Evaluation of a savings-led family-based economic empowerment intervention for AIDS-affected adolescents in Uganda: A four-year follow-up on efficacy and cost-effectiveness

BACKGROUND

Children who have lost a parent to HIV/AIDS, known as AIDS orphans, face multiple stressors affecting their health and development. Family economic empowerment (FEE) interventions have the potential to improve these outcomes and mitigate the risks they face. We present efficacy and cost-effectiveness analyses of the Bridges study, a savings-led FEE intervention among AIDS-orphaned adolescents in Uganda at four-year follow-up.

METHODS

Intent-to-treat analyses using multilevel models compared the effects of two savings-led treatment arms: Bridges (1:1 matched incentive) and BridgesPLUS (2:1 matched incentive) to a usual care control group on the following outcomes: self-rated health, sexual health, and mental health functioning. Total per-participant costs for each arm were calculated using the treatment-on-the-treated sample. Intervention effects and per-participant costs were used to calculate incremental cost-effectiveness ratios (ICERs).

FINDINGS

Among 1,383 participants, 55% were female, 20% were double orphans. Mean age was 12 years at baseline. At 48-months, BridgesPLUS significantly improved self-rated health, (0.25, 95% CI 0.06, 0.43), HIV knowledge (0.21, 95% CI 0.01, 0.41), self-concept (0.26, 95% CI 0.09, 0.44), and self-efficacy (0.26, 95% CI 0.09, 0.43) and lowered hopelessness (-0.28, 95% CI -0.43, -0.12); whereas Bridges improved self-rated health (0.26, 95% CI 0.08, 0.43) and HIV knowledge (0.22, 95% CI 0.05, 0.39). ICERs ranged from $224 for hopelessness to $298 for HIV knowledge per 0.2 standard deviation change.

CONCLUSIONS

Most intervention effects were sustained in both treatment arms at two years post-intervention. Higher matching incentives yielded a significant and lasting effect on a greater number of outcomes among adolescents compared to lower matching incentives at a similar incremental cost per unit effect. These findings contribute to the evidence supporting the incorporation of FEE interventions within national social protection frameworks.

The Impact of Local Welfare Offices on Children's Enrollment in Medicaid and SCHIP

Nearly 20% of children entering Kansas' State Children's Health Insurance Program (SCHIP) and more than 25% of children entering the state's Medicaid program leave public health insurance altogether before completing a full year of coverage, when the first redetermination of eligibility should occur. Analyses of administrative data indicate that high rates of premature disenrollment are strongly associated with case management practices at local social services offices. However, local offices enroll the vast majority of children into public health insurance. To avoid a potential trade-off between local offices' impact on enrollment and retention, the study suggests that states such as Kansas consider improvements in automation to support caseworkers' difficult jobs.

[Social exclusion and health inequity: a case study based on a cash distribution program (Bolsa Família) in Brazil]

OBJECTIVE

To understand the impact of Bolsa Família (PBF), a federal cash transfer program, and to analyze its effects on social inclusion and exclusion processes experienced by low-income families in Brazil, with a focus on the program's potential to help overcome health inequity.

METHODS

This qualitative investigation used a case study methodology including observant participation, review of documents, and semi-structured interviews with current and former PBF beneficiaries, as well as with the program's local managers. The study was conducted in a small city in the state of Rio de Janeiro with a high social exclusion index and 100% coverage by the Family Health Strategy (Estratégia Saúde da Família, ESF) program. The economic, political, social, and cultural dimensions of social exclusion and inclusion processes were used to guide data collection and analysis.

RESULTS

The program facilitated social inclusion of low-income families, especially in the economic and social dimensions. Nevertheless, it did not produce the changes desired by the beneficiaries in the work dimension. The effects on the political dimension were limited by the insufficient social engagement of the PBF. The interviewees underscored the positive effects of the ESF, which allowed them to exercise their right to health by granting them wider access to primary health care services. However, these effects appeared to be unrelated to the PBF.

CONCLUSIONS

The results reveal effects, limitations, and challenges of the PBF towards modifying the social determinants of health inequity, in order to promote more effective changes in the social exclusion/inclusion dynamics affecting low-income families.

Child allowances, fertility, and chaotic dynamics

This paper analyzes the dynamics in an overlapping generations model with the provision of child allowances. Fertility is an increasing function of child allowances and there exists a threshold effect of the marginal effect of child allowances on fertility. We show that if the effectiveness of child allowances is sufficiently high, an intermediate-sized tax rate will be enough to generate chaotic dynamics. Besides, a decrease in the inter-temporal elasticity of substitution will prevent the occurrence of irregular cycles.

Prevalence, characteristics, and poverty status of Supplemental Security Income multirecipients

"Multirecipients" are people who receive Supplemental Security Income (SSI) payments while living with other recipients (not including an SSI-eligible spouse). Using Social Security Administration records matched to Current Population Survey data for 2005, this article examines multirecipients' personal, family, household, and economic characteristics. I find that no more than 20 percent of the 2005 SSI population were multirecipients. Most multirecipients were adults, lived with one other recipient, and/or shared their homes with related recipients. Multirecipients were generally less likely to be poor than SSI recipients as a whole; but those who were children, lived with one other recipient, and/or shared their homes with a nonrecipient were more likely to be poor. Implementing sliding-scale SSI benefit reductions for children in multirecipient households would affect about 23 percent of multirecipients, or about 5 percent of all SSI recipients.

A profile of social security child beneficiaries and their families: sociodemographic and economic characteristics

Using a rich dataset that links the Census Bureau's Survey of Income and Program Participation calendar-year 2004 file with Social Security benefit records, this article provides a portrait of the sociodemographic and economic characteristics of Social Security child beneficiaries. We find that the incidence ofbenefit receipt in the child population differs substantially across individual and family-level characteristics. Average benefit amounts also vary across subgroups and benefit types. The findings provide a better understanding of the importance of Social Security to families with beneficiary children. Social Security is a major source of family income for many child beneficiaries, particularly among those with low income or family heads with lower education and labor earnings.

Child Support Enforcement program; medical support. Final regulation

This regulation revises Federal requirements for establishing and enforcing medical support obligations in Child Support Enforcement (CSE) program cases receiving services under title IV-D of the Social Security Act (the Act). The changes: require that all support orders in the IV-D program address medical support; redefine reasonable-cost health insurance; require health insurance to be accessible, as defined by the State; and make conforming changes to the Federal interstate, substantial compliance audit, and State self-assessment requirements.

SCHIP. Does this model for covering kids have legs?

The popular federal-state insurance program for kids is caught between legislators who want to expand its scope and others who want to rein it in.

A profile of children with disabilities receiving SSI: highlights from the National Survey of SSI Children and Families

This article provides a nationally representative profile of noninstitutionalized children 0 to 17 years of age who were receiving support from the Supplemental Security Income (SSI) program because of a disability. To assess the role of the SSI program in providing assistance to low-income children with disabilities and their families, it is important to obtain detailed information on demographic characteristics, income and assets, health and disabilities, and health care utilization. Yet administrative records of the Social Security Administration do not contain many of the relevant data items, and the records provide only an incomplete picture of the family relationships affecting the lives of children with disabilities. The National Survey of SSI Children and Families fills this gap. This summary article is based on survey interviews conducted between July 2001 and June 2002 and provides some highlights characterizing children with disabilities who were receiving SSI and their families. Most children receiving SSI (hereafter referred to as "SSI children") lived in a family headed by a single mother, and less than one in three lived with both parents. A very high proportion, about half, were living in a household with at least one other individual reported to have had a disability. About 70 percent of children received some kind of special education. SSI support was the most important source of family income, with earnings a close second. On average, SSI payments accounted for nearly half of the income for the children's families, and earnings accounted for almost 40 percent. When all sources of family income were considered, slightly more than half (54 percent) of SSI children lived in families above the poverty threshold, a notable fact given that the federal SSI program guarantees only a subpoverty level of income. However, beyond these averages there was substantial variation, with some children living in families with income well below the poverty threshold and others having income well over 200 percent of the poverty threshold. About one-third of SSI children lived in families owning a home, two-thirds lived with parents or guardians with at least one car, and about 40 percent lived with parents or guardians with zero liquid assets. Less than 4 percent lived with adults who owned stocks, mutual funds, notes, certificates of deposit, or savings bonds. The Social Security Administration's administrative records contain only a limited amount of information about disability diagnoses. The National Survey of SSI Children and Families supplements those records with data from an array of questions on functional limitations, self-reported health, and the perceived severity of disabilities. The data suggest that a great degree of variation in severity exists within the childhood caseload, as reflected in reports of the presence or absence of six functional limitations, perceived overall health status, and perceived impact of disability on the child's ability to do things. Overall, 36 percent of the children were reported to have had disabilities that affected their abilities to do things "a great deal," and for 21 percent their difficulties had very little or no impact. Physical disabilities were most common among children aged 0 to 5, and mental disabilities dominated the picture for the other two age groups: 6 to 12 and 13 to 17. Virtually all SSI children are covered by some form of health insurance, with Medicaid being by far the most common source of health insurance coverage. Just as in the case of the severity of disabilities, substantial variation was reported in health care utilization among SSI children. Almost 30 percent of children had two or fewer doctor visits during the 12 months preceding the interview, and close to 50 percent had five or more doctor visits. About four-fifths of the children had no reported hospitalizations or surgeries during the previous year. More than 40 percent of the children visited an emergency room during the previous year, most of them more than once. Importantly, no out-of-pocket costs associated with medical care were reported for more than two-thirds of the children, and only about 3 percent had annual expenses exceeding $1,000 for physical and mental health care. This finding suggests that SSI payments are not used to cover medical expenses for the overwhelming majority of children. The use of supportive therapies varied widely among SSI children: more than half reported having used physical, occupational, or speech therapy; only 8 percent used respite care for the parents or other family members. An analysis of the perception of the survey respondents shows that more than one-third of children had unmet needs for mental health counseling services, and about three-quarters of families had unmet needs for respite care. In several service categories, the proportion perceived to have had unmet service needs was around 10 percent or less. In the dominant service category of physical, occupational, and speech therapy, only 11 percent perceived to have had unmet service needs.

Re-reporting of child maltreatment: does participation in other public sector services moderate the likelihood of a second maltreatment report?

OBJECTIVE

This study uses administrative data to track the first re-reports of maltreatment in a low-income, urban child welfare population (n=4957) while controlling for other public service involvement. Service system involvement is explored across the following sectors: Child Welfare, Income Maintenance, Special Education, Juvenile Court, and various forms of Medicaid-reimbursed medical or mental health care. This study builds knowledge by adding the services dimension to an ecological framework for analyses and by following recurrence for a longer period of time than prior investigations (7.5 years).

METHOD

We model the re-reporting of a child for maltreatment as a function of child, caregiver, service, and neighborhood characteristics using data from birth records, child welfare, income maintenance, Medicaid, adult corrections, juvenile court, special education, law enforcement, and census sources. Bivariate and multivariate analyses are presented, the latter using Cox regression with a robust sandwich covariance matrix estimate to account for the intracluster dependence within tracts.

RESULTS

Key results across bivariate and multivariate analyses included a lower rate of re-reporting among children with parents who were high school graduates and/or permanently exited from the first spell on AFDC (p<.0001); and for children in families that received less intensive in-home services compared to those not receiving services, receiving intensive in-home, or foster care services (p<.0001). Higher rates of re-reporting were found for children with Medicaid mental health/substance abuse treatment records (p<.0001) and special education eligibility for emotional disturbance (p<.005).

CONCLUSIONS

Caretaker characteristics and non-child welfare service use patterns had a strong association with the likelihood of a child being re-reported to the child welfare agency and should be more heavily attended to by child welfare workers. High rates of service sector overlap suggest that interagency ties and cooperation should be strengthened. The lower risk associated with less intensive in-home services compared to un-served cases may indicate under-identification of in-home service eligibility following a first report of maltreatment.

Welfare recipients' involvement with child protective services after welfare reform

OBJECTIVE

This study identifies factors associated with child protective services (CPS) involvement among current and former welfare recipients after welfare reform legislation was passed in the US in 1996.

METHOD

Data come from the Women's Employment Study, a longitudinal study of randomly selected welfare recipients living in a Michigan city in 1997 (N=541). In order to identify risk factors for CPS involvement among current and former welfare recipients, multinomial logit analyses with 29 independent variables were employed on a trichotomous dependent variable: no CPS involvement, investigation only, and supervision by CPS after investigation.

RESULTS

The relationship between work and involvement with CPS differs by work experience prior to welfare reform. As the percentage of months working after welfare reform increased, the risk of being investigated by CPS declined among those with prior work experience but the risk increased among those without prior work experience. However, work variables were not significant predictors of supervision by CPS after an initial investigation. Further, race, cohabitation, childhood welfare receipt, having a learning disability, having a large number of children, being newly divorced, living in a high problem neighborhood, and being convicted of a crime were associated with one's probability of being either investigated or supervised by CPS.

CONCLUSIONS

These findings suggest that employment could have increased the stress levels of current or former welfare recipients without prior work experience to the point where they were prone to minor child rearing mistakes that resulted in a CPS investigation, but were not severe enough to warrant opening the case for supervision. Supports should be provided to welfare mothers who are prone to involvement with CPS; expansions in the childcare subsidy and a reduction or delay in work requirements might also help these families.

Disparities in children's use of oral health services

OBJECTIVES

We sought to determine if the recent expansions in Medicaid and the State Children's Health Insurance Program (SCHIP) have resulted in a narrowing of income disparities over time with the use of dental care in children 2 to 17 years of age.

METHODS

Six years of data from the National Health Interview Survey were utilized. A trend analysis was conducted using 1983 as a baseline, which predates the expansions, and 2001-2002, the endpoint, which postdates implementation of the expansions. In addition, we examined two intermediate time points (1989 and 1997-1998). We conducted unadjusted and adjusted analyses using logistic regression.

RESULTS

Overall, use of ambulatory dental care has increased dramatically for children over the past two decades. In 1983, more than one in three children (38.5%) had no dental care within the previous 12 months. By 2001-2002, about one-quarter of children (26.3%) were reported to have no dental care within the year, a reduction of 12.2% from 1983 (p<0.001). Frequency of unmet dental care remained unchanged between 1997-1998 (the first year this measure was available) and 2001-2002. A reduction in income disparities for use of dental care was found in our unadjusted analysis but this difference became statistically insignificant in the adjusted analysis. No changes in income disparities occurred for unmet dental needs in either the unadjusted or adjusted analyses.

CONCLUSIONS

A substantial overall improvement in dental care use has occurred among all income groups, including poor and near poor children. This "keeping up" with their higher-income counterparts represents an important public health accomplishment for children in low-income families. Nevertheless, additional efforts are needed to close remaining disparities in access to dental care.

Three Years Of State Fiscal Struggles: How Did Medicaid And SCHIP Fare?

During 2003-05, states faced some of the largest budget shortfalls since World War II. With a focus on Medicaid and SCHIP, we examine budget decisions in eight states during this period. Increasing Medicaid enrollment because of the economic down-turn and rising health care costs compounded state budget shortfalls as state revenues dropped; problems peaked in 2004. States, however, were reluctant to confront their budget deficits as long-term problems and implemented a variety of one-time revenue strategies and spending reductions that push fiscal problems into the future. The arrival of federal fiscal relief in late 2003 helped states avoid deeper cuts but did not eliminate cutbacks.

Public insurance eligibility and enrollment for special health care needs children

We estimated the proportion of children with special health care needs (CSHCN) eligible for Medicaid and the State Children's Health Insurance Program (SCHIP) using data from the 2000 and 2001 National Health Interview Survey (NHIS) and an algorithm to determine likely eligibility. We find that CSHCN were more likely to be eligible compared with other children (50 versus 43 percent), and that they were eligible through different program mechanisms. Relatively few faced waiting periods and premiums to participate in public programs. Participation rates were higher for CSHCN eligible through Medicaid Program rules prior to the SCHIP expansions, compared with those newly eligible after 1997. CSHCN had higher rates of participation than children without special needs (CWOSN), across all eligibility categories.

Federal Income Payments and Mental Retardation: The Political and Economic Context

Federal income maintenance programs for people with mental retardation in the United States were described. Combined SSI and DI spending in fiscal year 2000 totaled an estimated $20.6 billion for people with mental retardation. This population is particularly vulnerable to the vagaries of changing public policy and are particularly reliant upon public support. The relative importance of income programs in the lives of people with mental retardation is discussed and the changing role of federal social welfare policy with regard to these programs analyzed.

Family support in the United States: financing trends and emerging initiatives

Trends in family support spending and new programmatic initiatives across the country during the 1990s are summarized. Nationally, total spending for family support exceeded $1 billion in 2000. Between 1990 and 2000, spending for such services in the United States grew from 1.5% to 4% of total resources expended by state MR/DD agencies. However, we found considerable state variability in level of resources allocated to support families providing care to a member with developmental disabilities. Programmatic initiatives include trends toward family-directed services, targeted programs for special populations, such as ethnic minorities and aging caregivers, and the slow expansion of cash subsidies. Recommendations for the future course of policy in this area are provided.

Early assessments of SCHIP's effect on access to care for adolescents

PURPOSE

To examine implementation issues and challenges affecting access to care for adolescents during the first year of SCHIP operation in five states (California, Connecticut, Maryland, Missouri, and Utah).

METHODS

Information was obtained through on-site interviews with senior SCHIP program staff members, medical directors, and other key staff members from managed care organizations; key staff members from behavioral health subcontractors or the state's behavioral health plans; a variety of physical and mental health providers; and families. Analysis of relevant SCHIP documents and available enrollment, capitation, and quality data was also conducted.

RESULTS

The five states generally have focused little attention in the start-up phase to the unique service needs of adolescents. Although primary care was readily available, concerns were raised about training and experience in serving this population and the availability of multidisciplinary practice arrangements. Access to family planning did not appear to be a problem. However, access to mental health services and dental services was seriously affected by limited provider participants.

CONCLUSIONS

Because adolescents constitute a sizeable proportion of the SCHIP population, states and managed care organizations need to consider ways to increase the participants of adolescent providers and to identify various financial and other incentives to address the serious shortages in mental health services and dental care.

Medicaid managed care payment methods and capitation rates in 2001

We present results from a survey of Medicaid managed care payment methods and rates in 2001 for AFDC/TANF and poverty-related Medicaid populations, updating a similar survey of 1998 rates. Rates were adjusted for differences in age-sex groupings, maternity payments, and service carve-outs. A twofold variation in Medicaid capitation rates remains, although there was a change in the composition of states at the top and bottom. The data also show that the growth in Medicaid capitation rates between 1998 and 2001 averaged 18 percent, considerably more than the increase in Medicare+Choice rates.

The role of disability living allowance in the management of attention-deficit/hyperactivity disorder

OBJECTIVE

To explore the use of Disability Living Allowance (DLA) by families of children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD), and to discuss the implications for clinicians involved in their treatment.

STUDY DESIGN

Opportunistic survey of patients attending ADHD clinic.

SETTING

Urban area in the north-east of England.

SUBJECTS

A total of 32 carers of children being treated for ADHD with methylphenidate.

INTERVENTION

Semi-structured telephone interviews about receipt and use of DLA. This involved open and closed questions and a multiple-choice section.

RESULTS

In total, 19 out of the 32 families were receiving DLA. They chose to use it mainly to replace clothes and furniture and to provide diversions and activities for the children concerned. Some families were unaware of potential eligibility for DLA, whereas a few had chosen not to apply. Only one family's application for DLA had been unsuccessful. Carers were unanimously positive about the extra income.

CONCLUSIONS

Families view DLA as an important means to replace damaged items and to fund recreational activities to contain over-activity. Families receive little formal guidance on ways of using DLA money to support children with ADHD. Virtually no specific training in benefits awareness is provided to general practitioners and child health specialists, who are often asked to judge the child's level of impairment or incapacity. Applying for DLA may affect the therapeutic relationship for good or ill. There is a need for professionals in contact with children with ADHD to inform families of the possibility of receiving DLA and support them in applications. As diagnosis and treatment of ADHD becomes more commonplace, more families are likely to be entitled to claim DLA. This has definite implications for the social security budget.

How much did the Medicaid expansions for children cost? An analysis of state Medicaid spending, 1984-1994

The authors examine the relationship between the Medicaid eligibility expansions for children and state Medicaid spending during the period from 1984 to 1994. They find that the Medicaid expansions had relatively low incremental cost per enrollee--substantially below the average Medicaid expenditure for children. Expansion children tend to be older and have fewer disabilities. Moreover, many of the most expensive expansion children would have been covered by Medicaid-medically-needy provisions had the expansions not occurred. The authors examine the implications of our findings for intensified Medicaid outreach efforts and for the State Children's Health Insurance Program.

Managed care and children's behavioral health services in Massachusetts

OBJECTIVE

The authors investigated changes in treatment patterns and costs of care for children after the implementation of the Massachusetts Medicaid carve-out managed care plan.

METHODS

The authors hypothesized that after the introduction of managed care, per-child expenditures would be reduced, continuity of care would not improve, and per-child mental health expenditures would undergo larger reductions for disabled children, compared with children enrolled in the Aid to Families With Dependent Children program. Using data from Medicaid and the Massachusetts Department of Mental Health, the authors studied 16,664 Massachusetts Medicaid beneficiaries aged one to 17 years for whom reimbursement claims were submitted for psychiatric or substance use disorder treatment at least once during the two years before the introduction of managed care (1991 to 1992) or during the two years afterward (1994 to 1995). Multivariate analysis was used to estimate changes in probability of admission, and, among patients admitted, to identify factors accounting for variation in length of stay. To assess the variation in expenditures, we regressed the same variables, using the natural logarithm function to transform total mental health expenditures data and inpatient expenditures data to reduce skewness.

RESULTS

After the introduction of managed care, per-child expenditures were lower, especially for disabled children, and the Department of Mental Health was used as a safety net for the most seriously ill children without increasing state expenditures. Continuity of care appeared to decline for disabled children.

CONCLUSIONS

It is likely that a combination of factors related to the reported changes in patterns of care and expenditures were responsible for the overall per-child expenditures.

Reducing welfare benefits: consequences for adequacy of and eligibility for benefits

During the past two decades, most states have allowed welfare benefit levels to erode with inflation. Very little attention has been paid by academics and policy makers to the potential effects of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 on welfare benefit levels. This article provides a number of explanations for likely reductions in states' welfare benefit levels. Consequences of reducing welfare benefit levels are examined. The article shows how small changes in benefit levels can alter profoundly eligibility for welfare. Social workers need to advocate for increases in welfare benefit levels which, at the very least, keep up with inflation.

Improving health-based payment for Medicaid beneficiaries: CDPS

This article describes the Chronic Illness and Disability Payment System (CDPS), a diagnostic classification system that Medicaid programs can use to make health-based capitated payments for TANF and disabled Medicaid beneficiaries. The authors describe the diversity of diagnoses and different burdens of illness among disabled and AFDC Medicaid beneficiaries. Claims from seven States are analyzed, and payment weights are provided that States can use when adjusting HMO payments. The authors also compare the taxonomy and statistical performance of CDPS to other leading diagnostic classification systems and find that the new model performs better in a number of respects.

The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland

OBJECTIVE

To determine whether financial sanctions to Aid to Families With Dependent Children (AFDC) recipients can be used to improve vaccination coverage of young children.

DESIGN

Randomized controlled trial.

SETTING

Six AFDC jurisdictions in Maryland.

INTERVENTION

Recipients of AFDC were randomized to the experimental or control group of the Primary Prevention Initiative. Families in the experimental group were penalized financially for failing to verify that their children received preventive health care, including vaccinations; control families were not.

PARTICIPANTS

Children aged 3 to 24 months from assigned families were randomly selected for the evaluation (911 in the experimental, 864 in the control, and 471 in the baseline groups).

MAIN OUTCOME MEASURES

Up-to-date for age for diphtheria and tetanus toxoids and pertussis (DTP), polio, and measles-mumps-rubella (MMR) vaccines; missed opportunities to vaccinate; and number of visits per year.

ANALYSIS

Comparisons among baseline and postimplementation years 1 and 2.

RESULTS

Vaccination coverage of children was low. Less than 70% of children were up-to-date for age for polio and MMR vaccines; slightly more than 50% were up-to-date for DTP vaccine. Up-to-date rates differed little among baseline, experimental, and control groups. Over time, there was a decrease in missed opportunities, and more children made at least 1 well-child visit; however, neither improvement resulted in a change in vaccination status.

CONCLUSIONS

The Primary Prevention Initiative did not contribute to an increase in vaccination coverage among these children. Minimal economic sanctions alone levied against parents should not be expected substantially to affect vaccination rates.

Medicaid managed care payment rates in 1998

This paper reports on a new survey of state Medicaid managed care payment rates. We collected rate data for Medicaid's Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF) and poverty-related populations and made adjustments to make the data comparable across states. The results show a slightly more than twofold variation in capitation rates among states, caused primarily by fee-for-service spending levels and demographics. There is a very low correlation between the variation in Medicaid capitation rates among states and the variations in Medicare's adjusted average per capita cost. The data are not sufficient to answer questions about the adequacy of rates but should help to further policy discussions and research.

Public assistance receipt among immigrants and natives: how the unit of analysis affects research findings

Differences between immigrant and native households in rates of welfare receipt depend on nativity differences in individual-level rates of receipt, in household size, in mean number of recipients in receiving households, and in household nativity composition. We present algebraic derivations of these relationships and use data from the 1990 and 1991 panels of the Survey of Income and Program Participation to examine empirically the extent to which levels of welfare receipt for immigrants and natives are sensitive to the use of household-, family-, or individual-level units of analysis or presentation. The findings show that nativity differences are statistically significant only at the level of larger units. The results also indicate that if immigrants and natives had identical living arrangements, immigrants' household-level receipt of Supplemental Security Income would significantly exceed natives' receipt even more than it actually does, but the nativity difference in receipt of Aid to Families with Dependent Children (AFDC) would reverse directions. Moreover, the level of AFDC receipt of immigrant households falls significantly below that of native households when native-born children living in households headed by immigrants are treated as if they were foreign born.

Managed (not to) care: Medicaid and children with disabilities

The emphasis that managed care programs place on cost containment complicates further the already complex setting for Medicaid health services for children with disabilities by adding an additional barrier to access care to those that already exist. A review considers the attitudes toward and working of Medicaid managed care arrangements for children in general and children with disabilities in particular.

A longitudinal perspective on entitlement income among homeless adults

OBJECTIVE

Sources of entitlement income were examined in a sample of homeless adults to determine whether certain subgroups more consistently obtain entitlement income and are more likely to continue receiving it over time.

METHODS

From a baseline sample of 564 homeless residents of Alameda County, California, 397 were interviewed at both five- and 15-month follow-ups. Information was obtained on income received from public sources in the 30 days before each interview, including general assistance, Aid to Families With Dependent Children (AFDC), Supplemental Security Income, or Social Security Disability Insurance. Data were also obtained on psychiatric diagnosis, race, marital status, education, duration of homelessness in adulthood, household status, and reported disability.

RESULTS

At baseline fewer than half of the respondents were receiving any entitlement income. The benefits of almost half of the AFDC and general assistance recipients were terminated during the 15-month period. Respondents who continued receiving entitlement income over the 15-month period were more likely to be black, to be women alone or with children, to have a family history of receiving welfare, and to report a disability. Respondents with dual disorders were six times more likely than others to have their benefits terminated.

CONCLUSIONS

Entitlement income is tenuous for many homeless adults, particularly those with dual diagnoses.

Young unwed fathers of AFDC children: do they provide support?

We examine the support provided by fathers of children born to disadvantaged teenage mothers. Our sample includes the fathers of 6,009 children born over a two-year period to 3,855 teenage mothers receiving AFDC in three economically depressed inner cities. These fathers provide little social and economic support to their children. Support declines as their children age from infants to toddlers and as fathers' relationships with the mothers grow more distant. Fathers' employment status and educational attainment positively affect the amount of economic support that they provide but do not strongly influence the amount of social support they provide.

Do training programs help AFDC recipients leave the welfare rolls? An evaluation of New York City's BEGIN (Begin Employment Gain Independence Now) program

Guided by the Federal Family Support Act of 1988 and the Job Opportunity and Basic Skills Program (JOBS), welfare reform initiatives on state and local levels were designed to foster employability among the public assistance population. Reform has focused on enhancing the supply of labor rather than the demand for labor as a route to labor force participation for the public assistance population. Program reforms assume that, by providing job training, educational services, and training-related expenses, labor market entry of the participating clientele would be facilitated while caseloads and public expenditures would decline. To date, analysis of similar programs in many states indicates that the impact of such programs in reducing public assistance caseloads is marginal. In New York City, despite the large investment of public funds in such programs, prior to this study the outcome of program implementation remained largely unknown. This study evaluates New York City's BEGIN program outcome target defined as the ability of the program to move welfare clients off public assistance and into the labor market. While the results of the study indicate that New York City's BEGIN program does not improve client's odds of leaving welfare, when compared to the odds of a non-participation client, there are several significant findings. The impact of program participation can be distinguished among distinct age groups. While older clients responded positively to BEGIN participation, access to day care was the only factor that significantly improved the probability that clients younger than 36 years of age would leave the welfare rolls within a two-year period. In response to the findings, the researchers suggest that future welfare reform efforts should grant localities broader flexibility to determine their own target population so that resources can be allocated to those groups that are most likely to benefit from specific programs.

Paternalistic welfare reform: current perceptions and behavioral models

Most of the current welfare reform incentives make assumptions about the behavior of AFDC clients. Among these assumptions are that clients will seek to maximize their financial resources; that they understand the requirements of the welfare reform; and that they can control the behaviors targeted by the welfare reform effort. Using survey data gathered from AFDC clients involved in Maryland's welfare reform initiative, the authors suggest that the assumptions underlying these welfare reform initiatives may be too simplistic. For welfare reform to be effective, the authors argue that these initiatives must reflect the complexity of the problems and concerns faced by the AFDC client.

Cost neutrality and welfare reform

Many states have chosen to reform welfare through the Social Security Act's Section 1115 waivers. When states choose this method, the Departments of Health and Human Services and Agriculture require the states to determine whether these initiatives are cost neutral to the federal government. States using this cost neutrality information as an ongoing piece of evaluation information must be careful in interpreting cost neutrality data. This article discusses two reasons for state and federal policy-makers to be cautious in using cost neutrality data as an indicator of welfare reform success.

Breaking the cycle of dependency: dual diagnosis and AFDC families

This paper proposes that a comprehensive, long-term program with a case-management focus will produce better outcomes and be more cost-effective than the current approach to managing the illnesses of women on Temporary Assistance for Needy Families (or TANF, formerly known as AFDC) who are afflicted with both drug dependency and mental illness, i.e. a dual diagnosis. It is proposed that this comprehensive approach would diminish the generational cycle of substance abuse, dysfunction (including violence), and dependence on public support, which is too often the pattern in single-parent homes where the mother has been dually diagnosed. For our purposes, dual diagnosis is defined as any mental health diagnosis using the DSM-IV criteria coexisting with a diagnosis of substance abuse, whether licit or illicit. Current drug policy, particularly as it applies to those with a dual diagnosis, has an emphasis on criminal justice system solutions. It is extremely expensive (incarceration alone is variously estimated as costing $25,000 to $45,000 per year per person), and does little to treat, prevent, or consequently, reduce the problem. The model design discussed in this article provides for comprehensive treatment and support services to women with a dual diagnosis receiving TANF. Its goal is to help break the family cycle of system dependency. The article hypothesizes that if a well-designed program evaluation is implemented, it will demonstrate savings in reduced health care, criminal justice, and social service costs.

Comparison of access and costs of Medicaid dental services in a hospital clinic and community practices

OBJECTIVES

This paper reports the results of a three-year evaluation of access to dental care and its associated costs for Aid to Families with Dependent Children (AFDC) beneficiaries enrolled in a hospital-based health maintenance organization (HMO) or a fee-for-service (FFS) option.

METHODS

Medicaid enrollees (n = 3, l655) having a year of eligibility were assigned to either the hospital HMO or FFS care, and their use of dental care and its costs compared.

RESULTS

A higher percent of those beneficiaries enrolled in the FFS option used dental care than those in the HMO plan. FFS enrollees also had more annual visits per person than those in the randomly assigned HMO group. FFS dental patients treated in the hospital had the highest costs of any payment-provider combination studied.

CONCLUSIONS

To understand the mix of utilization rates, visits, and costs, one must take into account the way in which the HMO hospital plan is reimbursed, the way in which the dental department is reimbursed, and the way in which the dental provider is reimbursed.

Potential cost savings for Medi-Cal, AFDC, food stamps, and WIC programs associated with increasing breast-feeding among low-income Hmong women in California

OBJECTIVE

To determine the potential cost savings for four social service programs if breast-feeding rates increased among Hmong women in California.

DESIGN

Cost-savings analysis.

SUBJECTS/SETTING

Hmong women in California. In this population, breast-feeding is currently uncommon, and use of contraceptives is minimal.

MAIN OUTCOME MEASURES

Savings were based on estimates of the resulting decrease in infant morbidity, maternal fertility, and formula purchases (Special Supplemental Nutrition Program for Women, Infants, and Children) if women breast-fed each child for at least 6 months. Costs were projected over a 7.5-year period and future values were discounted with annual interest rates of 2% or 4%.

RESULTS

Substantial savings estimates were associated with breast-feeding for all four programs. The total projected savings over the 7.5-year period ranges from $3,442 to $4,944 (4% discount) to $4,475 to $6,0960 (0% discount) per family enrolled in all four programs. This translates into an estimated yearly savings of between $459 and $659 (4% discount) and $597 and $808 (0% discount) per family.

APPLICATIONS

Although health care providers generally accept that breast-feeding is the preferred method for feeding infants, many still view the choice as a neutral one; that is, they consider low breast-feeding rates in the United States a cultural choice with no cost to society. This analysis provides evidence that breast-feeding is economically advantageous for individuals and society.

The new politics of child and family policies

Given the slowdown in the legislative process and the absence of any closure on the proposed congressional initiatives on social safety net programs, the specifics of the policy developments are still unclear. What is clear, however, is that the United States is entering a period of social policy devolution, federal (and probably state) funding cuts for social benefits and services, and a major philosophical shift in the premises underlying social policy. These policy trends have major implications for the social work profession, for practitioners at all levels, for educators, and most important for low-income and vulnerable children and their families. Social workers need to become informed about these developments if they are to be effective practitioners, teachers, and advocates.

Economic incentives for financial and residential independence

In this paper we examine the impact of the resource of children and of their parents on the children's transition to residential and financial independence. Previous studies of this transition focused primarily on the impact of family structure and parent-child relationships on the decision to leave home, but much less in known about the role of economic factors in the transition to independence. Using data from the Panel Study of Income Dynamics (PSID) for the period 1968-1988, we estimate discrete-hazard models of the probability of achieving residential and financial independence. We find that the child's wage opportunities and the parents' income are important determinants of establishing independence. The effect of parental income changes with the child's age. We also find some evidence that federal tax policy influences the decision to become independent, although the magnitude of this effect is quite small.

The growing epidemic of uninsurance: new data on the health insurance coverage of Americans

Despite a massive expansion of Medicaid and an upswing in the economy, the total number of Americans uninsured in 1993 was 39.7 million, more than at any time since the passage of Medicaid and Medicare in the 1960s. Since 1989, the ranks of the uninsured have swelled by 6.3 million. Millions more would be uninsured if Medicaid enrollment had not risen dramatically, by 10.5 million people since 1989. Loss of health coverage is a growing problem for middle-income families, women, and children, as it has long been for low-income families. Even in Hawaii, whose employer mandate program is often cited as a model of universal coverage, there was a large increase in uninsurance. Nationwide, the sharp upswing in the number of Americans who are uninsured has coincided with government and corporate policies to encourage medical competition and push people into managed care plans. Republican proposals to limit AFDC benefits threaten to further increase uninsurance, particularly among women and children. Only a Canadian-style single-payer reform can assure universal coverage and simultaneously contain costs.

Access of rural AFDC Medicaid beneficiaries to mental health services

This article examines geographic differences in the use of mental health services among Aid to Families with Dependent Children (AFDC)-eligible Medicaid beneficiaries in Maine. Findings indicate that rural AFDC beneficiaries have significantly lower utilization of mental health services than urban beneficiaries. Specialty mental health providers account for the majority of ambulatory visits for both rural and urban beneficiaries. However, rural beneficiaries rely more on primary-care providers than do urban beneficiaries. Differences in use are largely explained by variations in the supply of specialty mental health providers. This finding supports the long-held assumption that lower supply is a barrier to access to mental health services in rural areas.