to which responsibility or authority is shared among these authorities often shifts over time. The locus of responsibility for many public benefit programs has shifted during the 1990s, with some responsibility "devolving" from the federal to the state level and, in many states, to the local level. This shift has increased the variability that has always existed from community to community in the organization, structure, and funding of health care services, creating important challenges to mounting an effective effort to reduce HIV perinatal transmission.

Implementation of the committee's recommendations will require changes in the policies developed by federal, state, and local government groups, managed care organizations, and professional groups, as well as broad dissemination of those policies.

Recent Changes In Health Care And Social Services

Several recent changes in federal policies will affect women and children at risk for or already infected with HIV/AIDS.

Welfare Reform

The 1996 welfare reform legislation—the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA)—mandated changes in a number of areas, including cash assistance, Medicaid, SSI, and access to federal means-tested benefits. PRWORA repealed the AFDC (Aid to Families with Dependent Children) program and replaced it with the Temporary Assistance for Needy Families (TANF) block grant, imposing limits on the amount of time a family can receive economic support, sanctioning those that do not comply with work requirements or requiring recipients to seek work or training first before applying for assistance, and restricting cash assistance to citizens and certain categories of legal immigrants. In addition, persons convicted of drug felonies are prohibited from receiving cash assistance. It is important to note that there has been a significant increase in the criminal prosecution of substance-abusing pregnant women over the past several years (Chavkin et al., 1998), thereby increasing the likelihood that these women will not be eligible for cash assistance during treatment.

PRWORA essentially bars many legal immigrants from receiving a range of federal means-tested benefits, including TANF, Medicaid, SSI, Food Stamps, and Social Service Block Grant services. It does, however, distinguish between "current" qualified immigrants—those residing in the United States on August 22, 1996—and "future" qualified immigrants—those arriving after that date. Current qualified immigrants are eligible for emergency Medicaid, may receive non-emergency Medicaid and/or TANF at the state's option, and may retain SSI if they were receiving benefits on August 22, 1996. Future qualified immigrants may receive emergency Medicaid only, are banned for five years from receiving



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