efforts to use these data for evaluation of welfare reform. Finally, we conclude by discussing some of the scientific sensibilities that should be respected in the use of such data during research on welfare reform, including a discussion of linkages between population surveys and administrative data.
Access to health care services is a central consideration in the assessment of welfare reform, as these reforms change existing relationships among income, employment, and insurance of health care services for poor families and children (Child Trends, 2000a; Darnell and Rosenbaum, 1997; Moffitt and Slade, 1997; Schorr, 1997). Measures of child health typically emphasize access to care as an important measure, recognizing that health care is necessary but not sufficient for positive child health outcomes (Gortmaker and Walker, 1984; Margolis et al., 1997; Andrulis, 1998).
Parents access health care for their children through several paths. Many children receive health insurance provided by their parent’s employer. However, some children of working parents may not have employer-sponsored health plans, and children of nonworking parents certainly do not have this benefit. These children of low-income or nonworking parents are eligible for services paid by publicly funded programs such as Medicaid or the new CHIP. The PRWORA legislation did not significantly alter Medicaid eligibility, and CHIP is designed to reach more of these uninsured children. Yet in July 1999 an estimated 4.7 million uninsured children were eligible for Medicaid but not enrolled (Families USA, 1999). Many states are beginning to track children’s enrollment in Medicaid and CHIP, implement outreach efforts to increase CHIP enrollment, and expand Medicaid and CHIP income-level guidelines (Families USA, 1999; Children’s Defense Fund, 1998).
The actual health services the child receives are also major determining factors in child health status. Examples of services may include (1) preventive care such as immunizations or dental care; (2) diagnostic screening such as vision and hearing screening, or weight for height measures; and (3) treatment for chronic conditions and disability, with corresponding risk of secondary disability. State policies about welfare reform have the potential to change, positively or negatively, the family environment where health behaviors and health decisions are carried out (Willis and Kleigman, 1997; O’Campo and Rojas-Smith, 1998; Brauner and Loprest, 1999). For example, even if a child is enrolled in Medicaid or CHIP, PRWORA work requirements may constrain a parent’s ability to access health care. When access to health care services is limited, either through limited availability or limited utilization of services, children’s health could suffer. Alternatively, the work requirements could encourage the parent to secure a job that includes health insurance (gaining access to health care), which may mean the family is able to utilize more services.