. . . Winter 2003 The
Poor Made Visible
I've spent a lot of the time in the last five years evaluating the effects of the welfare reform bill of 1996. So far, I can say the reform has encouraged many welfare recipients to get jobs and earn their own incomes. But few have managed to escape poverty, and the legislation's impact on mothers and children who might lose welfare benefits before they have stable employment is a cause for concern. Along certain lines, the reform has succeeded far beyond anyone's expectations. Caseloads have fallen by more than 50 percent since 1996. Labor force participation among single mothers increased by more than 10 percentage points between 1995-96 and 2000, to nearly 80 percent, although some of these gains have now been lost in the last few years. The fact that caseloads have fallen and workforce participation has gone up doesn't necessarily mean the bill is a huge success, however. Have the new workers increased their real incomes over what they received from welfare? Most people haven't gained a lot. We might be talking about an additional $500 to $1,000 a year in many cases. But the evidence says we at least haven't made many people worse offthrough 2001, that is, and that's a big caveat that I'm going to come back to. If a higher percentage of the poor are now earning their income rather than receiving welfare, the question remains, will significant numbers escape poverty in the long run? That's a big concern of mine, and I have others as well. What's happening to the kids? When we emphasize new jobs, we're focusing on the moms, but how has the reform affected family life? The strongest, explicit purpose written into the bill was to lower out-of-wedlock childbearing and increase marriage rates among the poor. It said nothing about increasing jobs, decreasing welfare caseloads or benefiting family life. Did the bill accomplish its stated purpose? Out-of-wedlock childbearing has declined recently, but that trend started before passage of this bill. As for promoting marriage, there's not much evidence so far that this has occurred. The bigger effect has been to increase cohabitation rather than marriage. Now let's return to the biggest question around all of the positive economic statistics: How many changes were due to the policy and how many of them reflect the incredibly strong economy between 1996 and 2001? People left welfare and went to work, but they clearly would have done that in larger numbers anyway, given what was going on in the labor market and the economy. I've done quite a bit of research trying to tease out how much of this is policy, how much of this effect is economy and how much of this effect is other things. Evidence shows pretty clearly that at least three thingsthe 1996 legislation, the dynamic economy and other policy changesall mattered a lot to the welfare picture. The most important of these other policy changes were the expansions in the earned income tax credit, which added to people's earnings. If the current economic slowdown continues, unemployment will keep creeping up, and we will steadily erode some of the work gains of the last decade.
This is a remarkable time in history in terms of both the interest in and funding of public health and science devoted to health. We have the 800-pound genome gorilla: People are reading every day that the health problems in society will be solved by information coming from the elaboration of what we know about the human genome. Everything from the rarest disease to problems of racism, people are now saying, can be solved by what we may learn about the genome. It gets pretty extreme. In my lectures I quote a former head of the National Institute of Health saying it's not unreasonable to think that research on the human genome will lead to the end of disease and disability. I immediately follow up that quotation by showing figures on life expectancy in Eastern Europe over the last 20 years. The life expectancy of a 14-year-old male in Hungary decreased by three and a half years. That's equivalent to the amount of life expectancy that would be gained if we eliminated cancer and heart disease. It's a huge amount. We know this was a time of tremendous social, political and economic turmoil in Hungary as it went from a planned economy to essentially a free market economy. It affected people at every level from what they could eat to how they felt about themselves. And it had tremendous impact on their health. I contend that understanding the genetic aspects of health is only a very small part of the picture. What we need to do is build bridges between the biological and social sciences if we're to close the great health divide between the people in the mainstream and those who are marginalized. My research is focused in two ways, elaborating what these health divides are and, second, trying to develop ways of understanding the forces that produce health disparities in the population, both the biological and the social forces. It's this intellectual integration of knowledge across multiple levels of study that I think is key today. Take the question of whether or not societies that have a greater gap between rich and poor have poorer health. Comparisons between the United States and Canada are particularly interesting because in many respects we're the same and in some respects we're different. When we started this work, we found that if we arrayed the states, or metropolitan areas within the states, by the extent to which there are large income gaps between rich and poor, people in the states with smaller gaps have better health. Their death rates were lower, and almost every other indicator we looked at was better in those states. When we did the same study in Canada, however, we found no relationship whatsoever between income disparity and health. We think that one of the reasons is that there is less racial and economic residential segregation in Canada, as well as greater regional planning. Racial and economic segregation are associated with greater adverse exposures and fewer resources with which to combat these exposures. Regional planning can help to reduce some of the unequal concentration of these exposures and resources. Canadians set policies mainly at the provincial, that is regional, rather than local level. In Canada it would be much harder to have a Detroit-area residential pattern, where you have hypersegregation in the city and suburbs. When you leave Detroit's boundaries, you cross from the most heavily segregated area in the country with respect to Blacks to the most heavily segregated area with respect to Whites. How does that happen? Local governments can lure jobs from one area to another. A wealthy locality can give all sorts of tax breaks and actually bleed jobs out of Detroit and into the surrounding areas. Political processes that allow for enormous differences in material being can get instituted. Where you have regional government you can't do that. This is an example of a policy determination that can have a big impact on kids and their eventual opportunities to have good health versus worse health. We need to train people to get out of their disciplinary boxes from the research point of view and policy point of view to understand how all these things fit together. The first thing we have to do is change two prevailing mindsets. The first is that the only way to improve health is to invest huge amounts of money in fundamental science, basic science. I'm not against that, but we have to understand its limitations. The second mindset is that the only way to influence health and reduce disparities in health is to have some impact on medical care and the financing of medical care. It is a sad truth that we are the only wealthy country in the world that doesn't consider health care a right for all members of society. I don't mean to indicate in any way that we shouldn't try to change that. But we're increasingly seeing that, in addition to delivery of medical care, issues of income distribution, labor policy, the structure and quality of community, housingall these domains that people don't tend to think of as involved in health policyare integral parts of the quality of health. We have to get policy people to start evaluating the health impact of the economic and social policies that they propose. And we need to convince them that there's a tremendous need for training and for research in this area.
I'm particularly interested in social and environmental factors associated with depression in low-income women. Material hardship is an important predictor of depression that is too often overlooked. It is important because many risk factors for depression are global or difficult to change. One of the most significant findings to come out of my work is that women who report in our studies that they sometimes or often run out of food are much more likely to meet the diagnostic criteria for major depression. My epidemiological study of household food insufficiency is part of the Women's Employment Study, which involves 753 women in an urban Michigan county who were welfare recipients in February 1997. Interviewers from our Institute for Social Research (ISR) interviewed a random sample of the women, and we have been following them for several years. In the first year, we found that 25 percent met the diagnostic criteria for major depression. After we controlled for many other factors known to increase risk of depression, food insufficiency remained substantially and significantly associated with depression. This relationship has persisted over time. The policy implications seem pretty clear: Give people enough to eat! This is a really rich country; we shouldn't have large numbers of poor mothers running out of food. Interesting enough, but not surprising, when mothers can't secure enough food for their household, they feed their children before themselves. I'm planning another study with Prof. David Williams at ISR, a much larger study using the National Survey of American Life to look at the relationship between household food insufficiency and major depression in African Americans and in Afro-Caribbean Americans. Some years ago I studied racial disparities in maternal and infant mortality, and I'm sorry to say that the conditions I found are still a national disgrace. Black maternal mortality rates in Chicago and Detroit were three to four times higher than they were for White women. At the national level, those sorry statistics have not improved. The gap has even widened. One thing that really appalls me about our country's performance in this area is that it is an issue in which the risk factors are modifiable: adequate nutrition, access to good, quality care, a decent standard of living. The same holds true for food insufficiency, which is far higher among African- and Hispanic-American families than among White families and associated with a host of serious diseases for children and adults. I see two explanations, both of which require policy remedies. One is institutional racism, the other is individual racism. At the institutional level we need to take steps to eradicate racism, and affirmative action is one effective approach. It's certainly worked well for White women because of their more privileged history and experience in this country, but it will take more time for African Americans and other people of color to make similar gains. At the individual level, the National Academy of Science's Institute of Medicine recently published a major book documenting case after case of racism on the part of health care providers. It's the thing no one wants to talk about. Whether health care providers are conscious of it or not, it still has the same deadly effect. We've had disgraceful health disparities in this country for decades. It's time that we faced the reasons and did something about it. I've been working since 1977 on maternal and child health and women's health. What has become crystal clear to me over the course of many years, especially looking at history as well as the present, is the role of racism in health disparities. It's something that we as a society are only beginning to acknowledge. There's so much denial and refusal to acknowledge what's just so glaringly there. We need more African Americans and more Hispanics in policy-making positions, as deans and faculty of health professional schools, as providers. Affirmative action is so important. We need anti-racist curricula in all of the helping professions. It needs to start in elementary school. And we must have legislative remedies, because unless the law backs up corrective efforts, the corrections are not going to be enough. What's really important to my heart is eliminating health disparities. All mothers and children, all people in this country, should have a good start in lifethe same chance to be healthy and happy. Poor White women experience health-damaging stresses, but they don't experience the pervasive, everyday racism as well as the larger more institutional forms of it that women of color experience. It's two different worlds. Actually, despite their greater exposure to stressors and risk factors, African-American women have lower rates of major depression than White women. That's one of the really interesting things that I'm hoping to look at with David Williams. One of the things David and others have speculated is that religion may play a protective role. It's important to look at belief systems as well as other protective factors and strengths because they have implications for health policy, too.
A substantial percentage of single mothers are working today as a result of the 1996 welfare reform. Prior to 1996, single mothers were entitled to receive cash assistance; now they are expected to move quickly from welfare into the labor market. However, the current system has little flexibility to deal with people who want to work, are out looking for work, but who can't find work. If the new work-oriented welfare system is going to be effective, there must be a way for single mothers to support their families. This is most evident when the economy is in a recession. Because it is more difficult to find work and because the welfare system still expects people to work as much as they did during the boom, more attention needs to be paid to the following kinds of policies: · providing access to work-for-welfare jobs of last resort, or · changing the unemployment insurance system to make it easier for people with part-time and sporadic work histories to qualify for unemployment insurance, or · granting exceptions to welfare's five-year limit on benefits during recessions. If government is no longer going to provide welfare recipients with a monthly check, then a system needs to be in place whereby people who cannot find an employer to hire them can work for their welfare. The work-oriented welfare reform of 1996 has increased the personal responsibility of recipients to search for work but reduced government's responsibility to help even those who are willing to work but are unable to find jobs. I'm addressing these issues with Prof. Sandra Danziger in a book tentatively titled After Welfare Reform: Toward a Work-based Safety Net. After the 1996 welfare reform and up to the 2001 recessions, incomes rose for single-mother families with children, and poverty fell. However, most working former welfare recipients earned less than $15,000 a year. It is not the case that people are going from being very poor welfare recipients to being comfortable middle-class workers. They're going from being very poor welfare recipients to being poor and near-poor workers. The poverty rate remains very high even among women who have successfully left welfare to work and get subsidized childcare and the earned income tax credit. In a study being conducted by the Michigan Program on Poverty and Social Welfare Policy, women who were still on welfare had a poverty rate of about 80 percent in 1998, whereas women who had successfully left welfare for work had a poverty rate of 50 percent. While it does pay now to move from welfare to work, 50 percent is a very high poverty rate. The provision of public jobs of last resort is just one policy that is needed if we are to have an effective work-based safety net. Another important policy change would be to devote more attention to identifying some of the problems that keep people from working steadily. For example, many recipients have underlying health and mental health problems that make it difficult to get and keep jobs. Often the welfare office is not aware of the extent of these and other problems, such as learning disabilities and low reading scores. The welfare-to-work programs that operate in most states do not devote enough time to assessing and screening clients and offering services that might address such problems and increase their employment prospects. At any one time in the first five years after welfare reform, about two-thirds to three-fourths of the women who left welfare were working. The good news is that more single mothers were working than most policy analysts thought was possible. The bad news is that in any month about a quarter to a third of the women who left welfare were not working. In other words, welfare receipt has declined even more than work has increased. That means some people aren't getting either welfare or work and have great difficulty making ends meet. Clearly, some people are worse off under the new welfare system than they were under the old system, especially if they have health and mental health problems that the current system doesn't treat effectively. Yet, there are some women who have moved into good jobs and are better off. Politicians and the media have tended to focus more on the success stories than on those who are falling between the cracks in the new system. Top Ten Research Challenges of the 2000s >> |
