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© 2002 American Public Health Association
RESEARCH AND PRACTICE |
The authors are with the Department of Pediatrics, Boston University of Medicine, Boston, Mass.
Correspondence: Requests for reprints should be sent to Lauren A. Smith, MD, MPH, Boston Medical Center, Department of Pediatrics, Dowling 3 South, One Boston Medical Center Pl, Boston, MA 02118 (e-mail: lauren.smith{at}bmc.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. This study examined the knowledge of and application for health-related welfare program provisions among beneficiaries with children who have chronic conditions.
Methods. We administered a survey to 143 parents of children aged 3 to 16 years with asthma or sickle cell anemia in 2 clinical settings.
Results. Respondents indicated incomplete knowledge of work requirements (69.9%) and work exemptions (50.3%). Applications for work exemptions were rare, even among Supplemental Security Income recipients (30%).
Conclusions. Welfare beneficiaries with children who have chronic conditions show limited knowledge and use of program provisions, placing them at risk for penalties or benefit termination.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The 1996 welfare reform legislation significantly changed welfare policy in the United States by eliminating entitlements to cash benefits and instituting work requirements, a 5-year lifetime limit for benefits, and benefit reductions or terminations for noncompliance with program rules.1 Parents of children with chronic conditions could be expected to experience difficulties complying with the new requirements because their children's health needs may affect employment. Working parents receiving welfare are more likely than other poor parents to lack sick or vacation leave to care for a sick child.2,3 However, work exemptions and time limit extensions are available based on several criteria, including child illness or disability. We examined knowledge of and application for these welfare program provisions among parents of children with chronic conditions.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Data were collected from June 1998 through February 1999 from 143 English-speaking parents or primary caregivers who met the eligibility criteria of having children aged 3 to 16 years with asthma or sickle cell anemia. Trained interviewers approached each family, determined eligibility, and administered a structured survey containing original and previously validated questions.4 Enrollment sites included the primary care and specialty care clinics at 2 urban hospitals and the pediatric emergency department and pediatric inpatient unit at 1 of the hospitals. Welfare status was defined as "current" or "recent" on the basis of whether respondents were receiving Temporary Assistance for Needy Families benefits at enrollment or at any time in the prior 12 months. Other benefits, such as general assistance, were not defined as welfare. Families were given information about welfare program provisions and appropriate community and state agencies. Institutional review board approval was granted at both sites, and informed consent was obtained from all subjects.
The primary dependent variables were knowledge of work requirements, work exemptions, time limits, and time limit extensions and application for exemptions and extensions. Chi-square tests and multivariate analyses were performed to examine the association of demographic variables with knowledge of welfare program provision variables.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Most respondents were Black or Hispanic and were current recipients of welfare benefits (Table 1
). Thirty-eight percent had less than a high school education. Although nearly half of the respondents had received welfare benefits for less than 2 years (45%), more than a third (35%) had received benefits for more than 5 years. A fifth of the respondents received Supplemental Security Income for their child, and 15% received Supplemental Security Income benefits for themselves.
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Seventy percent of the respondents were aware of work requirements, and 50% were aware of work exemptions (Table 1
). Only 13% of all respondents overall and 26% of those aware of exemptions had applied for one. Thirty-eight percent of the respondents indicated that they had received information about work exemptions at their welfare offices. Although most respondents (94%) were aware of the existence of time limits, only 48% of the current recipients were aware of their own time limit. Only a small proportion (10%) of the current recipients had applied for a time limit extension. Of the 21% of the respondents who received Supplemental Security Income for their child (n = 30), 37% were unaware of work requirement exemptions. Seventy percent had not applied for an exemption, even though their child met strict federal disability standards.
Table 2 presents the results of a multiple logistic regression that examined the knowledge of and application for work requirement exemptions, while controlling for parental educational level, language, race/ethnicity, parental age, welfare status, length of welfare benefit receipt, and Supplemental Security Income benefit receipt. Supplemental Security Income receipt (odds ratio [OR] = 2.36; 95% confidence interval [CI] = 1.04, 5.38) was a predictive factor for knowledge of work exemptions and for applying for them (OR = 3.32; 95% CI = 1.09, 10.09). High school education (OR = 2.19; 95% CI = 0.97, 4.94) and English as a first language (OR = 3.41; 95% CI = 0.91, 12.74) tended to be predictors, although the association was not statistically significant. We used the same model to examine predictors of knowledge of time limits and application for time limit extensions and found that no associations achieved statistical significance.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Current and recent welfare recipients with children who have chronic conditions showed limited understanding of welfare program provisions, including work requirements, work exemptions, and time limit extensions. Although Supplemental Security Income recipients were more knowledgeable about health-related program provisions, they had limited application for these options. The demographic factors considered were inconsistently predictive of knowledge of and application for program options. Recipients who are unaware of program options face potentially avoidable benefit reductions or benefit terminations.
Although women leaving welfare often face substantial barriers to employment,5–7 recipients whose children have chronic conditions may face additional obstacles.3 Children's medical needs, including physician appointments and hospitalizations, may require absences from work. Health-related waivers, such as work exemptions and time limit extensions, could play an important role in preserving cash and safety net benefits for families of children with chronic conditions. One third to two thirds of the families leaving welfare also lose food stamp benefits, and approximately 25% lose Medicaid benefits for their children, even though they are often still eligible for both of these programs.8–12
Because this study included only English-speaking parents, the results may not be generalizable to non-English-speaking families. However, because limited English proficiency could be expected to affect understanding of welfare rules, our findings likely underestimate the knowledge deficits of such families. Patient enrollment in hospital settings could overestimate the severity of illness, limiting generalizability to all children with asthma or sickle cell anemia. However, because health-related waivers are available only for children with significant health needs, restricting our study to children with chronic conditions who are more likely to qualify for such waivers was appropriate.
In assessing welfare reform, local, state, and federal agencies should consider whether safety net mechanisms, such as health-related program options, transitional Medicaid, and food stamps, are available to those who need them. Health care providers serving families receiving welfare should consider how to increase patient awareness of available program provisions. The combined efforts of welfare agencies, public health officials, and health care providers will ensure that important safety net mechanisms are used to assist vulnerable families to transition off welfare when appropriate.
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Acknowledgments |
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This work was supported by funding from the National Institutes of Health, the National Institute of Allergy and Infectious Diseases, the Health Resources and Services Administration, the William T. Grant Foundation, the Barbara and Joel Alpert Endowment for the Children of the City, and the Peabody Foundation.
We wish to thank Christine Chen, Lindsey Dalrymple, Lindsey Davidson, Sameera Fazili, Lauren Garsten, Yvonne Ou, Colleen Pearson, and Tarsha Phillibert for their assistance with interviewing and data management. We also wish to thank William Adams, MD, Howard Bauchner, MD, John Cook, PhD, and Jennifer Kasper, MD, for their helpful comments and Michelle Villarta, MA, for her assistance in the preparation of the paper.
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Footnotes |
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Note. This work was approved by the institutional review boards at Boston Medical Center and Children's Hospital, Boston. All subjects consented to be interviewed.
L. A. Smith planned the study, analyzed the data, and wrote the paper. P. H. Wise contributed to the development of hypotheses, to the planning of the study, and to the preparation of the paper. N. S. Wampler contributed to the data analysis and the preparation of the paper.
Accepted for publication March 16, 2001.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Administration for Children and Families. Temporary Assistance for Needy Families Program (TANF); Final Rule, 64 Federal Register 69 (1999).
2. Parrott S. Welfare recipients who find jobs: what do we know about their employment and earnings? Available at: http://www.cbpp.org/11-16-98wel.htm. Accessed August 5, 1999.
3.
Heymann SJ, Earle A. The impact of welfare reform on parents' ability to care for their children's health. Am J Public Health.1999;89:502–505.
4. National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat 10. 1995;No. 193.
5. Pavetti L. How much more can welfare mothers work? Focus. 1999;20:16–19.
6. Danziger S, Corcoran M, Danziger S, et al. Barriers to work among welfare recipients. Focus. 1999;20:31–35.
7. Zedlewski SR. Work-Related Activities and Limitations of Current Welfare Recipients. Washington, DC: The Urban Institute; 1999.
8. Prendergast M, Nagle G, Goodro B. How Are They Doing? A Longitudinal Study of Households Leaving Welfare Under Massachusetts Reform. Boston: Massachusetts Dept of Transitional Assistance; 1999.
9. Loprest P. Families Who Left Welfare: Who Are They and How Are They Doing? Washington, DC: The Urban Institute; 1999.
10. Medicaid Enrollment: Amid Declines, State Efforts to Ensure Coverage After Welfare Reform Vary. Washington, DC: US General Accounting Office; 1999. GAO/HEH-99-163.
11. Ellwood M, Ku L. Welfare and immigration reforms: unintended side effects for Medicaid. Health Aff (Millwood).1998;17:137–151.[Abstract]
12. Tweedie J, Reichert D, O'Connor M. Tracking recipients after they leave welfare. Available at: http://www.ncsl.org/statefed/welfare/leavers.html. Accessed April 14, 2000.
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