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Making 'Welfare to Work' Really Work
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Health Care
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
- All health clinicians need training to increase awareness of abuse and assault and their link with physical and mental health consequences.
- States should encourage and develop partnerships among health and mental health professionals to coordinate comprehensive responses.
- States should make children's mental health a priority by increasing funding to school-based programs and programs that provide early intervention.
- The U.S. Department of Agriculture should support food banks.
- States should compensate for the reductions in federal subsidies of nutrition programs for children and the elderly.
- Federal legislation should expand the Women, Infants, and Children (WIC) program for women and children who have reduced food stamp benefits.
- States should fully fund comprehensive programs to prevent teenage pregnancies (school-based clinics, mental health, dropout prevention).
- 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
- 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.
- 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.
- 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.
- 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).
- 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.
- 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.
- States should maintain existing eligibility for state-funded medical programs, including those that serve legal and undocumented immigrants.
- 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.
- States should include in programs a structured quality assurance system to monitor, measure, and report on underutilization and overutilization of
services.
- 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.
- States need to guarantee confidentiality, which is particularly important to women seeking sensitive services, such as reproductive health and mental
health.
- 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.
- 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.
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