In the Clinic: The Medicalization of Welfare

The U.S. welfare system has been radically restructured in recent years. As a result, the welfare rolls fell dramatically from 14.2 million in 1993 to 7.6 million by December 1998, thereby enabling President Clinton to claim he has made good on his 1992 campaign promise to "end welfare as we know it." ¹ A major factor in this restructuring is the welfare reform law passed in 1996. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) requires adult welfare recipients, largely single mothers, to work outside the home in order to receive aid and imposes a five-year lifetime limit on eligibility, after which time recipients are expected to be supporting themselves. Yet there are many features of contemporary welfare reform that make it as self-defeating as it is self-legitimating.

Prominent among the self-defeating features are the self-legitimating practices focused on "welfare dependency." The focus on welfare dependency achieves its own legitimation in good part by representing itself as a return to older social policy concerns. The country has moved away from the "war on poverty" initiated in the 1960s to the "war on welfare" that has dominated the 1990s. ² The pre-1960s assumption that reliance on public assistance for anything other than a very short period of time is unquestionably wrong has reasserted itself. For people like Newt Gingrich, extended welfare use was a sure sign of how late-twentieth-century America had become a "sick society." ³ As a result, welfare receipt has been transformed from use to abuse, from an active exercise of one's legal rights to income to a passive dependency on the government. Welfare dependency is seen as a universal deficiency that almost no one can actively support, while poverty is no longer considered a public problem that must be attacked. Unfortunately, the way welfare reform in recent years has articulated treatment for welfare dependency ensures that poverty will persist and intensify.

In what follows, I suggest there is more to the story. While recent policy changes reflect a return to the focus on welfare dependency, a "new paternalism" is changing the culture of welfare administration so that welfare dependency is itself increasingly being redefined from an economic problem to a medicalized one. ⁴ This medicalization is more than individualization. ⁵ The latter locates the problem in the individual; the former specifies it as akin to an illness that afflicts the individual. I suggest that welfare reform has helped accelerate the tendency to construct welfare dependency as an illness. In the process, welfare itself is being transformed from a repudiated program of benefit allocation into a socially accepted set of therapeutic interventions. ⁶

While medicalization is different from individualization, particularly in terms of the specific interventions associated with it, its implications are the same. It legitimates new forms of power, procedures, and processes in the administration of welfare that deemphasize the allocation of income and emphasize the treatment of poverty in terms of correcting personal problems and monitoring behavior. To medicalize welfare dependency is to create the conditions for moving welfare from an income redistribution scheme to a behavior modification regime. In other words, medicalization is an effective way to locate the problems of low-income families in their behaviors rather than in the broader political economy. Yet given the growing inequality of economic opportunities in the postindustrial economy, the medicalization of welfare dependency is not only a serious mistake but also a devastating distraction that diverts much-needed financial and organizational resources away from creating economic opportunities. ⁷ In the process, yet another way has been found to elaborate cultural distinctions that once again marginalize people who use welfare. The medicalization of welfare dependency proves that in some respects the more things change, the more they stay the same.

Nonetheless, the medicalization of welfare dependency is accelerating without much attention to its historical context, cultural significance, and political-economic implications. Very little attention has been devoted...