[Social exclusion and health inequity: a case study based on a cash distribution program (Bolsa Família) in Brazil]. / Processos de exclusão social e iniquidades em saúde: um estudo de caso a partir do Programa Bolsa Família, Brasil.

OBJECTIVE: To understand the impact of Bolsa Família (PBF), a federal cash transfer program, and to analyze its effects on social inclusion and exclusion processes experienced by low-income families in Brazil, with a focus on the program's potential to help overcome health inequity. METHODS: This qualitative investigation used a case study methodology including observant participation, review of documents, and semi-structured interviews with current and former PBF beneficiaries, as well as with the program's local managers. The study was conducted in a small city in the state of Rio de Janeiro with a high social exclusion index and 100% coverage by the Family Health Strategy (Estratégia Saúde da Família, ESF) program. The economic, political, social, and cultural dimensions of social exclusion and inclusion processes were used to guide data collection and analysis. RESULTS: The program facilitated social inclusion of low-income families, especially in the economic and social dimensions. Nevertheless, it did not produce the changes desired by the beneficiaries in the work dimension. The effects on the political dimension were limited by the insufficient social engagement of the PBF. The interviewees underscored the positive effects of the ESF, which allowed them to exercise their right to health by granting them wider access to primary health care services. However, these effects appeared to be unrelated to the PBF. CONCLUSIONS: The results reveal effects, limitations, and challenges of the PBF towards modifying the social determinants of health inequity, in order to promote more effective changes in the social exclusion/inclusion dynamics affecting low-income families.

Welfare reform, time limits, and infant health.

This paper offers evidence that welfare time limits contributed to a deterioration of infant health. We use the fact that the dates at which TANF recipients were first subject to timing out varied by state. We show that by 2000 there was a marked difference in TANF duration spells depending on whether the state employed the 60-month Federally imposed time limit, or a shorter limit, differences that were not present under AFDC. There were significant increases in infant mortality when time limits became binding in a state. These increases occurred primarily among mothers who could have plausibly timed-out of TANF: poorly educated and unmarried women with at least one previous live-birth. There is some evidence that the population of mothers affected by time limits were less likely to seek prenatal care in the first trimester, suggesting a possible role for reduced medical care in explaining the deterioration in infant health.

SCHIP. Does this model for covering kids have legs?

The popular federal-state insurance program for kids is caught between legislators who want to expand its scope and others who want to rein it in.

SCHIP expansion and parental coverage: an evaluation of Wisconsin's BadgerCare.

The Wisconsin BadgerCare program, which became operational in July 1999, expanded public health insurance eligibility to both parents and children in families with incomes below 185% of the U.S. poverty line (200% for those already enrolled). This eligibility expansion was part of a federal initiative known as the State Children's Health Insurance Program (SCHIP). Wisconsin was one of only four states that initially expanded coverage to parents of eligible children. In this paper, we attempt to answer the following question: To what extent does a public program with the characteristics of Wisconsin's BadgerCare program reduce the proportion of the low-income adult population without health care coverage? Using a coordinated set of administrative databases, we track three cohorts of mother-only families: those who were receiving cash assistance under the Wisconsin AFDC and TANF programs in September 1995, 1997, and 1999, and who subsequently left welfare. We follow these 19,201 "welfare leaver" families on a quarterly basis for up to 25 quarters, from 2 years before they left welfare through the end of 2001, making it possible to use the labor market information and welfare history of the women in analyzing outcomes. We apply multiple methods to address the policy evaluation question, including probit, random effects, and two difference-in-difference strategies, and compare the results across methods. All of our estimates indicate that BadgerCare substantially increased public health care coverage for mother-only families leaving welfare. Our best estimate is that BadgerCare increased the public health care coverage of all adult leavers by about 17-25% points.

Role of SCHIP in serving children with special health care needs.

The purpose of this article is to provide new information about two policy issues: (1) Is the State Children's Health Insurance Program (SCHIP) an important source of health insurance for children with special health care needs (CSHCN)? and (2) Does SCHIP provide CSHCN with better access to care, compared with other insurance coverage? Using the 2001 National Survey of CSHCN, we found that a limited fraction of CSHCN were eligible for SCHIP while a relatively small proportion of SCHIP-eligible CSHCN were uninsured. Access to care for CSHCN under SCHIP was better than those SCHIP-eligible but uninsured, and similar to those income-eligible for SCHIP but privately insured.

The children's hour: the State Children's Health Insurance Program.

The State Children's Health Insurance Program (CHIP) is the product of a series of policy and political compromises and generates numerous structural and policy issues for states. CHIP entitles states to federal financial aid to provide health assistance to targeted children, through Medicaid expansions, new program implementation, or a product of the two. States that elect to operate CHIP programs apart from Medicaid have enormous discretion under the law to determine how they will structure their programs, the services they will cover, the form that benefits will take, and the conditions of participation and consumer protections that will apply. Determining what approach to take, as well as how to respond to the choices posed by the statute, represents a major test of how states address the needs of children and families.

Effects of Medicaid managed care programs on health services access and use.

OBJECTIVE: To estimate the effects of Medicaid managed care (MMC) programs on Medicaid enrollees' access to and use of health care services at the national level. DATA SOURCES/STUDY SETTING: 1991-1995 National Health Interview Surveys (NHIS) and a 1998 Urban Institute survey on state Medicaid managed care programs. STUDY DESIGN: Using multivariate regression models, we estimated the effect of living in a county with an MMC program on several access and use measures for nonelderly women who receive Medicaid through AFDC and child Medicaid recipients. We focus on mandatory programs and estimate separate effects for primary care case management (PCCM) programs, health maintenance organization (HMO) programs, and mixed PCCM/HMO programs, relative to fee-for-service (FFS) Medicaid. We control for individual and county characteristics, and state and year effects. DATA COLLECTION/EXTRACTION METHOD: This study uses pooled individual-level data from up to five years of the NHIS (1991-1995), linked to information on Medicaid managed care characteristics at the county level from the 1998 MMC survey. PRINCIPAL FINDINGS: We find virtually no effects of mandatory PCCM programs. For women, mandatory HMO programs reduce some types of non-emergency room (ER) use, and increase reported unmet need for medical care. The PCCM/HMO programs increase access, but had no effects on use. For children, mandatory HMO programs reduce ER visits, and increase the use of specialists. The PCCM/HMO programs reduce ER visits, while increasing other types of use and access. CONCLUSIONS: Mandatory PCCM/HMO programs improved access and utilization relative to traditional FFS Medicaid, primarily for children. Mandatory HMO programs caused some access problems for women.

Medicaid mysteries: transitional benefits, Medicaid coverage, and welfare exits.

The links between Medicaid and welfare exits are examined using longitudinal Medicaid program data. Few people who leave welfare get any sort of ongoing or transitional Medicaid protection. Moreover, it appears that many who are eligible for transitional benefits are not getting them. Finally, people with high expected medical costs appear to be less likely to leave welfare. The loss of Medicaid associated with leaving welfare probably does have an important deterrent effect on welfare exists.

Fashioning a work-based strategy for welfare reform based on international human rights doctrine.

The role of work in debates over welfare reform in the United States is analyzed. Five issues are identified and discussed under this heading, with special emphasis on the question of whether enough jobs exist to make it possible for all able-bodied welfare recipients to find paid employment in the regular labor market. It is argued that there are not enough jobs available--not even low-wage jobs--to make this a reasonable goal, and that neither conservatives nor liberals have faced up to the dilemma posed by this job shortage. International human rights doctrine concerning the availability of work at decent wages is cited in support of the proposition that the government should be held accountable for filling this job gap, not only for welfare recipients but for all other job-seekers as well. The costs of a hypothetical jobs program capable of achieving this goal are assessed, with the surprising result that it might actually save the public money. It is suggested that such a program could constitute an effective alternative to current welfare reform proposals.

Medicaid recipients' experiences under mandatory managed care.

OBJECTIVE: To describe Medicaid recipients' experiences with the outcomes of access, quality, and satisfaction in a mandatory managed care (MC) program. STUDY DESIGN: A qualitative case study design with content analysis of narrative focus group (FG) data, which was part of a comprehensive program evaluation that also involved pre- and postsurveys and analyses of cost and utilization data. PATIENTS AND METHODS: Six FG interviews were conducted in the autumn of 1997 with 31 women on the Aid to Families with Dependent Children program. Participants were recruited from a randomly ordered list of women who had responded to a 1996 premanaged care survey regarding their or their child's healthcare experiences under traditional Medicaid. RESULTS: There was general consensus across all focus groups on a range of issues, including improvements in access to primary care and continuity of care. Overall, few participants expressed discontent with restriction of choice of provider and on MC policies regarding use of the emergency room. There was no consensus on what factors influenced choice of MC plan, although convenience of location was named most frequently. An unanticipated outcome was the recurrent theme across all focus groups of disrespectful treatment by healthcare personnel, especially under traditional Medicaid, which had declined somewhat under managed care. CONCLUSIONS: These contextual accounts identify specific features of a mandatory Medicaid MC program that are viewed as improvements over traditional Medicaid. Specific features that were dissatisfying can be addressed to improve both enrollee satisfaction and the transition to managed care for Medicaid recipients.

Mandated managed care for blind and disabled Medicaid beneficiaries in a county-organized health system: implementation challenges and access issues.

OBJECTIVES: The challenges of Medicaid managed care organizations that serve blind and disabled members are reviewed. Beneficiary satisfaction and access to care are assessed, and access problems are identified and resolved or minimized to the greatest degree possible. STUDY DESIGN: Formative evaluation consisting of a mailed survey and follow-up telephone outreach contacts. PATIENTS AND METHODS: A written survey was sent to more than 18,000 Supplemental Security Income (SSI) beneficiary members who were blind or disabled, with 5574 recipients responding. Of these, 1981 members identified issues that warranted 2106 follow-up telephone calls. RESULTS: Survey responses showed that beneficiaries had limited experience with managed care and were generally satisfied with access to primary care. The healthcare system used the study findings to develop focused training programs and materials, to initiate a special needs liaison program, and to revise guidelines to simplify and standardize authorization procedures for obtaining medical supplies and repairing equipment. CONCLUSIONS: Factors found to be associated with the success of a Medicaid managed care program serving blind and disabled beneficiaries include educating the members and providers for better understanding of managed care, incorporating collaborative service improvement activities, and documenting trends.

Pregnant women eligible under Medicaid expansion of maternity services. Implications for outreach.

Recent reforms in federal legislation have made Medicaid-financed prenatal care available to pregnant women from households at nearly twice the poverty level. Census and birth certificate data provide little information about the newly eligible group beyond estimates of their size. This article reports on efforts to compare the Medicaid expansion group to traditional Medicaid prenatal care patients in terms of demographics, access problems, and prenatal care adequacy by employing a short-term, hospital-based survey of postpartum women in Michigan. Differences between pregnant women eligible under the expansions and traditionally eligible pregnant women suggested that major changes in outreach and enrollment activities of state Medicaid agencies may be necessary to fulfill the opportunity represented by the Medicaid expansions.

The impact of local welfare offices on children's enrollment in Medicaid and SCHIP.

Nearly 20% of children entering Kansas' State Children's Health Insurance Program (SCHIP) and more than 25% of children entering the state's Medicaid program leave public health insurance altogether before completing a full year of coverage, when the first redetermination of eligibility should occur. Analyses of administrative data indicate that high rates of premature disenrollment are strongly associated with case management practices at local social services offices. However, local offices enroll the vast majority of children into public health insurance. To avoid a potential trade-off between local offices' impact on enrollment and retention, the study suggests that states such as Kansas consider improvements in automation to support caseworkers' difficult jobs.

Medicaid managed care and the emergency department: the first one hundred days.

Spurred by concerns over increasing costs and variable quality, public and private third-party payors are moving their subscribers into managed care plans. A central feature of many of these plans is coordination of patient care through a primary care provider (PCP). In exchange for easy access to the PCP, patients are expected to limit their use of emergency services for episodic, primary, and urgent care problems. The State of Connecticut has begun a transition from a fee-for-service Medicaid plan into a managed care product. Because many Medicaid patients had freely used emergency services under the fee-for-service arrangement, urban teaching hospital emergency departments rapidly became a focus of efforts to control cost and change care-seeking behavior. The Hartford Hospital Emergency Department (ED) began screening, education, and referral of managed Medicaid patients in the fall of 1995 and recorded experiences with patients, administrators, and health care providers involved in the implementation of the managed care program. The first 3 mo following plan implementation were chaotic and frustrating for all parties, with many difficulties due to an unprepared infrastructure. Changes in ED operations and maturation of the payor and health care provider network eventually resulted in a reasonably smooth system accompanied by reductions in ED visit volumes of at least 15%. Continual evolution of role and goals will be necessary if EDs are to maintain an active presence in a health care system dominated by managed care plans.

Changing work ethic and welfare dependence through welfare reform. The 100-hour rule waiver experiment for AFDC-U.

Assumptions about welfare dependency and work are examined in a randomized experiment that tested the impact of the 100-hour rule waiver for two-parent welfare families: Aid to Families with Dependent Children-Unemployed (AFDC-U). The 100-hour rule was waived for the experiment group, allowing the primary wage earners in these families to work more than 100 hours a month without losing welfare eligibility. The analysis uses county administrative data, unemployment insurance records, and Medicaid data, and compares regression adjusted least squares means for the control and experiment group. The results from the impact analysis indicate that waiving the 100-hour rule has no effect on primary wage earners' work activity and earnings. The 100-hour rule waiver also has little effect on time on aid and AFDC-U payments, and does not have an effect in reducing marital dissolution. The results cast doubts about the validity of the assumptions underlying some of the recent welfare reform initiatives.

A nursing critique of US welfare system reform.

In 1996, the Aid to Families with Dependent Children program was repealed, and the welfare system in the United States was changed. This article critiques, from a nursing perspective, US welfare system reform. It interrogates dominant ideologies about poverty, welfare, and waged labor; examines federal welfare reform legislation of the 1990s and its programmatic implementation at the state level; discusses global health and safety implications of welfare replacement initiatives; and challenges nurses to political and scholarly action.

Need determination in AFDC program.

This study summarizes the State policy with respect to the determination of need in the Federal-State program of AFDC. The areas discussed are the individual State definitions of need, the content of need standard, the types of persons included in the payment, the amount of income and resources allowed recipient families, the method of determining need, and a comparison of State food allowances with the Department of Agriculture cost figures. The cumulative effect of these policies on payments is also explored. The information in the report is based on data assembled for the biennial report of program plan characteristics early in 1978.

Deficit Reduction Act of 1984: provisions related to the AFDC program.

This article summarizes the provisions of the Deficit Reduction Act of 1984 that relate to the Aid to Families with Dependent Children (AFDC) program. Among other changes, the new legislation identifies certain individuals living in the same household with the dependent child who must file for assistance and have their income and resources considered in determining the child's eligibility for an AFDC payment. The new law requires that the States disregard, in determining AFDC eligibility and payment amounts, the first +50 per month of the current monthly support obligation of any child support collected on the family's behalf or received directly by the family. It also extends the +30 earned income disregard for an additional 8 months and exempts from countable resources burial plots, funeral agreements, and (for a limited period) real property that the family is making a good faith effort to sell. The legislation also broadens the types of work programs that the States may require AFDC recipients to participate in by allowing States to use AFDC payments to subsidize certain public and private sector employment. The new law also includes a provision based on a Grace Commission recommendation that requires the States to establish an income and eligibility verification system for certain Federal and federally assisted programs.

Transitions from AFDC to SSI before welfare reform.

The Supplemental Security Income (SSI) and Aid to Families with Dependent Children (AFDC) programs serve populations with similar characteristics. SSI serves adults and children with disabilities who are in low-income families, and AFDC serves low-income families with children. Because of that overlap, policy changes in one program can affect the other. In 1996, Congress enacted the Personal Responsibility and Work Opportunity Reconciliation Act, which transformed AFDC into the Temporary Assistance for Needy Families (TANF) program. Many people have expected that implementing that welfare reform legislation would eventually increase SSI participation, for two reasons. First, TANF includes new work requirements and time limits that induce more AFDC/TANF recipients with disabilities to obtain SSI benefits. Second, the change in the funding mechanism--from open-ended funding on a matching basis for AFDC to cash assistance block grants for TANF--gives states a stronger incentive to shift welfare recipients to SSI. This article examines the interaction between the SSI and AFDC programs in the prereform period (1990 to 1996) and discusses the potential implications of welfare reform on that interaction. Using matched data from the Survey of Income and Program Participation and Social Security Administration (SSA) records, our analysis focuses on how the interaction of those programs affects young women (aged 18 to 40) and children (aged 0 to 17). We find a very strong link between AFDC and SSI for young women and children. Significant portions of young female and child SSI beneficiaries in the 1990-1993 period were in AFDC families or had received AFDC in the past. In addition, a substantial share of young women and children who received AFDC during that period eventually entered SSI. Because the SSI program is now serving a much larger population of families with young women and children than in the past, SSA might need to develop policies to better serve that group. The findings also suggest that the prereform period is a poor baseline against which to measure the impact of TANF, primarily because of the instability in programs and policies.