Twenty years ago Congress passed and President Bill Clinton signed into law an act to “end welfare as we know it”. This act replaced Aid to Families with Dependent Children (AFDC) with the current program, Temporary Assistance for Needy Families (TANF), thereby converting the program to a block grant and implementing stringent work requirements and a system of penalties (sanctions), among other reforms.

Shortly after what we now refer to as welfare reform, a group of pediatricians, including Drs. Deborah A. Frank in Boston, Diana Cutts in Minneapolis, and Patrick Casey in Little Rock and pediatric psychologist Dr. Maureen Black in Baltimore, began to see the maternal and child health effects of welfare sanctions on families living in poverty. Sanctions included losing benefits or having benefits decreased for not completing work or job search requirements. However, even for highly motivated parents, these requirements were often impossible to fulfill while addressing the health and safety needs of their young children.

Welfare reform’s harmful impact was readily observable in the clinical setting as caregivers struggled to provide their children with the resources necessary to grow and thrive. Moving from concern to action, this group of clinicians along with expert colleagues, including Dr. John Cook, began to discuss ways of documenting the effects of welfare reform in hopes of providing evidence that could inform welfare policy. In their first peer-reviewed article on the subject, published six years following welfare reform, the team of clinicians and researchers found that young children in families whose benefits were terminated or reduced due to sanctions, compared to children in families where benefits were not affected, were at greater risk of food insecurity. In addition, these young children were not only  more likely to be hospitalized in their lifetime but were also more likely to be urgently admitted to the hospital from the emergency department on the day of the interview, indicating that welfare sanctions were associated with more severe health problems among children in sanctioned families. Later research from Children’s HealthWatch also showed an association between reduction or loss of welfare benefits and increased maternal depression.

The intent of welfare reform was to encourage workforce participation, but the policies implemented did not match the reality of limited jobs, poor wages, lack of child care, and subsistence benefits. Some of the most harmful policies have been amended over time, but over the last twenty years, the cash assistance safety net to families facing economic hardship has shrunk dramatically. Today, 23 percent of families with children living in poverty receive TANF compared with 68 percent of families with children receiving AFDC in 1996. The last two decades have also brought tumultuous economic shifts and policy changes to other safety-net programs, including the Supplemental Nutrition Assistance Program (SNAP), our nation’s largest food assistance program. Though SNAP benefits were also cut in the welfare reform law, it maintained a key feature – the mandate to serve all those eligible.  Thus it has become an increasingly important support for children living in some of the nation’s poorest families and acts as a vaccine to protect children from negative health and developmental outcomes.

The group of concerned clinicians and researchers that formed in the late 1990s has since become Children’s HealthWatch. Our network of pediatricians, public health researchers, and child health policy experts has continued to document and publicize findings as positive and negative policy changes have impacted the brains and bodies of our nation’s infants, toddlers, and preschoolers. We hear stories of tearful parents stressed over how they will afford enough food or a roof over their heads for their children when benefits are cut. We know firsthand in our clinics and through the stories of Witnesses to Hunger and caregivers participating in the Children’s HealthWatch interview that each statistic has a name and a face. Despite some forward progress, there has been a trend of increasing hardship. The next two decades, however, do not have to follow this pattern.

Breaking the cycle of poverty will require innovative solutions that respond to the realities families face. The Center for Hunger-Free Communities, which houses the Philadelphia site of Children’s HealthWatch, has developed an innovative microfinance demonstration project for families on TANF called the Building Wealth and Health Network. The Network is a major innovation to TANF programming in that its focus is not solely on “work participation,” but also on supporting caregivers in developing capabilities to heal from trauma and adversity and to build financial and executive functioning skills. The Network offers matched saving accounts, financial self-empowerment classes, and evaluation surveys to give caregivers the opportunity to improve the lives of their families. This pilot rethinks the structure of the public welfare system by empowering families to build their assets, social networks, and career success.

Innovative solutions to public assistance programs must also be paired with comprehensive policy solutions so that families are able to move out of poverty.  Higher wages, stable schedules, quality child care, and greater public funding for education programs which increase adults’ jobs skills, as well as programs (such as food assistance, income support, housing subsidies, utility benefits and tax credits) addressing basic needs for all low income families, whether or not they can find employment, are crucial for ensuring that young children remain healthy and ready to learn. The needs of families which include adults or children with disabilities also require increased attention.

Identifying and implementing evidence-based policy solutions that respond in the current economic reality to the complex, changing, and diverse needs of families lays the solid foundation for our nation’s future.