Welfare Reform Increases Health Risks, Experts Warn

The welfare reform measure that President Clinton signed Thursday might achieve its objective of prodding millions of Americans to get productive jobs, but some public health officials are expressing the fear that it could cause many to simply get sick.

And the poor, they said, might not get sick alone.

As legal immigrants lose access to Medicaid and families run up against a new five-year limit on cash benefits, these health experts anticipate a resurgence of tuberculosis and sexually transmitted diseases not likely to confine themselves to neighborhoods with low-income residents. Over time, they foresee a rising infant mortality rate and a gradual lowering of life expectancy for many Americans, not just those on welfare.

“Sooner or later, we will find ourselves with housekeepers who are tubercular, workers dying of infectious illnesses. No matter how much we create isolated enclaves, we depend on people who live in poor communities to make our clothes, package our food, work at our McDonald’s,” said David Rosner, professor of history and public health at City University of New York. “We have developed a sense of invulnerability to these things and it will come back to haunt us.”

Such problems, if they occur, could be particularly acute in Los Angeles and New York, homes to teeming populations of legal immigrants who receive subsidized health services under Medicaid, or its California equivalent, Medi-Cal. Under the sweeping welfare reform legislation, states are authorized to deny Medicaid coverage to legal immigrants.

Welfare reform advocates dismissed such scenarios as scare talk, in large part because they dispute the underlying premise that poor people cut off from public assistance will fail to fend for themselves.

“The basic assumption of liberals is that some people have virtually no capacity to care for themselves, that if you are not stuffing free services at them they will go blind and starve to death. That’s simply not true,” said Robert Rector, senior policy analyst for welfare at the Heritage Foundation, a conservative Washington think tank.

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The fastest growing group of welfare dependents are elderly immigrants who come to the United States to retire. If left unchecked, their needs would cost the American taxpayer $312 billion in the next 10 years, said Rector, who helped craft the congressional welfare measure.

“Washington is excellent at finding stupid things to do with taxpayer dollars. But setting the nation up as a government retirement home for people from Hong Kong, Mexico and the Philippines is utterly indefensible,” he said. “They should not be here. They should go home. It sounds cruel, but it is not inconceivable.”

The welfare measure rolls up the federal safety net that has guaranteed for 61 years that America’s poor would receive assistance underwritten by Washington. It replaces that open-ended assurance with finite block grants and leaves it to the states to decide what benefits to provide.

In addition to the Medicaid changes, states operating under the new law could impose new restrictions on aid to needy families with children. In addition, the new law would limit cash assistance to two years, unless recipients find work or enter a job program, and it would impose a lifetime cap of five years on cash benefits.

At the same time, the legislation contains exceptions designed to cushion the blow on vulnerable populations. States could choose to continue providing Medicaid benefits to legal immigrants, and they would be permitted to exempt as many as 20% of their cash welfare recipients from the work requirements and benefit caps.

But some health officials said they fear those safety valves are not sufficient to prevent a gradual deterioration of medical services for the poor and that the consequences could spread far beyond the people most directly affected.

“The sooner you get a communicable disease isolated and treated, the sooner you have a noncontagious person,” said Dr. Shirley Fannin, director of disease control programs for the Los Angeles County Department of Health Services. “Going into the 21st century with this kind of backward-thinking legislation--I think we will rue the day.”

With prenatal and well-baby care no longer guaranteed for legal immigrants, infant mortality and developmental impairment are likely to increase, these officials said. Children in families denied cash assistance or basic medical services could report to school sick, hungry or not at all.

Some are likely to infect their classmates, have difficulty learning and grow up without the education skills necessary to find the work that the new welfare system insists must be found, the officials predicted.

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For example, a simple ear infection, left untreated, can lead to permanent hearing impairment, even brain abscesses, said Dr. Margaret Hamburg, commissioner of the New York City Department of Health.

“They will miss school because they are sick or will come to school starving and be unable to learn. That means a lower rate of graduation, less job readiness, more welfare. It’s just a vicious cycle,” said Nicole Lurie, professor of medicine and public health at the University of Minnesota.

Still, states are only beginning to analyze the details of the welfare legislation, and it is difficult to predict with certainty how each will choose to spend the federal block grants it receives for assistance to the poor.

If the reformed system works as its crafters hope, the result could be better health for the nation’s needy, advocates said. States eager to move people off welfare might be more likely to expand health care coverage to help them do it. Already, about 20 states have pending waivers asking permission to give welfare recipients who find work transitional health benefits for one year rather than the customary six months.

“People who work are healthier than people who don’t work,” said Douglas Besharov, resident scholar at the American Enterprise Institute in Washington, who studies the transition between welfare and work. “If this gets people moving, it will be good for them.”

Reformers also noted that the bill provides benefits to noncitizens for treatment of communicable diseases. In addition, it leaves untouched free immunization programs already in existence.

Critics, however, said there is no immunization for tuberculosis, the most threatening contagion that is already at high levels in New York and Los Angeles. And poor people routinely succumb to a variety of infectious illness without knowing it. Most cases are detected during regular doctor visits that the poor will likely avoid if the cost is too high or the wait too long, some experts predicted.

A study conducted by Lurie offers a window into what happened when 270,000 medically indigent people in California were cut off from Medi-Cal in 1982. The patients were shifted to county services, which charged as much as $40 per visit.

After tracking 186 patients, Lurie found that the conditions of most of them had deteriorated within a year. Many, particularly those with high blood pressure, had serious health problems.

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The patients reported long waits for an appointment and additional delays once they reached the doctor’s office. Those who tried to get free medicine from safety-net pharmacies waited six hours on average for a 10-day supply. Many discontinued their medication or took less than the recommended dose to make it last longer. One year later, four people were dead from lack of access to care, including a cardiac patient who ran out of heart medication, a person with a perforated ulcer who delayed seeking care after spitting up blood, and a diabetic who died of pneumonia and malnutrition.

“What is going to happen is fairly obvious. We know that people are going to get sick, they are going to have a lot of avoidable health conditions and in the long run, they will be a much greater burden on society,” Lurie said.