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Drawing on developmental and policy research, this study examined whether 3 dimensions of caseworkerrecipient interaction in welfare offices functioned as critical ecological contexts for recipient families. The sample consisted of 1,098 families from 10 welfare offices in National Evaluation of Welfare to Work Strategies (NEWWS). In multilevel analyses, caseworker support, caseload size, and emphasis on employment predicted 5-year quarterly trajectories of earnings, income, and welfare receipt. Recipients in offices characterized by high support had steeper increases in earnings and income; those in offices with high caseload size had steeper decreases in income and welfare receipt; and those in offices with high emphasis on employment had steeper decreases in welfare receipt. These economic trajectories were associated with children's reading and math achievement and internalizing behavior at ages 8-10.

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. 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). 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. 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.

Objectives. We evaluated the economic benefits of Temporary Assistance to Needy Families (TANF) relative to the previous program, Aid to Families with Dependent Children (AFDC). Methods. We used pooled mortality hazard ratios from 2 randomized controlled trials—Connecticut Jobs First and the Florida Transition Program, which had follow-up from the early and mid-1990s through December 2011—and previous estimates of health and economic benefits of TANF and AFDC. We entered them into a Markov model to evaluate TANF’s economic benefits relative to AFDC and weigh them against the potential health threats of TANF. Results. Over the working life of the average cash assistance recipient, AFDC would cost approximately$28 000 more than TANF from the societal perspective. However, it would also bring 0.44 additional years of life. The incremental cost effectiveness of AFDC would be approximately $ 64 000 per life-year saved relative to TANF. Conclusions. AFDC may provide more value as a health investment than TANF. Additional attention given to the neediest US families denied cash assistance could improve the value of TANF.

During the 1990s reforms to the US welfare system introduced new time limits on people's eligibility to receive public assistance. These limits were developed to encourage welfare recipients to seek employment. Little is known about how such social policy programs may have affected participants' health. We explored whether the Florida Family Transition Program randomized trial, a welfare reform experiment, led to long-term changes in mortality among participants. The Florida program included a 24-36-month time limit for welfare participation, intensive job training, and placement assistance. We linked 3,224 participants from the experiment to 17-18 years of prospective mortality follow-up data and found that participants in the program experienced a 16 percent higher mortality rate than recipients of traditional welfare. If our results are generalizable to national welfare reform efforts, they raise questions about whether the cost savings associated with welfare reform justify the additional loss of life. [PUBLICATION ABSTRACT]

Context: Multiple federal public health programs use funding formulas to allocate funds to states. Objective: To characterize the effects of adjusting formula-based allocations for differences among states in the cost of implementing programs, the potential for generating in-state resources, and income disparities, which might be associated with disease risk. Setting: Fifty US states and the District of Columbia. Intervention: Formula-based funding allocations to states for 4 representative federal public health programs were adjusted using indicators of cost (average salaries), potential within-state revenues (per-capita income, the Federal Medical Assistance Percentage, per-capita aggregate home values), and income disparities (Theil index). Main Outcome: Percentage of allocation shifted by adjustment, the number of states and the percentage of US population living in states with a more than 20% increase or decrease in funding, maximum percentage increase or decrease in funding. Results: Each adjuster had a comparable impact on allocations across the 4 program allocations examined. Approximately 2% to 8% of total allocations were shifted, with adjustments for variations in income disparity and housing values having the least and greatest effects, respectively. The salary cost and per-capita income adjusters were inversely correlated and had offsetting effects on allocations. With the exception of the housing values adjustment, fewer than 10 states had more than 20% increases or decreases in allocations, and less than 10% of the US population lived in such states. Conclusions: Selection of adjusters for formula-based funding allocations should consider the impacts of different adjustments, correlations between adjusters and other data elements in funding formulas, and the relationship of formula inputs to program objectives.

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.

In this paper we examine the impact of the resources 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 is 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.

This paper presents results from a survey of Medicaid managed care payment methods and rates in 2001 for Aid to Families with Dependent Children/Temporary Assistance for Needy Families (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%, considerably more than the increase in Medicare+Choice rates. The adequacy of Medicaid managed care rates is a major issue to states, plans and beneficiaries. There seems little doubt that the level of rates, as well as the way states adjust for risk, will affect managed care plans' willingness to serve the Medicaid clientele.

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 downturn 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. [PUBLICATION ABSTRACT]

This analysis explores the effects of the 1996 welfare reform on health insurance coverage and access to care among former recipients of cash aid. Using panel data from the Women's Employment Study, which conducted five interviews between 1997 and 2003 in one Michigan county, we find that 25% of welfare leavers lacked health insurance coverage in fall 2003. Uninsured adults were significantly more likely than others to report that they could not afford a medical or dental visit during the year prior to the 2003 interview. Fixed-effect logistic regression analysis indicates that women who had been off the welfare rolls for at least 12 months (the duration of transitional Medicaid) were significantly more likely to be uninsured than women who had made more recent welfare exits, and were significantly more likely to report financial obstacles to the receipt of medical and dental care.