This page intentionally left blank Poor Families in America’s Health Care Crisis Poor Families in America’s Health Care Crisis examines the implications of the fragmented and two-tiered health insurance system in the United States for the health care access of low-income families For a large fraction of Americans, their jobs not provide health insurance or other benefits, and although government programs are available for children, adults without private health care coverage have few options Detailed ethnographic and survey data from selected low-income neighborhoods in Boston, Chicago, and San Antonio document the lapses in medical coverage that poor families experience and reveal the extent of untreated medical conditions, delayed treatment, medical indebtedness, and irregular health care that women and children suffer as a result Extensive poverty, the increasing proportion of minority households, and the growing dependence on insecure service-sector work all influence access to health care for families at the economic margin Ronald J Angel, Ph.D., is Professor of Sociology at the University of Texas at Austin With his wife, Jacqueline Angel, he is the author of Painful Inheritance: Health and the New Generation of Fatherless Families and Who Will Care for Us? Aging and Long-Term Care in Multicultural America Professor Angel served as editor of the Journal of Health and Social Behavior from 1994 to 1997, and he has served on the editorial boards of numerous other journals He has administered several large grants from NIA, NIMH, NICHD, and several private foundations Laura Lein, Ph.D., is Professor in the School of Social Work and the Department of Anthropology at the University of Texas at Austin She received her doctorate in social anthropology from Harvard University in 1973 She is the author, with Kathryn Edin, of Making Ends Meet: How Single Mothers Survive Welfare and Low-Wage Work She has published numerous articles, most recently in Community, Work and Family, Violence Against Women, and Journal of Adolescent Research Jane Henrici, Ph.D., is an Assistant Professor of Anthropology at the University of Memphis She earned her doctorate from the University of Texas at Austin She has published articles and chapters on development ´ programs and their interaction with ethnicity and gender in Peru, as well as on social programs and their effects on poor women in the United States With respect to the latter, she edited and contributed to a volume titled Doing Without: Women and Work after Welfare Reform (forthcoming) She is also the recipient of a Fulbright fellowship Poor Families in America’s Health Care Crisis RONALD J ANGEL The University of Texas at Austin LAURA LEIN The University of Texas at Austin JANE HENRICI University of Memphis cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge cb2 2ru, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521837743 © Ronald J Angel, Laura Lein, Jane Henrici 2006 This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published in print format 2006 isbn-13 isbn-10 978-0-511-21971-9 eBook (EBL) 0-511-21971-7 eBook (EBL) isbn-13 isbn-10 978-0-521-83774-3 hardback 0-521-83774-x hardback isbn-13 isbn-10 978-0-521-54676-8 0-521-54676-1 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Contents Preface The Unrealized Hope of Welfare Reform: Implications for Health Care The Health Care Welfare State in America The Tattered Health Care Safety Net for Poor Americans State Differences in Health Care Policies and Coverage Work and Health Insurance: A Tenuous Tie for the Working Poor Confronting the System: Minority Group Identity and Powerlessness The Nonexistent Safety Net for Parents Health Care for All Americans References Index page vii 33 53 77 101 129 158 186 213 239 v Preface The United States stands alone among developed nations in not providing publicly funded health care coverage to all citizens as a basic right Rather than a universal and comprehensive tax-based system of care, our health care financing system consists of three main components: private insurance, consisting mostly of group plans sponsored by employers; Medicare for those over sixty-five; and a means-tested system of public coverage for poor children, the disabled, and lowincome elderly individuals Unfortunately, these three components are far from comprehensive More than forty-five million Americans have no health care coverage of any sort, and millions more have episodic and inadequate coverage As a consequence, the health care they receive is often inadequate, and their health is placed at risk Although many of those without coverage receive charitable care or are seen at emergency rooms, they enjoy neither the continuity of care nor the high-quality care that fully insured Americans expect As we demonstrate in this book, the lack of adequate health care coverage is part of a vicious cycle in which the poor face more serious risks to their health and receive less adequate preventive and acute care Because minority Americans are more likely than majority Americans to be poor, this health and productivity penalty takes on an aspect of color African Americans live shorter lives on average than white Americans do, and they suffer disproportionately from the preventable consequences of the diseases of poverty vii viii Preface Because of the universally recognized fact that good health represents the foundation of a productive and happy life, in recent years the U.S Congress has extended the health care safety net for poor children Medicaid and the new State Children’s Health Insurance Program (SCHIP) have extended medical coverage to nearly all children and teenagers in low-income families Unfortunately, as we document in the following chapters, not all children who qualify on the basis of low family income are enrolled For nondisabled adults under the age of sixty-five, no such programs exist Pregnant women and those with serious disabilities, including HIV/AIDS, qualify for publicly funded health care, but adults who are not disabled or pregnant or those in families not receiving cash assistance have few options Those who work in service-sector jobs are unlikely to be offered employer-sponsored group coverage that they can afford, and in the absence of universal health care they have no choice but to go into debt in the case of serious illness or simply without care Conservatives and liberals approach health care financing and any potential reform of the current system from different perspectives As is the case with other aspects of the welfare state, those approaches are based on different philosophies concerning individual responsibility and the role of the state in providing citizens with the necessities of a dignified and productive life Health care, however, is different from other aspects of the welfare state, including cash assistance for the poor Since the 1980s and 1990s, public disenchantment with cash assistance has led to a demand that the poor be forced to take more responsibility for their own welfare and not become wards of the state As part of welfare reform, the entire apparatus of time limits, sanctions, and work requirements with which the states had experimented for a decade before the federal government made it the law of the land was put in place Even in this changed climate, with its rejection of long-term cash assistance, health care for the poor was recognized to be different Welfare reform was intended to reduce the cash assistance rolls but not the Medicaid rolls Medicaid use was, in fact, expected to increase, even though the unintended consequence of welfare reform was to reduce the Medicaid rolls at least in the short term The expansion of public coverage for poor children represents a response to the new reality of 240 Index attention deficit hyperactivity disorder (ADHD), 164 automobiles, see car ownership uninsured children in, 61, 93, 94 see also Massachusetts bronchitis, 19 bankruptcy, medical expenses as cause of, 55, 126 barrio humor of, 156–157 and inequalities, 147, 148–149 and intergenerational transmission of poverty, 136–137 Yvonne’s case, 139–143 see also Hispanics; residential exclusion and segregation blacks, see African Americans; race and ethnicity Blue Cross/Blue Shield, 204, 209 Boston African Americans in, 81–82, 87, 130, 132 characteristics of poor families in, 12 continuity of health insurance in, 87 economy of, 81 employment patterns in and statistics on, 106, 107, 108, 109–110, 111 employment-based health insurance in, 87 health care coverage in, 87, 88, 171, 172 Hispanics in, 80–81, 86, 130, 132, 157 Medicaid coverage in, 57, 62, 93, 94 monthly income in, 111, 112 physical and social environments of, 80–82, 96 public housing in, 81–82, 157 public transportation in, 81, 82, 96 racial and ethnic tensions in, 155–156 recruitment of poor families in, 11 Three City Study of, 6–12 cancer, 19, 170, 199, 212 car ownership, 95–96 cardiovascular diseases, 160, 170, 177, 199, 212 caseworkers, negative attitudes of, 150–153, 155, 156–157 Cecilia, 1–5 children of, 1–5 elusiveness of daily routines for, 17 employment of, 2, 4, family of, and Food Stamps, health problems of, 2, and Medicaid, 3–5 medical and dental problems of children of, medical debt of, 3, and noncompliance with welfare regulations, 3–4 and Temporary Assistance to Needy Families (TANF), 2–4 Census Bureau, 176 Chicago African Americans in, 80, 87, 130, 132, 155 economy of, 80 employment patterns in and statistics on, 106, 107, 108, 111, 122 employment-based health insurance in, 87 Graciela case, 150–151 Head Start programs in, 11, 12 health care coverage in, 88, 171, 172 Medicaid coverage in, 57, 62, 93, 94 Mexican Americans and other Hispanics in, 26, 86, 130, 132, 155 monthly income in, 111–112, 124 Index physical and social environments of, 79–80, 96 public transportation in, 96 racial and ethnic tensions in, 155 recruitment of poor families in, 11 Three City Study of, 6–12 uninsured children in, 61, 93, 94 see also Illinois child care, 2, 12, 70, 109, 112–113, 118, 121, 147 child support, 70, 146 children Cecilia’s children, 1–5 Claudia’s children, 146 Darlene’s children, 65 Darlene’s grandchildren, 64–65 with disabilities, 140–141, 144–145, 164 Elizabeth’s children, 177 Gloria’s children, 114–115, 118 immunization of, 192 Leticia’s children, 69–70 of noncitizens, 36 Norma’s children, 68 obesity of, 192–193 Sarah’s children, 33–34, 101–103, 115–116, 124 Sonia’s grandchildren, 143–145 statistics on child poverty, 23–24, 42 statistics on health insurance for, 35, 56–57, 58, 61–62, 92–94, 188 Teresa’s children, 161, 164 Yvonne’s children, 140–141 see also health care; health problems; Medicaid; State Children’s Health Insurance Program (SCHIP) Civil Rights Act (1964), 131 Claudia, 53–54, 146–148 and child care, 147 and child support, 146 children of, 53–54, 146 241 and food stamps, 54 housing for, 146–147 and Medicaid, 53–54, 146 and Temporary Assistance to Needy Families (TANF), 146 clinics for poor patients, 179 Clinton, Bill, 45, 193–194, 195–196, 197, 204 coalition building, barriers to, 153–157 COBRA (Consolidated Omnibus Budget Reconciliation Act), 203 Consolidated Omnibus Budget Reconciliation Act (COBRA), 203 contingent employment, see employment CPS (Current Population Survey), 176 Current Population Survey (CPS), 176 daily routines of poor families, 15–17, 23 Darlene, 64, 67 children of, 65 dental care for, 67 employment of, 66 grandchildren of, 64–65 health problems of, 65, 66–67 housing for, 65 and Medicaid, 64, 65, 66–67, 95 and SSI, 65, 67 and Temporary Assistance to Needy Families (TANF), 66 day care, see child care debt for medical expenses, see medical debt demoralization, 137–148, 167, 178–179, 184–185 dental care, 67, 72, 113, 125, 176, 177, 183 diabetes, 18, 19, 102, 159, 160, 161–167, 177, 179 242 disabilities children with, 140–141, 144–145, 164 Medicaid for adults with, 186, 187, 188 discrimination, see race and ethnicity; residential exclusion and segregation domestic violence, 114–115, 116, 153 Dominicans, 132 see also Hispanics Dora, 120–121 drugs, see prescription drugs ear infections, 19 earnings, see income education of African Americans, 183 and antipoverty programs, 174 compared with health care, 198, 199, 210 and health insurance, 174 of Hispanics, 183 job training and placement program, 71 and social mobility, 110, 137 Teresa’s case, 164 and welfare reform, 174 Yvonne’s case, 143 elderly expenditures by, on health care, 203 Medicaid for, 186, 187, 188 medical debt of, 203 Medicare for, 37, 49, 199, 203 and Social Security, 37, 48, 131, 193, 208, 211 support of retirees by workforce, 193, 211 Elizabeth, 177–179 children of, 177 health care for, 178–179 health problems of, 178–179 and Medicaid, 178 medical debt of, 177 Index mental health problems of, 178–179 and Temporary Assistance to Needy Families (TANF), 177 emergency assistance, 104 emergency rooms, 19, 55, 59, 179 Employee Retirement and Income Security Act (ERISA), 203 employment of African Americans, 22, 36, 183 Cecilia’s case, 2, 4, and child care, 2, 12, 70, 112–113, 118, 121 confusion about, 10, 110–111 contingent and contract employment, 46–47, 126–127 Darlene’s case, 66 Dora’s case, 120–121 earning from, for poor families, 110–111 expectations about, for poor families, 124–125 factors concerning, 15–16 future nature of workforce, 48, 189, 210–211 and globalization, 46, 127, 211 Gloria’s case, 117–118 of Hispanics, 22, 36, 110, 141, 149–150, 183 as inadequate for providing health insurance, 101, 105, 113, 124–125, 181 informal work, 141–142 instability of, 14–15, 22–23, 44, 55–56, 106–112, 114, 123–124 and lack of job security, 123–124 part-time employment, 107–108 patterns of and statistics on, for poor families, 106–114 potential errors in research on, 110–111 and race and ethnicity, 22, 110, 127, 128, 149–150 Sarah’s case, 33, 102, 103, 105, 115–116, 123–124 Index service-sector jobs, 18, 22–23, 36, 108–110, 112–113, 120–124, 127, 142 of single mothers, 112–114 stability in, 109–110, 113 statistical evaluations of, 22 statistics on workers supporting retirees, 193, 211 Teresa’s case, 164–166 underemployment, 114 and unpredictable schedules, 121–123 as welfare reform objective, 16, 27, 74, 99, 101 Yvonne’s case, 141–142 employment-based health insurance co-payments and deductibles for, 125 and contingent employment, 46–47, 126–127 cost of, for employees, 69, 124, 125 cost of, for employers, 35, 58, 124 decline in, 35, 124, 126–127 employer subsidies for, 58 federal legislation on, 203 instability and lack of, for poor families, 55–56, 105, 111–112, 113, 124 lack of, for service sector jobs, 18, 22–23, 36, 105, 113 and middle class, 29, 35, 126–127, 183, 197 Norma’s case, 64, 68–69 as primary route to health insurance, 17, 35, 99–100 prohibitive cost of, for poor families, 17, 56, 58–59, 67 proposals for mandated coverage, 206–207 statistics on, 92 in Three City Study, 57, 87 equality of opportunity, 44–45 ERISA (Employee Retirement and Income Security Act), 203 243 Esping-Anderson, G., 40–41 ethnicity, see race and ethnicity ethnography and instability of poor families, 15, 21 of San Antonio, 10–11 in Three City Study, 7, 8–9 Europe labor-management relations in, 38 public health policies in, 35 and supply-side economics, 191–192 welfare state in, 38, 39, 40–41, 45, 191–192 eye care, 113, 125, 177, 183 families, see poor families fathers, 181–182, 184 see also child support; poor families food stamps, 3, 29–30, 54, 98, 144–145, 151, 156–157 ghetto humor, 156–157 ghettoization, 148–149 see also residential exclusion and segregation globalization of diseases, 41 and employment, 46, 127, 211 and welfare state, 39, 41 Gloria, 117–120 children of, 114–115, 118 employment of, 117–118 health problems of children of, 117, 118 identity of, as mother, 119–120 and Medicaid, 117, 119 work-related accident of, 117, 118 Graciela, 150–151 Hacker, Jacob S., 38 Hawaii, 206–207, 210 244 Head Start Programs, 11, 12 health as collective good and collective problem, 48–49, 210–212 compared with education, 198, 199, 210 and equality of opportunity, 44–45 and workforce of future, 48, 189, 210–211 see also health care; health problems health care affordability of, 200–201 barriers to, and state Medicaid policies, 94–97 clinics for poor patients, 179 and common weal, 47–51, 98 compared with education, 198, 199, 210 complexity of health care system for poor, 169–170 constrained rationality of choices on, 175–180 cost of, for the poor, 19 current financing systems for, 35–37 Elizabeth’s case, 178–179 and equal opportunity, 44–45 in Europe, 35 fragmented and incomplete health care coverage for poor families, 54–60, 72–74, 106, 169–175, 176–177, 183–185 and health as common good, 210–212 for Hispanics, 159 and immunization of children, 192 impact of lack of, 111–112, 159–161, 189 importance of, for children, 49–50 Kaiser study on, 159 lack of, for poor parents, 27–29, 60 need for new discourse on, 26–27 Norma’s case, 68–69 parent’s dilemma on, 180–183 Index policy context of family health care coverage, 20–22 proposals for reform of, 197–200 and public health measures, 192–193 for racial and ethnic groups, 74 rationing of, 212 redistributional aspects of, 42–44 requirements for equitable and sustainable system of, 200–202 rising costs of, 41–42, 46, 124, 126, 198 Sarah’s case, 103 struggle by poor families to maintain coverage for, 61–72 Teresa’s case, 162–167, 176 Three City Study of, 6–12, 17–22, 26–29, 49–51, 170–175 see also dental care; emergency rooms; eye care; health insurance; health problems health care debt, see medical debt health care reform and affordability of health care, 200–201 barriers to, 195–196, 197 Clinton plan for, 45, 193–194, 195–196, 197, 204 conflicting objectives for, 202–204 and expansion of existing programs, 205–206 federal legislation on, 203–204 federal program for comprehensive health care coverage for all citizens, 206–207, 210 and managed care, 211–212 mandated coverage through employment-based health insurance, 206–207 medical savings accounts, 205 proposals for, 197–200 and Public Private Partnerships (PPPs), 194–195 realistic options for, 193–196, 204–210 Index and requirements for equitable and sustainable health care system, 200–202 subsidy to individuals for purchasing health care coverage, 207 see also universal health care coverage health insurance for children, 35 confusion about, among poor families, 62–63 and educational attainment, 174 impact of lack of, 111–112, 159–161, 189 and marital status, 173–174 policy context of family health care coverage, 20–22 and race and ethnicity, 172–173 and risk pool, 209 for single parents, 62, 63–72 as social marker, 51–52 strategies by mothers for maintaining, 62, 63–72 Three City Study of, 171–175 underinsurance, 76 and underwriting, 198, 209 see also employment-based health insurance; health care; Medicaid; uninsured children and adults; universal health care coverage Health Insurance Portability and Accountability Act (HIPPA), 203 health problems Anita’s case, 71 Cecilia’s case, 2, of Cecilia’s children, of children generally, 18–19, 43, 72–74, 164 chronic diseases of adulthood, 159–167, 176–177, 199, 212 Darlene’s case, 65 and discrimination against minority groups, 134 245 Elizabeth’s case, 178–179 globalization of, 41 of Gloria’s children, 117, 118 of Hispanics, 18, 74, 159, 161–168 of Leticia’s children, 70 morbidity and death rates of poor, 134, 170 Natalie’s case, 84, 85 Norma’s case, 68 of parents, 158–169 of the poor, 18–19, 27–29, 55, 72–74, 159–161 of racial and ethnic groups, 74, 132–136 of Sarah’s children, 33–34, 102, 103, 115–116, 124 Sonia’s case, 145 of Sonia’s grandsons, 144–145 Teresa’s case, 161–167, 176 Yvonne’s case, 141, 167–168 of Yvonne’s children, 141 see also disabilities; health care; and specific illnesses heart disease, 160, 170, 177, 199, 212 Helen, 95–96 helplessness, see demoralization HIPPA (Health Insurance Portability and Accountability Act), 203 Hispanics barrio and intergenerational transmission of poverty, 136–137 in Boston, 80–81, 86, 130, 132, 157 in Chicago, 26, 80, 86, 130, 132 Claudia’s case, 53–54 and demoralization, 137–143, 167 discrimination and racism against, 24–25, 44–45, 130, 132, 134 education of, 183 employment of, 22, 36, 110, 149–150, 183 Graciela’s case, 150–151 246 Hispanics (cont.) health care coverage for, 172–173, 175, 182–183 health care for, 159 health problems of, 18, 74, 159, 161–168 and immunization of children, 192 Leticia’s case, 64, 69–70 marriage penalty against, 75 and Medicaid and SCHIP, 49, 189 Mexican and Anglo cultures, 25–26 Mexican culture in San Antonio, 25–26, 77–79 Natalie’s case, 83–86 Norma’s case, 64, 68–69 and obesity of children, 192–193 population statistics on, in Texas, 210 on racial and ethnic tensions, 155 residential exclusion and segregation of, 131–132, 136–137, 147, 148–149 in San Antonio, 25–26, 77–79, 86, 130, 132, 156 and Spanish language, 132 statistics on child poverty, 23–24 Teresa’s case, 161–167 in Three City Study, 8–9, 130, 132 and uninsured children, 93 vulnerability, health and, 132–136 in workforce of future, 48, 210–211 Yvonne’s case, 139–143, 167–168 see also Mexican Americans; race and ethnicity HIV/AIDS, 41, 141, 168 HMOs, 169 hopelessness, see demoralization housing barrio and intergenerational transmission of poverty, 136–137 Boston public housing, 81–82, 157 Claudia’s case, 146–147 Darlene’s case, 65 Index evictions in Texas, 10–11, 12 Natalie’s case, 85 and overcrowding, 140 and residential exclusion and segregation, 131–132, 136–137, 147, 148–149 San Antonio public housing, 78–79, 139–140, 153–154 Sarah’s case, 101–102, 104–105 Sheila’s case, 153–154 and tenant protection, 10–11, 12 Yvonne’s case, 139–140 humiliation of poor families, 104, 119, 131–132, 150–153 humor, 156–157 hypertension, 19, 159, 177 illegal immigrants, see immigration status Illinois Medicaid in, 30, 90, 91, 114 minority and noncitizen populations in, 127–128 post-welfare reform drop in Medicaid coverage in, 88–89 retrenchment in eligibility for welfare and other public benefits, 88 State Children’s Health Insurance Program (SCHIP) in, 88–89, 99 Temporary Assistance to Needy Families (TANF) in, 29–30, 51 tenant protection in, 12 see also Chicago immigration status, 36, 127–128, 142, 173, 175, 183 immunization of children, 192 income federal poverty level, 111, 112 income distribution in United States, 42 instability of, 14–15 statistics on, 111 inequality apologists for, 43 and barrio, 147, 148–149 Index see also race and ethnicity; residential exclusion and segregation instability of employment and income, 14–15, 22–23, 44, 55–56, 106–112, 114, 124 and lack of health care coverage, 17–20, 21, 55–56, 111–112, 124, 183–185 of poor families, 12–15, 17–20, 21, 55–56, 101–105, 183–185 Institute of Medicine of the National Academies of Science, 192 jobs, see employment Johnson, Lyndon, 126 Kaiser (Henry J.) Family Foundation, 159 labor unions, 33–34, 35, 120 labor–management relations, 38–39 Latinos, see Hispanics; race and ethnicity Legal Aid Services, 144, 145 Leticia, 64, 69–70 child support for, 70 children of, 69–70 employment of, 69 health problems of children of, 70 and Medicaid, 64, 70 and Temporary Assistance to Needy Families (TANF), 69 Lewis, Oscar, 133 low-income families, see poor families; and specific individuals managed care, 211–212 marital status and health insurance, 173–174 marriage penalty for Medicaid, 74–76 Marshall, T H., 40, 204 Maryland, 60 Massachusetts 247 food stamp policies in, 29–30, 98 mandated coverage through employment-based health insurance in, 206–207, 210 Medicaid in, 29–30, 87, 88, 90, 91, 94, 98, 114 and mental health problems, 88 minority and noncitizen populations in, 127–128 post-welfare reform drop in Medicaid coverage in, 88–89 retrenchment in eligibility for welfare and other public benefits, 88 State Children’s Health Insurance Program (SCHIP) in, 88–89, 91, 99 Temporary Assistance to Needy Families (TANF) in, 29–30, 50 tenant protection in, 12 see also Boston Medicaid and access to basic care, 49, 54, 111, 112 Anita’s case, 64, 71–72 barriers to health care and state policies on, 94–97 beginning of, 35 Cecilia’s case, 3–5 Claudia’s case, 53–54, 146 comparison of coverage by, in Three City Study, 57, 62, 93–94 complexity of application and recertification process for, 11, 53–54, 73, 83–84, 95, 98–99, 116, 122, 176, 187, 190–191 and constraints on “appropriate” use of medical services, 66, 95 and cost of health care, 19 cycling on and off, 22, 171 Darlene’s case, 64, 65, 66–67, 95 for disabled adults, 186, 187, 188 for elderly, 186, 187, 188 eligibility threshold for, 106, 114, 158, 189–191 Elizabeth’s case, 178 248 Medicaid (cont.) failure to enroll in, 25, 50, 203 federal expenditures on, 188 Gloria’s case, 117, 119 and HMOs, 169 in Illinois, 30, 90, 91, 114 Leticia’s case, 64 locating provider for, 95, 169 and managed care, 211 marriage penalty for, 74–76, 175, 181 in Massachusetts, 29–30, 87, 88, 90, 91, 94, 98, 114 means-tested nature of, as barrier, 94–95 Natalie’s case, 83–84 Norma’s case, 68, 69 for older children, 187 and prescription drugs, 67, 72, 178 problems and frustrations with, 66–67, 69 proposals for expansion of, 205–206 purpose of, 208 and racial and ethnic groups, 49 reductions in coverage by, 88–89, 183, 187, 188, 189 reforms to application process for, 187 Sarah’s case, 33, 34, 103–104, 105, 113, 114, 115, 116 Sonia’s case, 144–145 and SSI, 141 state policies on, 89–91, 189–191 statistics on children enrolled in, 35, 92, 93–94, 187 successes and failures of, 188–189, 203 and TANF, 190 Teresa’s case, 163, 165 in Texas, 30, 90, 94, 98, 99, 114, 188, 189–190 and welfare reform, 20 Yvonne’s case, 141, 167 Index medical care, see health care medical debt Anita’s case, 70–72 bankruptcy caused by, 55, 126 Cecilia’s case, 3, cycle of serious illness and rising debt, 28–29, 50, 59 of elderly, 203 Elizabeth’s case, 177 Gloria’s case, 119 Natalie’s case, 84, 85 medical problems, see health problems medical savings accounts, 58, 205 Medicare beginning of, 35 for elderly, 37, 49, 199, 203 and managed care, 211 and prescription drugs, 46, 197 proposals for expansion of, 205–206 purpose of, 208 taxes for, 48, 193 mental health problems, 65, 67, 88, 160, 167, 168, 177, 178–180 Mexican Americans in Chicago, 26, 80, 86, 130, 132 discrimination against, 132 employment of, 142 health care coverage for, 172–173, 175 health problems of, 18, 74, 159, 161–168 marriage penalty against, 75 and Medicaid, 49 in San Antonio, 25–26, 77–79, 86, 130, 132 Teresa’s case, 161–167 and uninsured children, 93 Yvonne’s case, 139–143, 167–168 see also Hispanics; race and ethnicity middle class health insurance for, 29, 35, 126–127, 183, 197 social mobility of, 137 Index minority groups, see African Americans; Hispanics; Mexican Americans; race and ethnicity mothers, see single parents; and specific individuals narrative interviews with poor families, Natalie, 83–86 children of, 83 employment and unemployment of, 84–85 and grandmother’s death, 85 health problems of, 84, 85 housing for, 85 and Medicaid, 83–84 medical debt of, 84, 85 New York, 60 noncitizens, see immigration status non-Hispanic whites Anita’s case, 64, 70–72 Elizabeth case, 177–179 Gloria’s case, 117–120 health care coverage for, 172 poverty of, 45 on racial and ethnic tensions, 155–156 Sheila’s case, 153–154 statistics on child poverty, 23–24 in Three City Study, 8–9, 130, 132 and uninsured children, 93 Norma, 64, 68–69 children of, 68 employment of, 69 and employment-based health insurance coverage, 64, 68–69 health care for, 68–69 health problems for, 68 marriage of, 68 and Medicaid, 68, 69 obesity, 19, 159, 192–193 O’Connor, Alice, 13 “path dependence” and welfare state, 45 249 police, 151 policy context of family health care coverage, 20–22 poor families barriers to social mobility for, 17 barrio and intergenerational transmission of poverty, 136–137 car ownership by, 95–96 confusion in lives of, 5, 10–11 coping by, 21 elusiveness of daily routines of, 15–17, 23 fathers’ contributions to, 181–182 federal poverty level, 111, 112 fragmented health care coverage for, 54–60, 72–74, 169–175 health problems of the poor, 18–19, 27–29, 55, 72–74, 159–161 humiliation of, in applying for assistance, 104, 119, 132, 150–153, 156–157 instability and uncertainty in, 12–15, 17–20, 21, 55–56, 101–105, 183–185 invisibility of, 129–130 irresponsible behavior by, 181, 184 Johnson’s War on Poverty, 126 Oscar Lewis on, 133 medical debt of, 3, 5, 28–29, 50, 59, 70–72, 84, 85 narrative interviews with, need for new discourse on, 26–27 need for qualitative research on, 12–15 policy context of family health care coverage, 20–22 potential errors in research on, 63, 110–111, 147, 148–149 problems and characteristics of, 5–6, 9–12, 16–17, 51–52, 180 quantitative research on, 13–14 250 poor families (cont.) and race and ethnicity, 23–25, 44–45, 127–128, 129–130, 157, 211 statistics on child poverty, 23–24, 42 strategies by, maintaining health insurance coverage, 62, 63–72 struggle by, to maintain health care coverage, 61–72 survival strategies of, 138 Three City Study of, 6–12 vulnerabilities of, 132–136, 186 see also employment; health care; single parents; and specific cities and specific individuals poverty, see poor families PPPs (Public Private Partnerships), 194–195 prescription drugs cost of, 125 and Medicaid, 67, 72, 178 and Medicare, 46, 197 psychiatric medication, 67, 177, 178 refills for, 177 Ritalin, 164 prevention, 212 public health measures, 192–193 public housing, see housing Public Private Partnerships (PPPs), 194–195 public transportation in Boston, 81, 82, 96 in Chicago, 96 in San Antonio, 79, 95–96 Puerto Ricans, 64, 80, 86, 93, 132 see also Hispanics race and ethnicity barrio and intergenerational transmission of poverty, 136–137 in Boston, 80–82, 86, 87, 130, 132, 155–156 Index in Chicago, 26, 80, 86, 87, 130, 132, 155 as complex psychological constructions, 135 conflict and barriers to coalition building, 153–157 and demoralization, 137–148, 167 discrimination and racial conflict, 24–25, 44–45, 130, 132, 134 and employment, 22, 110, 127, 128 and ghetto or barrio humor, 156–157 and health care coverage, 172–173, 182–183 health problems and lack of health care, 74, 132–136 in Illinois, 127–128 invisibility of minority poor, 129–130 in Massachusetts, 127–128 and Medicaid, 49 and negative perceptions by caseworkers and welfare program personnel, 150–153, 155, 156–157 and poverty, 23–25, 44–45, 127–128, 129–130, 157, 211 and powerlessness, 134–136 problems associated with, 135–136 rejection of racial or ethnic attribution for problems, 139 and residential exclusion and segregation, 131–132, 136–137, 147, 148–149 in San Antonio, 25–26, 77–79, 86, 87, 130, 132, 153, 154, 155, 156 statistics on child poverty, 23–24 and survival strategies, 138 in Texas, 127–128 uninsured children by, 92–93 vulnerability, health and, 132–136 and workforce of future, 48, 210–211 see also African Americans; Hispanics; Mexican Americans Index rationing of health care, 212 Reagan, Ronald, 191 reform of health care, see health care reform; universal health care coverage residential exclusion and segregation, 131–132, 136–137, 147, 148–149 risk pool, 209 San Antonio African Americans in, 87, 130, 132, 156 Cecilia’s case, 1–5 continuity of health insurance in, 87, 88 economy of, 78 employment patterns in and statistics on, 106, 107, 108, 111, 113 employment-based health insurance, 87 ethnography of, 10–11 evictions and residential mobility in, 12 health care in, 179 health care coverage in, 87, 88, 171, 172 Medicaid coverage in, 57, 62, 93, 94 Mexican Americans and other Hispanics in, 25–26, 77–79, 86, 130, 132, 156 monthly income in, 111–112 Natalie’s case, 83–86 physical and social environments of, 77–79, 96 public housing developments in, 78–79, 139–140, 153–154 public transportation in, 79, 95–96 race and ethnicity in, 130, 132 racial and ethnic tensions in, 153, 154, 155, 156 recruitment of poor families in, 11 251 Sheila’s case, 153–154 Three City Study of, 6–12 uninsured children in, 61, 93, 94 see also Texas Sarah, 33–34, 101–105, 114–116, 123–124 abusive partner of, 114–115, 116 children of, 101–103, 115–116, 124 emergency assistance for, 104 employment of, 102, 103, 105, 115–116, 123–124 health care for children of, 103 health insurance for, 115–116, 123 health problems of family of, 102, 103, 115–116, 124 housing for, 101–102, 104–105 humiliation of, in applying for emergency assistance, 104 and Medicaid, 103–104, 105, 113, 114, 115, 116 medical problems of children of, 33–34 and Temporary Assistance to Needy Families (TANF), 114 SARS (Sudden Acute Respiratory Syndrome), 41 savings accounts, see medical savings accounts SCHIP, see State Children’s Health Insurance Program (SCHIP) segregation, see race and ethnicity; residential exclusion and segregation service-sector jobs, see employment Sheila, 153–154 single parents Anita’s case, 70–72 Cecilia’s case, 1–5 Claudia’s case, 53–54 employment of, 112–114 fathers’ contributions to family, 181–182 Gloria’s case, 117–120 health insurance for, 62, 63–72 health problems of, 158–169 252 single parents (cont.) health problems of and lack of health care for, 27–29, 60 Natalie’s case, 83–86 Norma’s case, 64, 68–69 Sarah’s case, 33–34 strategies by, maintaining health insurance coverage, 62, 63–72 Tawiah’s case, 101–105, 114–116 see also employment; health care; health problems; poor families social Darwinism, 43 social mobility, 17, 110, 137 Social Security, 37, 48, 131, 193, 208, 211 social welfare, see welfare state Sonia, 143–146, 147–148 competence of, in dealing with welfare bureaucracy, 144–145, 147–148 grandchildren of, 143–145 health problems of, 145 health problems of grandchildren of, 144–145 and Legal Aid Services, 144, 145 and Medicaid, 144–145 and SSI, 144–145 SSI (Supplemental Security income), 65, 67, 124, 141, 144–145, 165, 166, 168 State Children’s Health Insurance Program (SCHIP) and basic care, 54, 111, 112, 158 coverage of, 99, 106 decline in enrollment in, 60, 99, 187 enrollment in, 41, 49, 99, 187 failure to enroll in, 25, 203 in Illinois, 88–89, 99 in Massachusetts, 88–89, 91, 99 need for and public support for, 60 proposals for expansion of, 205–206 purpose of, 89 state policies on, 20 Index successes and failures of, 188–189, 203 in Texas, 56, 60, 89, 99, 187, 188 Sudden Acute Respiratory Syndrome (SARS), 41 Sumner, William Graham, 43 Supplemental Security income (SSI), 65, 67, 124, 141, 144–145, 165, 166, 168 supply-side economics, 191–192 survival strategies, 138 TA (Trade Act) of 2002, 203 TANF, see Temporary Assistance to Needy Families (TANF) taxation and Medicare, 48, 193 and public weal, 191–193 and supply-side economics, 191–192 Temporary Assistance to Needy Families (TANF) Anita’s case, 71 Cecilia’s case, 2–4 Claudia’s case, 146 Darlene’s case, 66 Elizabeth’s case, 177 in Illinois, 29–30, 51 Leticia’s case, 69 in Massachusetts, 29–30, 50 and Medicaid, 190 Sarah’s case, 114 stipends from, 152 Teresa’s case, 165 in Texas, 30, 50–51, 152 Yvonne’s case, 142–143 tenant protection, 10–11, 12 Teresa, 161–167 children of, 161, 164 education of, 164 employment of, 164–166 health care for, 162–167, 176 and health care for children, 163 health problems of, 161–167, 176 Index health problems of children of, 164 in homeless shelter, 165 and Medicaid, 163, 165 and SSI, 165, 166 and Temporary Assistance to Needy Families (TANF), 165 Texas eviction in, 10–11, 12 Medicaid in, 30, 90, 94, 98, 99, 114, 188, 189–190 minority and noncitizen populations in, 127–128, 210 post-welfare reform drop in Medicaid coverage in, 88–89 retrenchment in eligibility for welfare and other public benefits, 88 as right to work state, 120 State Children’s Health Insurance Program (SCHIP) in, 56, 60, 99, 187, 188 Temporary Assistance to Needy Families (TANF) in, 30, 50–51, 152 uninsured children and adults in, 11, 61, 62, 86 see also San Antonio Texas Healthy Kids Corporation, 90 Three City Study on elusiveness of daily routines, 15–17 on employment patterns and statistics, 106–114 ethnography components of, 7, 8–9 on extent of health insurance coverage, 92–94 on health problems of poor parents, 27–29 on instability of poor families, 12–15 on jobs with no stability and no health insurance, 22–23 253 on lack of health care coverage, 17–20, 27–29, 49–51, 170–175 on Medicaid coverage, 57, 62, 93–94 on Mexican and Anglo cultures, 25–26 on need for new discourse on poverty and health care, 26–27 and need for qualitative research on poor families, 12–15 overview of, 6–12 physical, cultural, and health contexts of, 29–31 and policy context of family health care coverage, 20–22 on racial and ethnic factor, 23–25, 130, 132 similarity of health problems and health care for poor families in, 82–83, 86–88, 97–98 Trade Act (TA) of 2002, 203 training, see education Truman, Harry, 204 underwriting, 198, 209 undocumented workers, see immigration status unemployment, see employment uninsured children and adults family life of, 17–20 and jobs with no stability, 22–23 by race and ethnicity, 92–93 statistics on, 56–57, 58, 61–62, 92–94, 176, 188, 197, 198, 208 in Texas, 11, 61, 62, 86 working poor as uninsured, 36–37 see also poor families unions, see labor unions universal health care coverage and affordability, 200–201 Clinton’s plan for, 45, 193–194, 195–196, 197, 204 and conflicting objectives for health care reform, 202–204 funding for, 207–208 justification for, 204 254 universal health care coverage (cont.) and mandated coverage through employment-based health insurance, 206–207 need for, 27, 98 obstacles to, 195, 196, 197, 208, 210 proposal for, 206–207, 210 and Public Private Partnerships (PPPs), 194–195 realistic options for, 193–196 and requirements for equitable and sustainable health care system, 200–202 see also health care reform Index welfare state benefits of, 39–40 Esping-Anderson on typology of, 40–41 in Europe, 38, 39, 40–41, 45, 191–192 and globalization, 39, 41 limited nature of, in United States, 37–42 Marshall on, 40, 204 and “path dependence,” 45 problems facing, 41–42 social welfare expenditures in United States, 37–38 whites, see non-Hispanic whites work, see employment voting discrimination, 131 Wagner-Murray-Dingell bill, 204 War on Poverty, 126 welfare benefits confusion about amount of, 11 loss of, due to employment, 182 welfare reform and drop in Medicaid coverage, 88–89 and education, 174 and Medicaid, 20 motivation for, 14 objectives of, 16, 27, 74, 75, 88–89, 99 potential failure of, 27 Yvonne, 139–143 children of, 140–141 and disabled child, 140–141 education of, 143 employment, 141–142 health problems of, 141, 167–168 health problems of children of, 141 housing for, 139–140 and Medicaid, 141, 167 mental health problems of, 167, 168 and SSI, 141 and Temporary Assistance to Needy Families (TANF), 142–143 ... page intentionally left blank Poor Families in America’s Health Care Crisis Poor Families in America’s Health Care Crisis examines the implications of the fragmented and two-tiered health insurance... nongovernmental health insurance We collected Poor Families in America’s Health Care Crisis in the survey extensive information on income, education, earnings, employment, health, private health care coverage,... Implications for Health Care The Health Care Welfare State in America The Tattered Health Care Safety Net for Poor Americans State Differences in Health Care Policies and Coverage Work and Health Insurance: