Published in Sacramento Medicine, April 1997

This issue of Sacramento Medicine focuses on one of the most important social changes of our time: the reassessment of the scope of government responsibility for the health and welfare of the poor. Liberals have traditionally viewed poverty and unemployment in terms of social or environmental determinants that are best addressed by correcting deficits and providing opportunity. Conservatives view poverty as a sign of personal antisocial dysfunction. Illustrative of the conservative view is Governor Wilson’s 1997 ‘State of the State’ address in which he described welfare as "A program (that) has become a major incentive to the skyrocketing increase in out-of-wedlock births." These welfare babies then become criminals and drug addicts requiring "massive government spending for health care, for police protection, for drug and alcohol rehabilitation, for criminal courts, for prisons, probation and parole supervision." "Welfare," the Governor states, "has made fathers financially irrelevant... It is the most important of all the pervasive incentives encouraging the formation of fatherless families." He vows that the new reform will "insist on responsibility so the taxpayers no longer subsidize idleness, or promiscuity...and no longer suffer when illegitimacy hatches into social pathology."

Welfare reform gives us an opportunity to revisit the problem of poverty. There is no reason not to experiment with new approaches, provided they are not extremist. Society is dynamic and solutions to problems need to be equally dynamic. However, we must raise the level of discussion above a mean-spirited and deeply flawed equation of poverty with pathology, illegitimacy, promiscuity, subsidized idleness, etc. Help rendered to the poor doesn’t mean government has license to demean. Targeting individual defects as the cause of complex social problems like joblessness has the insidious effect of relieving the politically powerful of responsibility. Encouraging the public to feel moral by refusing help, since help is merely fostering "social pathology," seems perverse.

An alternative understanding of the meaning of help is presented in a January 1997 policy brief from the Legislative Analyst’s Office (LAO) titled "Welfare Reform in California: A Welfare-to-Work Approach." This assessment of poverty tries to strike a balance between the need for incentives/mandates for work and the need to preserve the safety net for children and those who cannot meet mandated requirements. Their approach relies on data from past job-promotion programs, such as GAIN, and ongoing experiments in other states. It emphasizes services to prepare recipients for employment, including "community service employment," namely, jobs outside the "regular" labor market arranged by the government for welfare recipients. In discussing economic incentives such as withholding cash payments for nonparticipation in work, the LAO report states that "work incentives (are) features in our model not because of any belief that welfare recipients wish to avoid work, but because people in general respond to financial incentives." This is a significant contrast to the Governor’s view of the poor seeking a life of subsidized idleness and promiscuity. The LAO proposal deserves serious discussion.

A very important element in the new federal legislation is that eligibility for health care benefits is not time-limited. This measure of common sense comes as a relief after the chaos created by the first step in welfare reform: the elimination of SSI benefits for thousands of unemployed individuals with drug and alcohol disabilities. In that legislation, health care benefits were denied to, arguably, our most medically ill population, creating a local health care crisis. On the positive side, however, there has resulted a remarkable community collaborative effort between our county health department, community-based drug treatment programs, SSI service providers, and legal advocates for the poor to respond to the complex problems and needs of a population of unemployed people who suddenly had neither income nor Medi-Cal. This experience has given me a sense of hope that we can work effectively together at the local level to monitor and provide feedback on the deficits of these broad legislative changes.

In this issue of Sacramento Medicine, Dr. Glennah Trochet, from the Sacramento County Health Department, and attorney Jennifer Home, who is monitoring the legal rights of those affected by these new laws, will discuss some of the local implications of new laws and alert us to very troublesome areas where significant harm might occur. We have an obligation to expose to public scrutiny approaches that save money by wreaking havoc on the poor.

The delegation of responsibility from federal to state and local government has potential benefits. Increased local autonomy encourages a wide variety of creative solutions. The LAO report leads me to believe that, out of the variety of state and local experiments with welfare, sound data will emerge on whether there really are more effective approaches to dealing with poverty and unemployment than our present system. The key is the availability of jobs. Eliminating the safety net for the poor when there are no jobs to be had would be reprehensible.

In the final analysis, it may be our attitudes that will determine how effective welfare reform will be. Shakespeare, in The Merchant of Venice, says "The quality of mercy is not strained...It southeth him that gives and him that takes." The two sides should benefit from help. Welfare reform could result in a better way to manage poverty and unemployment, if the dignity and integrity of welfare recipients are respected and if they are treated as equal partners, working with government toward the same goal of employment and self-sufficiency.