What Is Changing In Health And Social Welfare Programs?

This section provides an overview of recent changes to health and social welfare systems in the United States, focusing on legislative provisions that affect data collection and statistical reporting. Legislative changes have direct implications for data that are needed to track programs. More broadly there are also needs for data to track and help assess the interaction of economic trends and changes in private-sector sources of income and benefits (e.g., employer health and pension benefits) with changes in government programs, although this was not considered explicitly at the workshop.

The most important new legislation is PRWORA, which not only gives states increased discretion in defining eligibility rules and benefits under the TANF block grant that replaces AFDC, but also affects SSI, food stamps, Medicaid, benefits for legal immigrants, child care, and the Child Support Enforcement Program. (For additional details on PRWORA, see Appendix B.)

Temporary Assistance For Needy Families Block Grant

By replacing AFDC with the TANF block grant to states, PRWORA eliminates the longstanding federal entitlement of families with dependent children to cash assistance, and it gives states broad powers to develop social service programs for specific population groups and not others.1 For instance, states can refuse assistance to teenage parents, two-parent families, and noncitizen families, and limit assistance to families who have migrated from other states. States may also reduce or eliminate cash benefits, relying instead on such alternatives as in-kind transfers, services to families, or wage supplements for employers.

While PRWORA gives states broad powers to experiment with welfare programs, there are a number of strict limits imposed on the length of time adults can receive unconditional assistance from programs funded by the TANF grant. In particular, there is a 2-year limit, after which adult recipients are required to participate in work activities in order to receive assistance, and a 5-year limit, after which adult recipients are ineligible for assistance from programs funded by the TANF grant.

1  

States had until July 1, 1997, to submit a state plan and begin implementing the TANF block grant.



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--> What Is Changing In Health And Social Welfare Programs? This section provides an overview of recent changes to health and social welfare systems in the United States, focusing on legislative provisions that affect data collection and statistical reporting. Legislative changes have direct implications for data that are needed to track programs. More broadly there are also needs for data to track and help assess the interaction of economic trends and changes in private-sector sources of income and benefits (e.g., employer health and pension benefits) with changes in government programs, although this was not considered explicitly at the workshop. The most important new legislation is PRWORA, which not only gives states increased discretion in defining eligibility rules and benefits under the TANF block grant that replaces AFDC, but also affects SSI, food stamps, Medicaid, benefits for legal immigrants, child care, and the Child Support Enforcement Program. (For additional details on PRWORA, see Appendix B.) Temporary Assistance For Needy Families Block Grant By replacing AFDC with the TANF block grant to states, PRWORA eliminates the longstanding federal entitlement of families with dependent children to cash assistance, and it gives states broad powers to develop social service programs for specific population groups and not others.1 For instance, states can refuse assistance to teenage parents, two-parent families, and noncitizen families, and limit assistance to families who have migrated from other states. States may also reduce or eliminate cash benefits, relying instead on such alternatives as in-kind transfers, services to families, or wage supplements for employers. While PRWORA gives states broad powers to experiment with welfare programs, there are a number of strict limits imposed on the length of time adults can receive unconditional assistance from programs funded by the TANF grant. In particular, there is a 2-year limit, after which adult recipients are required to participate in work activities in order to receive assistance, and a 5-year limit, after which adult recipients are ineligible for assistance from programs funded by the TANF grant. 1   States had until July 1, 1997, to submit a state plan and begin implementing the TANF block grant.

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--> Thus, a single parent who has received TANF assistance for over 2 years must ''work'' for at least 20 hours per week (35 hours per week for a two-parent family) in one or more of the following activities: paid or unpaid employment, education (for teenage parents), on-the-job training, participating in or providing child care to individuals in community service activities, attending vocational training, or participating in job search assistance for up to 6 weeks. To avoid financial penalties, states are required to have at least 25 percent of single-parent recipients (with the exception of exempted families) participating in work activities in 1997. The proportion of adults who must be participating in work activities increases by 5 percent each year until it reaches 50 percent in 2002.2 After 5 cumulative years of receiving assistance under a state program funded by the TANF grant, adults are ineligible for TANF assistance. States may use their own funds to provide assistance after the 5-year limit and may exempt up to 20 percent of the adult caseload from the lifetime limit. Child-only cases are not subject to the 5-year limit. Additional requirements are placed on teenage parents. To receive assistance, they must participate in educational activities directed toward receiving a high school diploma or general educational development (GED) certificate, and they must live with an adult or in an approved, adult-supervised setting. Supplemental Security Income PRWORA establishes a more restrictive disability standard for children to receive SSI. (The SSI program provides benefits according to federal standards for poor elderly individuals and couples and for poor nonelderly blind and disabled people.) Under the new definition, which eliminates the individual functional assessment and all references to maladaptive behavior, a child is considered to be disabled only if she or he has a medically determinable physical or mental impairment that results in marked functional limitations. Food Stamp Program Although the federal Food Stamp Program retains its current structure as an uncapped, individual entitlement, there are a number of substantial changes to it. In addition to reducing benefits to all recipients and restricting benefits to legal immigrants (see Appendix B), PRWORA imposes strict work requirements on able-bodied adults without dependents. In particular, recipients aged 18-50 with no dependents may receive food stamp benefits for only 3 months in every 36-month period unless they are working or participating in work programs for at least 20 hours per week.3 If a recipient finds work and then loses his or her job, an additional 3 months of benefits are allowed. Local jurisdictions with unemployment rates exceeding 10 percent or "insufficient jobs" can receive waivers from these provisions. In addition to the changes to the basic federal Food Stamp Program, a number of provisions in PRWORA enable state experimentation. States may operate a "simplified food stamp program," 2   A state must reduce assistance to a family pro rata (or more, at state option) for any period in which an adult member of the family refuses to engage in work as required under the TANF grant. A state will be penalized by a grant reduction of 5 percent the first year it fails to meet minimum federally established participation rates. For consecutive failures, penalties rise by 2 percent each year with a cap of a 21 percent reduction in the TANF block grant amount. 3   Qualifying work programs include programs under the Job Training Partnership Act, the Trade Adjustment Assistance Act, and workfare; job search programs do not qualify.

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--> which allows for a single set of rules for the food stamp and TANF programs. While generally restricted to TANF recipients, states may apply for a waiver to expand this simplified program to include non-TANF households. The new law also grants states expanded authority to apply for waivers from the federal food stamp regulations. The U.S. Department of Agriculture will now consider a broad range of waivers, including those that reduce benefits, require work, and institute consistent multiprogram rules. A number of changes will not be considered, including new projects to cash out food stamps and experiments with eligibility requirements that target behavior, such as a family cap that limits benefits for newborn children or time limits on benefit receipt. While new cash-out waivers will be denied, PRWORA allows certain states to cash out food stamp benefits for TANF recipients who are working in unsubsidized employment. This cash-out program is restricted to states in which at least 50 percent of the food stamp recipients received AFDC in 1993. Benefits for Immigrants PRWORA limits assistance to legal immigrants: legal immigrants are barred from receiving SSI and food stamps, while states have the option to determine the eligibility of current legal immigrants for assistance under TANF and Medicaid.4 Newly arriving legal immigrants are barred from all means-tested, federally funded public benefits for the first 5 years they are in the United States, after which states may provide services. Exceptions to these restrictions are made for refugees and asylees, who are eligible for their first 5 years in the United States; veterans; lawful permanent residents with 40 qualifying quarters of work; and Cuban-Haitian entrants. Medicaid Program and Health Care While comprehensive changes to the Medicaid program were not included in PRWORA, important modifications were made to the Medicaid eligibility requirements for welfare recipients and, as described above, immigrants. Under the previous law, people who were eligible for AFDC were automatically entitled to receive Medicaid. The TANF grant severs this automatic link, instead tying eligibility to the state's AFDC plan as it existed on July 16, 1996.5 Other recent changes to the Medicaid program and the broader U.S. health care system affect the ability of existing national surveys to measure costs, access, and quality of health care. The Medicaid program, for instance, continues to encourage state experimentation through the waiver process. Some key changes due to waivers include changes in the eligible population, in the copayments required of beneficiaries, and in the types of health care plans that are available.6 Overall, there has been an increase in the number of Medicaid beneficiaries in managed care programs, reflecting the changes in the broader health care industry that are transforming relation- 4   No state may deny coverage of emergency medical services to either illegal or legal aliens. The Balanced Budget Act of 1997 eased the restrictions on immigrants' eligibility for SSI: eligibility for SSI and associated Medicaid benefits (but not food stamps) was restored for all elderly and disabled immigrants who received SSI at the time PRWORA was enacted in August 1996 and for all legal immigrants in the United States at that time who become disabled in the future. The Balanced Budget Act of 1997 also extended the number of years for which refugees are entitled to SSI and associated Medicaid benefits from 5 to 7 years and expanded the groups of immigrants who are treated as refugees (see Fix and Tumlin, 1997). 5   When applying these "frozen" rules, states can choose to index the income standards to the Consumer Price Index. 6   In addition, the Balanced Budget Act of 1997 includes several provisions that affect Medicaid, notably, new funding for states to expand Medicaid eligibility for children (see Weil, 1997).

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--> ships between patients, health plans, and providers. Because of these changes, such classifications as Health Maintenance Organization, Independent Practice Association, Preferred Provider Organization, and fee-for-service no longer adequately distinguish among types of health care plans. Finally, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates several changes in the private health insurance market that may affect participation and costs for Medicaid and other social welfare programs. For example, HIPAA extends the portability of health insurance coverage for workers who change jobs, and it limits restrictions on pre-existing conditions for new coverage. (For a more detailed description of the changing public and private sector health care systems and the implications for the adequacy of existing data, see Harvey, 1996.)