Changes in Use of Health Insurance and Food Assistance Programs in Medically Underserved Communities in the Era of Welfare Reform: An Urban Study

Changes in Use of Health Insurance and Food Assistance Programs in Medically Underserved Communities in the Era of Welfare Reform: An Urban Study Susmita Pati, MD, MPH, Diana Romero, PhD, MA, and Wendy Chavkin, MD, MPH Passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ended standard entitlement and most regulatory oversight of traditional welfare mechanisms in the United States and separated cash assistance from food assistance and health insurance. 1 As part of the federal Balanced Budget Act of 1997, the State Child Health Insurance Plan was established to allow many low-income children to be eligible for health insurance even if their parents were not. 2 Although many people no longer eligible for cash assistance could have continued to receive food assistance and health insurance, various reports have documented declines in enrollment in all 3 programs. 3 11 Nationally, there have been reduced Food Stamp 5 and Medicaid 6 program enrollments, a rise in the uninsured population, 12 and inadequate enrollment in the State Child Health Insurance Plan. 13 The devolution of welfare responsibility to the states under the Personal Responsibility and Work Opportunity Reconciliation Act has resulted in more than 50 versions of welfare reform. Previous studies have documented declines in Medicaid and Food Stamp program enrollment at the state level. 6,14 16 However, it is important to learn how these policy changes have affected underserved populations at the local level. In New York City, the welfare caseload declined from 1.16 million in 1995 to less than half a million in 2001. 17 In 1998, a lawsuit filed by 7 poor New York City residents (Reynolds v Giuliani, 35 F Supp 2d 331 [SDNY 1999]) alleged that the city did not always provide Food Stamps and Medicaid benefits to eligible people who filed applications for cash assistance. 18 Our hypothesis was that welfare reform would be adversely associated with use of health insurance and food assistance programs among underserved populations. To Objectives. The purpose of this study was to assess changes in health insurance and food assistance enrollment following passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Methods. Extant data sources were used to calculate changes in Temporary Assistance for Needy Families (TANF), Medicaid, and Food Stamp program enrollment in medically underserved Manhattan communities after 1996. Results. Dramatic declines in TANF enrollment were accompanied by declines in Food Stamp program enrollment and a deceleration in Medicaid enrollment among several communities. Conclusions. As the Personal Responsibility and Work Opportunity Reconciliation Act comes up for reauthorization later in 2002, policymakers should revise legislation so that needy families do not lose health insurance or food assistance support. (Am J Public Health. 2002;92:1441 1445) test this hypothesis, we examined welfare, Medicaid, and Food Stamp program enrollment data from the 12 community districts in the New York City borough of Manhattan. METHODS Sociodemographic data were obtained from the US Bureau of the Census and the New York City Department of City Planning. Designations of medically underserved areas were obtained from the United States Centers for Medicare and Medicaid Services. 19 These designations are based on a scoring system ranging from 0 to 100 for specified geographic areas (e.g., census tracts, counties). Scores are weighted sums of 4 components: ratio of primary care physicians per 1000 population, infant mortality rate, percentage of the population with incomes below the federal poverty level, and percentage of the population aged 65 years or older. To qualify as medically underserved, an area must have a score of 62 or lower. Data on Temporary Assistance for Needy Families (TANF), Medicaid, and Food Stamp enrollment were obtained from the New York City Human Resources Administration. Data are reported for each of the 12 community districts in Manhattan. In the case of TANF and Medicaid, enrollment was reported as the number of individuals receiving benefits during the years 1994, 1996, 1998, and 2001. In the case of Food Stamps, enrollment was reported as the number of households receiving benefits in 1996, 1998, and 2001. Overall trends in enrollment before and after enactment of welfare reform are reported according to available data (TANF and Medicaid data were available only for 1994, 1996, 1998, and 2001; Food Stamp data were available only for 1996, 1998, and 2001). To better relate changes in enrollment to welfare policy changes, we also calculated percentage changes in enrollment (based on available data) in each community district for shorter time intervals (1994 1996, 1996 1998, and 1996 2001). RESULTS Three community districts in Manhattan (Table 1) have been designated medically underserved areas by the Centers for Medicare and Medicaid Services: Central Harlem, East Harlem, and Washington Heights/Inwood. 19 These districts have larger populations with greater proportions of children September 2002, Vol 92, No. 9 American Journal of Public Health Pati et al. Peer Reviewed Forum on Welfare Reform 1441

TABLE 1 Sociodemographic Characteristics of 12 Community Districts in Manhattan, 2000 Income, a Median Community District Population Children, % Adults, % Elderly, % Males, % (Poverty, %) White, % African American, % Hispanic, % Battery Park City, Tribeca 34 420 11.8 81.1 7.1 52.7 47 445 (21.8) 66.9 6.8 8.1 Greenwich Village, Soho 93119 8.2 80.1 11.7 49.8 39592 (23.5) 74.8 2.4 5.7 Lower East Side, Chinatown 164 407 17.1 69.5 13.4 49.3 20 007 (53.5) 28.2 7.1 26.9 Chelsea, Clinton 87 479 9.1 79.2 11.7 52.9 30 450 (30.9) 60.3 7.3 20.8 Midtown Business District 44 028 6.4 83.1 10.5 48.9 42 050 (23.9) 72.3 4.4 6.7 Stuyvesant Town, Turtle Bay 136 152 7.6 77.5 14.9 45.4 45 912 (14.5) 76.3 3.8 7.0 West Side, Upper West Side 207 699 13.5 73.4 13.1 47.0 40 852 (23.0) 66.3 9.0 16.7 Upper East Side 217 063 12.1 73.7 14.2 44.7 53 000 (12.0) 82.6 3.2 6.0 Manhattanville, Hamilton Heights 111 724 22.2 67.9 9.9 47.2 20 775 (51.8) 17.8 31.3 43.2 Central Harlem b 107 109 27.6 61.0 11.4 45.9 13 252 (60.6) 2.0 77.3 16.8 East Harlem b 117 743 27.5 61.1 11.4 47.1 14 882 (62.1) 7.3 35.7 52.7 Washington Heights, Inwood b 208 414 25.8 64.3 9.9 47.5 21 800 (53.8) 13.6 8.4 74.1 Note. Data were derived from the Department of City Planning, New York City, 2000, with the exception of income data as noted. a 1990 median household income and percentage of persons with poverty status under 200% of federal poverty level (from Department of City Planning). b Medically underserved area as designated by the Centers for Medicare and Medicaid Services. and minorities than do the districts not so designated. Among the Manhattan underserved areas, Washington Heights/Inwood has the highest proportion of Hispanic residents; Central Harlem and East Harlem have the highest proportions of African American residents. There were declines of at least 50% in TANF enrollment among all 12 community districts of Manhattan from 1994 to 2001 (data not shown). In terms of the 3 medically underserved community districts, TANF enrollment declined by 56.9% in Central Harlem, 53.5% in East Harlem, and 62.1% in Washington Heights/Inwood. In contrast, Medicaid enrollment increased during this period and doubled in all 3 medically underserved community districts. Enrollment trends from 1996 to 2001 (data not shown) showed that declines in TANF enrollment were accompanied by declines of nearly one third in Food Stamp enrollment in the medically underserved community districts. To assess the temporal relationship between enactment of the Personal Responsibility and Work Opportunity Reconciliation Act and changes in enrollment in these programs more closely, we examined percentage changes in enrollment over shorter time intervals (see Table 2 and Figure 1). During 1994 to 1996, TANF caseloads had already begun to decline throughout Manhattan. Medicaid enrollment increased in the medically underserved community districts but remained steady in other areas. In the immediate period after passage of the legislation (1996 1998), TANF enrollment continued to fall, Food Stamp enrollment began to decrease, and Medicaid enrollment decelerated or actually decreased. TANF enrollment dropped precipitously between 1998 and 2001, with declines of an additional one third in nearly all community districts. After Reynolds v Giuliani was filed in 1998 alleging that benefits had been inappropriately denied to applicants, Medicaid enrollment increased by more than 50% in Central and East Harlem, by approximately 44% in Washington Heights/Inwood, and by 42% in all community districts combined. Food Stamp caseloads plateaued in Washington Heights/Inwood, while they continued to decline in Central and East Harlem. DISCUSSION Our results show that significant decreases in TANF enrollment were accompanied by decreases in Food Stamp enrollment and a deceleration in Medicaid enrollment from 1996 to 2001 in each of Manhattan s 12 community districts. The greatest declines in both Medicaid and Food Stamp enrollment were seen in community districts with the highest proportions of low-income individuals. Other studies conducted at the state level have yielded similar findings. 5,6,14,20,21 It has been hypothesized by some that these decreases may be due to an unintended churning effect wherein recipients have been categorically denied Medicaid and Food Stamp benefits along with TANF benefits owing to links in the application processes for the 3 programs. In a recent policy analysis of all 50 states, guidelines that deterred TANF application predicted decreases in Medicaid enrollment and increases in the number of people without insurance coverage. 14 In South Carolina (P. Bailey, chief, Health and Demographics Section, Office of Research and Statistics, South Carolina State and Budget Control Board, oral communication, November 2001) and Wisconsin, 20 identification of churning led to changes in the application process, and Medicaid and Food Stamp enrollment subsequently increased. Boston Medical Center s Department of Pediatrics recently instituted a welfare screening project to assist families by advocating for appropriate benefits. 22 Our findings add to the current state of knowledge by focusing on the effects 1442 Forum on Welfare Reform Peer Reviewed Pati et al. American Journal of Public Health September 2002, Vol 92, No. 9

of welfare reform on medically underserved neighborhoods in New York City. An alternative explanation for these findings is that decreases in TANF, Food Stamp, and Medicaid enrollment were due to former TANF recipients having obtained employment during the economic boom of the 1990s and no longer requiring Food Stamp and Medicaid benefits. However, employment trends do not account for all of the observed decreases in Food Stamp and Medicaid enrollment. 23,24 In addition, studies have shown that jobs obtained through welfare-to-work programs have been seasonal or part-time positions rather than entry-level positions that could potentially lead to established careers with steady incomes. 25 There were limitations to this study. The analysis involved a single locale, Manhattan; thus, generalizability to other areas may be limited. However, because devolution of responsibility to the states under the Personal Responsibility and Work Opportunity Reconciliation Act resulted in more than 50 versions of welfare reform, it is difficult to collect data that are generalizable to the state or national level. Given Manhattan is a major urban center with a large population of un- Number Enrolled 150 000 120 000 90 000 60 000 30 000 0 Welfare reform Lawsuit filed TANF Medicaid Food stamps 9/11 1994 1996 1998 2001 Note. Shown are the number of individuals enrolled in TANF and Medicaid and the number of households enrolled in the Food Stamp program during 1994, 1996, 1998, and 2001. TANF = Temporary Assistance for Needy Families. FIGURE 1 Time line of combined TANF, Medicaid, and Food Stamp program enrollment: Central Harlem, East Harlem, and Washington Heights/Inwood community districts, 1994 to 2001. TABLE 2 Percentage Changes in Temporary Assistance for Needy Families (TANF), Medicaid, and Food Stamp Enrollment in 12 Community Districts of Manhattan: 1994 1996, 1996 1998, and 1998 2001 TANF, % Medicaid, % Food Stamps, % Community District 1994 1996 1996 1998 1998 2001 1994 1996 1996 1998 1998 2001 1996 1998 1998 2001 Battery Park City, Tribeca 7.8 14.6 27.7 90.8 2.0 39.7 61.8 20.1 Greenwich Village, Soho 39.0 12.3 21.5 0.0 10.0 26.8 3.7 8.1 Lower East Side, Chinatown 33.0 17.5 34.7 23.3 5.6 38.0 20.5 10.1 Chelsea, Clinton 41.1 7.9 35.0 22.5 4.3 34.3 18.3 4.1 Midtown Business District 64.8 14.7 2.5 13.5 6.5 74.3 5.7 0.0 Stuyvesant Town, Turtle Bay 43.9 10.2 9.9 1.1 4.9 18.0 25.1 7.5 West Side, Upper West Side 32.8 10.2 33.0 11.1 6.8 29.5 16.3 13.5 Upper East Side 40.4 26.5 38.8 0.0 5.9 27.1 15.2 12.4 Manhattanville, Hamilton Heights 21.1 16.0 29.4 16.7 16.2 42.6 22.1 8.3 Central Harlem a 29.4 9.0 32.9 27.9 13.1 50.8 18.4 19.5 East Harlem a 21.4 10.3 34.1 16.1 15.8 53.7 17.4 17.9 Washington Heights, Inwood a 30.9 14.4 35.9 23.7 14.2 43.8 22.4 0.0 All 12 community districts 30.1 12.6 33.0 7.2 11.0 42.2 0.0 26.7 Note. Percentage changes were calculated as A B/B, where A is the number of enrollees in year 2 and B is the number of enrollees in year 1. Enrollees were numbers of individuals for TANF and Medicaid and number of households for Food Stamps. a Medically underserved area as designated by the Centers for Medicare and Medicaid Services. September 2002, Vol 92, No. 9 American Journal of Public Health Pati et al. Peer Reviewed Forum on Welfare Reform 1443

derserved residents, our results suggest that policy reform may be relevant for other urban centers with areas of concentrated poverty. Also, because ours was an ecological study, we could not identify specific attributes of individuals who may have lost benefits. However, the intent of the Personal Responsibility and Work Opportunity Reconciliation Act was to decrease cash assistance caseloads while maintaining Medicaid and Food Stamp enrollment, and thus examination of rates of enrollment rather than individual attributes is appropriate. 26 Low socioeconomic status has been repeatedly and persistently shown to have harmful effects on the health status of children and families. 27 31 National studies, state-level data, and our findings all suggest that welfare reform has influenced the well-being of poor children and their families through changes in the availability of family resources (i.e., access to health insurance and food assistance). There is evidence that decreases in family resources, including food assistance 32 and food sufficiency, 33,34 have the potential to lead to predictable consequences in terms of child health. These consequences include impaired academic performance and psychosocial development, 34 both of which may impede future success in adulthood. Uninsured populations, especially low-income groups, have limited access to health care services. 35,36 Policy reform is a crucial component of efforts to reduce health disparities between socioeconomic groups. In conclusion, declines in cash assistance enrollment in the wake of welfare reform have been accompanied by decelerations in Medicaid enrollment and declines in Food Stamp enrollment in the underserved communities of Manhattan. These declines have occurred at a time when the needs of underserved populations in New York City are clearly increasing and the city is facing an economic recession. In the 6 weeks following the tragedies of September 11, more than 75 000 families in New York City enrolled in a temporary Medicaid program created to offer 4 months of relief to all low-income New York City residents, not only those directly affected by the attacks. 37 This was one of the largest single enrollment increases in Medicaid history, 38 demonstrating the need for streamlined and simplified administration of benefits. In New York City neighborhoods with large proportions of immigrants, there has been an increase in the number of Women, Infants, and Children (WIC) program benefit checks left uncollected, and investigators suspect that this increase may have been due to confusion about eligibility. 39 Between September 2001 and March 2002, nearly 33 000 New Yorkers applied for Food Stamps, 40 but the newly appointed commissioner of the city s Human Resources Administration refused to accept a federal waiver that would have allowed unemployed heads of households to continue receiving Food Stamps beyond the current limit of 3 months in a 3-year period. 41 As the Personal Responsibility and Work Opportunity Reconciliation Act comes up for reauthorization later in 2002, policymakers should consider revisions to improve access to health insurance and food assistance for underserved populations. About the Authors Susmita Pati is with the Departments of General Pediatrics and General Medicine, Columbia University College of Physicians and Surgeons, New York City. Diana Romero and Wendy Chavkin are with the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City. Requests for reprints should be sent to Susmita Pati, MD, MPH, Division of General Medicine, 622 West 168th St, PH 9 East, Room 105, New York, NY 10032 (e-mail: sp293@columbia.edu). This article was accepted May 1, 2002. Contributors S. Pati was responsible for study conception and design, data analysis and interpretation, and article preparation. D. Romero and W. Chavkin contributed to study conception, data interpretation, and critical revision of the article. Acknowledgments This study was supported by a National Research Service Award (T32 PE10012-07) to Susmita Pati and by a Maternal and Child Health Bureau grant to Diana Romero and Wendy Chavkin. Human Participant Protection This project was approved by the institutional review board of Columbia Presbyterian Medical Center. References 1. New York City Human Resources Administration. Welfare reform in New York State. Available at: http:// www.nyc.gov. Accessed August 20, 2001. 2. Cunningham PJ, Park MH. Recent Trends in Children s Health Insurance Coverage: No Gains for Low- Income Children. Washington, DC: Center for Studying Health System Change; 2000. 3. Change in Welfare Caseloads Since Enactment of New Welfare Law. Washington, DC: US Dept of Health and Human Services, Administration for Children and Families; 1999. 4. Change in TANF Caseloads Since Enactment of New Welfare Law. Washington, DC: US Dept of Health and Human Services, Administration for Children and Families; 2000. 5. The Decline in Food Stamp Participation: A Report to Congress. Washington, DC: US Dept of Agriculture; 2001. 6. Medicaid Enrollment: Amid Declines, State Efforts to Ensure Coverage After Welfare Reform Vary. Washington, DC: US General Accounting Office; 1999. 7. Losing Health Insurance: The Unintended Consequences of Welfare Reform. Washington, DC: Families USA Foundation; 1999. 8. demause N. Food stamp probe spurs Fed probe. In These Times. December 27, 1998:8. 9. Polner R. A welfare mess : Fed report, state official fault city s food stamp policy. Newsday. January 21, 1999:A3. 10. Mann CM, Hudman J, Salganicoff A, Folsom A. Five years later: poor women s health care coverage after welfare reform. J Am Med Womens Assoc. 2002; 57:16 22. 11. Zedlweski SR. Leaving welfare often severs families connections to the Food Stamp program. J Am Med Womens Assoc. 2002;57:23 27. 12. Kaiser Commission on Medicaid and the Uninsured. The Uninsured and Their Access to Health Care. Washington, DC: Families USA Foundation; 1999. 13. Vastag B. Education needed to expand SCHIP eligibility. JAMA. 2002;287:1101. 14. Chavkin W, Romero D, Wise PH. State welfare reform policies and declines in health insurance. Am J Public Health. 2000;90:900 908. 15. Romero D, Chavkin W, Wise PH, Hess C, Van- Landeghem K. State welfare reform policies and maternal and child health services: a national study. Maternal Child Health J. In press. 16. Romero D, Chavkin W, Wise PH. The impact of welfare reform policies on child protective services: a national study. J Soc Issues. 2000;56:799 810. 17. New York City Human Resources Administration. Public assistance recipients in NYC: 1955 2001. Available at: http://www.nyc.gov.html/hra/home.html. Accessed December 6, 2001. 18. Lipton E. In settlement, welfare offices will become city job centers. New York Times. February 15, 2001:B3. 19. Centers for Medicare and Medicaid Services. Scores of medically underserved areas within the United States of America. Available at: http://bphc. hrsa.gov/databases/newmua. Accessed December 10, 2001. 20. Willis E, Malloy M, Kliegman RM. Welfare reform consequences for children: the Wisconsin experience. Pediatrics. 2000;106:E83. 1444 Forum on Welfare Reform Peer Reviewed Pati et al. American Journal of Public Health September 2002, Vol 92, No. 9

21. Kronebusch K. Medicaid for children: federal mandates, welfare reform, and policy backsliding. Health Aff. 2001;20:97 111. 22. Lawton E, Leiter K, Todd J, Smith L. Welfare reform: advocacy and intervention in the health care setting. Public Health Rep. 1999;114:540 549. 23. Holzer HJ, Wissoker D. How Can We Encourage Job Retention and Advancement for Welfare Recipients? Washington, DC: Urban Institute; 2001. 24. Bavier R. Welfare reform data from the Survey of Income and Program Participants. Monthly Labor Rev. 2001;124(7):13 24. 25. Moving Hard-to-Employ Recipients Into the Workforce. Washington, DC: US General Accounting Office; 2001. 26. Schwarz S, Carpenter KM. The right answer for the wrong question: consequences of type III error for public health research. Am J Public Health. 1999;89: 1175 1180. 27. Wise PH, Meyer A. Poverty and child health. Pediatr Clin North Am. 1988;35:1169 1186. 28. Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child. 1997;7:55 71. 29. Askew GL, Wise PH. The neighborhood: poverty, affluence, geographic mobility, and violence. In: Levine M, Carey W, Crocker A, eds. Developmental Behavioral Pediatrics. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1999:177 187. 30. Parker S, Greer S, Zuckerman G. Double jeopardy: the impact of poverty on early childhood development. Pediatr Clin North Am. 1988;35:1227 1240. 31. Garfield R, Greene D, Abramson D, Burkhardt S, eds. Washington Heights/Inwood: The Health of a Community II. New York, NY: Health of the Public Program, Columbia University; 1997. 32. Smith LA, Wise PH, Chavkin W, Romero D, Zuckerman B. Implications of welfare reform for child health: emerging challenges for clinical practice and policy. Pediatrics. 2000;106:1117 1125. 33. Alaimo K, Olson CM, Frongillo EA, Breifel RR. Food insufficiency, family income, and health in US preschool and school-aged children. Am J Public Health. 2001;91:781 786. 34. Alaimo K, Olson CM, Frongillo EA. Food insufficiency and American school-aged children s cognitive, academic, and psychosocial development. Pediatrics. 2001;108:44 53. 35. Wyn R, Teleki S, Brown ER. Differences in Access to Health Care Among the Moderate- and Low-Income Population Across Urban Areas. Los Angeles, Calif: Center for Health Policy Research, University of California, Los Angeles, 1998:1 4. 36. Kuttner R. The American health care system health insurance coverage. N Engl J Med. 1999;340: 163 168. 37. Finkelstein KE. Disaster gives the uninsured wider access to Medicaid. New York Times. November 23, 2001:D1. 38. Russakoff D. Out of tragedy, NY finds way to treat Medicaid need: streamlined post-crisis process draws record enrollment through multilingual grapevine. Washington Post. November 26, 2001:A2. 39. Jessop D, Finkelstein R, Rosenberg T, et al. The Impact of Recent Immigration Policy Changes on the Receipt of WIC Services: An Aggregate Analysis. New York, NY: Medical Health Research Association; 1999. 40. Barton T. 9/11 six months on: New York factfile. The Observer. March 10, 2002:2. 41. Bernstein N. New welfare director defends stance on food stamp waiver. New York Times. March 15, 2002:B3. Community-Based Public Health: A Partnership Model Edited by Thomas A. Bruce, MD, and Steven Uranga McKane, DMD Published by APHA and the W.K. Kellogg Foundation Developing meaningful partnerships with the communities they serve is crucial to the success of institutions, nonprofit organizations and corporations. This book contributes to a wider understanding of how to initiate and sustain viable partnerships and improve community life in the process. Community-Based Public Health: A Partnership Model focuses on public health practice in communities, the education and training of public health professionals at colleges and universities, and public health research and scholarly practice within academic institutions. ISBN 0-87553-184-9 2000 129 pages softcover $17.00 APHA Members $22.00 Nonmembers plus shipping and handling American Public Health Association Publication Sales Web: www.apha.org E-mail: APHA@TASCO1.com Tel: (301) 893-1894 FAX: (301) 843-0159 KL02J2 September 2002, Vol 92, No. 9 American Journal of Public Health Pati et al. Peer Reviewed Forum on Welfare Reform 1445

[(H3F)] 1446 [(H2F)] Peer Reviewed [(H1F)] American Journal of Public Health September 2002, Vol 92, No. 9