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Am J Public Health. 2000 Jun;90(6):900-8.

State welfare reform policies and declines in health insurance.

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Center for Population and Family Health, Joseph L. Mailman School of Public Health, Columbia University, New York, NY 10032, USA.



This study sought to determine whether there is a relationship between state policies on Temporary Assistance to Needy Families (TANF), declines in both TANF and Medicaid caseloads, and the rise in the number of uninsured.


Extant data sources of state TANF policies, TANF and Medicaid participation, and uninsurance rates were analyzed, with the state as the unit of analysis. The independent variables included state TANF policies that directly address receipt of benefits or relate to health; dependent variables included changes in state TANF enrollment, Medicaid enrollment, and health insurance status since the enactment of the law.


In the bivariate analysis, declines in Medicaid were associated with sanction for work noncompliance, lack of a child care guarantee, and strategies to deter TANF enrollment; this last factor was also associated with increased uninsurance. In the multivariate analysis, lack of a child care guarantee and deterrent strategies predicted TANF declines; deterrent strategies predicted Medicaid decline and uninsurance increases.


This analysis suggests that policies deterring TANF enrollment may contribute to declines in Medicaid and increased uninsurance. To maintain health insurance for the poor, policymakers should consider revising policies that deter TANF enrollment.

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