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The Social Impact of Aids in the United States
A second anomaly in the deployment of resources is the differences in expenditures among the states. The AFDC program rests on federal legislation, but it is partially funded by the states, and the states are largely free to fix the grant levels. States are also free to vary the range of care provided through Medicaid. New York and Florida aptly illustrate the gross disparity of payments among the states. In New York, in early 1991, the basic AFDC grant for a parent and one child was $439 per month; in Florida, the same family would have received $211 per month. This difference cannot be explained by differences in the costs of living—Florida does not estimate that children need less to live on than New York estimates; rather, the difference lies in fundamental differences in the political environments of the two states. New York taxes its citizens at high rates (compared with almost all other states) and supports one of the nation's most extensive social welfare systems. Florida, without a state income tax, has chosen to spend much less on the needs of the poor and on services of all sorts. Florida ranks 48th among the states in expenditures per capita for health and social services, and it ranks 47th in Medicaid expenditures per capita for eligible poor people (Preston, Andrews, and Howell, 1989). In this light, Florida's unusually high payments to foster parents caring for HIV-symptomatic children is particularly anomalous.
AIDS arose in the context of a welfare system already widely divergent among states. In some respects, the federal response to AIDS has ameliorated the differences among states, for Congress has accepted the burdens of AIDS as so extraordinary that it has agreed that the federal government should bear nearly all the costs of special demonstration projects, such as those to provide extra services for HIV-infected children living at home. The Ryan White CARE Act similarly provides extra federal money to heavily affected cities, such as New York City and Miami, without regard to variations in the financial commitment that the particular cities and states have already made. Still, even with these extra infusions of money, a child with HIV who is eligible for AFDC in Florida and living with his or her mother has less income available and probably will be helped by a caseworker with a substantially larger caseload than a similar child in New York.
The disparities among states are matched by disparities within states. Even within Florida or New York, a child with HIV disease living in some settings receives much more support from the state than a child living in other settings. Some of these differences are the inevitable product of large bureaucracies and patchwork programs. In New York City, for example, some children with HIV disease are in the enriched, low-caseload demonstration programs for families operated by the Department of AIDS Services. Other children receive help from the division but not through a special program and have a caseworker with a larger caseload. Still others, particularly children who have HIV disease who live in a family in which