States experiment with using welfare as leverage to get preventive care for kids
Welfare Preventive / Kids
July 31, 1997
Under the Aid to Families with Dependent Children (AFDC) program, federal law contained no requirement that a parents get immunizations for their children or participate in preventive health care, and states were not permitted to add such conditions themselves.
In the past few years, however, states have been granted welfare waivers that allowed them greater flexibility in imposing such requirements and using sanctions against those who didn’t comply.
No statistics are available yet, but under the new Temporary Aid to Needy Families (TANF) program, several states are introducing new requirements or revising existing ones tying preventive care to welfare benefits. Some states are including provisions in personal responsibility contracts that welfare recipients must sign before they can get benefits.
About a third of the states included an immunization requirement in waiver applications submitted under the AFDC program, with smaller numbers of states making other medical requirements as well, such as participation in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and getting regular medical check-ups for children.
Under Maryland’s new Family Investment welfare program (the state elected not to continue its old waiver program), Maryland can reduce a family’s cash welfare payment by $25 a month if children under 6 do not receive preventive care, including immunizations. Such screenings are required for both children and adults seeking to enroll in the state’s Medicaid managed care program. A family enrolled in the cash welfare program can earn a $20 bonus for each family member age 8 and older who obtains the screening.
Several consumer advocates say they support the general concept of the requirements made by many states, but worry that sanctions could be imposed in error because of recordkeeping problems in welfare programs.
Waivers granted by the federal government under the old AFDC program "typically included a requirement that sanctions not be imposed until reason for failure to comply was identified and barriers to access were addressed," says Mark Greenberg, senior staff attorney for the Center on Law and Social Policy, Washington, D.C. "States were expected to insure that immunizations and health care were accessible and available.
"One of the dangers under the new law is that none of those safeguards are assured. There is no requirement that a state provide any needed assistance, address barriers, or provide for good cause exception," Mr. Greenberg says.
West Virginia has attempted to address these issues with its new West Virginia Works program. Sue Buster, director of the policy unit for the state’s Office of Family Support, says West Virginia has tried to get local maternal and child health workers to help ensure that parents keep EPSDT appointments for their children. Before anyone is sanctioned, they are "given an opportunity to request a hearing where an independent officer listens to both sides," she says.
The new welfare program began operating in nine West Virginia counties Jan. 1 and is set to be introduced in the remaining counties, Oct. 1, she says. Under the program, a personal responsibility contract negotiated between a case worker and a client can include requirements that the parent bring children for well-baby and other doctor appointments. Recipients can lose up to one third of their cash assistance the first time they fail to abide by the contract without good cause, up to two-thirds the second time, and can lose all of their benefits the third time.
Gordon Bonnyman, of the Tennessee Justice Center, says one of the challenges of implementing such health requirements is that studies have shown that "the ability of parents to recall accurately what immunizations their children have is very poor." Getting medical records can be especially problematic when the burden is put on people with very limited educational and social skills, he says.
Tennessee included an immunization requirement in its personal responsibility contract under a welfare waiver that took effect last September. A family’s grant can be reduced by 20% for failure to comply, although it does include a good cause exception. Adding to the problem in Tennessee, Mr. Bonnyman says, is that "the state has enormous technical problems creating systems for compiling information on an individual specific basis" that follow patients from provider to provider or from one geographic region to another.
In Michigan, a family can lose $25 a month if the parent does not declare that children under 6 have been immunized, but they generally do not need to show proof.
Linda Rose, policy analyst with the Family Independence Agency in Michigan, says welfare recipients are being penalized at redetermination for eligibility if they have children under 6 who are not immunized.
She says the numbers of sanctions have remained fairly steady over the past year. In January 1996, sanctions were imposed in the cases of 135 children who were not immunized, compared with 155 cases a year later. At that point, the families of 53 children were in penalty status for 12 or more months, she says. Children fall off the list when they turn 6-years old.
Contact Ms. Buster at 304-558-2878; Ms. Rose at 517-335-3593; Mr. Greenberg at 202-328-5140; and Mr. Bonnyman at 615-255-0331.
States experiment with using welfare as leverage to get preventive care for kids
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