Medicaid and TANF benefits, and are ineligible for SSI until citizenship. Undocumented and "unqualified" immigrants are eligible for emergency Medicaid, but are barred from all other federal means-tested benefits.
Under PRWORA, Medicaid is maintained as a federal entitlement for low-income citizens. Medicaid eligibility is not linked with TANF; instead, families are eligible if they meet AFDC eligibility requirements that were in effect as of July 16, 1996.
Children with disabilities are also affected by PRWORA in that they must meet a narrower definition of disability to become eligible for assistance through the SSI Disabled Children's Program (SSIDCP), a common entry point for Medicaid eligibility and enrollment. The Balanced Budget Act of 1997 restores Medicaid for children who were receiving SSI on August 22, 1996, but lost it due to changes in the welfare law.
These and other changes have a complex and significant impact on access to care and, therefore, primary and secondary prevention opportunities for reducing perinatal transmission. Most women with or at risk for HIV have low-incomes, are uninsured, and/or often rely on government programs to support their access to health care. Women with HIV disease may become impoverished because the disease itself prevents them from working or because of the expenses associated with it. The traditional linkage of women with the Medicaid program often came with their enrollment in AFDC (the former welfare program). With reduced access to welfare due to changes in eligibility and the imposition of time limits and sanctions, women may not be aware of their potential eligibility for Medicaid or how to access the program. Although many states have attempted to ease access to Medicaid for those applying for TANF benefits by creating a single application for TANF and Medicaid, access has been made more complicated for those not eligible or interested in TANF benefits because separate routes to Medicaid have not been effectively established in many jurisdictions.
With access to both welfare and health care services restricted to certain categories of legal immigrants and unavailable for the undocumented, opportunities for prevention and treatment are more limited. Many undocumented women are fearful of accessing care because of Immigration and Naturalization Service reporting requirements. Recent reports indicate that, at least in some states, applications for Medicaid (and therefore presumably Medicaid enrollment) have dropped precipitously among households headed by non-citizens, even though many non-citizens and/or their children remain eligible (Lewis et al., 1998). Another potential problem is that even though transitional Medicaid is maintained under welfare reform, many women who move from welfare to work may eventually secure employment that places them above Medicaid income eligibility cut-offs, but do not provide private insurance. In some cases, newly found jobs may offer insurance but former welfare recipients may find it too expensive to cover themselves or their dependents.
Beyond any impact from welfare reform, there is also an ongoing problem of