AJN/March 1998/vol.98, no. 3 |
| Washington Watch | Issues Update | Foundations of Practice | Vital Signs |
by David Keepnews, JD, MPH, RN
Welfare reform has affected access to health care for the nation's poorest residents. Here's why nurses should be concerned.
On August 22, 1996, President Clinton signed the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. This federal welfare reform bill made a number of substantive changes in welfare programs--reducing benefits in some areas, restructuring the former Aid to Families with Dependent Children (AFDC) program, and changing some criteria for Medicaid eligibility.
Nurses have several reasons to be concerned with the implementation of welfare reform. First, welfare programs have historically been linked to health care coverage for poor people, particularly children, chiefly through Medicaid. Second, the evolution of welfare programs has implications for the future of Medicaid, principally in shifting control from the federal to state governments. Third, the nursing profession has traditionally been aware of the ways in which poverty and inadequate living conditions affect the health of families and communities.
The 1996 federal welfare reform bill made some significant changes in Medicaid eligibility for many welfare beneficiaries. Some of the more radical changes, such as eliminating Medicaid eligibility for many legal immigrants and disabled children, have since been corrected (at least partially) by the Balanced Budget Act passed by Congress and signed by the president in August 1997.
Perhaps the most prominent feature of the 1996 welfare reform bill was to transform AFDC, a joint federal-state program, into Temporary Aid to Needy Families (TANF), a state-based program. AFDC was an open-ended entitlement program, meaning that the amount of money the federal government spent on it depended on how many people received benefits and how much they received. Federal funding for TANF, however, is through block grants, a predetermined level of funding based on 1994 expenditures. States receiving TANF block grants are subject to some federally determined conditions. The federal welfare reform bill requires that federal funding not be used to support families that have received assistance for five years or more. States can adopt shorter time limits as well. Under the previous program, AFDC-qualifying families also qualified for Medicaid coverage. But since TANF's eligibility requirements are stricter and include a time limit on receipt of benefits, many poor families would have lost Medicaid coverage under the new program. In order to address concerns that the TANF program would result in loss of Medicaid coverage, especially for poor children, the welfare reform bill requires states to use the AFDC-eligibility requirements from July 1996--the month before the law changed--to determine whether families with children qualify for Medicaid. This means that Medicaid coverage can continue or begin regardless of whether a parent qualifies for TANF. By separating general welfare support from Medicaid, the 1996 federal welfare reform bill potentially maintained Medicaid benefits for many poor families. Whether this separation presents administrative complications by maintaining two sets of eligibility criteria has yet to be determined.
The 1996 welfare reform bill drew much criticism for changes it made in eligibility criteria for disabled children who receive support through Supplemental Security Income (SSI), a federal-state program of support for disabled persons. As with the old AFDC program, receipt of SSI benefits also qualifies a recipient for Medicaid coverage. Before the welfare reform bill, children could qualify for SSI through two routes. One was by having a disability that's on a government list of conditions that would result in SSI eligibility. The other was by having an "individual functional assessment," which concluded that a child, even though his or her condition was not on the government list, was sufficiently impaired to qualify for SSI. Children on SSI who qualified through this route were largely, but not exclusively, mentally impaired. The 1996 bill eliminated the use of individual assessments for disabled children and gave the Social Security Administration a one-year period in which to review the cases of children who would be affected by the new standard.
The 1997 Balanced Budget Act extended the time allowed to complete this review. It also created a new category for which states must provide Medicaid eligibility: disabled children who were receiving SSI as of August 22, 1996, and who would continue to be eligible if the welfare reform bill had not changed the eligibility criteria.
One of the more controversial aspects of welfare reform was its effect on eligibility of noncitizen immigrants for Medicaid benefits. The 1996 welfare reform bill restricted immigrants' eligibility for SSI benefits and allowed states to exclude noncitizen immigrants from receiving all but emergency Medicaid services. It sharply curtailed the ability of legal immigrants arriving in the United States after August 1996 to qualify for Medicaid by barring eligibility for the first five years and, at state's option, continuing this restriction until immigrants attain citizenship.
The 1997 Balanced Budget Act restored Medicaid eligibility for many immigrants. Those who were receiving SSI (and who thus also qualified for Medicaid) as of August 22, 1996, and who were lawfully residing in the United States at that time, remain SSI eligible, as do those who were lawfully in the United States on that date and who meet SSI disability criteria now or in the future.
As Congress enacted sweeping changes in welfare programs, it was considering similarly radical changes in the Medicaid program as well. Medicaid is a joint federal-state program administered in each state under federal requirements that address benefits, eligibility, and administration, while allowing states substantial flexibility in coverage and services beyond the federal mandate.
One approach to Medicaid restructuring would have been to transform it from a federal-state program into a state-based program with federal block-grant funding, similar to the way in which AFDC was changed to TANF. But block-granting proposals have raised concerns about their potential effects on the level of funding available for Medicaid programs and on the public health infrastructure in many communities.
A major question was what effect block-granting Medicaid would have on federal protections for nursing home residents. The Omnibus Budget Reconciliation Act (OBRA) of 1987 instituted nursing home reforms resulting from a broad consensus about the need for clear, uniform federal standards to ensure adequate care and quality of life for nursing home residents. Americans' concerns that block-granting Medicaid would dissolve federal nursing home reform eventually helped to derail the block-grant movement. Whether the failure of block-grant proposals is permanent, or whether strong pressures will continue to "reform" Medicaid as welfare programs have been reformed, remains to be seen.
A third but no less important reason nurses should note the changes in welfare is the link between poverty and health status. That nurses need to be concerned with the living conditions of the patients, families, and communities for whom we provide care is not a new or revolutionary idea. For instance, Lillian Wald, an important early nursing leader and pioneer of public health and homes in New York's Lower East Side. Her concern for her patients also led her to support a range of social reform efforts.
As nurses, we must also continue to recognize that the ability of families to provide for their children--to ensure adequate nutrition, shelter, clothing, and other basic necessities--is linked to children's health, growth, and development.
Welfare reform has complicated our ability to know how many poor Americans are having difficulties accessing adequate health care. While some of the initial problems of welfare reform have been corrected in the Balanced Budget Act of 1997, it is still unclear how this reform will impact attempts to revamp Medicaid. Nor is it known what affect this reform will have on ongoing attempts by health care providers and consumer groups to ensure health care coverage for all Americans.
The nursing profession has clearly understood for some time that everyone in this country has a right to access quality care. That understanding was the cornerstone of "Nursing's Agenda for Health Care Reform," developed by the American Nurses Association in a coalition with other national organizations representing nurses in the early 1990s. This sensibility continues to be central to the ANA's efforts as it develops "Nursing's Blueprint for Action in a Managed Care Environment," a sequel to "Nursing's Agenda" (see AJN Issues Update, September 1997).
David Keepnews, a former ANA staff member, is currently an independent consultant in health policy based in Boston. He continues to work with the ANA on policy issues.