Health Behaviors, Mental Health, and Health Care Utilization Among Single Mothers After Welfare Reforms in the 1990s

Abstract

We studied the health of low-income US women affected by the largest social policy change in recent US history: the 1996 welfare reforms. Using the Behavioral Risk Factor Surveillance System (1993-2012), we performed 2 types of analysis. First, we used difference-in-difference-in-differences analyses to estimate associations between welfare reforms and health outcomes among the most affected women (single mothers aged 18-64 years in 1997; n = 219,469) compared with less affected women (married mothers, single nonmothers, and married nonmothers of the same age range in 1997; n = 2,422,265). We also used a synthetic control approach in which we constructed a more ideal control group for single mothers by weighting outcomes among the less affected groups to match pre-reform outcomes among single mothers. In both specifications, the group most affected by welfare reforms (single mothers) experienced worse health outcomes than comparison groups less affected by the reforms. For example, the reforms were associated with at least a 4.0-percentage-point increase in binge drinking (95% confidence interval: 0.9, 7.0) and a 2.4-percentage-point decrease in the probability of being able to afford medical care (95% confidence interval: 0.1, 4.8) after controlling for age, educational level, and health care insurance status. Although the reforms were applauded for reducing welfare dependency, they may have adversely affected health.

Keywords: health behaviors; health care utilization; self-rated health; single mothers; welfare reform.

Figure 1.

Welfare reforms and health outcomes among single mothers in the Behavioral Risk Factor Surveillance System, 1993–2012. The Figure presents the estimated percentage-point change in health status of single mothers associated with the 1996 welfare reforms using both a difference-in-difference-in-differences model (triangles) and a synthetic control estimation method (squares). The difference-in-difference-in-differences model expressed in equation 1 corrects for pre-existing secular trends in health, as well as unmeasured time-invariant and time-varying confounders between the single mothers and “control” groups (married mothers, single nonmothers, and married nonmothers). The synthetic control method compares single mothers with a control group constructed by weighting members of the less affected groups (married mothers, single nonmothers, and married nonmothers) to better match the health characteristics of single mothers prior to welfare reforms in order to strengthen the quality of inferences when there is no single ideal control group. The y-axis reflects a percent change in probability of a health outcome; negative results reflect worsening health; that is, single mothers experienced a 4-percentage-point (absolute, not relative change) lower chance of safe alcohol drinking in association with the welfare reforms, per the difference-in-difference-in-difference model. Outcomes are defined in Table 1. See Web Table 4 for coefficients. Bars, 95% confidence intervals.

Figure 2.

Welfare reforms and health outcomes among employed (triangles) and unemployed (squares) single mothers in the Behavioral Risk Factor Surveillance System, 1993–2012. Data are based on difference-in-difference-in-differences specifications. The Figure presents the estimated association between the 1996 welfare reforms and the change in health status of single mothers by employment status, using a difference-in-difference-in-differences model. The difference-in-difference-in-differences model expressed in equation 1 corrects for pre-existing secular trends in health, as well as unmeasured time-invariant and time-varying confounders between the single mothers and “control” groups (married mothers, single nonmothers, and married nonmothers). The y-axis reflects a percent change in the probability of a health outcome; negative results reflect worsening health; that is, employed single mothers experienced a 3-percentage-point (absolute, not relative) lower chance of safe alcohol drinking in association with the welfare reforms. Outcomes are defined in Table 1. See Web Table 5 for coefficients. Bars, 95% confidence intervals.