History of Welfare in United States: Equality for Some

Summer White is a senior political science major with a concentration in policy studies at Grinnell College. Interested in pursuing public health and social justice oriented policy, Summer will begin her career this July in Washington, DC as a federal strategy and operations business analyst.

Health is a universal human experience. Physical, social, emotional, mental, and spiritual wellness contributes to what it means to live healthily. Our experiences in health vary around the world, but we all share the need to tend to our health whether we like it or not. Tending to health is essential in order to live and do whatever else we want to do. In spite of such a strong commonality, people in the United States hold deeply polarized perspectives on how people should get connected to healthcare. Some view healthcare as a responsibility of the government, whereas some consider it to be under the purview of the private sector. The presence of disagreement about whether healthcare should be private or public is not inherently problematic. Millions of people forgoing care they need is. This situation is especially unjust because those who are more likely to lack insurance are low-income people and people of color, whose identities are already marginalized [1]. Upon analysis of the development of welfare systems in the US, it is clear that ever since the beginning, care has only been for some, often excluding women and people of color. Thus, having a greater awareness of those left out of accessing public assistance services may improve activists, medical professionals, and policymakers as they strive to improve the health of all Americans.

From the start of healthcare in the US, only those deemed truly deserving received assistance. Influenced by British Poor Laws, the US colonies, local governments, state governments, and charities arranged poorhouses and orphanages for the neediest of people in the 19th century [2]. While conditions were harsh and eligibility was narrow, they provided a crucial service to an especially vulnerable part of the population. To determine if one was “worthy” to secure minimal aid, “Overseers of the Poor,” who were usually unfamiliar with the realities of poverty, judged individuals seeking assistance [3]. Overseers typically deemed men who looked capable of working (likely with severe mental illness) and women who were immoral (had sex outside of marriage) unworthy of getting aid. Evidently, these services were helpful for many Americans in desperate need of support, but excluded those who had invisible disabilities or practiced socially unacceptable behaviors.

It is unlikely that people would lie about needing extra support because at this time, Americans generally had a strong sense of pride in their ability to care for themselves [4]. However, with the devastation of the Great Depression, self-reliance could only go so far. With high unemployment rates, many Americans struggled to pay for food. A New York Times headline from February, 1931, calls attention to hundreds of people at an unemployment demonstration in Minneapolis who broke into a grocery store to steal food as a last resort. An overwhelming number of people turned to state and local governments and charities for their basic life necessities. Eventually, the need became greater than state and local governments and charities could handle.

Federal action was necessary to help the many people in need, but even these solutions only worked for some. In response to such high demand of vital resources, in 1935, the federal government began taking responsibility for the welfare of children and other dependent people. President Franklin Roosevelt signed the Social Security Act establishing a federal retirement program for people older than 65 years old, unemployment insurance, and a national welfare system [5]. Medicaid, established through 1965 legislation, provided medical assistance for low-income people and replaced previous systems [6]. Since the beginning, specific groups among the deserving were left out of receiving benefits. For example, many farm laborers and domestic servants did not get social security old age retirement program benefits that social security granted to others. Then, in 1996, a reform law called the Personal Responsibility and Work Opportunity Reconciliation Act returned most of the control of welfare back to state governments. While this was a period of expansion of welfare, it was only helpful to those who visibly needed support.

Throughout the 1990s, some considered fertility as the problem causing people to need government assistance [7]. Some even accused women of intentionally having more children just to qualify for or maintain their government assistance benefits. Further, politicians were concerned that those with lower income were not only using government money for more children, but they were also producing children who will eventually contribute to increased crime. The government viewed the “solution” to this problem as forced control of reproduction through fertility regulations and sterilization. For mothers receiving aid from Aid to Families with Dependent Children (AFDC), sterilization became a requirement before they could get the care they needed. Furthermore, involuntary sterilization due to “defective heredity” and “overpopulation” limited women’s access to care and reduced their personal agency [8]. These procedures were ineffective at reducing welfare needs and unjust, specifically impeding on the bodily autonomy of low income women and women of color.

A more effective solution likely would have been entirely reforming the healthcare system. Jumping ahead to March 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (also known as the Affordable Care Act, ACA, or Obamacare) [9]. This huge program was the result of years of work to establish a better healthcare system for the US. With this law came small business tax credits, reinsurance for retiree health benefit plans, and pre-existing condition insurance plan (PCIP). Before the Affordable Care Act, up to 129 millions Americans were discriminated against because of a pre-existing condition [10]. As of April 2012, over 56,000 people enrolled in PCIPs. ACA also closed the coverage gap in Medicare prescription drug coverage, ensured patient protections, expanded dependent coverage for young adults, required preventative care coverage, and banned lifetime limits on coverage. Between 2010 and 2016, the US uninsured rate for people ages 18-64 decreased from 22.3 to 11.9% [11]. While ACA has its flaws, overall, this was an impactful move towards improving healthcare access in the US [12].

The Affordable Care Act especially had a positive influence on the care of many people of color, gender non-binary people, and women, and its dismantling threatens access to this care. With the Affordable Care Act, over 2 million Asian American Pacific Islander women and gender non-binary people got coverage that they previously lacked. Additionally, 80% of women of color in most states got insured [13]. Race has long been a strong narrative of welfare debates [14]. Examining debates from 1935, these social policies often had “unhappy effects” on African Americans [15]. Unmistakably, ACA has not been helpful for all Americans, but has been an overall improvement for people with marginalized identities.

Flashing forward to November 2016, Donald Trump was elected to be the next US president with the promise to repeal and replace Obamacare, and by extension, further limit access to healthcare [16]. Attempts were made, but none passed in 2017. However, the government used other tools at their disposal to implement changes. In fall 2017, federal government stopped funding cost-sharing reduction payments and limited the enrollment period by about a month. The Trump Administration cut outreach funding from $100 million to $10 million and reduced funding for people to help consumers understand their options for signing up [17]. They also expanded the groups that could be exempt from covering contraceptives on a basis of religious and moral grounds. In spite of ACA appeal efforts failing, the Trump administration has managed to modify implementation in ways that have reduced people’s access to care and diminished women’s autonomy.

These changes are a relief to many who despise the ACA and are simultaneously far from relief to those who rely on it. According to research from the Urban Institute, up to 30 million people may lose health insurance coverage upon repealing ACA [18]. Of those 30 million people, people of color and low-income people will be disproportionately negative affected [19]. Changes will cause premiums to cost more and up to 52 million people with pre-existing conditions will lose coverage. While pre-existing conditions includes diabetes, asthma, and cancer, it will also include everyday women’s health needs like pregnancy, domestic violence history, and depression. Loss of coverage for young people, job loss, premature death, and increased deficit are projected as well. As you can see, this program designed to benefit those who are in need remains exclusionary to some who are already marginalized.

Exclusion was an influencer in the original designs of welfare programs and remains impactful, as disparities in accessing adequate health care persist as a form of inequality [20]. Still today, racist and sexist narratives cover conversations around the state of welfare in the US. Future reforms must consider their incorporation of women, people of color, and gender non-binary people. The Affordable Care Act made great strides, but even that did not reach everyone. For instance, the difference between rural and urban insurance among young adults persisted between 2010 and 2014 [21]. Additionally, Mexicans, including citizens and legal residents who are significantly uninsured or underinsured, enrolled in the program in low numbers [22]. Previous questionable health practices as well as threats of mistreatment may motivate their choice to access or to not access government-affiliated health care. Even if it is available, racial minorities and others “othered” by the government may not feel entitled or comfortable to take advantage of the resources offered.

As policymakers pursue reform, they need to be aware that ability to get care does not necessitate people feeling comfortable getting it. Future welfare programs must prioritize outreach and inclusion of all people who need services, making an intentional effort to better include women and people of color. Offering care does not equate to people trusting that the providers have their best interest in mind, and progress on these issues does not mean that is enough.

NOTES:

[1] Henry J. Kaiser Family Foundation (KFF), “Key Facts about the Uninsured Population,” KFF. https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Published Nov 29, 2017.

[2] “History of Welfare Info,” Welfare Info, WelfareInfo.org, http://www.welfareinfo.org/history/.

[3] David Wagner, “Poor Relief and the Almshouse,” Virginia Commonwealth University Social Welfare History Project. https://socialwelfare.library.vcu.edu/issues/poor-relief-almshouse/.

[4] “Bill of Rights in Action,” Constitutional Rights Foundation http://www.crf-usa.org/bill-of-rights-in-action/bria-14-3-a-how-welfare-began-in-the-united-states.html.

[5] Ibid.

[6] “Historical Development,” Social Security Administration, https://www.ssa.gov/history/pdf/histdev.pdf.

[7] Susan L. Thomas. “Race, Gender, and Welfare Reform: The Antinatalist Response,” Journal of Black Studies 28 no. 4 (1998): p419-416.  http://www.jstor.org/stable/2784831.

[8] Alexandra Minna Stern, “Sterilized in the Name of Public Health: Race, Immigration, and Reproductive Control in Modern California,” American Journal of Public Health 95 no. 7 (2005): p1128-1138. https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2004.041608.

[9] “History and Timeline of the Affordable Care Act,” eHealth, eHealthInsurance Services, Inc., https://resources.ehealthinsurance.com/affordable-care-act/history-timeline-affordable-care-act-aca.

[10] David Simas, “Health Coverage Before the ACA, And Why All Americans Are Better Off Now,” the White House, https://obamawhitehouse.archives.gov/blog/2014/01/23/health-coverage-aca-and-why-all-americans-are-better-now.

[11] Obamacare Facts, “ObamaCare Uninsured Rates,” Obamacare Facts, https://obamacarefacts.com/uninsured-rates/.

[12] Olveen Carrasquillo and Michael Mueller, “Refinement of the Affordable Care Act: A Progressive Perspective,” Annual Review of Medicine 69 (2018): p29+, https://doi.org/10.1146/annurev-med-090916-120540.

[13] Sung Yeon Choimorrow, “Why dismantle the Affordable Care Act when it’s working for people of color?” The Hill, http://thehill.com/blogs/pundits-blog/healthcare/340101-why-dismantle-the-affordable-care-act-when-its-working-for.

[14] Jacob S. Hacker, “Bringing the Welfare State Back In: The Promise (and Perils) of the New Social Welfare History,” Journal of Policy History 17 no. 1 (2005): 125-154 https://muse.jhu.edu/article/178296.

[15] James T. Patterson, “Congress and the Welfare State: Some Historical Reflections,” Social Science History 24 no. 2 (2000): 367-378 https://muse.jhu.edu/article/32153.

[16] “History and Timeline of the Affordable Care Act,” eHealth, eHealthInsurance Services, Inc., https://resources.ehealthinsurance.com/affordable-care-act/history-timeline-affordable-care-act-aca.

[17] Matt Rocheleau, “Here’s what President Trump has done to unravel the ACA,” Boston Globe, https://www.bostonglobe.com/news/nation/2017/10/13/here-what-president-trump-has-done-dismantle-aca/0U8PCKyTg9H9sNeA48sigM/story.html.

[18] Bowen Garret and Anuj Gangopadhyaya, “Who Gained Health Insurance Coverage under the ACA, and Where Do They Live?” Urban Institute, https://www.urban.org/research/publication/who-gained-health-insurance-coverage-under-aca-and-where-do-they-live.

[19] Public Health Awakened, “Consequences of Dismantling the Affordable Care Act (For Progressive Public Health Professionals),” Public Health Awakened, https://publichealthawakened.com/what-happens-to-health-health-equity-if-the-affordable-care-act-is-dismantled/.

[20] W. David Koeninger, “The statute whose name we dare not speak: EMTALA and the Affordable Care Act,” Journal of Gender, Race and Justice 16 no. 1 (2013): 139-186, http://go.galegroup.com.grinnell.idm.oclc.org/ps/retrieve.do?tabID=T002&resultListType=RESULT_LIST&searchResultsType=SingleTab&searchType=BasicSearchForm&currentPosition=3&docId=GALE%7CA328421823&docType=Article&sort=Relevance&contentSegment=&prodId=HRCA&contentSet=GALE%7CA328421823&searchId=R1&userGroupName=grinnellc&inPS=true.

[21] Laura J. Chavez, Kelly J. Kelleher, Steven C. Matson, Thomas M. Wickizer and Deena J. Chisolm, “Mental Health and Substance Use Care Among Young Adults Before and After Affordable Care Act (ACA) Implementation: A Rural and Urban Comparison,” Journal of Rural Health 34 no. 1 (2018): p42+, http://dx.doi.org.grinnell.idm.oclc.org/10.1111/jrh.12258.

[22] Natalia Molina, “Why Didn’t More Ethnic Mexicans Sign Up For Obamacare?: Examining Public Health’s Impact Over One Hundred Fifty Years,” American Journal of Medical Research 4 no. 2 (2017): p20+, http://dx.doi.org.grinnell.idm.oclc.org/10.22381/AJMR4220172.

FURTHER READING:

Bigelow, W. F. (1929, 02). A new welfare bill.Good Housekeeping, 88, 4. Retrieved from https://search.proquest.com/docview/1807523398?accountid=7379.

Olivia Carter-Pokras, and Claudia Baquet. “What Is a “Health Disparity”?” Public Health Reports (1974-)117, no. 5 (2002): 426-34. http://www.jstor.org/stable/4598774.

Brown, Jessica P., and J. Kathleen Tracy. “Lesbians and Cancer: An Overlooked Health Disparity.” Cancer Causes & Control19, no. 10 (2008): 1009-020. http://www.jstor.org/stable/40271802.