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Before defining needed supports and services for low-income families under welfare reform, it is important to remind ourselves of the complex circumstances that affect the daily lives of many poor children and their families. Many struggle with low income, financial insecurity, limited job opportunities, marginal living conditions, lack of transportation, and social inequality. The supports and services provided by programs such as Temporary Assistance for Needy Families (TANF) and Medicaid can be extremely important to these families, yet may not be enough to lessen the impact of poverty and promote positive outcomes for children. The inability of programs to adapt to families' special circumstances or to respond when families are in crisis situations seriously limits their effectiveness. In addition, the barriers restricting access for poor immigrant families limit the effectiveness of these programs even further. Stories from the lives of some of our nation's poorest families can help to inform the debate concerning reauthorization of the federal welfare reform law in 2002, and encourage policymakers to look beyond the numbers of families leaving the welfare rolls and improve the way supports and services are provided to our nation's poor.

The Precariousness of Poor Families' Lives

For many poor children and their families, there is a precariousness to their daily lives beyond what may be apparent on the surface. My observations over the past few years have convinced me that welfare reform is not working in the best interests of these families. Moreover, some of the negative impacts appear to be cumulative and far-reaching across groups in a community, region, or population. Brief descriptions of the circumstances of several poor families receiving medical services in a primary care clinic where I work call attention to the difficulties these families encounter as they struggle to cope with the current welfare system.¹

• A young mother on welfare, with a high school equivalency certificate, has recently completed a job training program and is transitioning to work as a receiving clerk in a laundry. She has two young children, 6 months and 17 months of age. The child care center staff tell her not to bring her children back to the center until she gets clearance from a physician because the younger of the two had a "loose stool" on one occasion during the day. The mother has already missed work three times this month because of her children's illnesses, and her employer has told her that if she misses work again, she may lose her job. This young mother is overwhelmed with the warning from work, the demands of child care, and the need to miss work for what is, at most, nothing more than a minor illness.



• While still in the hospital, a 17-year-old mother of a newborn infant pleads desperately with a social worker for assistance with housing. The teen mother and her baby cannot stay with relatives because the family's home is already overcrowded. The infant and mother are scheduled for early discharge from the hospital, which only adds to the mother's difficulties.



• An immigrant family from Mexico has a U.S.-born son with irreversible neurological problems resulting from trauma at birth. The child requires constant attention and home-based services. The family is facing loss of Medicaid benefits, as well as food stamps and utility assistance, because the father's annual earnings from his produce business are $2,000 above the maximum income allowed.



• A functionally illiterate single father with a third-grade education has two young school-age sons. The boys are disruptive and unable to settle into a classroom. The family lives in an unsafe, drug-infested public housing unit, which contributes to the children's behavioral problems. The father would like to participate in a job training program to help him earn more than he receives from TANF, but he cannot find a suitable program because he lacks the ability to read and other basic skills. Without access to public transportation, the father transports his children and himself on a bicycle.



• A stressed, worried, depressed grandmother in her sixties has taken her three adolescent grandchildren into her home because their mother is mentally ill. The grandmother's diabetes and high blood pressure are out of control, making it almost impossible for her to cope with the daily needs of young, energetic adolescents, much less help her daughter.



• A 22-year-old mother has just given birth to her fourth child. She had limited prenatal care and a history of tobacco use, and has admitted to using cocaine regularly during pregnancy. She recently tested positive for hepatitis C. She would like to get into a treatment program for drug-dependent mothers because she worries about losing her children to foster care, but no treatment program vacancies are available.

Since welfare reform was enacted in 1996, many former welfare families have been able to transition to steady work with the help of a strong economy and interim supports such as Medicaid, food stamps, subsidized housing, and child care assistance.^2–4 However, many other families, like those described above, have not been able to make this transition. Perhaps there always have been some families experiencing such problems, especially in large urban centers, but their numbers and the complexity of their problems seem to have increased. Targeted supports over longer periods of time may be required to offset the profound cumulative impacts on these children and their families. For some, the inability to cope may be so serious that it is easier to continue providing welfare than to try helping them overcome their problems.^5,6 For others, such as those in smaller or more rural communities, a lack of opportunities for jobs, education, literacy, child care, and access to basic physical and mental health services presents an even greater challenge.^7,8 Finally, poor families of color, families with different cultures or languages, and those with disabilities quite often are unable to access even the smallest of "safety nets."⁹

The Limitations of the Current Welfare System

The family stories shared above illustrate the limitations of the current welfare system. All of these families are just barely getting by. All are struggling to provide the basics for their children: food, housing, utilities, transportation, child care, after-school and summer programs, periodic medical exams, dental exams, and immunizations. In addition to dealing with these challenges, all of the families must complete voluminous forms and meet rigorous eligibility requirements to access benefits. And some benefits—such as TANF—come with sanctions or penalties for lack of compliance with work and other requirements.

Because the procedures to obtain benefits often add to the daily demands on these families, it should come as no surprise that, for many, welfare reform has not worked, and it may even have contributed to adverse outcomes. When an unanticipated crisis occurs, there is little opportunity for immediate assistance, and a downward spiral can sometimes follow with grave consequences, including child abuse, domestic violence, suicide, or abandonment. There is a compelling need to assure access to resources and services beyond those currently being provided.

Throughout the welfare system, workers make decisions based on regulations that cannot be readily adapted to the special circumstances of individual families. For example, the plight of the young mother about to lose her job because her infant was perhaps mildly ill could be avoided if the child care worker understood that an occasional "loose stool" is not associated with much risk for spreading disease. The family from Mexico with the neurologically impaired child would not have to face giving up a portion of income to protect their child's medical benefits if more flexible income guidelines took into account the variability in income from agriculture-based businesses. And perhaps the grandmother would not have had to take in her three adolescent grandchildren if her daughter had received more counseling from the mental health system.

In addition, when considering welfare reform and its consequences, whether positive or negative, it is important to recognize the influence of contemporary values, expectations, and political forces in determining who is considered "deserving" versus "undeserving" of assistance. In particular, as discussed in the article by Greenberg and colleagues in this journal issue, society has decided to make it considerably more difficult for poor immigrant families to qualify for benefits, especially TANF and Medicaid. For the most part, immigrant families can access benefits only if they lived in the United States prior to 1996 or if they become citizens.⁹ The benefits available through various immigrant and refugee programs are generally not enough to help immigrant families overcome the consequences of poverty and other language and cultural barriers.

Recommended Changes to Improve Supports for Poor Families

As we prepare for the discussion and debate that will undoubtedly accompany the legislative process for reauthorization, it is important to consider the many challenges faced by poor children and their families. With their complex and difficult lives in mind, I offer the following six recommendations:

1. Ensure that the interpretation of research findings from studies on the impact of welfare reform take into account the interrelationships of conditions that are closely tied to social class and income inequalities. Many factors other than poverty contribute to poor health, domestic violence, poor pregnancy outcomes, low levels of educational attainment, and hopelessness. These factors must be better understood to keep families that have been negatively affected by welfare reform from falling further behind.¹⁰



2. Revisit past programs and projects that incorporated components to help low-income families develop coping and problem-solving skills for lessons about how best to improve these families' health and social well-being. Examples of such programs might include the longitudinal Ypsilanti Michigan Study; the California Wellness Project; and community mental health and substance abuse treatment programs.^4,6,7



3. Encourage a greater mix of public and private resources to help poor families whose daily lives are so precarious. Such families cannot be the sole responsibility of government. Responsibility must be shared with every community, urban or rural, and with the families themselves. Leaders from the private sector and the community can offer mentoring, networking, and promotion of social and interactive skills that can help families secure greater financial security.



4. Clarify which immigrants are qualified to receive which benefits, and provide guidance to states, especially those with large immigrant populations. Eligibility workers and Immigration and Naturalization Service representatives must be more sensitive and willing to assist immigrant families through the maze of bureaucracies in a way that recognizes their cultural and language needs.



5. Assure families that when they are no longer eligible for TANF, they may still be eligible for other benefits as they transition to work, such as food stamps, Medicaid, and subsidized housing.



6. Establish a "job safety net" of publicly funded, low-wage service jobs that allows for a sense of purpose and future opportunity for individuals who are willing to work but unable to find employment.

What is most apparent in my work with poor families is that many barely get by, and they are struggling with the complex circumstances in their lives. Some families do just fine under welfare reform, but they are the exception.¹¹ Many others will continue to need support from government and society. Helping these families is a shared responsibility. For communities with large numbers of families in transition, the burden of social and economic costs can be excessive and must be distributed across public and private sectors. When possible, individuals who benefit should assume personal responsibility. But as policymakers debate and craft the reauthorization legislation, they must also recognize and support the critical dimensions of human need of those struggling under the system. To do otherwise is unconscionable.

Endnotes

1. These brief case histories reflect the circumstances of several families receiving services in a primary care clinic in San Antonio, Texas. The descriptions were kept general to protect the families' identities.



2. Daly, M., Duncan, G., Kaplina, G., et al. Macro-to-micro links in the relation between income inequality and mortality. The Milbank Quarterly (September 1998) 76(3):315–55.



3. Danziger, S. Approaching the limit: Early lessons from welfare reform. JCPR working paper 195. Chicago: Joint Center for Poverty Research, Northwestern University/University of Chicago, June 2000.



4. Sorensen, E., Mincy, R., and Holgen, A. Redirecting welfare policy toward building strong families. Washington, DC: Urban Institute Press, May 2000.



5. Finding Common Ground. National and state-level welfare reform developments and the health of women and children. Presentation for staff at the San Antonio Metropolitan Health District. San Antonio, Texas. June 2000. See also Romero, D., Chavkin, W., Wise, P.H., et al. State welfare reform policies and maternal and child health services: A national study. Maternal and Child Health Journal (2001) 5(3):199–206.



6. Chafel, J.A., ed. Child poverty and public policy. Washington, DC: Urban Institute Press, 1993.



7. Syme, S.L. Social and economic disparities in health: Thoughts about intervention. The Milbank Quarterly (1998) 76(3):493–503.



8. Evanson, E., Manski, C.F., and Scanlan, T.M., eds. Evaluating food assistance programs in an era of welfare reform: Summary of a workshop. Washington, DC: Committee on National Statistics, National Research Council and Institute of Medicine/National Academy Press, 1999.



9. Zimmermann, W., and Tumlin, K. Patchwork policies: State assistance for immigrants under welfare reform. Washington, DC: Urban Institute, 1999. See also note 5, Romero, et al.



10. A good example of such an approach can be found in Healthy People 2010, with its specific goals and measures for mothers, children, and adolescents, including risk-taking behaviors and a variety of other measures that allow for comparison with national trends. See U.S. Department of Health and Human Services. Healthy people 2010: Understanding and improving health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.



11. See the Urban Institute's Assessing the New Federalism Newsletter, January 2000. Available online at http://newfederalism.urban.org/html/
    newsletter.html. See also note 4, Sorensen, et al.; and note 6, Chafel.