Implications of Welfare Reform for Child Health: Emerging Challenges for Clinical Practice and Policy

The passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996 represented one of the most profound developments in American social policy since the Great Society programs of the mid- 1960s and has the potential to affect the health of millions of American children. The overall purpose of the legislation, commonly referred to as welfare reform, was to decrease reliance on welfare and increase the economic independence of poor families. Its impact has been far-reaching, affecting many determinants of child health and well-being, such as family resources, reproductive choices, maternal employment, parental supervision, childcare, and access to health insurance.

The implementation of PRWORA has been associated with unprecedented declines in the number of children receiving public benefits. In the first 2 years after welfare reform, the number of children receiving welfare benefits fell by 28%.^1,2 In addition, the number of children enrolled in Medicaid, the principal public health insurance program for poor children in the United States, also fell, despite provisions in the legislation to extend Medicaid coverage to all children who lose welfare benefits.³ Similarly, the number of children receiving food stamps has dropped by 20% between 1996 and 1998.^4–6 Although there is consensus that both growth in the economy and welfare policies themselves have contributed to these declines, the exact proportion attributable to each factor remains unclear.^7–9

This discussion considers how these major shifts in public support for poor children and their families are likely to affect patterns of child health and the provision of clinical services to children. It addresses these concerns by exploring 4 related issues: the elements of the welfare legislation most likely to affect child health, the impact of this legislation on enrollment in public programs for children, the potential health effects of welfare reform, and the …