摘要：Objectives. We evaluated the economic benefits of Temporary Assistance to Needy Families (TANF) relative to the previous program, Aid to Families with Dependent Children (AFDC). Methods. We used pooled mortality hazard ratios from 2 randomized controlled trials—Connecticut Jobs First and the Florida Transition Program, which had follow-up from the early and mid-1990s through December 2011—and previous estimates of health and economic benefits of TANF and AFDC. We entered them into a Markov model to evaluate TANF’s economic benefits relative to AFDC and weigh them against the potential health threats of TANF. Results. Over the working life of the average cash assistance recipient, AFDC would cost approximately $28 000 more than TANF from the societal perspective. However, it would also bring 0.44 additional years of life. The incremental cost effectiveness of AFDC would be approximately $64 000 per life-year saved relative to TANF. Conclusions. AFDC may provide more value as a health investment than TANF. Additional attention given to the neediest US families denied cash assistance could improve the value of TANF. Aid to Families with Dependent Children (AFDC) was the primary cash assistance program in the United States until 1996. 1 In that program, participants could receive cash assistance indefinitely. However, some policymakers questioned the logic of paying able-bodied citizens indefinitely because welfare might serve as an incentive to stay out of the workforce. These concerns were heard, and a number of randomized controlled trials were conducted in multiple states to test the effect of time limits for welfare benefits. 2 These randomized controlled trials found not only that time limits to cash assistance incentivized participants to move into the workforce, but also that they produced increases in earnings relative to traditional AFDC. 2,3 Ultimately, these experiments contributed to the passage of the Personal Responsibility and Work Opportunity Reconciliation Act in 1996. 1 This act was perhaps one of the most sweeping US policies enacted within the past 2 decades and one of the few large-scale policies to be passed on the basis of a large and convincing body of scientific evidence. 1,4 This act ended the federal guarantee of income support to poor families, replacing AFDC with a program called Temporary Assistance to Needy Families (TANF). Under TANF, states were given block grants along with relative autonomy over many aspects of welfare policy. Thus, TANF was implemented differently in different states, with some states offering much more generous benefits than others. 5 The time limits in TANF were accompanied by incentives for work, such as earnings disregards (allowing recipients to remain on welfare even while earning money) and, in some instances, job training. As a result of TANF, welfare rolls have plummeted, saving taxpayer money and increasing family earnings. 6 However, despite these net benefits, both the early randomized controlled trials and later studies of the real-world impacts of TANF showed that some participants—almost all of whom were single women with children—were simply unable to get jobs. 2,7 Risk factors for unemployment after the expiration of time limits may have included large family size, the presence of young children at home, or mothers who have a mental or physical disability. 5,8–10 Those who could not garner employment after their time limits expired often had to rely on friends and family for survival. 2,7,9,10 Moreover, the earlier trials that uncovered these problems almost always coupled time limits with extensive benefits (such as child care) that are not provided under TANF in the vast majority of states today. As welfare rolls declined, states tended to spend the extra funds left over in their federal block grants on other, often unrelated programs. 7 Therefore, one might expect more adverse outcomes in the real-world implementation of TANF than in the early randomized controlled trials. Fortunately, because states implemented TANF in different ways, these impacts were possible to study in a quasi-experimental manner. Studies exploiting spatiotemporal variations in implementation of time limits in the real world have shown similar benefits to the earlier randomized controlled trials, 2,6,11,12 but also similar harms. 7,10,13 Specifically, TANF enrollees with preschool-aged children or larger families are both more likely to be food insecure and, at least among those required to enter the workforce quickly, in poorer mental health. 7,9,10,14 Spatiotemporal analyses have suggested that time limits imposed under TANF were also associated with an overall increase in infant mortality. 13 Long-term follow-up data from one such trial, Connecticut Jobs First (CJF), subsequently showed that treatment produced a nonsignificant 13% increase in mortality among all recipients and a nonsignificant 54% increase in mortality among women with more than 2 children. 15 In the Florida Transition Program (FTP), treatment with time limits produced a 16% increase in mortality hazards. 16 Whether this increase was statistically significant depended on the model specification. Taken together, these data suggest that women with smaller families and who are able bodied are better off under TANF than AFDC. However, women who cannot work because of disability or family obligations may have been better off with respect to health and longevity under AFDC than TANF. This hypothesis is supported by evidence that many women shifted from TANF to Supplemental Security Income, the program responsible for providing disability payments. 17 Despite its overall benefits, TANF is a program for which the nonpartisan US Government Accountability Office has pointed out that reform is needed, particularly with respect to provisions for those who are unable to work (e.g., because of caregiving responsibilities or poor mental or physical health). 7 Although many experts have felt that TANF has been a success when evaluated on the basis of mean monetary and social impacts, we asked whether TANF retains its value when adverse health impacts are assessed.
