Edition: Available editions United States. Become an author Sign up as a reader Sign in. Articles Contributors Links Articles on social welfare Displaying 1 - 20 of 27 articles.
Canadians with disabilities were hit hardest during the pandemic. I used to work in a grocery store and constantly overheard grumbling from the shoppers who were having to pinch their pennies when they observed a heavily loaded shopping cart of choice items being paid for with food stamps.
Not only are ill feelings fostered but also there is provided an excuse to shift responsibility when private charities appeal for funds:. They will handle the situation. It destroys, through excessive taxation, the capacity of private citizens and organizations to help. Personal income is eroded through redistributive tax schemes, thus leaving fewer funds for personal charity. Remember the recent uproar over the enormous increase in the Social Security tax?
There goes some more money that could have been available for private charity. It undermines personal responsibility and incentive in the poor to help themselves. Welfare funds are addictive. Withdrawal is hard. It promotes a false sense of security among the needy. It promotes a false sense of equality among minorities. They can either be led to believe they are getting their "fair share" or that they are receiving "remuneration" for past offenses against them.
Dependency does not promote equality. It is less efficient than private charity. Private, local charity is true charity: it is voluntary and it is not subject to the bureaucratic filtering process. I have never heard the government or any of its programs praised for efficiency—except by the government and those who head the programs! It promotes conflict among groups clamoring to get their hands on the handouts.
There is never enough money to make everyone happy; therefore, groups fight to get to the front of the line. We then tested it over ranges described in the literature. We used the total expenditures of federal TANF money, the percentage spent on cash assistance, and caseloads for TANF in , the last year for which we had data. Our spreadsheet and Markov models therefore simply compared the net present value of societal costs and deaths for the average year-old female recipient from through —the point at which the participant will have reached retirement age.
To obtain these estimates for TANF recipients, we used mean annual changes in family income as benefits in the numerator. We also applied mortality hazards to age-specific mortality rates and tally discounted infant mortality impacts to the denominator.
To the AFDC cohort, we added annual deadweight losses. Model inputs and ranges are presented in Table 1. Because we evaluated a single cohort of women, we estimated excess life-years lost to infant mortality using the product of a single year of infant mortality and the average number of children born to recipients under TANF. The box on this page lists the major assumptions of the models, and Table 1 lists the model inputs. From the societal perspective, our concern is with the cost of a program, regardless of who pays.
These figures were sensitive to some model assumptions, however Table 3. In one-way sensitivity analyses, deadweight loss estimates did not produce much variance in the incremental cost-effectiveness ratios.
Infant mortality impacts produced very little influence on the model. In 2-way sensitivity analyses comparing the hazard ratio with infant mortality, infant mortality exerted only 0. Each value represents the incremental cost-effectiveness ratio in dollars per life-year gained when the high and low values from Table 1 were input into the model. Welfare reform may have produced very large direct monetary savings, including returns for both individuals and for the US government.
Some may have ended up relying on weak financial networks or become homeless. Finally, 7,25 although some families benefit, those who cannot work because of mental or physical limitations may increasingly be excluded from the program because they, like able participants, face time limits.
Unfortunately, the main disability program, Supplemental Security Income, is also in need of reform and is struggling under higher caseloads even as TANF caseloads decline. As with any social policy, changes to TANF would likely have unforeseen macroeconomic consequences. Second, the other national and local safety net programs that have been partially accommodating unemployed former TANF recipients are in an unprecedented state of flux and transition. Some states have resisted increasing Medicaid enrollment under the Patient Protection and Affordable Care Act, and the future of Supplemental Nutritional Assistance Program was unclear at the time this article was written.
The extent to which TANF modifications would impact these dynamics within the US political economy is unknown and well beyond the scope of this article. Future work could include systems dynamics models, which allow for the broader impacts of a given social policy on health and economic well-being to be modeled over time.
Third, to the extent that such modifications would reduce mortality, they may also have an impact on morbidity and therefore produce intangible benefits e. Our study had several strengths. Foremost, we used real-world cost data and derived mortality data from a meta-analysis of 2 multicenter randomized controlled trials with mortality follow-up over nearly 2 decades. Despite these strengths, the study had a number of important limitations.
For one, none of the randomized controlled trials of welfare reform that we examined included a measure of quality-adjusted life-years. Thus, we could not incorporate morbidity impacts in our study. Second, we based our mortality estimates on randomized controlled trials in various locations in 2 states, Connecticut and Florida. Although these states fall roughly in the middle range of benefits offered by states under TANF, these results might not be generalizable to the nation as a whole.
Third, the experiments included much more generous benefits than TANF in most states, and participants and controls were both treated with TANF roughly halfway through the follow-up period. Both of these factors likely resulted in an underestimation of mortality hazards.
It is important to note that when clustering is removed from the FTP model, the confidence intervals widen, and the results become only marginally significant. The clustered meta-analysis is statistically significant; however, the meta-analysis without clustering of CJF and FTP is only statistically significant when all sites are included.
If the adverse health impacts of TANF arise because some women cannot work, reform efforts should focus on this subgroup of recipients. Reform of the disability system could include the use of specially trained physicians for disability assessments.
Given that women with large families appear to be disproportionately affected, 9,10,15 redoubled family planning efforts and child care investments could also help. Current efforts to plan a universal prekindergarten program could simultaneously provide respite for mothers and cognitive enhancements for children.
We thank Ron Haskins and Robert Moffit for their invaluable input and patience in the development of this article. This study involved only secondary analysis of published data and was exempt from institutional review board review. National Center for Biotechnology Information , U. Am J Public Health. Published online February. The most common methodological issue was the absence of an experimental or quasi-experimental study design that is capable, at least to some extent, of controlling for unobserved sources of confounding.
Only four of the studies were specifically designed to distinguish true policy effects from potential sources of selection bias that render a comparison of recipients and non-recipients problematic.
Furthermore, though many of the studies controlled for the most common confounders e. There are several important insights to be gained from our systematic review. Most notably, the results of our review suggest that social assistance recipients tend to exhibit worse health outcomes relative to their non-recipient counterparts.
This appears to be the case even after controlling for key demographic and socioeconomic characteristics. This is somewhat puzzling, given that public health theory would predict that these programs are beneficial to health status [ 1 , 9 ].
The observation that those receiving benefits are faring worse than seemingly comparable non-recipients may reflect that there are, in fact, systematic differences between these populations that are not readily observable using the data upon which these studies rely.
There are least two major sources of confounding that could be biasing the results of the reviewed studies. Firstly, individuals who suffer from pre-existing health problems may be selecting into social assistance programs as a means of accessing ancillary benefits that are otherwise out of reach e.
Secondly, pre-existing health problems may contribute to adverse socioeconomic experiences such as job loss which in turn predict social assistance status. Indeed, there is evidence suggesting that those who suffer from psychological problems have a greater likelihood of experiencing socioeconomic disadvantage and selecting into social assistance [ 41 , 42 , 43 ]. In a similar vein, findings from the extant literature indicate that problematic risk behaviours such as binge drinking may predict later life socioeconomic hardship, thereby influencing social assistance status [ 44 , 45 ].
In addition, individuals with unreported material resources such as savings and family wealth may be opting out of, or be ineligible for, these benefits. In all three cases, these residual sources of confounding are likely to bias results towards a negative association between income support and health status. Alternatively, these findings may reflect the fact that social assistance is increasingly conditional on a range of punitive, work-related obligations that compel entry into precarious employment conditions [ 46 , 47 , 48 ].
While these measures have been shown to marginally improve employment outcomes among welfare recipients, the terms of their attachment to the labour market tend to be short-lived and produce their own set of adverse socioeconomic consequences, including higher rates of in-work poverty [ 49 ].
In fact, recent evidence suggests that these precarious working conditions may pose an equal if not greater risk to health status than the experience of unemployment [ 50 , 51 , 52 ]. Based on these findings, we might expect social assistance programs that compel marginal labour market attachment to produce negligible or even negative returns to health.
Indeed, evidence from the broader literature demonstrates that alternative income maintenance programs which place fewer behavioural requirements on recipients and provide more generous benefit levels than social assistance programs e.
The finding here that social assistance programs are not similarly associated with positive health outcomes may reflect that, unlike other forms of income maintenance, the scope and generosity of existing social assistance programs are insufficient to offset the negative health consequences of the severe socioeconomic disadvantage that renders one eligible for such programs.
In contrast to the puzzling findings reported in descriptive studies, evidence from experimental and quasi-experimental studies of welfare reform in the United States conform to our theoretical expectations.
When benefits were reduced and work conditionalities were intensified, there were observable declines in the health status of the socioeconomically disadvantaged groups who tend to be the principal recipients of welfare; namely, poor and low-educated single mothers.
Welfare reform is often assumed to promote work and earnings by encouraging reattachment to the labour market. However, the results of existing evaluations suggest that these returns are lukewarm at best [ 58 , 59 ]. Furthermore, many households affected by welfare reform experienced heightened levels of material hardship [ 60 ].
Often, this was because women who were forced to leave welfare ended up in low-paying, insecure jobs [ 61 ]. The results of our systematic review lend support to this view by demonstrating that these reforms have had a negative impact on health status, an outcome that is sensitive to material conditions. Thus, while the main finding that social assistance programs do not appear to be succeeding at maintaining the health of the poor frustrates prevailing public health theory, our review provides some evidence suggesting that a reversal of these earlier welfare reforms and a resulting increase in the scope and generosity of social assistance benefits may have a positive effect on the health of socioeconomically disadvantaged populations.
There are several limitations to our analysis. First, we were not able to identify and include studies evaluating policy experiments involving the expansion of social assistance programs. Policy reforms in high-income countries have overwhelmingly involved the retrenchment of established levels of social protection [ 62 , 63 , 64 ].
Consequently, there are few examples of expansionary policymaking available for evaluation. Second, we restricted our search to peer-reviewed journal articles. Evidence collected in books, reports, and working papers were excluded from the review. We also restricted our search to English-language publications. This may explain why most of the studies included in the review were from English-speaking countries characterized by relatively weak welfare state infrastructures, with a majority being from the United States.
Finally, due to heterogeneity across studies both in policy exposures and health outcomes, we were not able to conduct a meta-analysis of their results. The overall results of our systematic review suggest that evidence on the health impacts of social assistance remains patchy. Rigorous evaluations of these programs are particularly lacking. Few of the studies accounted for systematic differences between social assistance recipients and their non-recipient counterparts.
Fewer still adopted the strongest available methods and study designs to evaluate the health effects of policies. We believe there are several principal reasons for the lack of available evidence on the question examined in this review. It may be the case that existing sources of data provide insufficient information for the conduct of rigorous policy evaluations.
For example, population-based health surveys tend to provide little if any information on the benefit characteristics of respondents. In addition, while those working in the field of public health may be increasingly familiar with appropriate statistical techniques to evaluate societal-level policy interventions [ 65 , 66 , 67 ], social assistance programs may not be particularly amenable to the application of such methods.
For example, many of the best available methods e. In contrast to other areas of public policymaking, such as tobacco or food labelling, social assistance programs are rarely affected by such abrupt punctuations.
A notable exception in this regard is welfare reform in the United States, for which there is evidence that we have reviewed here [ 23 , 31 , 36 , 37 ]. Finally, institutional barriers associated with the conduct of politically sensitive research may be standing in the way of the generation and dissemination of evidence on social assistance programs.
Tackling the structural determinants of health requires large-scale government interventions e. Such efforts can attract opposition from political actors who oppose such a role for governments [ 68 , 69 , 70 , 71 , 72 , 73 , 74 ]. Many epidemiologists and other scientists contributing to the health inequalities literature may, in turn, feel that conducting and disseminating research of this nature is too political or, by virtue of the political opposition they believe it might face, too challenging to undertake [ 75 , 76 ].
Notwithstanding these important challenges, there is a growing need for evidence on the health effects of social assistance and similar social policies [ 77 ]. While governments often identify health equity as an important priority, their choice of interventions have largely relied on behavioural health promotion strategies that fail to account for the role of social policies as necessary levers to reduce health inequalities [ 78 , 79 ].
Because efforts to eliminate or even reduce health inequalities are unlikely to be successful if they fail to intervene upon their fundamental causes, it is imperative that public health researchers examine these policies and identify the structural interventions that hold the greatest and the least promise for reducing health inequalities [ 80 ]. The paucity of such evidence is particularly problematic in light of growing evidence that, despite more than a decade of efforts to promote health equity, inequalities in major indicators of population health appear to be widening [ 81 , 82 ].
These troubling findings may reflect underlying changes in the social and economic architectures of high-income countries, such as the retrenchment of social protection policies — including social assistance programs [ 49 , 62 , 83 ] — and concomitant increases in adverse socioeconomic experiences, such as poverty and unemployment [ 84 , 85 ]. Taken together, these broader trends highlight a continuing need for solid evidence to marshal in support of interventions that target the fundamental determinants of health.
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