Simon Kosali Ilayperuma, Handler Arden
Department of Policy Analysis and Management, Cornell University, Ithaca, New York 14853-4401, USA.
Womens Health Issues. 2008 Nov-Dec;18(6 Suppl):S97-S106. doi: 10.1016/j.whi.2008.08.004.
Welfare reform has had far-reaching consequences for unmarried women and their children, including effects on their health insurance status. Those who would be receiving cash assistance absent welfare reform may have lower rates of health insurance if they failed to enroll separately for Medicaid (whose rules did not tighten over this time period), or if the new employment they entered did not provide health insurance. Administrative difficulties involved in accessing Medicaid separately from cash welfare may also have been a factor in the short run. Our research uses data from a large and nationally representative household survey that tracks the same individuals over time, the Survey of Income and Program Participation, to examine the effect of welfare reform (AFDC waivers and TANF implementation) on the health insurance status of unmarried mothers with High School completion or less (the population whose health insurance we expect would be affected by the welfare reform, or the "treatment group") in the time period surrounding a particularly important life event, pregnancy. We look at the effects of these policies over the time period 1990--1999, as well as over the time period 1990--2003, to explore the short run vs. long run impact. Our "control group", those who should not be affected by welfare reform itself but are expected to be affected by other national or state events that are happening contemporaneously, consists of married mothers with High School completion or less; the insurance experience of these women is used to control for the other forces that might otherwise lead us to attribute too little or too large an effect to welfare reform. Given the importance of access to health care at all points in the period surrounding and during pregnancy, we look at how welfare reform has affected insurance status before conception, during pregnancy, and after the birth of the child. We find that the Aid to Families with Dependent Children (AFDC) waivers of the 1990s as well as Temporary Assistance for Needy Families implementation have decreased access to Medicaid health insurance, increased access to employer health insurance, and led to a decrease in overall insurance, depending on the point in pregnancy considered and the time period of the study, with the largest effects found in coverage after the birth of a child. These findings have particular implications for the increasing emphasis on preconception and interconception care as a strategy to improve women's and infant's health.
福利改革对未婚女性及其子女产生了深远影响，包括对她们医疗保险状况的影响。如果那些在没有福利改革的情况下本可获得现金援助的人未能单独登记参加医疗补助（其规定在这一时期并未收紧），或者如果她们新进入的工作没有提供医疗保险，那么她们获得医疗保险的比例可能会较低。短期内，与现金福利分开申请医疗补助所涉及的行政困难也可能是一个因素。我们的研究使用了来自一项大型全国代表性家庭调查的数据，该调查随时间跟踪同一批个体，即收入与项目参与调查，以研究福利改革（对有子女家庭补助计划豁免和临时援助贫困家庭计划实施）对高中及以下学历未婚母亲（我们预计其医疗保险会受到福利改革影响的人群，即“治疗组”）在一个特别重要的生活事件——怀孕前后这段时间内医疗保险状况的影响。我们考察这些政策在1990 - 1999年以及1990 - 2003年期间的影响，以探究短期与长期的影响。我们的“对照组”由高中及以下学历的已婚母亲组成，她们不应受到福利改革本身的影响，但预计会受到同期发生的其他国家或州事件的影响；这些女性的保险经历用于控制其他可能导致我们将福利改革的影响归因过少或过多的因素。鉴于在怀孕前后及怀孕期间获得医疗保健的重要性，我们考察福利改革如何影响受孕前、怀孕期间以及孩子出生后的保险状况。我们发现，20世纪90年代的对有子女家庭补助计划豁免以及临时援助贫困家庭计划的实施减少了获得医疗补助医疗保险的机会，增加了获得雇主医疗保险的机会，并导致总体保险覆盖率下降，具体取决于所考虑的怀孕阶段和研究时间段，其中孩子出生后的覆盖率受影响最大。这些发现对于日益强调孕前和孕后保健作为改善妇女和婴儿健康的策略具有特别的意义。
