Evaluation of a savings-led family-based economic empowerment intervention for AIDS-affected adolescents in Uganda: A four-year follow-up on efficacy and cost-effectiveness.

BACKGROUND: Children who have lost a parent to HIV/AIDS, known as AIDS orphans, face multiple stressors affecting their health and development. Family economic empowerment (FEE) interventions have the potential to improve these outcomes and mitigate the risks they face. We present efficacy and cost-effectiveness analyses of the Bridges study, a savings-led FEE intervention among AIDS-orphaned adolescents in Uganda at four-year follow-up. METHODS: Intent-to-treat analyses using multilevel models compared the effects of two savings-led treatment arms: Bridges (1:1 matched incentive) and BridgesPLUS (2:1 matched incentive) to a usual care control group on the following outcomes: self-rated health, sexual health, and mental health functioning. Total per-participant costs for each arm were calculated using the treatment-on-the-treated sample. Intervention effects and per-participant costs were used to calculate incremental cost-effectiveness ratios (ICERs). FINDINGS: Among 1,383 participants, 55% were female, 20% were double orphans. Mean age was 12 years at baseline. At 48-months, BridgesPLUS significantly improved self-rated health, (0.25, 95% CI 0.06, 0.43), HIV knowledge (0.21, 95% CI 0.01, 0.41), self-concept (0.26, 95% CI 0.09, 0.44), and self-efficacy (0.26, 95% CI 0.09, 0.43) and lowered hopelessness (-0.28, 95% CI -0.43, -0.12); whereas Bridges improved self-rated health (0.26, 95% CI 0.08, 0.43) and HIV knowledge (0.22, 95% CI 0.05, 0.39). ICERs ranged from $224 for hopelessness to $298 for HIV knowledge per 0.2 standard deviation change. CONCLUSIONS: Most intervention effects were sustained in both treatment arms at two years post-intervention. Higher matching incentives yielded a significant and lasting effect on a greater number of outcomes among adolescents compared to lower matching incentives at a similar incremental cost per unit effect. These findings contribute to the evidence supporting the incorporation of FEE interventions within national social protection frameworks.

More money, fewer lives: the cost effectiveness of welfare reform in the United States.

OBJECTIVES: We evaluated the economic benefits of Temporary Assistance to Needy Families (TANF) relative to the previous program, Aid to Families with Dependent Children (AFDC). METHODS: We used pooled mortality hazard ratios from 2 randomized controlled trials-Connecticut Jobs First and the Florida Transition Program, which had follow-up from the early and mid-1990s through December 2011-and previous estimates of health and economic benefits of TANF and AFDC. We entered them into a Markov model to evaluate TANF's economic benefits relative to AFDC and weigh them against the potential health threats of TANF. RESULTS: Over the working life of the average cash assistance recipient, AFDC would cost approximately $28000 more than TANF from the societal perspective. However, it would also bring 0.44 additional years of life. The incremental cost effectiveness of AFDC would be approximately $64000 per life-year saved relative to TANF. CONCLUSIONS: AFDC may provide more value as a health investment than TANF. Additional attention given to the neediest US families denied cash assistance could improve the value of TANF.

Processos de exclusão social e iniquidades em saúde: um estudo de caso a partir do Programa Bolsa Família, Brasil / Social exclusion and health inequity: a case study based on a cash distribution program (Bolsa Família) in Brazil

OBJETIVO: Compreender as repercussões do Programa Bolsa Família (PBF) e analisar seus efeitos nos processos de inclusão e exclusão social vividos pelas famílias pobres no Brasil, em especial sua potencialidade para enfrentar iniquidades em saúde. MÉTODOS: A investigação de abordagem qualitativa empregou a metodologia de estudo de caso com utilização das técnicas de observação participante, pesquisa documental e entrevistas semiestruturadas com famílias beneficiárias e ex-beneficiárias do PBF, além de gestores municipais. O estudo foi conduzido em um município de pequeno porte do estado do Rio de Janeiro, com elevado índice de exclusão social e cobertura de 100% da Estratégia Saúde da Família (ESF).A abordagem dosprocessos deinclusão e exclusão socialem suas dimensões econômica, social, política e cultural foi utilizada para orientar a coleta e análise dos dados. RESULTADOS: O programa favoreceu a inclusão social das famílias pobres, especialmente nas dimensões econômica e social, apesar de não promover as mudanças reivindicadas pelos beneficiários na esfera do trabalho. Os efeitos na dimensão política foram limitados pelo funcionamento inadequado das instâncias de participação social. Os entrevistados destacaram os efeitos positivos da ESF relacionados ao usufruto do direito à saúde, em particular a ampliação do acesso e utilização de serviços de saúde de atenção primária. No entanto, esses efeitos mostraram-se desvinculados do PBF. CONCLUSÕES: O trabalho aponta efeitos, limites e desafios do PBF para modificar os determinantes sociais produtores de iniquidades da saúde, a fim de que se alterem, de modo mais permanente, as dinâmicas de exclusão/inclusão social de famílias vivendo em situação de pobreza.

OBJECTIVE: To understand the impact of Bolsa Família (PBF), a federal cash transfer program, and to analyze its effects on social inclusion and exclusion processes experienced by low-income families in Brazil, with a focus on the program's potential to help overcome health inequity. METHODS: This qualitative investigation used a case study methodology including observant participation, review of documents, and semi-structured interviews with current and former PBF beneficiaries, as well as with the program's local managers. The study was conducted in a small city in the state of Rio de Janeiro with a high social exclusion index and 100% coverage by the Family Health Strategy (Estratégia Saúde da Família, ESF) program. The economic, political, social, and cultural dimensions of social exclusion and inclusion processes were used to guide data collection and analysis. RESULTS: The program facilitated social inclusion of low-income families, especially in the economic and social dimensions. Nevertheless, it did not produce the changes desired by the beneficiaries in the work dimension. The effects on the political dimension were limited by the insufficient social engagement of the PBF. The interviewees underscored the positive effects of the ESF, which allowed them to exercise their right to health by granting them wider access to primary health care services. However, these effects appeared to be unrelated to the PBF. CONCLUSIONS: The results reveal effects, limitations, and challenges of the PBF towards modifying the social determinants of health inequity, in order to promote more effective changes in the social exclusion/inclusion dynamics affecting low-income families.

Prevalence, characteristics, and poverty status of Supplemental Security Income multirecipients.

"Multirecipients" are people who receive Supplemental Security Income (SSI) payments while living with other recipients (not including an SSI-eligible spouse). Using Social Security Administration records matched to Current Population Survey data for 2005, this article examines multirecipients' personal, family, household, and economic characteristics. I find that no more than 20 percent of the 2005 SSI population were multirecipients. Most multirecipients were adults, lived with one other recipient, and/or shared their homes with related recipients. Multirecipients were generally less likely to be poor than SSI recipients as a whole; but those who were children, lived with one other recipient, and/or shared their homes with a nonrecipient were more likely to be poor. Implementing sliding-scale SSI benefit reductions for children in multirecipient households would affect about 23 percent of multirecipients, or about 5 percent of all SSI recipients.

Child allowances, fertility, and chaotic dynamics.

This paper analyzes the dynamics in an overlapping generations model with the provision of child allowances. Fertility is an increasing function of child allowances and there exists a threshold effect of the marginal effect of child allowances on fertility. We show that if the effectiveness of child allowances is sufficiently high, an intermediate-sized tax rate will be enough to generate chaotic dynamics. Besides, a decrease in the inter-temporal elasticity of substitution will prevent the occurrence of irregular cycles.

Welfare programs that target workforce participation may negatively affect mortality.

During the 1990s reforms to the US welfare system introduced new time limits on people's eligibility to receive public assistance. These limits were developed to encourage welfare recipients to seek employment. Little is known about how such social policy programs may have affected participants' health. We explored whether the Florida Family Transition Program randomized trial, a welfare reform experiment, led to long-term changes in mortality among participants. The Florida program included a 24-36-month time limit for welfare participation, intensive job training, and placement assistance. We linked 3,224 participants from the experiment to 17-18 years of prospective mortality follow-up data and found that participants in the program experienced a 16 percent higher mortality rate than recipients of traditional welfare. If our results are generalizable to national welfare reform efforts, they raise questions about whether the cost savings associated with welfare reform justify the additional loss of life.

[Social exclusion and health inequity: a case study based on a cash distribution program (Bolsa Família) in Brazil]. / Processos de exclusão social e iniquidades em saúde: um estudo de caso a partir do Programa Bolsa Família, Brasil.

OBJECTIVE: To understand the impact of Bolsa Família (PBF), a federal cash transfer program, and to analyze its effects on social inclusion and exclusion processes experienced by low-income families in Brazil, with a focus on the program's potential to help overcome health inequity. METHODS: This qualitative investigation used a case study methodology including observant participation, review of documents, and semi-structured interviews with current and former PBF beneficiaries, as well as with the program's local managers. The study was conducted in a small city in the state of Rio de Janeiro with a high social exclusion index and 100% coverage by the Family Health Strategy (Estratégia Saúde da Família, ESF) program. The economic, political, social, and cultural dimensions of social exclusion and inclusion processes were used to guide data collection and analysis. RESULTS: The program facilitated social inclusion of low-income families, especially in the economic and social dimensions. Nevertheless, it did not produce the changes desired by the beneficiaries in the work dimension. The effects on the political dimension were limited by the insufficient social engagement of the PBF. The interviewees underscored the positive effects of the ESF, which allowed them to exercise their right to health by granting them wider access to primary health care services. However, these effects appeared to be unrelated to the PBF. CONCLUSIONS: The results reveal effects, limitations, and challenges of the PBF towards modifying the social determinants of health inequity, in order to promote more effective changes in the social exclusion/inclusion dynamics affecting low-income families.

Resource and cost adjustment in the design of allocation funding formulas in public health programs.

CONTEXT: Multiple federal public health programs use funding formulas to allocate funds to states. OBJECTIVE: To characterize the effects of adjusting formula-based allocations for differences among states in the cost of implementing programs, the potential for generating in-state resources, and income disparities, which might be associated with disease risk. SETTING: Fifty US states and the District of Columbia. INTERVENTION: Formula-based funding allocations to states for 4 representative federal public health programs were adjusted using indicators of cost (average salaries), potential within-state revenues (per-capita income, the Federal Medical Assistance Percentage, per-capita aggregate home values), and income disparities (Theil index). MAIN OUTCOME: Percentage of allocation shifted by adjustment, the number of states and the percentage of US population living in states with a more than 20% increase or decrease in funding, maximum percentage increase or decrease in funding. RESULTS: Each adjustor had a comparable impact on allocations across the 4 program allocations examined. Approximately 2% to 8% of total allocations were shifted, with adjustments for variations in income disparity and housing values having the least and greatest effects, respectively. The salary cost and per-capita income adjustors were inversely correlated and had offsetting effects on allocations. With the exception of the housing values adjustment, fewer than 10 states had more than 20% increases or decreases in allocations, and less than 10% of the US population lived in such states. CONCLUSIONS: Selection of adjustors for formula-based funding allocations should consider the impacts of different adjustments, correlations between adjustors and other data elements in funding formulas, and the relationship of formula inputs to program objectives.

Caseworker-recipient interaction: welfare office differences, economic trajectories, and child outcomes.

Drawing on developmental and policy research, this study examined whether 3 dimensions of caseworker-recipient interaction in welfare offices functioned as critical ecological contexts for recipient families. The sample consisted of 1,098 families from 10 welfare offices in National Evaluation of Welfare to Work Strategies (NEWWS). In multilevel analyses, caseworker support, caseload size, and emphasis on employment predicted 5-year quarterly trajectories of earnings, income, and welfare receipt. Recipients in offices characterized by high support had steeper increases in earnings and income; those in offices with high caseload size had steeper decreases in income and welfare receipt; and those in offices with high emphasis on employment had steeper decreases in welfare receipt. These economic trajectories were associated with children's reading and math achievement and internalizing behavior at ages 8-10.

A profile of social security child beneficiaries and their families: sociodemographic and economic characteristics.

Using a rich dataset that links the Census Bureau's Survey of Income and Program Participation calendar-year 2004 file with Social Security benefit records, this article provides a portrait of the sociodemographic and economic characteristics of Social Security child beneficiaries. We find that the incidence ofbenefit receipt in the child population differs substantially across individual and family-level characteristics. Average benefit amounts also vary across subgroups and benefit types. The findings provide a better understanding of the importance of Social Security to families with beneficiary children. Social Security is a major source of family income for many child beneficiaries, particularly among those with low income or family heads with lower education and labor earnings.

Child Support Enforcement program; medical support. Final regulation.

This regulation revises Federal requirements for establishing and enforcing medical support obligations in Child Support Enforcement (CSE) program cases receiving services under title IV-D of the Social Security Act (the Act). The changes: require that all support orders in the IV-D program address medical support; redefine reasonable-cost health insurance; require health insurance to be accessible, as defined by the State; and make conforming changes to the Federal interstate, substantial compliance audit, and State self-assessment requirements.

Health insurance and access to care among welfare leavers.

This analysis explores the effects of the 1996 welfare reform on health insurance coverage and access to care among former recipients of cash aid. Using panel data from the Women's Employment Study, which conducted five interviews between 1997 and 2003 in one Michigan county, we find that 25% of welfare leavers lacked health insurance coverage in fall 2003. Uninsured adults were significantly more likely than others to report that they could not afford a medical or dental visit during the year prior to the 2003 interview. Fixed-effect logistic regression analysis indicates that women who had been off the welfare rolls for at least 12 months (the duration of transitional Medicaid) were significantly more likely to be uninsured than women who had made more recent welfare exits, and were significantly more likely to report financial obstacles to the receipt of medical and dental care.

SCHIP. Does this model for covering kids have legs?

The popular federal-state insurance program for kids is caught between legislators who want to expand its scope and others who want to rein it in.

Welfare recipients' involvement with child protective services after welfare reform.

OBJECTIVE: This study identifies factors associated with child protective services (CPS) involvement among current and former welfare recipients after welfare reform legislation was passed in the US in 1996. METHOD: Data come from the Women's Employment Study, a longitudinal study of randomly selected welfare recipients living in a Michigan city in 1997 (N=541). In order to identify risk factors for CPS involvement among current and former welfare recipients, multinomial logit analyses with 29 independent variables were employed on a trichotomous dependent variable: no CPS involvement, investigation only, and supervision by CPS after investigation. RESULTS: The relationship between work and involvement with CPS differs by work experience prior to welfare reform. As the percentage of months working after welfare reform increased, the risk of being investigated by CPS declined among those with prior work experience but the risk increased among those without prior work experience. However, work variables were not significant predictors of supervision by CPS after an initial investigation. Further, race, cohabitation, childhood welfare receipt, having a learning disability, having a large number of children, being newly divorced, living in a high problem neighborhood, and being convicted of a crime were associated with one's probability of being either investigated or supervised by CPS. CONCLUSIONS: These findings suggest that employment could have increased the stress levels of current or former welfare recipients without prior work experience to the point where they were prone to minor child rearing mistakes that resulted in a CPS investigation, but were not severe enough to warrant opening the case for supervision. Supports should be provided to welfare mothers who are prone to involvement with CPS; expansions in the childcare subsidy and a reduction or delay in work requirements might also help these families.

Re-reporting of child maltreatment: does participation in other public sector services moderate the likelihood of a second maltreatment report?

OBJECTIVE: This study uses administrative data to track the first re-reports of maltreatment in a low-income, urban child welfare population (n=4957) while controlling for other public service involvement. Service system involvement is explored across the following sectors: Child Welfare, Income Maintenance, Special Education, Juvenile Court, and various forms of Medicaid-reimbursed medical or mental health care. This study builds knowledge by adding the services dimension to an ecological framework for analyses and by following recurrence for a longer period of time than prior investigations (7.5 years). METHOD: We model the re-reporting of a child for maltreatment as a function of child, caregiver, service, and neighborhood characteristics using data from birth records, child welfare, income maintenance, Medicaid, adult corrections, juvenile court, special education, law enforcement, and census sources. Bivariate and multivariate analyses are presented, the latter using Cox regression with a robust sandwich covariance matrix estimate to account for the intracluster dependence within tracts. RESULTS: Key results across bivariate and multivariate analyses included a lower rate of re-reporting among children with parents who were high school graduates and/or permanently exited from the first spell on AFDC (p<.0001); and for children in families that received less intensive in-home services compared to those not receiving services, receiving intensive in-home, or foster care services (p<.0001). Higher rates of re-reporting were found for children with Medicaid mental health/substance abuse treatment records (p<.0001) and special education eligibility for emotional disturbance (p<.005). CONCLUSIONS: Caretaker characteristics and non-child welfare service use patterns had a strong association with the likelihood of a child being re-reported to the child welfare agency and should be more heavily attended to by child welfare workers. High rates of service sector overlap suggest that interagency ties and cooperation should be strengthened. The lower risk associated with less intensive in-home services compared to un-served cases may indicate under-identification of in-home service eligibility following a first report of maltreatment.

Three years of state fiscal struggles: how did Medicaid and SCHIP fare?

During 2003-05, states faced some of the largest budget shortfalls since World War II. With a focus on Medicaid and SCHIP, we examine budget decisions in eight states during this period. Increasing Medicaid enrollment because of the economic down-turn and rising health care costs compounded state budget shortfalls as state revenues dropped; problems peaked in 2004. States, however, were reluctant to confront their budget deficits as long-term problems and implemented a variety of one-time revenue strategies and spending reductions that push fiscal problems into the future. The arrival of federal fiscal relief in late 2003 helped states avoid deeper cuts but did not eliminate cutbacks.

Disparities in children's use of oral health services.

OBJECTIVES: We sought to determine if the recent expansions in Medicaid and the State Children's Health Insurance Program (SCHIP) have resulted in a narrowing of income disparities over time with the use of dental care in children 2 to 17 years of age. METHODS: Six years of data from the National Health Interview Survey were utilized. A trend analysis was conducted using 1983 as a baseline, which predates the expansions, and 2001-2002, the endpoint, which postdates implementation of the expansions. In addition, we examined two intermediate time points (1989 and 1997-1998). We conducted unadjusted and adjusted analyses using logistic regression. RESULTS: Overall, use of ambulatory dental care has increased dramatically for children over the past two decades. In 1983, more than one in three children (38.5%) had no dental care within the previous 12 months. By 2001-2002, about one-quarter of children (26.3%) were reported to have no dental care within the year, a reduction of 12.2% from 1983 (p<0.001). Frequency of unmet dental care remained unchanged between 1997-1998 (the first year this measure was available) and 2001-2002. A reduction in income disparities for use of dental care was found in our unadjusted analysis but this difference became statistically insignificant in the adjusted analysis. No changes in income disparities occurred for unmet dental needs in either the unadjusted or adjusted analyses. CONCLUSIONS: A substantial overall improvement in dental care use has occurred among all income groups, including poor and near poor children. This "keeping up" with their higher-income counterparts represents an important public health accomplishment for children in low-income families. Nevertheless, additional efforts are needed to close remaining disparities in access to dental care.