Welfare reform in the United States

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7064.1028 (Published 26 October 1996) Cite this as: BMJ 1996;313:1028
  1. Sarah Purdy, Visiting fellow
  1. Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, MA 02215, USA

    Will have important impacts on the nation's health

    The relation between economic status and health is well known, although the exact factors of the equation are less certain.1 Recent work from the United States2 3 confirms British research suggesting that not only is low income associated with higher mortality and ill health but that the wider the range of income in a population the greater the impact on mortality.

    US president Bill Clinton has signed a bill that will bring huge changes to the federal welfare system in the United States.4 The bill fundamentally changes the organisational framework of the delivery of welfare services. Federal welfare programmes will cease to exist, and savings will be allocated to individual states. Each state will then have the authority to determine who is entitled to benefits and what those benefits are.

    However, the bill does not stop at reorganising the system. The current open ended entitlement to benefits will be replaced by limits to the time over which benefits will be paid and stricter eligibility criteria. For example, provisions in the bill include limiting lifetime welfare benefits to a five year maximum, restricting poor children's eligibility for financial aid, limiting free food vouchers for childless adults who are not working to three months in any three year period, requiring able bodied adults to return to work after two years of receiving welfare, and denying government health insurance (Medicaid) to an adult who loses welfare benefits for not meeting work requirements. The penalties seem to be even harsher for those who are struggling most in society: cash aid and food stamps are to be denied to anyone convicted of felony drug charges, although pregnant women and those in drug treatment will be exempted.5

    Political considerations aside, this legislation is a very alarming development in a country that has over 250 000 low birthweight babies born a year, where 20–30% of 2 year old children have not been adequately immunised, and 16% of low income children aged under 5 are growth retarded.6 These figures are a small example of huge underlying national problems in public health outlined in Healthy People 2000, the national health promotion and disease prevention objectives for the year 2000.6 This highlights people with low income as a group with pressing health problems and needs.

    In 1991 the United States spent 13.2% of its gross domestic product on health care, a figure that is considerably larger than in other developed nations.7 In the same year the prevalence of poverty among black and white people aged 25–84 was 10.3%.8 This figure had risen from 9.2% in 1973. Despite having the highest per capita health spending of all countries in the Organisation for Economic Cooperation and Development (OECD), in 1990 the United States had the fourth highest infant mortality of the 24 countries. This figure almost certainly reflects underlying social problems in addition to the country's lack of universal health care.

    The poor are eligible for Medicaid, but eligibility varies from state to state and often a revolving door situation develops—a family has insurance for a short time but then loses eligibility until a further crisis occurs. Those in poorly paid and part time jobs do not normally receive employment related healthcare benefits, yet they are not eligible for Medicaid. The welfare bill has one provision that potentially improves this situation: Medicaid will be continued for one year for those people who leave welfare to go to work.

    Problems such as poor maternal and child health and high rates of drug abuse, road traffic accidents, and gunshot wounds cannot be attributed to the lack of universal health care. These are problems that result from poverty, poor housing and environmental conditions, and lack of opportunity. Welfare benefits are not a panacea for any of these problems. Proponents of this bill argue that it will provide incentives for greater personal responsibility and motivate people to return to work. President Clinton hailed the legislation as a “historic opportunity to make welfare what it was supposed to be, a second chance, not a way of life.”9

    This abrupt end to welfare benefits removes the safety net-for those most in need. The withdrawal of these entitlements adds a further burden to a population that is already underserved in terms of health care. There is a real risk that the gap between rich and poor in the United States will widen even further. The objectives stated in Healthy People 2000, which have less than four years to be realised, now seem to be dreams rather than achievable goals.


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