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  • A Note from the Editor
  • Virginia M. Brennan PhD, MA (bio)

As the summer of 2005 gives way to fall, we mark eleven years since the federal government considered and rejected broad national health care reform. Many of the facts that catalyzed reformers in the early 1990s remain, while others, among them consequences of the welfare reform legislation passed by Congress in 1996, have taken shape in the intervening decade plus one year. In this issue, the Journal presents a set of papers that bear on these matters, as they pertain to people (in most cases, women and children) with low incomes.

Two papers address welfare reform directly. Cheng examines the impact of welfare reform, as it was carried out in 45 different states and the District of Columbia, on the health care access of current and former welfare recipients through an analysis of national survey data. He finds that more restrictive state welfare policies were variously associated with lower likelihood of using dental care, visiting a physician and using prescriptions. Furthermore, the proportion of the surveyed population reporting fair or poor health was three times as great as the estimated proportion of their counterparts reporting fair or poor health in the general population.

Hartley and colleagues conducted a large qualitative study of Oregonians preparing to leave welfare for work, focusing on their preparation for securing health insurance once they no longer received income assistance. Through focus groups and one-on-one interviews, the paper examines (1) the information available to these individuals, (2) their planning and expectations about securing health insurance, and (3) their perceptions of opportunities for obtaining jobs that provide insurance. The researchers identify the fault lines in this programmatic change, among them the fact that less than 15% of people leaving welfare with jobs had employer-sponsored health insurance when first interviewed. In the course of the paper, we hear from the people themselves, expressing views that range from misunderstanding to practical resolve about getting health coverage once off welfare. Only a minority of respondents, most often those with immediate health care needs, appeared to possess sufficient information for health insurance planning. For most, the imperative to find work outweighed any real planning for health insurance, while the work that they found rarely came with affordable health insurance benefits, a point touched on in other papers in this issue (Kullgren et al., Okoro et al.) as well.

Okoro and colleagues report on the quarter of a million adults aged 65 and older in the U.S. who lack any health insurance, including Medicare and Medicaid. These uninsured older adults may not themselves have accumulated or have a spouse who accumulated the requisite 10 years of Medicare-qualifying employment (the situation for people who worked as domestics or farm laborers) a work history leaving them ineligible for Medicare. Some have household incomes that are too high to qualify for Medicaid and too low to buy into Medicare. Others are either unaware of their eligibility, are ineligible because of their citizenship status, or choose not to apply for coverage. Importantly, given the projected growth of the elderly population, particularly [End Page v] among blacks and Hispanics, the researchers found that blacks and Hispanics were disproportionately represented among uninsured older adults.

Lin and colleagues also report on a Medicare-related issue in their paper on the effects of financing reforms on home health agencies, specifically examining agencies in rural Pennsylvania and finding sharply increased financial vulnerability of the agencies as a result of the reforms. Leal touches on the upcoming drug benefit for Medicare beneficiaries in her ACU Column on ways pharmacists bridge gaps between under-insured populations and adequate health care.

A major reform to Medicaid in state after state over the past two decades came in the form of managed care, a topic on which the Journal has published a number of articles in the past. Willging and colleagues use ethnographic methods and a review of legal documents and state monitoring data to examine the impact of Medicaid reform on mental health services in New Mexico. A rural state, New Mexico implemented Medicaid managed care for both physical and mental health services in 1997, a reform that...

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