case managers and other appropriate personnel to advocate for, support, and follow up with clients in ways that are not adversarial or punitive during their job search process.

5. States and federal agencies should fund and conduct research on the impact of the transition of mothers to work on the mother and the family and on what strategies best promote most positive outcomes for the mothers and their families.

6. States should require and fund formative and summative evaluations of proposed programs.

Poor Women Are Often Battered Women

Women attempting to get off welfare and become economically independent face numerous obstacles. One of the most devastating is violence from intimate partners. Research increasingly and dramatically documents the pervasiveness of abuse against all women and the increased incidence among poor women, including welfare recipients. Violence, research shows, has a direct impact in keeping welfare recipients from holding jobs and becoming self-sufficient. For example, a recent study of a representative sample of welfare recipients in Massachusetts found that 65 percent were victims of violence by a current or former boyfriend or husband, and one-fifth had been victimized in the past 12 months (Colten & Allard, 1997). Similar results were found in a survey of welfare recipients in Washington State. There, 55 percent of the recipients reported being physically or sexually abused by a spouse or boyfriend (Roper & Weeks, 1993). Another study of 436 homeless and low-income housed mothers found that 63 percent reported assaults by intimate male partners (Bassuk, Browne, & Buckner, 1996a; Brooks & Buckner, 1996). This rate of intimate violence is substantially higher than that suffered by women in the general population, according to the National Crime Victimization Survey (Bachman & Saltzman, 1995).

Violence Is An Obstacle to Work

Job training providers report that a high proportion of women in welfare-to-work programs are being abused by their intimate partners. This abuse may take many forms, ranging from administering beatings to failing to fulfill child care responsibilities so that women cannot go to work (NOW Legal Defense and Education Fund, 1997; Raphael, 1996). Disruptive and threatening actions by their intimate partners may sabotage women's efforts at financial independence, perhaps out of the partner's fear that the woman will leave the relationship or form other relationships at work (NOW Legal and Defense Fund, 1997). A 1997 study on intimate violence and Black women's health found that rates of severe partner violence are higher for low-income Black women than for higher income Black women. Black women who have unemployed husbands experience particularly high rates of severe violence (Russo, Denious, Keita, & Koss, 1997).

Violence interferes with work, job training, and education and thus undermines women's attempts at economic independence. In addition, pervasive violence may also leave women with physical injuries and psychological consequences that make work difficult. Posttraumatic stress disorder (PTSD) and severe depression are common among victims of domestic violence (Koss, Goodman, Browne, Fitzgerald, Keita, & Russo, 1994; T.L. Weaver & Clum, 1995; Woods & Campbell, 1993). PTSD sufferers may feel helpless and terrified, experiencing flashbacks of the original trauma in recurrent and/or intrusive thoughts or dreams, have trouble sleeping and be unable to concentrate. Both physically and verbally abused women may experience PTSD; the more extensive the abuse, the greater the risk of PTSD (Kemp, Green, Hovanitz, & Rawlings, 1995).

Psychological control by the batterer, coupled with the demands of parenting and often by life in a dangerous neighborhood, isolates many victims of abuse (Bassuk et al., 1996a), leaving them without social and material support that could mitigate the psychological consequences of battering and could facilitate employment. Women need a range of psychological, medical, and social and legal services as they remove themselves from abusive relationships. Even after finding a safe environment, they need continuing psychological help to repair the damage to their self-esteem and to prepare them for job training and employment.

Some women may be unwilling to voluntarily identify themselves as victims. The Family Violence Option allows states to take the initiative to do the necessary screening. This initiative can save the lives of battered women, can help preserve their families, and can help them keep jobs and gain self-sufficiency.

Recommendations

1. States should adopt the Family Violence Option to the federal welfare law, which allows states to (a) screen welfare recipients for a history of domestic violence; (b) refer these individuals to counseling and support services; and (c) exempt individuals from certain requirements for as long as necessary when compliance would make it more difficult to escape a violent situation (Davis, 1996; Swarns, 1997).

2. States should grant extensions or temporary exemptions from time limits to welfare recipients who have experienced a history of domestic violence.

3. States should administer "good cause" exceptions which define domestic violence broadly without increasing the burden of proof upon the victim of abuse.

4. States should exempt young mothers living in abusive home environments from requirements that they live at home.

5. States should eliminate the two-tiered benefit system for welfare recipients who have relocated from other states to escape their abusers.

6. States should train job and employment staff to recognize domestic abuse among women applicants and should offer psychological services to women applicants identified as battered; this assistance is needed to support the efforts of these women to get training and to find and keep jobs.

7. States should protect battered women from benefit cuts as a result of reporting abuse by a live-in partner. This will mean a waiver of the rule attributing income of the man to the welfare recipient in states in which welfare benefits are available only to single-parent families.

8. States should establish "good cause" exemptions to requirements that paternity be established or child support enforced in situations in which it is likely to increase violence by or provoke retaliation from abusers.

The Double Message About Education

President Clinton has stressed the importance of education for the nation's workforce and for national well-being-assuring us that his education proposals will improve access to higher education and reward academic achievement by including tuition tax deductions and tax credits for students who maintain a "B" average (Clinton reaffirms, 1997). By stark contrast, the new welfare law will drastically limit the number of recipients who can participate in education, and it specifically mandates a work first policy. Poor women on welfare will be required to take any available jobs, with extremely limited options for job training and none for higher education. Higher education has been one of the most promising pathways out of poverty. But the double message from policymakers seems to be that "yes," widely available education and training is critical, but "no," this critical education and training will not be available to those who need it the most-women on welfare.

Education has long been honored in our society as a route to social mobility and material security. In the past, policymakers gave opportunities for postsecondary education to such disadvantaged groups as minorities and war veterans. Millions of Americans continue to take advantage of "educational welfare" in the form of government scholarships, student loans, GI bills, work-study programs, and work-based continuing education programs. Tax benefits support parents who can set up college trusts for their children, college tuition breaks are available to advantaged families who can lock in tuition costs by prepaying, and free postsecondary education is available to affluent retirees who as "guest students" on college campuses across the country take tuition-free college courses. Yet policymakers have continued to ignore the potential education has to help welfare recipients achieve similar goals.

Inadequate preparation and training place women in a revolving door of welfare. They are never able to earn the income necessary to lift themselves and their families out of poverty or to even match the welfare payment. A head of a family who is a single earner and female faces almost impossible odds of raising her family out of poverty when it takes two wage earners just to make ends meet. When that single wage earner does not have adequate skills or education, the odds against her increase. As our economy grows more dependent on technology, a rise out of poverty increasingly depends on technical and professional skills available only through postsecondary education, be it college, advanced technical training, or both. For example, it is estimated that by the turn of the century, 50 percent of all new jobs will require a college education (Solomon, 1990).

More welfare recipients may be eligible for postsecondary education than is generally believed (Bane & Ellwood, 1994). About half of welfare recipients already have a high school education or a General Equivalency Diploma (GED)(Center on Budget and Policy Priorities, 1993). In fact, many are already involved in some higher education (Burghardt & Gordon, 1990; Burke-Tatum, 1988).

However, under the new law a student on welfare who wants and needs income must get a job, even if taking a job forces her to leave school. While the President is sounding the theme that the country needs a better educated workforce, caseworkers are telling welfare recipients to find jobs and drop out of college. It is estimated that community colleges will lose up to 60 percent of their welfare students as states are mandated to put larger proportions of their caseloads to work (Ritter, 1997).

The new law restricts the type of education and training that count as work up to 1 year of job training or vocational training, although it is up to the states to interpret the rules. States can be more restrictive than the federal guidelines require or more open in their interpretation. However, given the current political mood of the country, states are tending toward a narrow work first interpretation of the provisions of the law. According to the Chronicle of Higher Education, Illinois, Kansas, Nevada, New Jersey, New Mexico, Ohio, South Dakota, and Wisconsin have limited the access of welfare recipients to college, some by limiting recipients to short-term training programs or by limiting college attendance to 1 year only (Nine issues affecting higher education, 1997).

High school graduates make 20 percent higher wages than do dropouts and are more likely to have administrative support jobs and blue collar jobs requiring skills. However, this by itself does not protect against a return to welfare. Women welfare recipients with a high school education are far more likely than women with more education to go back on welfare. One study found that only a quarter of high school graduates and 15 percent of high school dropouts left welfare for a job lasting 18 months or longer (Pavetti, 1992). This is in large part because there are fewer and fewer low-paying jobs requiring minimum skills. At minimum wage and with no income assistance, a woman must work 60-70 hours a week for 50 weeks a year to squeak above the poverty threshold. Census data clearly show that earning college credits and attending college for even short periods of time have a positive impact on earned income.

Access to Postsecondary Education Changes Lives

College brings the same advantages to welfare recipients as it does to anyone else-financial independence and security, social status, and mobility. The work first approach discounts the important studies that document the amazing economic, personal, and familial success of women who, despite enormous odds and institutional barriers, finish postsecondary advanced training and get jobs providing adequate earnings.

While education does not eliminate gender and racial discrimination in the job market, the persistent gap between the pay of women and men decreases with more education. In 1990, a woman with a master's degree earned 69 percent of the average male salary, whereas a woman with a high school diploma or less education earned less than half the wage of a man employed at a comparable level (Greenberg, 1993). The median weekly earnings of women with college degrees was $453, compared with a median $308 in weekly earnings of women with high school diplomas. Both, of course, were considerably less than the $548 weekly median earning of men with high school diplomas. A woman who is head of a household, in particular, needs a college degree to earn a living family wage that approaches that of a man with a high school diploma (Blank, 1995). Although every year of additional education brings an increase in earnings, it is still difficult for a woman head of household without a college degree to find a stable job that pays enough to support a family on that one income alone. Only women with bachelor's degrees earn enough ($19,404) to raise a family of three much above the poverty threshold, which was $11,890 for a family of three in 1993 (U.S. Department of Health and Human Services, 1993).

Follow-up studies of minority recipients who have attended college show significant improvement in their jobs, salaries, finances, family life, and self-esteem (Gittell, Gross, & Holdaway, 1993; Gittell, Schehl, & Facri, 1990; Johnson, 1991; Kates, 1991). Most telling, research has found that only 21 percent of families headed by African American women with at least 1 year of postsecondary education were at the poverty level versus the much larger 51 percent for those families headed by African American women whose formal education ended with a high school degree. Thus, the poverty rate for African American women heads of household was cut in half with only 1 year of postsecondary schooling. Similarly, 41 percent of families headed by Latina high school graduates lived in poverty, but that number dropped to 18.5 percent when the mother had 1 year of postsecondary education. For White women, the number dropped from 22 percent to 13 percent (Sherman, 1990).

National survey data show that 40 percent to 50 percent of women who exited welfare returned within 2 years. Five years after leaving welfare, nearly 80 percent of women remained poor or near poor. However, women who had more postsecondary education were more likely to consistently escape poverty (Meyer & Cancian, 1997). Similarly, in a 1990 survey in New York state by Gittell and Associates, 88 percent of welfare respondents who returned to college and graduated had been employed since graduation; 45 percent were earning more than $20,000, and 7 percent were earning, over $30,000. All who had degrees were off welfare. Those with a 4-year degree began earning an average income of $23,017, and those with an associate's degree, $19,738. Over half had gone on to undertake additional training, and 22 percent were in graduate school. Most significantly, only 13 percent of the respondents were still on public assistance, and all of these individuals had young children (Gittell et al., 1990).

Almost the same results were found in a replication of the survey in five other widely varying states (Illinois, Tennessee, Pennsylvania, Washington, and Wyoming). Across these states, 81 percent of female AFDC recipient college graduates had been continuously employed since graduation. When asked about what most helped them complete college, 90 percent listed financial aid as the single most important factor. The great majority of women were convinced that they could not have left welfare without their college degree, and it was college that enabled them to secure their present jobs (Gittell et al., 1993). Those who had completed a 4-year degree were the most likely to have left welfare for stable employment and adequate earnings to support a family.

One college counselor noted, given the great obstacles-personal, medical, and familial-and the institutional barriers these students face, "it is almost miraculous that any of our students graduate." Students who are on welfare may not be able to work or attend school because they cannot afford or find adequate child care or transportation or may be ill or disabled. Lack of money, time, or child care; sexual victimization; abusive relationships; substance abuse; and responsibility for sick and disabled relatives are common sources of stress among these students. Coping with family members who have been shot or killed or have AIDS is not uncommon (Hamilton, Brock, & Vargas, 1994; Polakow, 1993a; Raphael, 1996).

Special programs can greatly help women on public assistance succeed in postsecondary programs.

The City University of New York (CUNY) is one of the largest providers of higher education for people on public assistance. In 1993, 17 percent, or some 27,000 CUNY students, were on welfare or in families receiving welfare. For some of the CUNY colleges, up to 40 percent of their students were on welfare or from families on welfare. About 80 percent of these students were people of color, and 63 percent were women of color. Gittell et al. evaluated several special programs that were designed specifically for welfare recipients and that provided a mix of counseling, academic support, and financial aid. The students who were in programs that combined more rigorous requirements with more extensive services targeted to student needs did better than any other group of students. Students on welfare in all of these programs made above-average progress toward their degrees, which was not the case with welfare students not in programs.

Regardless of whether they participated in a special program, students on welfare accumulated credits toward their degrees at the same rate as students not on welfare, demonstrating their potential for success in college. Focus interviews on 13 campuses in 22 programs with hundreds of students turned up a clear consensus: They were eager to leave public assistance, and they were convinced that only higher education would ensure them stable employment and economic independence (Gittell, Vandersall, Holdaway, & Newman, 1996).

Empowering poor women through higher education not only improves their income and job prospects, but also positively affects their children.

Kates's (1991) study of welfare recipients in 28 states found that the college experience of the mothers has a profound effect on their children and that their own educational experiences helped to raise their children's desire and aspiration for college. Other studies in several states have consistently found similar results: that students on welfare report that their college experience has a significant and beneficial impact on the educational attitudes and aspirations of their own children and that the mother's level of education is a significant predictor of children's overall development and performance in school (Gittell et al., 1996; Kates, 1991; Quint, Musick, & Ladner, 1994; Zill, Moore, & Smith, 1991).

We have long understood that education is a powerful and dependable way to interrupt the intergenerational transmission of poverty. Individual mothers tell how that happens. Ninety-five percent of the students in one study said that the college experience had made them feel proud of themselves; they became more confident (90 percent), developed new insights into their abilities (85 percent), found their children were prouder of them (81 percent), and learned to better meet their children's needs (75 percent). They reported that they were better able to help their children with their homework, gave their children a more secure and safe home environment, and modeled reading and studying for their children. The children saw and experienced the direct results of their mother's motivation and work in school when she graduated and later found and kept a good job. The report concluded that-

"Without exception, every woman interviewed had a significant influence on at least one other person's education, ambition, or achievement, and the women with younger children [were] the most determined that their children [would] also go to college "(Gittell et al., 1990).

Low educational goals and low academic achievement are also positively associated with early initiation of sexual activity at a younger age, among both African American and White adolescents.

However, contrary to popular stereotype, no relationship has been documented between welfare per se and pregnancy; 77 poverty researchers signed a statement asserting that accumulated research indicates that "welfare has not played a major role in the rise of out-of-wedlock childbearing." Teenage pregnancy is, however, closely related to the absence of a future, of hope for anything beyond producing a child.

Job Training

Job training, remediation, and educational services are critical to ensure the success of the welfare-to-work transition for women on welfare.

The current labor market requires advanced technical skills, but welfare recipients are largely unskilled and therefore unable to secure jobs that will allow them to successfully support their families (Danziger & Danziger, 1995). They also often lack sufficient work experience and training. This is particularly true for longer term welfare recipients. Recent research indicates that among women who have been on welfare for 5 or more years, 50 percent have no work experience, and 63 percent have less than a high school degree (Pavetti, 1995).

Without job training and education, welfare mothers are often forced to work in jobs that require nontraditional work hours, a situation that further limits their child care options and taxes resources to pay for child care (Danziger & Danziger, 1995). Typically, welfare mothers are most likely to be employed as child care providers, waitresses, cleaners, orderlies, and attendants (U.S. Department of Labor, 1993). Single mothers are at high risk for being able to secure only part-time, minimum wage jobs, with poor opportunities for advancement, and the work options for women of color who are single are the most limited (Institute for Women's Policy Research [IWPR], 1995).

Middle-aged and older women and displaced homemakers face other work barriers. Most federal and state job training programs appear to overlook them (Butler & Weatherley, 1992). Older women have the additional disadvantage of having been bypassed by the computer age, and this technical illiteracy is a significant barrier to employment (Marsh, Pollan, McFadden, & Price, 1990). Therefore, many older, as well as younger, welfare recipients are likely to benefit from specific technical job training and reading instruction that is specific to targeted jobs and that promotes technical literacy.

Over the last 30 years, three strategies have been used to boost the employability of welfare recipients: financial incentives, requirements to search for and take jobs, and education and training programs. These three strategies, however, can only be successful when complemented by medical health insurance and earned income tax credits (Lerman, 1995), as well as quality child care.

The Institute on Women's Policy Research has shown that most mothers on welfare work, but they are unable to earn enough money to escape poverty, as their jobs are low paying, unstable, and do not offer health insurance and other benefits that would increase retention. For these families to escape poverty, they must be able to secure higher paying jobs with more benefits (Institute for Women's Policy Research, 1995).

More than 70 percent of mothers receiving assistance spend some time in the workforce, and those individuals not working are typically involved in the job search process. IWPR found that the most critical variables predicting successful work transition were the physical and emotional ability to work; living in states with good job availability and low unemployment; not having toddlers or infants (lower child care costs and reduced role strain); receiving child support and financial resources from other family members; and possessing the human capital of job training, that is previous labor force participation, and a high school education. IWPR concludes that job training and work incentives are beneficial and necessary, but not sufficient. Short-sighted attempts to lower welfare costs by placing restrictive time limits on food stamps, insurance, and financial resources will not successfully move mothers on welfare to work.

• PRWORA permits certain forms of education and training that meet the definition of "work," including up to 1 year of vocational educational training, job skills training, and education, which is directly related to employment. The general categories of "job skills training" and "education directly related to employment" should be interpreted to include options for postsecondary education. Thus:

a) State legislators should work with college administrators and job training personnel to ensure that higher education is included in the state's definition of work activities.

b) Caseworkers should apply flexible interpretations of work requirements that include postsecondary education and training in the assessment of their clients.

c) Applications for public assistance should openly present education and training as a viable option to the client.

• States should fight to change the law to permit education and training opportunities for women on public assistance for at least 4 years to complete associate and bachelor's degrees necessary to obtain meaningful jobs that pay a family wage and ensure long-term self-sufficiency.

• Because success in work and educational settings is strongly related to social supports, state legislators must include funding and programs for adequate housing opportunities, child care costs, health insurance, food stamps, earned income tax credits, protection from family abuse and violence, substance abuse treatment options, transportation costs, and access to appropriate clothing for women on public assistance who are trying to work and obtain more education and training. Medicaid and child care benefits need to be extended to families for at least 2 years after they leave welfare for work. In this period they may continue both work and the pursuit of higher education. Psychological services need to be provided to women dealing with violence, substance abuse, and other such problems.
• To widen the opportunity for higher education and encourage economic self-sufficiency, states should receive waivers to increase allowable limits on asset/resource accumulation and allow recipients to contribute to special education and training accounts in substantial amounts, up to $20,000.
• Service delivery providers should develop individualized self-sufficiency plans for and with each person receiving public assistance who is able to work. Such plans should recognize the wide differences between individuals' circumstances, skills, abilities, resources, and needs and ensure the continuation of help and benefits for as long as the individual works toward independence through broadly defined work activities that include vocational and higher education.
• Increased funds must be made available for case management and counseling to ensure that clients receive a thorough individual assessment of their skills, resources, and needs and the barriers to further education, training, and employment including factors such as lack of literacy skills, substance abuse, and violence that could affect their ability to become economically self-sufficient.
• College administrators and advisors should advocate and work with state legislators, welfare personnel, community organizations, and agencies to formulate policy, supportive programs and services, and flexible courses of study that help welfare students stay in college and finish their programs and degrees. They are also in a position to mitigate against some of the harsher effects of the new law by:

a) Acknowledging that these students have a legitimate place on the campus and a right to participate in higher education by developing supportive services, strategies, and environments to help students on welfare succeed;

b) Providing more funds for financial aid packages and for campus child care, housing, and other supplemental resources these women may need, and appointing a person who will act as liaison between the college and welfare agency; and

c) Establishing linkages with state welfare offices, businesses, and community organizations that can help women on welfare become self-sufficient.

• State policy must not penalize women on public assistance by cutting their benefits when they secure financial aid packages and student loans.
• Some potential recipients of public assistance may prefer not to use up the limited time for which they might be eligible, or may be ineligible for financial aid through welfare. Workforce development funds should be used to provide the income necessary to allow these individuals to participate in education and training programs.
• Policy action should ensure access for poor women to education and training for nontraditional employment such as in trades requiring skills and apprenticeships through funds available under the Job Training Partnership Act, the Carl D. Perkins Vocational and Applied Technology Education Act, and other sources of federal and state support.
• Sex equity in training and education and improved enforcement of the Equal Opportunity Act and equal opportunity laws should be a priority in facilitating women's access into higher paid, male-dominated occupations and in ensuring nondiscrimination in hiring, pay, promotion, and benefits in all occupations.
• States should design job training programs that assess and accommodate individual differences, for example, in each person's job and educational needs, in attitudes and behaviors that promote resilience and success in getting and keeping jobs, and in what kind of support systems are needed. Designing programs that accommodate differences will require research about the impact of these individual differences and what strategies work best for each.
• In their job referral networks, states should include referrals to jobs and job training in high-growth technological areas.

As noted earlier in this report, a woman who is the head of household needs a college degree to earn a living family wage that approaches that of a man with a high school diploma. That is, many women are poor because they are women. It is no surprise welfare mothers have more options at the lower levels of the labor market than the middle or higher levels. Welfare mothers most often take jobs as child care providers, waitresses, cleaners, orderlies, attendants, and so forth. These kinds of jobs tend to be part-time and low paying; to offer little or no paid sick leave, health insurance, or other benefits; and to require "nontraditional" work hours, making child care difficult to obtain and variable in quality (Piotrkowski & Kessler-Sklar, 1996). Depending on the size of the employer, federal requirements (e.g., family medical leave) may differ or not apply. Women often take part-time jobs because they offer greater flexibility in some cases, but the trade-offs in wages and other benefits are great.

Welfare reform imposes additional limitations on poor women, often requiring them to accept the first available job, regardless of wages, benefits, or flexibility and "family friendliness." Women who are forced into jobs with low wages and few or no family-friendly benefits and policies (e.g., health insurance, paid leave, flexible work hours, and help finding and paying for good child care) may not be able to hold onto those jobs and thus are likely to return to welfare (Piotrkowski & Kessler-Sklar, 1996). In a qualitative study of welfare recipients, illness or injury (of oneself or of a family member) or inadequate child care were found to result in loss of a job and a return to welfare with remarkable speed (Oliker 1995). If the goal is sustained economic self-sufficiency, welfare reform programs must make sure that mother-only families get (1) adequate wages and (2) the minimum family benefits (Piotrkowski & Kessler-Sklar, 1996). Minimum benefits include health insurance, paid sick leave, paid family leave, flexible work schedules, and assistance in finding and paying for quality child care. Unfortunately, research suggests that poor mothers have limited access to such family-supportive workplace benefits (Hagen & Davis, 1994; Kerlin, 1993; Oliker, 1995; Piotrkowski & Kessler-Sklar, 1996).

Recommendations

1. States should design welfare reform programs and job placement programs to ensure that jobs available to welfare recipients provide minimum family-friendly and supportive benefits, health insurance, paid sick leave. Caseworkers should also strive to make available jobs that provide family leave benefits, flexible work schedules, and assistance in finding and paying for good child care.

2. Jobs need to pay better than welfare. Rather than focusing on welfare time limits, policy action at the state and federal levels must address reforming the low-wage labor market by raising wages and increasing the ability of low-wage workers to join unions and bargain collectively.

3. States should design welfare reform programs and job placement programs that ensure that jobs available to welfare recipients pay adequate wages, that is, wages that will support mothers and their children.

One of the most critical variables mediating the success of work transition and training efforts for mothers on welfare is affordable, quality child care. Research has shown that families on welfare and other low-income families spend a greater percentage of their incomes on child care than do higher income families (Brooks & Buckner, 1996; Cherlin, 1995). In a just and far-sighted society, child care, viewed as child development and education, would be regarded as a public responsibility.

The United Nations Universal Declaration of Human Rights proclaims that "childhood is entitled to special care and assistance" (United Nations General Assembly, 1989). This suggests, as noted by Kagan (1993) that "entitlement should exist for all...children-rich, poor, urban, rural, handicapped, nonhandicapped, black, brown, white." But the current state of affairs for poor children in the United States is far different and supports the following grim view: "Poor children are cheap. They die as infants in greater numbers, they go hungry, they lack health care, many are homeless.... Born as they are to the undeserving poor, to single mothers, and to women of color, they - like Dickens's Oliver Twist - are 'badged and ticketed' at birth...they are consigned to contingency, to life on the edges . . . They are viewed as the troublesome byproducts of incomplete and problem families, not as the living symbols of the patterned inequities that result from the purposeful politics of distribution" (Polakow, 1993b).

While we in this country accept compulsory schooling as necessary preparation for an increasingly complex society, there continues to be opposition by lawmakers to a comprehensive national child care program. As pointed out by Lubeck (1995), "In the United States, responsibility [for young children] is largely privatized until children reach the age of school entry. When the government does take responsibility for children's well-being, it is nearly always because parents are thought to have failed in their child-rearing duties." This stigmatizes both the parents and the child. Many other major industrialized nations have taken a far different approach, with child care programs offering universal eligibility, in which fees and benefits are scaled according to income and which combine "some form of income maintenance with day-care centers and family day-care programs" (Norgren, 1988).

Australia, Belgium, and Italy, for example, have rejected the welfare model, which uses public funds only for the neediest children, and now provide nearly universal access to preschool opportunities. In France, preschool for children aged 3 to 6 is free to the families. "The French conceive of public support for preschool education, not as a reluctant handout to those whose parents cannot provide well for them, but rather as a `welcoming' of all children into French society" (Lubeck, 1995). Such models recognize that only programs that benefit all families with children are free of the stigma attached to programs for the poor (Stoper, 1998). Such an approach also addresses the fact that a large number of the poor are children. In fact, according to census data from 1991, 40 percent of all poor people in the United States are children under the age of 18 (Spencer, Blumenthal, & Richards, 1995). It is estimated that 13 million children in the United States live in poverty, a phenomenon some have identified as "nationally sanctioned child neglect" (Kagan, 1993, p. 16), and others as "the other childhood" (Polakow, 1993b, p. 158).

Census data from 1995 indicate that 11 million children under age 6 have mothers who work outside the home and thus make use of some form of child care. It has been estimated that this number will increase by almost 2 million when mothers who previously received AFDC assistance are required to find employment (Jones, 1996). A 1986 national study of a large diverse sample of children cited by Baydar and Brooks-Gunn (1991) found that 33.8 percent received "nonmaternal primary care" in their first year, 46.7 percent in their second year, and 53.3 percent in their third year.

There is strong evidence that women's decisions about whether and how much to work depends upon the availability and cost of child care and that these factors are significant barriers to employment for low-income mothers (Bowen & Neenan, 1992; Brooks & Buckner, 1996; Cherlin, 1995; Hernandez, 1993; Kisker & Silverberg, 1991). Mothers working and supporting young children rely on child care. Therefore, their efforts to escape dependence on welfare require a public commitment to supporting their child care needs (D.A. Phillips, 1991).

Data from the National Child Care Survey of 1990 and census data indicate that "[employed] married mothers with low incomes relied heavily on their husbands, who provided 42 percent of the primary child care among married couples below the poverty level...[S]ingle mothers in low-income families were more likely to rely on relative care in the home than were better-off single mothers. Relatives in the home [primarily grandmothers] provided 45 percent of the primary child care for employed, single mothers living below the poverty level. In contrast, center-based care accounted for just 20 percent..., a lower percentage than for better-off single mothers" (Cherlin, 1995). Other studies also find a heavy reliance on grandmothers for child care (Kisker & Silverberg, 1991; Sonenstein & Wolf, 1991). Among the grandmothers who care for the children of their single mother daughters, it has been estimated that one-third are themselves in the workforce, usually working a different shift from their daughters and are thus overloaded and heavily stressed (Cherlin, 1995).

One study of a sample of families in Illinois making the transition from welfare to work (Smith, 1995) found that 70.6 percent of those working less than 20 hours a week used in-own home or family child care compared with 32 percent of parents working more than 32 hours per week. These parents were in a program that provided child care subsidies to them for a limited time of 12 months. Over 74 percent reported that they did not know how they would be able to continue working when their day-care subsidy ended, since, on a wage of $5 per hour, it would take 55 percent of a parent's gross salary to pay for private child care.

Poor families use a substantially larger proportion of their incomes to pay for child care than more affluent families (Brooks & Buckner, 1996). Employed poor White mothers with children under age 5 paid 24 percent of the family income for child care and poor African American mothers paid 17 percent, compared with 8 percent by employed nonpoor White mothers and 10 percent by nonpoor African American mothers. Among AFDC mothers, the average child care expenditure was 32 percent of total income (Bassuk et al., 1996b; Cherlin, 1995).

Low-income families using paid child care services also use family day-care providers disproportionately more than child care centers. The former are characterized by "unregulated, unlicensed setting of unknown quality" (Cherlin, 1995). Family day care (a primarily underground operation) could provide high quality care at affordable rates if providers were trained and standards enforced. In fact, with appropriate training, family day care is an entrepreneurial opportunity that has the potential to develop into a high quality and affordable child care option (Frankel, 1994).

Two basic strategies have informed child care policies at both the federal and state levels (D.A. Phillips, 1991). The first approach is the welfare model, remedial or custodial in its approach to child care, that is geared entirely to promoting adult employment and, as noted by Fink (1995) and others, "has tended to ignore considerations of child care quality" by trading off quality for low costs. The second approach is the Head Start model, which focuses on children and their education and development. This approach is more costly, about $525 per child per month compared with custodial child care costs of about $310 per child per month (Albelda, Folbre, & Center for Popular Economics, 1996), but is associated with clear positive outcomes.

Quality of child care in centers is associated with diversity in backgrounds of the children and with training and salary of the staff. The likelihood of high quality in a child care program is increased by ensuring diversity in ethnic backgrounds and socioeconomic levels through the use of sliding fee scales based on family income. This has been recommended by a Children's Defense Fund Report (Chilman, 1988) and by Zigler (1994), who, as director of what is now the Administration for Children, Youth, and Families, administered the National Head Start Program. One study (D.A. Phillips, Voran, Kisker, Howes, et al., 1994) found that upper-income children in child care centers "were more likely than either their middle- or low-income peers to be cared for by better trained, stable, better compensated, and more sensitive teachers in more developmentally appropriate settings."

Mothers on welfare, like other mothers, "consider the developmental aspects of child care to be important-potentially as important as convenience" (Sonenstein & Wolf, 1991). Research findings indicate that, regardless of socioeconomic level, the quality of child care is positively correlated with child development outcomes (Chilman, 1988; Hernandez, 1993). A review and analysis of relevant research by the National Research Council concluded that child care outside the home that is of high quality can promote the intellectual and social development of children (Chilman, 1993). Likewise, data from a large scale national diverse sample (The National Longitudinal Survey of Youth) has documented that low-income children who attended day care in their first, second, or third years had significantly higher academic readiness scores in mathematics and reading recognition than comparable children who did not attend day care (Caughy, DiPietro, & Strobino, 1994). Results specific to Head Start, a quality program for preschoolers, are also consistently positive. The Report of the Carnegie Corporation's Task Force on Learning in the Primary Grades proposes that all 3- and 4-year olds have access to a high-quality preschool program that involves parents and community resources (Report, 1996).

So well documented are the positive effects of quality child care prior to entry into school that some experts in the field are now proposing a new research agenda "that would document the negative consequences of not providing high quality, affordable child care" to all children (Silverstein, 1991). Policymakers must understand that child care is needed before and after the traditional hours of 9:00 to 5:00 or 8:00 to 6:00 to accommodate the needs of poor parents with preschool children (Smith, 1995; Sonenstein & Wolf, 1991), many of whom are working during "alternative hours" (Brooks & Buckner, 1996).

Recommendations

• At federal and state levels, a comprehensive national child care policy should be created and supported that provides all preschool children with access to high-quality publicly funded child care centers

  • that focus on child development and education;

  • that are funded in part by parental contributions on a sliding scale;

  • that are community based and monitored by a local board of parents;

  • that compensate child care workers appropriately for their level of education, training, and responsibility; and

  • that are available to parents and children over an expanded period of time (i.e., early morning, evening, and weekend hours).

• States should offer incentives to neighborhood groups and to corporations and other businesses to provide high-quality day care for community children and to children of employees, staffed by well-trained and fairly compensated workers.

• Federal legislation should amend PRWORA to

  • eliminate the 60-month time limit for assistance to needy families; or

  • eliminate from the 60-month time limit such noncash assistance as child care vouchers/certificates, emergency assistance, counseling, etc.

Poverty is detrimental to physical and mental well-being. Compared to the general population, both homeless and low-income housed mothers have poorer physical functioning and a higher prevalence of chronic health conditions, including depressive disorder, PTSD, and substance abuse disorders. In fact, data from the National Institute of Mental Health tells us that the odds of people in the nation's lowest socioeconomic group having a diagnosable mental disorder is about 2-5 times that of those in the highest socioeconomic status group (Bourdon et al., 1994; Regier et al., 1993). Welfare reform cannot succeed without taking into account the special health problems and needs of poor women and children, including development of strategies of prevention, intervention, and treatment.

Mental and Physical Health of Poor Women

Poverty brings major stressors that are associated with depression, as well as significant obstacles to help for those depressive symptoms (McGrath, Keita, Strickland, & Russo, 1990). We have known for some time that poverty contributes to depression. Women with insufficient personal support, who have no assistance raising their children, and who live with the chronic stress of having children and self to support but little money with which to do that are at higher risk for depression. Single-parent status, responsibility for young children, social isolation, and lack of social supports are all related to depression, as well as to poverty.

Analysis of data from the National Longitudinal Survey of Youth showed that almost 90 percent of current welfare recipients between the ages of 27 and 35 experience one of five powerful barriers to employment. These include low basic skills, substance abuse, a health limitation, depression, or a child with a chronic medical condition or serious disability. About half of all recipients experience a more serious form of one or more of these barriers (i.e., depression 5 to 7 days a week, a health condition that prevents work, concern that one is an alcoholic, repeated use of crack or cocaine, or extremely low basic skills) (Olson & Pavetti, 1997). Others have also documented the high level of distress affecting women on welfare. For example, Leon and Weissman (1993) found that twice the numbers of women on AFDC met the criteria for some lifetime affective disorder compared to those not receiving financial assistance (13 percent versus 6.7 percent). Twice as many AFDC recipients sought help from general medical, specialized, and human services sources than did those not on assistance.

Yet poor women, because they live in poverty, do not have sufficient access to the care that could make a difference (McGrath et al., 1990). Health plans offered by employers tend to underfund mental health benefits. This is true as well of medicaid plans, which limit care and are often associated with poorer care. Health care provided to poor women needs to address the critical issue of depression and other mental health concerns, as well as such obstacles to care as lack of child care and lack of transportation. The "double whammy" of poverty is that it puts women at higher risk for depression and also makes it especially difficult to get treatment.

The health status of children is inextricably woven into the fabric of their lives, especially the well-being of their primary caretakers. Children living in poverty are at a higher risk of exposure to conditions that produce adverse health effects and are more susceptible to poor outcomes from these exposures (Parker, Greer, & Zuckerman, 1988).

There is a much higher health risk that poverty presents to children from low-income families compared with high-income families over a wide variety of health outcomes. For example, children from low-income families are more likely to suffer child abuse, neglect, iron deficiency anemia, die before age 3, suffer fatal injuries, and be diagnosed with medical conditions of asthma, pneumonia, low birth weight, developmental delays, and behavioral problems than children of high-income families (Geltman, Meyers, Greenberg, & Zuckerman, 1996).

Recommendations

1. All health clinicians need training to increase awareness of abuse and assault and their link with physical and mental health consequences.

2. States should encourage and develop partnerships among health and mental health professionals to coordinate comprehensive responses.

3. States should make children's mental health a priority by increasing funding to school-based programs and programs that provide early intervention.

4. The U.S. Department of Agriculture should support food banks.

5. States should compensate for the reductions in federal subsidies of nutrition programs for children and the elderly.

6. Federal legislation should expand the Women, Infants, and Children (WIC) program for women and children who have reduced food stamp benefits.

7. States should fully fund comprehensive programs to prevent teenage pregnancies (school-based clinics, mental health, dropout prevention).

8. States should support comprehensive programs (supported housing options, accessible quality health care) to prevent domestic violence, substance abuse, and child abuse and neglect.

Alcohol and Substance Abuse

According to the Legal Action Center (1997), results from several studies, using slightly different methodologies, have estimated that between 16.4 percent and 20 percent of welfare recipients have alcohol and drug problems. Elevated rates of alcohol and drug abuse among welfare recipients are partly attributable to their demographic risk factors:

Age: Young people abuse substances at the highest rates. For drugs, the highest use rates are for those between 16 and 20 years; for alcohol, rates are highest between the ages of 21 and 44.

Education: Among adults between 18 and 34 in 1995, those who had not completed high school had the highest rates of drug abuse (15.4 percent), while college graduates had the lowest rate (5.9 percent). Alcohol is the opposite; higher levels of education are associated with higher rates of use.

Employment: In 1995, 14.3 percent of unemployed adults over 18 were current drug users, compared to 5.5 percent of full-time employed adults (Legal Action Center, 1997).

Although more men than women use drugs, the consequences of drug use by women are often more severe, and after initial use, women may proceed more rapidly to drug abuse than men (Griffin, Weiss, Mirin, & Lange, 1989, cited in Research Agenda for Psychosocial and Behavioral Factors in Women's Health, 1996). A major issue among welfare recipients is the high incidence of those who have a mental disability and substance abuse problem or dual diagnosis (Jessup, 1996). The new law includes a number of provisions that relate to welfare recipients with drug and alcohol problems:

The law imposed a lifetime ban on cash welfare and food stamps to anyone with a drug felony conviction after August 22, 1996, unless the state enacts legislation "opting out" of the ban.

Individuals who are violating a condition of their parole or probation are ineligible for TANF, food stamps, Supplemental Security Income, and public housing.

States may test welfare recipients for drug use and sanction them for positive results without prior federal approval.

Women on welfare with drug and alcohol problems, like other Americans with these problems, will not be able to rise to the challenge of becoming self-sufficient without first receiving appropriate treatment for their addiction. Likewise, many children of welfare recipients who have alcohol and drug problems will not be able to avoid the cycle of welfare dependency without prevention services as early as possible.

Scientific evidence and clinical experience demonstrate that alcohol and drug treatment and prevention are effective. Treatment and prevention programs have been shown to reduce and avert use of alcohol and drugs, lower health care costs, substantially reduce the risk of HIV infection, increase employment, and reduce crime. The effects of treatment on reduced use of health care services have been shown to continue for many years after treatment.

Recommendations

1. States should reject universal drug testing as a method of identifying welfare recipients with alcohol and drug problems. If drug testing is implemented, states should adopt written protocols that prevent costly errors on the part of state welfare agencies and protect the due process rights of recipients.

2. States should train caseworkers to appropriately refer clients with substance abuse problems for treatment and to determine the eligibility of those with co-occurring mental and physical disabilities for SSI.

3. States should provide treatment to welfare recipients whose addiction prevents them from working and encourage their participation in treatment by not counting time spent in treatment toward their time limit on TANF. States should make every effort to increase the availability of treatment especially for women with children.

4. Participation in drug or alcohol treatment is a common condition placed on parolees and probationers; therefore states should define this term narrowly so they do not reduce treatment funding and access for individuals mandated into treatment by the criminal justice system.

Health Insurance Is Critical

As one might expect, women and children without medical insurance are less likely to receive medical care.

In 1993, 15 percent of all women aged 25 to 64 years had no health care coverage. Poor women were over 3 times as likely to be uninsured as nonpoor women (36 percent and 11 percent) (National Center for Health Statistics, 1995). Other studies looking at managed care and the public/private service delivery infrastructure within minority communities note that the system is undercapitalized and ill-equipped for the welfare transitions occurring in these communities (Lillie-Blanton et al., 1996). This has many ramifications, for example, lack of prenatal care and lower immunization rates among children (Baily, 1991). Infants born to uninsured mothers who had no prenatal care are more likely to have low birth weights, resulting in higher infant mortality rates and increased risk for birth defects, mental retardation, seizure disorders, and cerebral palsy (Oberg, 1990). A study by the Commonwealth Fund's Commission on Women's Health found that for many women the lack of a usual source of care reduced access to screenings such as Pap tests, clinical breast exams, and mammograms. The lowest screening rates for cervical cancer are found among low-income and less educated women, women who are not covered by insurance for preventive care, and women who do not have a regular source of care and are less likely to have an annual checkup. The low screening rates are even more pronounced for breast cancer. This is especially alarming when examining the rank of causes of death for women. In 1993, cancer was the number two killer of all populations of women, except Asian women in which it was the number one.

Managed care brings risks as well as benefits to poor women.

The majority of Americans are enrolled in managed care organizations (MCOs), and enrollment continues to grow. According to the Health Care Financing Administration (HCFA), 40 percent of Medicaid beneficiaries and nearly 14 percent of Medicare beneficiaries were enrolled in managed care organizations by mid-1996 (U.S. Department of Health and Human Services, 1997). Managed care has both opportunities and risks for women living in poverty. By providing preventive and screening services, managed care can remove some of the financial barriers to health care services that exist in a fee-for-service system.

However, there are problems. According to the Center for Reproductive Law and Policy's (1996) case study in reproductive health services and managed care, Medicaid managed care differs in several important ways from commercial managed care, where enrollees tend to be better educated, more self-sufficient, and able to afford needed care elsewhere if it is not available from the plan. Medicaid-eligible individuals often face persistent sociocultural barriers and other significant obstacles that undermine their ability to obtain timely care. Preventive services, in particular, tend to be pushed aside by (1) the demands of raising children; (2) lack of information about and support for early preventive care; (3) lack of provider capacity; (4) long waits for appointments; and (5) transportation, geographic, language, and other barriers.

Primary care providers are in short supply and are hard to recruit and retain in the inner cities and rural areas where Medicaid populations are concentrated. Medicaid eligibility often involves rapid turnover based on changes in income and employment or pregnancy-a pattern that disrupts continuity, makes quality of care difficult to assess, and may act as a disincentive for managed care plans to invest in upfront preventive and primary care services because they will very likely not see the direct benefits.

As a purchaser for Medicaid managed care, the state is vulnerable to outside political and interest group pressure to restrict access to reproductive health services, as well as internal pressures to meet ambitious enrollment targets and control costs. In addition, Medicaid managed care enrollees do not have the benefit of an employer's leverage to influence their managed care plans to ensure access and quality of care.

Of utmost importance is the need for a system of general health care coverage in this country that is not determined by differences in income, gender, or employment. Without health care reform and greater equality in the opportunity to obtain health care coverage, current disparities will persist. A critical part of equitable health care reform must be mental health parity.

Recommendations

These recommendations draw substantially from Hustead (1997).

1. States should ensure that managed care plans have mental health parity, that is, mental health insurance coverage equal to the coverage of other physical illnesses.

2. States should maintain and expand health care coverage to include all uninsured women and children and use income and resource methodologies that are less restrictive than those used under current state welfare plans for determining Medicaid eligibility.

3. States should maintain existing eligibility for state-funded medical programs, including those that serve legal and undocumented immigrants.

4. States should ensure that managed care plans provide access to a broad range of health services and a choice of providers that meet the particular health needs of women throughout the life cycle.

5. States should include in programs a structured quality assurance system to monitor, measure, and report on underutilization and overutilization of services.

6. States should ensure that managed care programs allow exceptions to any prescription drug formulary when the treating professional concludes that a particular combination of drugs is medically necessary or appropriate for the patient.

7. States need to guarantee confidentiality, which is particularly important to women seeking sensitive services, such as reproductive health and mental health.

8. States' managed care plans should require full, accurate, meaningful, and readable disclosure of benefits, exclusions, and cost-sharing arrangements, as well as plan structures and processes.

9. States' managed care plans should have in place a grievance and appeal procedure that is timely and responsive and that provides basic due process guarantees.

Successful Programs Are Mission Driven Yet Flexible

We all have common universal needs, but quite different individual circumstances. Effective programs recognize that interventions cannot be routinized or applied uniformly, and their interventions are adapted based on the client's personal circumstances (Schorr & Schorr, 1988). Some individuals may need to leave an abusive relationship to participate fully in an employment program. Others may need access to child care during evening hours or reliable transportation. Still others may need a combination of services. Successful programs recognize this and respond in kind.

However, successful programs also balance their flexibility with a mission statement of more general purpose. No single program can meet all the needs of all welfare recipients. An appropriate mission statement helps a program set a broad definition of its goals and the outside limits of what services it can provide. The mission statement serves as a stable core, and interventions are designed around it. Therefore, the program remains flexible and is capable of adapting to external changes to better attain its goals (Golden, 1992; Mueller & Patton, 1995).

Successful Programs Are Also Community Focused and Involve Collaboration

Because each individual program cannot meet all the needs of all its participants, successful programs have also incorporated some type of collaborative component and find mechanisms to circumvent professional and bureaucratic boundaries. In these programs, no one tells a client that "this may be what you need, but helping you get it is "outside our jurisdiction" or "not part of my job" (Schorr & Schorr, 1988).

Traditionally, most communities have a number of human service agencies that operate independently of each other. Often they are unaware of what the other is doing, they compete for resources, and, at times, they may even provide overlapping and redundant services. The result is a system of fragmented services, with each meeting only a part of a low-income family's needs. This fragmentation presents insurmountable barriers for clients with multiple needs (Edelman & Radlin, 1991). Effective programs have developed the ability to cross agency boundaries to help clients. Moreover, they use a variety of collaborative or case management methods to accomplish this, and they do more than just hand out referrals. Constructive efforts require contacts between agency personnel and an adaptation of services to community needs (Golden, 1992; Schorr & Both, 1991). For example, an appropriate job training program would develop contacts with local businesses to provide jobs for its clients. It might also provide or have collaborative relationships with counseling services, health services, and housing based on the needs of its clients.

Successful Programs View Their Clients as Individuals Who Are Part of a Larger Social Context

The recognition of the interdependence of family members, the importance of support from both family and the community, and a recognition of the powerful influences of environmental factors such as poverty, violence, current economic conditions, and job availability is essential for appropriate service delivery (Kagan & Shelley, 1987). Successful programs integrate this view of interdependence into their service efforts. They support families and help them support each other. They also provide opportunities for peer support (Kagan & Shelley, 1987; Pavetti, Olson, Pindus, & Pernas, 1996). Moreover, caseworkers in such programs recognize and appreciate the effects of the larger social context on their clients. Often, welfare recipients are unfairly labeled "unmotivated" when in actuality the complexities and stresses of their environments create serious barriers to participation in a workfare program. Nonparticipation simply may be a sign that other problems exist (Schorr & Schorr, 1988; Pavetti et al., 1996). In successful programs, service providers do not just assume that a client is unmotivated. They look at the entirety of a client's situation.

Successful Programs Allow Their Staffs to Establish Trusting, Personal Relationships With Clients and Maintain Appropriate Boundaries

The development of a trusting, personal relationship between client and caseworker is the essential ingredient for successful programs (Golden, 1992; Mueller & Patton, 1995; Pavetti et al., 1996; Schorr & Schorr, 1988). This connection helps to overcome many obstacles, such as isolation, hopelessness, and suspicion. For most welfare recipients, the programs developed from the new welfare reforms will not be the first programs in which they have participated. More than likely, they have developed a healthy suspicion of social service programs and their employees. Moreover, those most in need are also most likely to be socially isolated and mistrustful of professionals. It is difficult to reach such individuals and families (Golden, 1992). However, when a family begins to trust the human service professional, they are also likely to acknowledge that they have needs and to avail themselves of the services offered. In a qualitative investigation of low-income African American single mothers, the women defined helpful programs not by the services they received, but by the genuineness of the personal contact they had with professionals (McDonald & McKinney, 1996).

Good employee relations in the agency are also important for program success (Golden, 1992; Mueller & Patton, 1995; Pavetti et al., 1996; Schorr & Schorr, 1988). Paying attention to hiring issues and continued support of staff is crucial. How employees are treated affects how they treat those that they serve (Mueller & Patton, 1995). Professional staff cannot develop personal relationships with clients or create collaborative and flexible programs in rigid and bureaucratic environments. Successful programs encourage their staffs to take risks and to be creative. Thus, continued support, respect, and training of employees are needed for programs to work effectively (Pavetti et al., 1996). Effective programs also help their employees set healthy boundaries. Working with multiproblem families is stressful, and developing methods of avoiding professional burnout is important.

Successful Programs Are Well Managed and Funded

Programs that are flexible and collaborative and that empower employees and clients need appropriate management. Managers in such programs adhere to general mission statements, but also provide flexibility in day-to-day operations. They allow the program to evolve and remain responsive to client needs. This task involves an ability to take risks, to tolerate ambiguity, and to gain the trust of workers, funding sources, and the community (Schorr & Both, 1991). Research on successful managers finds that they also know how to exchange information and are open to continued learning. Moreover, they support high quality staff through supervision, training, appropriate caseload sizes, and consultation (Mueller & Patton, 1995).

Although successful programs are creative in their ability to gather necessary funds, long-term success means we must do more than rely on the ingenuity of good people who provide these direct services. The importance of adequate funding cannot be ignored. Often current methods of funding do not match the needs of programs that serve low-income families. Flexible programs also need flexible funding that allows for changes and the individualization of services. Moreover, funding sources need to fund long-term programs, replications of successful programs, and existing successful programs. The development of strong programs takes time, and the need to continually compete for funding and to develop new and innovative programs strains an agency's capabilities. For example, the McKnight Foundation advocates that funding last at least 5 years, and preferably longer. In addition, workers in effective programs have been found to have lower caseloads, which allows them to establish personal and individualized services. Finally, funding needs to be available for program evaluation (Mueller & Patton, 1995).

Current welfare reform will fail to improve the lot of poor women because it ignores the enormous impact of gender and race discrimination and the gender wage gap in the workforce, the effects of domestic violence and sexual abuse on a woman's ability to function and to work, the almost universal lack of education and training opportunities beyond those geared to traditional, low-wage women's work, the critical need for family-friendly work and benefits, the need for high-quality, universally based child care, and the impact of health on a woman's ability to work.

Nonetheless, helping a great majority of poor women, children, and families raise themselves out of poverty is within our reach. The failure of programs and the enormity of the problems makes one despairing of change. However, careful review of hundreds of successful community interventions reveals that although underfunded, expedient, shallow programs almost always fail, intensive, creative, highly flexible, well-funded programs led by energetic visionaries succeed beyond anyone's dreams (Schorr & Schorr, 1988). For example, many community-based housing programs, often without federal assistance, such as Habitat for Humanity, combine volunteers, private funding, and work by residents to build and rehabilitate housing. A brief survey of some of these programs shows successful approaches that combine social services with housing programs. Solutions to poverty and homelessness will not be easy. They will have to be creative, thoughtful, and well planned. But the alternative, attributing blame to the poor and abdicating significant meaningful assistance, is simply unacceptable in a society that calls itself progressive and just. Unfortunately, because of policymakers' unwillingness to significantly fund these programs, because of their reluctance to commit to a long-term human capital approach, and because individually we all consciously and unconsciously distance ourselves from "the poor" and are unwilling to see them as us, the poor remain the poor-separate, apart, the other.

On the other hand, we know that real long-term success is possible. We know this is more than theoretical-there are programs out there that have worked and that are working now. We know enough about what people need and about what kinds of approaches and procedures work best to design and implement programs that (1) will successfully move people off welfare and into the workplace, (2) will help them stay there, and (3) will use the available dollars effectively and efficiently rather than wastefully. We hope the information in this report helps policymakers sort through the myriad options before them and settle on the kinds of programs that will achieve long-term success.

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