Public Benefit Programs and Differential Associations With Child Maltreatment by Race and Ethnicity

Importance

Public benefit programs, including state spending on local, state, and federal-state partnership programs, have consistently been associated with overall reductions in child protective services (CPS) involvement. Inequities in eligibility and access to benefit programs may contribute to varying associations by race and ethnicity.

Objective

To determine whether associations between state spending on benefit programs and rates of CPS investigations differ by race and ethnicity.

Design, Setting, and Participants

This cross-sectional ecological study used repeated state-level measures of child maltreatment from the National Child Abuse and Neglect Data System and population estimates from the US Census Bureau for all Black, Hispanic, and White children. All 50 US states from October 1, 2009, through September 30, 2019 (fiscal years 2010-2019), were included. Data were collected and analyzed from May 13, 2022, to March 2, 2023.

Exposures

Annual state spending on benefit programs per person living below the federal poverty limit, total and by the following subcategories: (1) cash, housing, and in-kind; (2) housing infrastructure; (3) child care assistance; (4) refundable earned income tax credit; and (5) medical assistance programs.

Main Outcomes and Measures

Race- and ethnicity-specific rates of CPS investigations. Generalized estimating equations, with repeated measures of states, an interaction between race and spending, and estimated incidence rate ratios (IRRs) and 95% CIs for incremental changes in spending of US $1000 per person living below the federal poverty limit were calculated after adjustment for federal spending, race- and ethnicity-specific child poverty rate, and year.

Results

A total of 493 state-year observations were included in the analysis. The association between total spending and CPS investigations differed significantly by race and ethnicity: there was an inverse association between total state spending and CPS investigations for White children (IRR, 0.94 [95% CI, 0.91-0.98]) but not for Black children (IRR, 0.98 [95% CI, 0.94-1.02]) or Hispanic children (IRR, 0.99 [95% CI, 0.95-1.03]) (P = .02 for interaction). Likewise, inverse associations were present for only White children with respect to all subcategories of state spending and differed significantly from Black and Hispanic children for all subcategories except the refundable earned income tax credit (eg, IRR for medical assistance programs for White children, 0.89 [95% CI, 0.82-0.96]; P = .005 for race and spending interaction term).

Conclusions and Relevance

These results raise concerns that benefit programs may add relative advantages for White children compared with Black and Hispanic children and contribute to racial and ethnic disparities in CPS investigations. States' eligibility criteria and distribution practices should be examined to promote equitable effects on adverse child outcomes.

Sociodemographic inequities in unscheduled asthma care visits among public assistance recipients in Japan: additional risk by household composition among workers

BACKGROUND

Public assistance programs aim to prevent financial poverty by guaranteeing a minimum income for basic needs, including medical care. However, time poverty also matters, especially in the medical care adherence of people with chronic diseases. This study aimed to examine the association between the dual burden of working and household responsibilities, with unscheduled asthma care visits among public assistance recipients in Japan.

METHODS

This retrospective cohort study included public assistance recipients from two municipalities. We obtained participants' sociodemographic data in January 2016 from the public assistance database and identified the incidence of asthma care visits. Participants' unscheduled asthma visits and the frequency of asthma visits were used as the outcome variables. Unscheduled visits were defined as visits by recipients who did not receive asthma care during the first three months of the observation period. Participants' age, sex, household composition, and work status were used as explanatory variables. Multiple Poisson regression analyses were performed to calculate the cumulative incidence ratio (IR) with a 95% confidence interval (CI) of unscheduled visits across the explanatory variables. The effect of modification on the work status by household composition was also examined.

RESULTS

We identified 2,386 recipients at risk of having unscheduled visits, among which 121 patients (5.1%) had unscheduled visits. The multivariable Poisson regression revealed that the working recipients had a higher incidence of unscheduled visits than the non-working recipients (IR 1.44, 95% CI 1.00-2.07). Among working recipients, the IRs of unscheduled visits were higher among recipients cohabiting with adults (IR 1.90 95% CI 1.00-3.59) and with children (IR 2.35, 95% CI 1.11-4.95) than for recipients living alone. Among non-working recipients, the IRs of unscheduled visits were lower for recipients living with family (IR 0.74, 95% CI 0.41-1.35) and those living with children (IR 0.50, 95% CI 0.20-1.23). A higher frequency in asthma visits was observed among working recipients living with family.

CONCLUSIONS

Working adults cohabiting with children are at the greatest risk of unscheduled visits among adults receiving public assistance. To support healthy lifestyles of public assistance recipients, medical care providers and policymakers should pay special attention to the potentially underserved populations.

Copay assistance use and prescription abandonment across race, ethnicity, or household income levels for select rheumatoid arthritis and oral oncolytic medicines

BACKGROUND: Disparities in prescription abandonment may exacerbate health inequities. Whether copay assistance is associated with changes in prescription abandonment across different patient groups is unknown. OBJECTIVE: To assess disparities in copay assistance use; prescription abandonment across race, ethnicity, or income; and association of copay use with prescription abandonment and whether it differs across race, ethnicity, or household income. METHODS: This pooled, cross-sectional study assessed claims-level prescription data linked to a consumer database containing information on race, ethnicity, and household income for commercially insured patients. The first prescription for rheumatoid arthritis (RA) or oral oncolytic medicines from 2016 to 2020 was included. Logistic regression models measured odds of copay assistance use (copay/discount cards or free-trial voucher) and prescription abandonment (prescription not filled within 30 days of health plan approval). Interaction terms for copay assistance use by race, ethnicity, and income were tested. RESULTS: The sample included 67,674 patients prescribed RA medications and 9,560 prescribed oral oncolytic medications. Copay assistance use across race, ethnicity, and income ranged from 28.2% to 31.1% (RA medicines) and 27.2% to 36.7% (oral oncolytic medicines). Among those prescribed RA medicines and not using copay assistance, Black/African American, Hispanic patients, and those with household incomes less than $50,000 were more likely to abandon prescriptions than White patients and patients with household incomes more than $200,000 (odds ratio [OR] [95% CI], P value: Black/African American: 1.17 [1.06-1.29], P < 0.01; Hispanic: 1.11 [1.01-1.22], P = 0.03; income <$50,000: 1.24 [1.11-1.37], P < 0.01). Among patients using oral oncolytic medicines and not using copay assistance, there was no racial or ethnic difference in prescription abandonment. Patients using oral oncolytics with household incomes less than $50,000 were more likely to use copay assistance (1.34 [1.12-1.61], P < 0.01), but also more likely to abandon their prescriptions if not using copay assistance (1.44 [1.12-1.85], P < 0.01). Copay assistance was associated with a 79% (RA) and 71% (oral oncolytics) lower odds of prescription abandonment (0.21 [0.19-0.24], P < 0.01; 0.29 [0.24-0.36], P < 0.01), which did not differ across race, ethnicity, or income levels (P > 0.05). CONCLUSIONS: Copay assistance has potential to narrow disparities in prescription abandonment for commercially insured Black/African American or Hispanic patients taking RA medicines and patients with household incomes less than $50,000; however, efforts to improve access to copay assistance are needed. Copay assistance, as a factor facilitating equal access to medicines, is an important consideration when evaluating policies that impact access to copay assistance programs. DISCLOSURES: Genentech, Inc., provided funding and support for this study. Dr Wong is an employee of Genentech, Inc., and shareholder of Roche, Inc. Ms Donahue, Mr Thiesen, and Mr Yeaw are employees of IQVIA.

Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data

BACKGROUND

Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years.

METHODS

The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables.

RESULTS

BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07).

CONCLUSION

Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.

The effects of a cash transfer intervention on sexual partnerships and HIV in the HPTN 068 study in South Africa

Evidence on cash transfer interventions for HIV prevention in adolescent girls and young women is unclear and indicates that they may not work uniformly in all settings. Qualitative interviews were conducted with 22 girls and young women post-intervention to determine how a cash transfer study (HPTN 068) in South Africa was perceived to influence sexual behaviours and to explore mechanisms for these changes. Participants described how the intervention motivated them to increase condom use, have fewer partners, end risky relationships and access HIV testing services at local primary health clinics. Changes were attributed to receipt of the cash transfer, in addition to HIV testing and sexual health information. Processes of change included improved communication with partners and increased negotiation power in sexual decision-making. Economic empowerment interventions increase confidence in negotiating behaviours with sexual partners and are complementary to sexual health information and health services that provide young women with a foundation on which to make informed decisions about how to protect themselves.

Financial health as a measurable social determinant of health

OBJECTIVES

Financial health, understood as one's ability to manage expenses, prepare for and recover from financial shocks, have minimal debt, and ability to build wealth, underlies all facets of daily living such as securing food and paying for housing, yet there is inconsistency in measurement and definition of this critical concept. Most social determinants research and interventions focus on siloed solutions (housing, food, utilities) rather than on a root solution such as financial health. In light of the paucity of public health research on financial health, particularly among low-income populations, this study seeks to: 1) introduce the construct of financial health into the domain of public health as a useful root term that underlies other individual measures of economic hardship and 2) demonstrate through outcomes on financial, physical and mental health among low-income caregivers of young children that the construct of financial health belongs in the canon of social determinants of health.

MATERIALS AND METHODS

In order to extract features of financial health relevant to overall well-being, principal components analysis were used to assess survey data on banking and personal finances among caregivers of young children who participate in public assistance. Then, a series of logistic regressions were utilized to examine the relationship between components of financial health, depression and self-rated health.

RESULTS

Components aligned with other measures of financial health in the literature, and there were strong associations between financial health and health outcomes.

PRACTICE IMPLICATIONS

Financial health can be conceived of and measured as a key social determinant of health.

The effect of cash transfers on mental health - new evidence from South Africa

BACKGROUND

Mental health and poverty are strongly interlinked. There is a gap in the literature on the effects of poverty alleviation programmes on mental health. We aim to fill this gap by studying the effect of an exogenous income shock generated by the Child Support Grant, South Africa's largest Unconditional Cash Transfer (UCT) programme, on mental health.

METHODS

We use biennial data on 10,925 individuals from the National Income Dynamics Study between 2008 and 2014. We exploit the programme's eligibility criteria to estimate instrumental variable Fixed Effects models.

RESULTS

We find that receiving the Child Support Grant improves adult mental health by 0.822 points (on a 0-30 scale), 4.1% of the sample mean.

CONCLUSION

Our findings show that UCT programmes have strong mental health benefits for the poor adult population.

Opioid misuse, labor market outcomes, and means-tested public expenditures: a conceptual framework

As the opioid epidemic has drawn increased attention, many researchers are attempting to estimate the financial burden of opioid misuse. These estimates have become particularly relevant as state and local governments have begun to take legal action against pharmaceutical manufacturers, distributors, and others who are identified as being potentially responsible for the worsening epidemic. An important category of costs includes those related to the effect of opioid misuse on labor market outcomes and productivity. Most published estimates of opioid-attributable productivity losses estimate the financial burden borne by society, failing to distinguish between costs internalized by individuals and those that spill over to third parties, such as state and federal governments. This article provides an overview and a conceptual framework for 2 types of labor market-related costs borne by state and federal governments that typically have not been incorporated into existing estimates, which may represent important categories of expenditures. Because detailed estimates of lost tax revenue are available elsewhere, this article focuses largely on whether, and how, to incorporate opioid-related expenses incurred by means-tested government programs into more general estimates of the economic harm created by the opioid epidemic.

Can a conditional cash transfer reduce teen fertility? The case of Brazil's Bolsa Familia

In 2008, Brazil's conditional cash transfer program expanded to cover a wider range of ages. Poor families are now given stipends for their children's school attendance up to age seventeen, whereas prior the maximum age was fifteen. Using a nationally representative household survey, we estimate the impact of this policy on teen fertility with a triple difference analysis on the fertility outcomes of treated cohorts vs. non-treated cohorts based on income eligibility, age eligibility, and timing of program implementation. We find a three percentage point drop in fertility among eligible teens within five years of program implementation. This offsets the difference in fertility between poor and non-poor teens. The impact is concentrated in urban areas, with no program effects found in rural areas. We are able to replicate these findings using National Birth Registry Data.

Homelessness in the child welfare system: A randomized controlled trial to assess the impact of housing subsidies on foster care placements and costs

Inadequate housing and homelessness among families represent a substantial challenge for child and adolescent well-being. Child welfare services confront housing that threatens placement into foster care with little resources and evidence to guide practice. The present study provides the first rigorous test of the Family Unification Program (FUP) - a federal program that offers housing subsidies for inadequately housed families under investigation for child maltreatment. A randomized controlled trial assesses program impact on foster care placement and costs. The experiment referred intact child welfare-involved families whose inadequate housing threatened foster placement in Chicago, IL to FUP plus housing advocacy (n = 89 families with 257 children) or housing advocacy alone (n = 89 families with 257 children). Families were referred from 2011 to 2013, and administrative data recorded dates and costs of foster placements over a 3-year follow-up. Intent-to-treat analyses suggested families randomly assigned for FUP exhibited slower increases in rates of foster placement following housing intervention compared with families referred for housing advocacy alone. The program generates average savings of nearly $500 per family per year to the foster care system. Housing subsidies provide the foster care system small but significant benefits for keeping homeless families together. Findings inform the design of a coordinated child welfare response to housing insecurity.

List randomization for soliciting experience of intimate partner violence: Application to the evaluation of Zambia's unconditional child grant program

Social scientists have increasingly invested in understanding how to improve data quality and measurement of sensitive topics in household surveys. We utilize the technique of list randomization to collect measures of physical intimate partner violence in an experimental impact evaluation of the Government of Zambia's Child Grant Program. The Child Grant Program is an unconditional cash transfer, which targeted female caregivers of children under the age of 5 in rural areas to receive the equivalent of US $24 as a bimonthly stipend. The implementation results show that the list randomization methodology functioned as planned, with approximately 15% of the sample identifying 12-month prevalence of physical intimate partner violence. According to this measure, after 4 years, the program had no measurable effect on partner violence. List randomization is a promising approach to incorporate sensitive measures into multitopic evaluations; however, more research is needed to improve upon methodology for application to measurement of violence.

Using Photo-Elicitation Methods to Understand Resilience Among Ultra-Poor Youth and Their Caregivers in Malawi

Unconditional cash transfer programs are a form of structural intervention to address poverty, a "fundamental cause" of disease. Such programs increasingly aim to build resilience to sustain improved outcomes and provide a solid foundation for longer term transformations. As such, there is a need to understand what resilience means in specific contexts. The goal of this formative study was to explore local experiences of resilience and vulnerability among 11 youth-caregiver dyads ( n = 22) who were beneficiaries of the Malawi Social Cash Transfer Program in Balaka district. We used a photo-elicitation approach informed by the participatory, visual methodology photovoice to guide the study and conducted an iterative content analysis using thematic coding of transcripts and photos. Participants took pictures of their daily struggles and shocks and participated in audio-recorded discussions to reflect on the photos using an adapted version of the SHOWeD method. We found that participants characterized resilience as a tireless process of using all available individual, family, and community resources at all times in pursuit of survival and well-being. In the context of daily struggles, resilience was an essential part of survival. Shocks, mostly health-related, were depicted through staged images candidly highlighting individual and environmental vulnerabilities. Community support was an essential component of resilience for both daily struggles and shocks. Using photo-elicitation methods facilitated an intergenerational, community-driven reflection on the meaning of resilience and the multilevel determinants of health in a context of extreme poverty. Findings can inform the design of resilience-focused cash transfer programs to improve health equity.

Does Public Assistance Reduce Recidivism?

Under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, individuals convicted of drug-related felonies were permanently banned from receiving welfare and food stamps. Since then, over 30 states have opted out of the federal ban. In this paper, I estimate the impact of public assistance eligibility on recidivism by exploiting both the adoption of the federal ban and subsequent passage of state laws that lifted the ban. Using administrative prison records on five million offenders and a triple-differences research design, I find that public assistance eligibility for drug offenders reduces one-year recidivism rates by 10 percent.

Disability, poverty, and role of the basic livelihood security system on health services utilization among the elderly in South Korea

With rapid aging, many of the elderly suffer from poverty and high healthcare needs. In Korea, there is a means-tested and non-contributory public assistance, the National Basic Livelihood Security System (NBLSS). The purpose of this study is to show older population's condition of disability and poverty, to evaluate the impact of NBLSS on health services utilization, and to examine the differential effect of the NBLSS by disability status among the elderly. This study used the Korea Welfare Panel Study data 2005-2014 with the final sample of 40,365, who were 65 years and older. The participants were divided into people with mild disability, severe disability, and without disability according to the Korean disability registration system. The income-level was defined to the low-income with NBLSS, the low-income without NBLSS, and the middle and high income, using the relative poverty line as a proxy of the low-income. The dependent variables were the number of outpatient visits and inpatient days, experience of home care services, total healthcare expenditure, and financial burden of healthcare expenditure. We performed Generalized Estimating Equations population-averaged model using the ten years of panel data. The result showed that within the same disability status, the low-income without NBLSS group used the least amount of inpatient care, but their financial burden of health expenditure was the highest among the three income groups. The regression model showed that if the elderly with severe disability were in the low-income without NBLSS, they reduced the outpatient and inpatient days; but their financial burden of healthcare became intensified. This study shows that the low-income elderly with disability but without adequate social protection are the most disadvantaged group. Policy is called for to mitigate the difficulties of this vulnerable population.

Only Making Things Worse: A Qualitative Study of the Impact of Wrongly Removing Disability Benefits from People with Mental Illness

Many countries belonging to the Organisation for Economic Co-operation and Development (OECD) have seen a considerable increase in the number of disability benefits recipients (DBRs), in addition to an increase in the proportion of people with mental illness. As in other countries, changes to the welfare benefits system in England were made in order to reduce the number of DBRs. Many people lost their benefit payments, although a considerable number had them reinstated after appeal. Our aim was to investigate the impact of the process on DBRs whose disability was related to mental health and who won their appeal. Seventeen DBRs were interviewed. The participants reported three main types of impact. Beyond the practical reduction of income and the related anxiety, interviewees reported considerable stress when coping with the 'never-ending' cycle of bureaucracy. They also expressed anger, frustration and demoralisation at mistrust on the part of the authorities partly due to the 'invisibility' of their disability.

Reductions in the United Kingdom's Government Housing Benefit and Symptoms of Depression in Low-Income Households

Housing security is an important determinant of mental ill health. We used a quasinatural experiment to evaluate this association, comparing the prevalence of mental ill health in the United Kingdom before and after the government's April 2011 reduction in financial support for low-income persons who rent private-sector housing (mean reduction of approximately £1,220 ($2,315) per year). Data came from the United Kingdom's Annual Population Survey, a repeated quarterly cross-sectional survey. We focused our analysis on renters in the private sector, disaggregating data between an intervention group receiving the government's Housing Benefit (n = 36,859) and a control group not receiving the Housing Benefit (n = 142,205). The main outcome was a binary measure of self-reported mental health problems. After controlling for preexisting time trends, we observed that between April 2011 and March 2013, the prevalence of depressive symptoms among private renters receiving the Housing Benefit increased by 1.8 percentage points (95% confidence interval: 1.0, 2.7) compared with those not receiving the Housing Benefit. Our models estimated that approximately 26,000 (95% confidence interval: 14,000, 38,000) people newly experienced depressive symptoms in association with the cuts to the Housing Benefit. We conclude that reducing housing support to low-income persons in the private rental sector increased the prevalence of depressive symptoms in the United Kingdom.

Grandma's Hands: Black Grandmothers Speak about Their Experiences Rearing Grandchildren on Tanf

Based on the guiding principles of the symbolic interactions theory, the authors used symbolic interaction theory to understand the views and meanings attached to welfare, poverty, and poor families, as well as to decipher grandmothers' policy recommendations. The culturally variant perspective provided a conceptual lens that placed grandmothers' adaptive behaviors in a historical, socio-political context. Using Grounded Theory Methods, the authors analyzed 20 personal interviews from a larger multiple-case study that examines the influence of TANF on grandparent-led families in southwest Virginia. Grandparents' views create a continuum of beliefs toward poverty, TANF, and personal responsibility with themes of individualistic, structural, and fatalistic views. They made distinct policy recommendations to remove the penalties attached to kinship care. Kinship care continues to be an adaptive family feature, but Black grandmothers' maintain some of the same societal and familial values as the larger society.

Economic evaluation of 'Return to Country': A remote Australian initiative to address indigenous homelessness

BACKGROUND

An increase in the number of Indigenous homeless persons in Cairns, Northern Australia, prompted the Queensland Police Service (QPS) to commence a pilot 'Return to Country' (R2C) program. The program was designed to assist homeless people who were voluntarily seeking to return to their home communities. This study assesses the costs of running the program and evaluates its net economic impact.

METHODS

Retrospective uncontrolled cost, cost-effectiveness and cost-offset analyses were undertaken from a societal perspective. All costs were expressed in 2014 AU$.

RESULTS

The R2C program successfully assisted 140 participants to return home, reducing the prevalence of homelessness in the regional center by 9.6%. The total program cost was estimated as AU$ 135,831 or AU$ 970 per participant. The economic analysis indicated that R2C was value for money, potentially saving AU$ 2,714,460. Limitations of the study included retrospective data collection and no established alternative comparison group.

CONCLUSION

R2C is a relatively simple, minimal cost program, which can be utilized by policy makers to offer one solution to homelessness. This economic evaluation informs the QPS of the effects of the R2C program in order to guide further program initiatives. The R2C model may be applied to assist temporarily stranded Indigenous people in other locations within Australia or internationally to return home. No funding was obtained for conducting this study.

The Long-Run Impact of Cash Transfers to Poor Families

We estimate the long-run impact of cash transfers to poor families on children's longevity, educational attainment, nutritional status, and income in adulthood. To do so, we collected individual-level administrative records of applicants to the Mothers' Pension program-the first government-sponsored welfare program in the United States (1911-1935)-and matched them to census, WWII, and death records. Male children of accepted applicants lived one year longer than those of rejected mothers. They also obtained one-third more years of schooling, were less likely to be underweight, and had higher income in adulthood than children of rejected mothers.

Still-Born Autonomy Insurance Plan in Quebec: An Example of a Public Long-Term Care Insurance System in Canada

Funding long-term care (LTC) is a challenge under the existing Beveridgean universal healthcare system. The Autonomy Insurance (AI) plan developed in Quebec was an attempt to introduce public LTC insurance into our healthcare system. The AI benefit was based on an assessment of the needs of older people and those with disabilities using a disability scale (SMAF) and case-mix classification system (Iso-SMAF Profiles). Under the plan, the benefit would be used to fund public institutions or purchase services from private organizations. Case managers were responsible for assessments and helping users and their families plan services and decide how to use the AI benefit. Funding AI was based on general tax revenues without capitalized funding, under a separate protected budget program. Projections were made for the additional budget needed to support AI, which would have mitigated the forecast increase in LTC spending due to population aging. All the legal, administrative, funding, training and contractual issues were dealt with, for implementation of the plan in April 2015. Unfortunately, the project was still-born for political reasons, but it demonstrates the feasibility of this essential innovation for Canada.

THE MEXICAN POPULAR HEALTH INSURANCE: MYTHS AND REALITIES

Universal health coverage (UHC) is today a dominant issue in the global health policy debate. The hegemonic proposal is UHC that recommends universal health insurance with an explicit service package and a payer-provider split with public and private managers. The Mexican Popular Health Insurance (PHI) is widely presented as a UHC success case to be followed. This article reviews critically its achievements after a decade of implementation. It shows that universal coverage has not been reached and about 30 million Mexicans are uninsured. Access to needed services is quite limited for PHI affiliates given the restrictions of the service package, which excludes common high-cost diseases, and the lack of health facilities. Public health expenditure has increased 0.36 percent of Gross National Product, favoring the PHI at the expense of public social security. These funds are, however, lower than legal specifications and the service package under-priced. Private health expenditure as a percentage of total expenditure has not varied much and PHI affiliates' out-of-pocket payment is larger than the whole PHI budget. There is no evidence of health impact. The Mexican health reform corresponds to neoclassic-neoliberal reorganization of society on the market principle. Although some of the PHI problems are particular to Mexico, it illustrates some of the overall flaws of the UHC model.

Work or welfare after cancer? Explorations of identity and stigma

With increasing numbers of people living with cancer, a greater focus is required on the social consequences of the disease. This article explores the connections between cancer and employment and the constraints imposed by ill health and wider structural conditions. Narrative data from 23 people of working age with cancer in north-east England collected longitudinally over 16 months highlight the impact of financial strain caused by temporary or permanent interruption to employment, and the positive benefits of an upstream welfare rights intervention in enabling participants to claim benefit entitlements and boost incomes. Returning to work, for those who were able, helped repair the disruption caused by the illness. For those unable to work, reliance on welfare benefits, while necessary, conferred a stigmatised identity that compounded the disruption wrought by cancer. While stigma occurs at the individual level, the structural dimensions of stigma need to be acknowledged in order to analyse the forces that cause, maintain and perpetuate the stigma associated with claiming welfare while ill. We conclude that current UK policies and welfare reforms to reduce sickness-related welfare claims will lead to greater hardship during periods of ill health and increase inequalities.

The REFANI Pakistan study--a cluster randomised controlled trial of the effectiveness and cost-effectiveness of cash-based transfer programmes on child nutrition status: study protocol

BACKGROUND

Cash-based transfer programmes are an emerging strategy in the prevention of wasting in children, especially targeted at vulnerable households during periods of food insecurity or during emergencies. However, the evidence surrounding the use of either cash or voucher transfer programmes in the humanitarian context and on nutritional outcomes is elusive. More evidence is needed not only to inform the global community of practice on best practices in humanitarian settings, but also to help strengthen national mitigation responses.

METHODS/DESIGN

The Research for Food Assistance on Nutrition Impact Pakistan study (REFANI-P) sets out to evaluate the impact of three cash-based interventions on nutritional outcomes in children aged less than five years from poor and very poor households in Dadu District. This four-arm parallel cluster randomised controlled trial is set among Action Against Hunger (ACF) programme villages in Dadu District, Sindh Province. Mothers are the target recipients of either seasonal unconditional cash transfers or fresh food vouchers. A comparison group receives 'standard care' provided by the ACF programme to which all groups have the same access. The primary outcomes are prevalence of wasting and mean weight-for-height Z-score (WHZ) in children. Impact will be assessed at 6 months and at 1 year from baseline. Using a theory-based approach we will determine 'how' the different interventions work by looking at the processes involved and the impact pathways following the theory of change developed for this context. Quantitative and qualitative data are collected on morbidity, health seeking, hygiene and nutrition behaviours, dietary diversity, haemoglobin concentration, women's empowerment, household food security and expenditures and social capital. The direct and indirect costs of each intervention borne by the implementing organisation and their partners as well as by beneficiaries and their communities are also assessed.

DISCUSSION

The results of this trial will provide robust evidence to help increase knowledge about the predictability of how different modalities of cash-based transfer work best to reduce the risk of child wasting during a season where food insecurity is at its highest. Evidence on costing and cost-effectiveness will further aid decisions on choice of modality in terms of effectiveness and sustainability.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10761532 . Registered 26 March 2015.

The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010

OBJECTIVES

I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil.

METHODS

I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest.

RESULTS

The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%.

CONCLUSIONS

The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

Home for now: A mixed-methods evaluation of a short-term housing support program for homeless families

The use of short-term rental subsidy vouchers offers a new approach to addressing the housing needs of families facing homelessness. In Massachusetts, the Family Home pilot program placed homeless families in housing instead of shelter, providing two years of rental subsidy plus support services with the goal of enabling families to maintain market rate housing. This mixed-method case study complements staff and participant interview data with participant survey and administrative data to evaluate the implementation and short-term outcomes of Family Home in one region. Data point to improved family well-being in housing but also persistent barriers to achieving longer-term housing and economic stability. Of the families who had exited the program at the end of the study, one quarter were able to retain their housing at market rate, only 9% returned to shelter, and one in five moved in with families/friends. Lack of affordable housing in a high rental cost region and jobs that pay living wages were among the major reasons that families struggled to maintain housing. This research points to the need for integrating supportive services from the program's start, including targeted workforce development, to plan for the end of the short-term rental subsidy.

The Hidden Poor: Over Three-Quarters of a Million Older Californians Overlooked by Official Poverty Line

More than three-quarters of a million (772,000) older Californians are among the "hidden poor"--older adults with incomes above the federal poverty line (FPL) but below a minimally decent standard of living as determined by the Elder Economic Security Standard™ Index (Elder Index) in 2011. This policy brief uses the most recent Elder Index calculations to document the wide discrepancy that exists between the FPL and the Elder Index. This study finds that the FPL significantly underestimates the number of economically insecure older adults who are unable to make ends meet. Yet, because many public assistance programs are aligned with the FPL, potentially hundreds of thousands of economically insecure older Californians are denied aid. The highest rates of the hidden poor among older adults are found among renters, Latinos, women, those who are raising grandchildren, and people in the oldest age groups. Raising the income and asset eligibility requirement thresholds for social support programs such as Supplemental Security Income (SSI), housing, health care, and food assistance would help California's older hidden poor make ends meet.

Administrative Privatization and Employment Outcomes in the Implementation of Temporary Assistance to Needy Families

BACKGROUND

Welfare reform in the 1990s encouraged states and localities to contract out cash assistance services to for-profit and nonprofit firms operating within the private sector. Although privatized welfare delivery was heralded in the wake of Temporary Assistance to Needy Families (TANF), scant empirical research evaluates welfare privatization and its potential relationship with administrative quality and program outcomes.

OBJECTIVES

This study examines the relationship between administrative privatization and TANF program outcomes, including work participation activities, unsubsidized employment, employment closure, and monthly earnings, across a large sample of individual welfare clients in the state of Florida.

RESULTS

The results of methodologically appropriate hierarchical linear models demonstrate that ownership variables seldom enhance the quality of TANF outcomes, suggesting that privatization alone is not an administrative panacea in human support services. Although direct privatization effects are often found to be substantively small and inconsistent in terms of service quality improvement, in closed-case models, there is evidence that nonprofit welfare delivery is associated with superior TANF employment closure outcomes.

The prevalence and economic value of doubling up

"Doubling up" (living with relatives or nonkin) is a common source of support for low-income families, yet no study to date has estimated its economic value relative to other types of public and private support. Using longitudinal data from the Fragile Families and Child Wellbeing Study, we examine the prevalence and economic value of doubling up among families with young children living in large American cities. We find that doubling up is a very important part of the private safety net in the first few years of a child's life, with nearly 50 % of mothers reporting at least one instance of doubling up by the time their child is 9 years old. The estimated rental savings from doubling up is significant and comparable in magnitude to other public and private transfers.

Older adults challenged financially when adult children move home

This policy brief looks at the financial burdens imposed on older Californians when adult children return home, often due to a crisis not of their own making, to live with their parents. The findings show that on average in California, the amount of money that older adults need in order to maintain a minimally decent standard of living while supporting one adult child in their home increases their expenses by a minimum of 50 percent. Low-income older adults are usually on fixed incomes, so helping an adult child can provide the child with a critical safety net but at the cost of the parents' own financial well-being. Policy approaches to assisting this vulnerable population of older adults include implementing reforms to increase Supplemental Security Income (SSI), improving the availability of affordable housing, assuring that all eligible nonelderly adults obtain health insurance through health care reform's expansion of Medi-Cal and subsidies, and increasing food assistance through SNAP and senior meal programs.

Very low food security in the USA is linked with exposure to violence

OBJECTIVE

To investigate characteristics of exposure to violence in relation to food security status among female-headed households.

DESIGN

Ongoing mixed-method participatory action study. Questions addressed food insecurity, public assistance, and maternal and child health. Grounded theory analysis of qualitative themes related to violence was performed. These themes were then categorized by food security status.

SETTING

Homes of low-income families in Philadelphia, PA, USA.

SUBJECTS

Forty-four mothers of children under 3 years of age participating in public assistance programmes.

RESULTS

Forty women described exposure to violence ranging from fear of violence to personal experiences with rape. Exposure to violence affected mental health, ability to continue school and obtain work with living wages, and subsequently the ability to afford food. Exposure to violence during childhood and being a perpetrator of violence were both linked to very low food security status and depressive symptoms. Ten of seventeen (59%) participants reporting very low food security described life-changing violence, compared with three of fifteen (20%) participants reporting low food security and four of twelve (33%) reporting food security. Examples of violent experiences among the very low food secure group included exposure to child abuse, neglect and rape that suggest exposure to violence is an important factor in the experience of very low food security.

CONCLUSIONS

Descriptions of childhood trauma and life-changing violence are linked with severe food security. Policy makers and clinicians should incorporate violence prevention efforts when addressing hunger.

Women's experiences in a community-based participatory research randomized controlled trial

Integrating community-based participatory research (CBPR) into traditional study designs can enhance outcomes in studies with disadvantaged groups. Little is known, however, about study participants' experiences with these approaches, the underlying processes involved in creating more positive outcomes, and whether undesirable effects on study outcomes occur simultaneously. We conducted focus group interviews with 31 disadvantaged women who participated in a CBPR-driven randomized controlled trial (RCT) both to explore their study experiences and to obtain their interpretations of select study findings. Using dimensional analysis, we found the tailored health questionnaire, treatment by study staff members, and RCT participants' understandings of and responses to randomization were salient to what women described as transformative experiences that occurred over the course of the RCT. These findings have implications for understanding how CBPR and non-CBPR aspects of interventions and study designs have the potential to affect both process and endpoint study outcomes.

Promoting healthy food consumption: a review of state-level policies to improve access to fruits and vegetables

Research indicates poor nutrition is a leading determinant of the development of chronic disease, and increasing fruit and vegetable consumption is one method for decreasing obesity. Many policies have focused on increasing the demand for fruits and vegetables through price reductions and coupons. However, without ensuring a stable supply, increased demand can continue to raise prices, crowding out individuals who may otherwise have purchased fruits and vegetables and ultimately leading to continued disparities in access. This paper presents a review of selected state-level policy options recently proposed or implemented in states across the United States, and provides an evidence-based lens through which food access policy can be shaped in the Midwest. This review and potential framework uses Wisconsin to illustrate the feasibility of different state-level decisions and their potential impact on particular populations. Future supply-side policies to consider include expanding Electronic Benefit Transfer to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC),program and farmers markets, incentivizing the purchase of locally grown produce, assisting local specialty farmers directly, and/or establishing a state-level food policy council. This review reveals that a food policy council would create a more sustainable policy analysis process to better ensure future policy adoption is truly comprehensive, encompassing the production, distribution and purchase of locally grown fruits and vegetables.

Improving food choices among Supplemental Nutrition Assistance Program recipients

We used a principal-agent framework to examine the feasibility of two proposed modifications to the Supplemental Nutrition Assistance Program with the goal of encouraging healthier food choices among program participants. Specifically, we analyzed two types of contract: a restricted contract and an incentive contract. The restricted contract did not allow the purchase of unhealthy foods with program benefits, but compensated participants by increasing total benefits. The incentive contract provided increased benefits that varied according to the percentage of healthy foods purchased with program benefits. The theoretical results revealed the mechanisms for the two alternative contracts, the conditions under which each would be effective, and the key empirical questions to be examined for future policy analysis.

Nearly four million Californians are food insecure

Food insecurity has increased significantly among low-income Californians over the last decade. According to data from the 2009 California Health Interview Survey, 3.8 million adults in households with incomes at or below 200% of the Federal Poverty Level (FPL) could not afford enough food at least once in the previous year. Low-income households with children and Spanish-speaking households suffered from the worst levels of food insecurity. Expanding nutrition assistance programs, such as the Supplemental Nutrition Assistance Program, could help reduce high rates of food insecurity among the low-income population.

Free tax assistance and the earned income tax credit: vital resources for social workers and low-income families

As the United States' economy continues to experience challenges, more families at or near the poverty level fall prey to predatory financial practices. Their vulnerability to these operations is increased by a lack of knowledge of asset-building resources and alternative financial services. This article focuses on Volunteer Income Tax Assistance (VITA)--a free income tax preparation program, which is a vital resource available to low-income families. Unfortunately, VITA is largely underused and often unknown to economically strained families and to the social workers and other professionals to whom these families turn for assistance. This article concludes with policy and practice implications for social workers and other professionals engaged in providing services to financially vulnerable families.

Welfare policymaking and intersections of race, ethnicity, and gender in U.S. state legislatures

Welfare policy in the American states has been shaped profoundly by race, ethnicity, and representation. Does gender matter as well? Focusing on state welfare reform in the mid-1990s, we test hypotheses derived from two alternative approaches to incorporating gender into the study of representation and welfare policymaking. An additive approach, which assumes gender and race/ethnicity are distinct and independent, suggests that female state legislators—regardless of race/ethnicity—will mitigate the more restrictive and punitive aspects of welfare reform, much like their African American and Latino counterparts do. In contrast, an intersectional approach, which highlights the overlapping and interdependent nature of gender and race/ethnicity, suggests that legislative women of color will have the strongest countervailing effect on state welfare reform—stronger than that of other women or men of color. Our empirical analyses suggest an intersectional approach yields a more accurate understanding of gender, race/ethnicity, and welfare politics in the states.

Belonging and community: understandings of "home" and "friends" among the English poor, 1750-1850

This article is based on unique ‘narratives of the poor’, that is, letters from poor people to their parishes of settlement, petitions to the London Refuge of the Destitute, and letters from mothers to the London Foundling Hospital, with supportive evidence from newspapers. These display fundamental concepts among the English poor, who were often poorly literate, and who comprised the majority of the population. Discussion focuses upon their understandings of ‘home’, ‘belonging’, ‘friends’, and ‘community’. These key concepts are related here to modern discussions, to set important concerns into historical perspective. ‘Friends’, valuably studied by sociologists such as Pahl, had a wide meaning in the past. ‘Home’ meant (alongside abode) one's parish of legal settlement, where one was entitled to poor relief under the settlement/poor laws. This was where one ‘belonged’. Ideas of ‘community’ were held and displayed even at a distance, among frequently migrant poor, who wrote to their parishes showing strong ties of attachment, right, and local obligation. This discussion explores these issues in connection with belonging and identity. It elucidates the meaning and working of poor law settlement, and is also an exploration of popular mentalities and the semi-literate ways in which these were expressed.

Rural income transfer programs and rural household food security in Ethiopia

Based on household food security surveys conducted in Ethiopia, this study seeks to understand the roles and limitations of income transfer projects as determinants of households’ food security. By covering the Food-For-Work Programs (FFWPs) and the Productive Safety Net Programs (PSNPs), the study shows that these programs served as temporary safety nets for food availability, but they were limited in boosting the dietary diversity of households and their coping strategies. Households which participated in the programs increased their supply of food as a temporary buffer to seasonal asset depletion. However, participation in the programs was marred by inclusion error (food-secure households were included) and exclusion error (food-insecure households were excluded). Income transfer projects alone were not robust determinants of household food security. Rather, socio-demographic variables of education and family size as well as agricultural input of land size were found to be significant in accounting for changes in households’ food security. The programs in the research sites were funded through foreign aid, and the findings of the study imply the need to reexamine the approaches adopted by bilateral donors in allocating aid to Ethiopia. At the same time the study underscores the need to improve domestic policy framework in terms of engendering rural local institutional participation in project management.

Electronic access to food and cash benefits

The authors' purpose was to examine access to Family Independence Program and Food benefits in relation to customer service and an automated helpline. In addition, participants identified impediments and limitations to the receipt of services. Two hundred forty-four surveys were mailed to recipients of over-the-counter electronic benefit transfer cards; 58 were returned. The findings indicate that when customers (age 21-92) received assistance navigating the electronic benefits transfer system from local office staff, they were able to obtain benefits successfully. Negative credit/debit card history and touchtone phones were related to difficulty using the system. The results suggest that the local office and the contracted service provider (automatic helpline) need to provide assistance that promotes greater autonomy for the customer to make successful transitions to benefits that are delivered electronically.