(Y)PG$. CWLI f ^'-V c {\ t> / PUBLIC ASSISTANCE PROGRAMS for POOR WOMEN IN MASSACHUSETTS GWfRNMflV BuiWjtfy of MassacfcuseH, D ^/tory Copy Massachusetts Caucus of Women Legislators Task Force on Women and Poverty tSAe loemmo/i'aiteaMA in a serious effort to integrate the application forms. A considerable source of the many forms stems from the federal sanctions that have been levied by the U.S. Department of Health and Human Services (DHHS) in an effort to reduce the high error rates as well as to maintain a tight ceiling on eligibility, In the last three years, Massachusetts has been able to reduce the AFDC error rate from 11.3% in 1982 to 3.0% in 1985 through an increase in caseworkers, permitting more face to face interviews, and improved matching of applications and ongoing recipient records with the Department of Pevenue, Division of Employment Security and the bank deposit records of recipients/applicants. II. CASE LOAD "SIZE The actual size of the AFDC caseload, has become the subject of much interest recently following the widely publicized results of the first 20 months of the Employment & Training Choices (ET) program. Through ET job placements 23,000 AFDC recipients have found jobs, contributing to the lowest caseload levels in over 12 years. A dramatic reduction which occurred between 1983 and 1985 has leveled off; and, in fact, the DPW is predicting that the caseload may go up because of the number of unwed mothers coming on to the rolls, changes in eligibility for pregnant women and seasonal fluctuations. - 5 - The largest drop in the caseload occured nationwide between 1981 and 1983 due to the severe cutbacks following the Omnibus Reconciliation Act of 1981 (OBRA). By reducing the allowable income and deductions for welfare recipients who were in low paying jobs, 500,000 families (nearly all of whom were female headed households with 700,000 children) were abruptly cut off welfare assistance and Medicaid. Another 300,000 working families with even lower incomes remained on AFDC, but they suffered an average loss of $2000 a year in benefits. Medicaid coverage was reduced, and services such as eye glasses and dental care for poor children were eliminated. Pent subsidies were cut, and support for new low-rent housing construction was cut by two thirds. The impact of the budget cuts fell heaviest on women and minorities. According to an Urban Institute study, "the real income of black Americans declined both absolutely and relative to the incomes of whites." The average black family received 300% less in benefits as the average white family, while for Hispanics the cuts were 200% less. Other programs of critical importance to those struggling with poverty were also substantially affected by the budget reductions, including public service employment, CETA, WIN, Child Nutrition, Legal Services, Compensatory Education, Food Stamps, and Energy Assistance. In addition, funding cuts for civil rights and equal opportunity enforcement have also taken their toll. In sum, nearly half of the total reduction in benefits from the 1981-1983 cuts fell on households below $10,000 a year. In Massachusetts 31,000 families lost their benefits in the two years. One other change - 6 - that has affected the working poor most unfairly has been the soaring tax increase. In 1978, a two-parent family at poverty level paid $269 in federal income and payroll taxes. In 1980, it was $460; and in 1985 it reached $1,147, an increase from 4% of the income in 1978 to 10.4% in 1985. Although new tax reform changes will exempt a large proportion of the working poor from paying personal income taxes, they will still be required to contribute an increasing percentage in Social Security taxes. Further decreases in the caseload have also resulted from stringent regulations put in place to reduce the error rate (as well as from the start-up of ET). One result of the ET program coupled with the strong Massachusetts economy has been the 50% reduction in the number of "unemployed parents" on the caseload in which the number of unemployed principle wage earners decreased from approximately 2800 in FY '83 to about 1600 in FY '85. Currently, the "Unemployed Parent" category makes up only 2% of the caseload. The DPW argues that without ET and the healthy state economy, the AFDC caseload could be expected to rise, as it has in eleven of the other top welfare states. It also claims that without ET the caseload would have risen to 95,000 by November 1985, based on the DPW's analysis of the matching of ET placements and actual case closings. One reason for the signs of an upturn in the caseload is actually a program which has strong preventive overtones. AFPC eligibility has been extended in Massachusetts to financially eligible women with no dependents during the first and second trimesters of their pregnancies - a benefit which was disallowed by the 0BPA cutbacks of 1981. This act 7 - (Chapter 398, 1984) has allowed 1000 women to become enrolled, thereby receiving the health coverage and assistance with living expenses so critical during pregnancy. Another group of concern contributing to the current increase in the caseload are unwed mothers coming on to AFDC who, because of their age, lack of job experience and schooling, will be more difficult to move into self-supporting roles. By 1986, DPW predicts that half of all the single parents on AFDC will have never been married, up from 23% in 1975. It is of note that Massachusetts has the lowest divorce rate in the country, so this group is coming on to the welfare rolls with a different set of problems. Single families headed by women are the most vulnerable for remaining on AFDC, and these mothers require substantially more support services if they are to move into paid employment or return to finish schooling. If these mothers come on to welfare before the age of 19 with a dependent child, their chances of remaining on for a long period are much greater. When pregnant women go without the necessary pre-natal care and the children born to them are unable to have access to the necessary financial support and health care, serious long-term consequences can be predicted, from preventable birth related injuries and handicaps to long- term disabilities. Assistance given by AFDC is only a partial answer since the benefits remain so low. The numbers are sobering. Twenty-nine percent of all children born in 1984 to mothers under the age of 19 and 28% of children born to mothers between 20 and 24 had been on AFDC by November 1985 (DPW). This adds up to one-third of the children born in - 8 - the last two years in Massachusetts living on grants over 35% - 37% below the poverty line in Massachusetts. The price of long-term dependency is well known. Adequate support for pregnancy prevention programs is essential. III. ELIGIBILITY FOP. AFDC To become eligible for AFDC, applicants must comply with the following criteria in terms of family make-up and work history. In addition to there being a dependent child in financial need: 1) one parent must be dead, absent for more than 20 days, or incapacitated as verified by a licensed M.D. or psychologist, OR if both parents are present in the household, 2) the principle wage earner must meet all of the following conditions: a) unemployed or, at the most, underemployed (less than 100 hours of work in the last 30 days), b) have a work history as demonstrated by receipt of or eligibility for Unemployment Compensation; have had 1 1/2 years of work over the last 3 1/2 years and/or have participated in work- related training programs within the last 3 1/2 years, c) registered with Employment and Training and not refused a bonafide job offer within 30 days. To be eligible for AFDC on the basis of total financial assets and amount of income (if already working at a low-paying job), the criteria include the following: 1) Total assets of less than $1000, including cash on hand and in the bank, securities and insurance policies, any real estate equity except for the family home and equity in an automobile valued over $1500; - 9 - 2) Gross income of less than 185% of the "Standard of Eligibility" which in Massachusetts amounts to $880.60 for a family of 3; AND 3) If the applicant meets the above criteria and is working, the following deductions from gross income are taken into account in determining the amount of the cash grant: (a) a flat $75 monthly for all work-related expenses (which is to cover taxes, transportation costs, and all other work-related expenses except child care); (b) cost of dependent care for a child or disabled person in the home up to $160 monthly (but not to exceed $1.00 per hour); (c) a work incentive disregard of $30 monthly plus 1/3 of the remaining net income for 4 months only (with $30.00 allowed only for an additional 8 months); (d) federal education loans, grants and work study are exempt for income purposes for AFDC eligibility BUT not for Food Stamps. 4) The countable income must include not only that of the grantee relative, but of certain other specific individuals including stepparents, spouses of pregnant women, and any parent in the home even if the parent is not included in the grant. In addition, when the DPW initiates the implementation of certain DEFPA (Deficit Reduction Act of 1983) changes, the income of alien sponsors, grandparents and siblings will also be automatically counted. The amount of the grant for a working applicant is the difference between the amount of countable (or net) income and the "Standard of Payment" (or grant) which for a family of three in Massachusetts is currently $476. The documentation required in the application is lengthy, ranging from birth certificates, social security numbers (all infants must have a number by the age of three months), medical reports, pay stubs, bank deposits, etc., as well as evidence which certifies the marital status, death, divorce or desertion of a spouse. The DPW has 30 days in which to rule on the application, but in case of disputes the applicant can - 10 - request an extension to obtain further required verificatton documents. Chapter 450 of the Acts of 1983 required the Department to simplify verification requirements to avoid denials where families and individuals were otherwise eligible but for a piece of paper. The legislature required the Department to allow for alternative forms of verifications, to accept third-party affidavits and to not require repeat verification of conditions which do not change. Balancing the needs of the Department to ensure eligibility and comply with the federal quality control requirements with the basic needs of the poor and their capabilities to provide documents has been a difficult challenge for the Department. A. CATEGORICAL ELIGIBILITY ISSUES IN AFDC : Federal statutes and regulations limit benefits to those families with chldren (and pregnant women in the last trimester) who are "deprived of parental support or care." The "deprivation factor" is defined as: a) a single parent family where one parent is absent; b) a child or children living with certain relatives where both parents are absent; c) a two-parent family where one parent is incapacitated; or d) a two parent family where at least one of the parents has a work history (includes prior receipt of Unemployment Compensation or six 3-month periods of documented earnings). This "Unemployed Parent" category was a Congressional attempt to prevent a father unable to support his family from deserting but was limited to those families with a demonstrated work history and therefore a potential likelihood of short-term need. AFDC is further limited to "dependent children" who are under 18 years of age or - 11 - in some cases up to the 19th birthday even though the child may continue in school beyond age 18 or 19. In 1981, AFDC for dependents 18-21 in college and AFDC for pregnant women for the first six months of pregnancy were eliminated by the Reagan administration in the Omnibus Budget Reconciliation Act (OBRA). 1. PROBLEM: Incapacity Standard : Intact two-parent families often have difficulty proving incapacity (i.e., the inability of the principal wage-earner to work) or meeting the current AFDC standard of incapacity. Access to physicians is uneven statewide causing difficulty for incapacitated parents to secure medical examinations for verification. Moreover, the current incapacity criteria used by the state is more restrictive than required by the federal government, failing to recognize persons marginally employed or those who have suffered a reduction in earnings or hours of employment due to an incapacity. Both practices cause families to go without benefits or to apply for the state-funded General Relief program. RECOMMENDATION : a) State Law : Amend state statute (M.G.L. c.112 Section 2) and related statutes to encourage physician participation in the Medicaid program. (See also Part III, Medicaid) b) State Policy : i) Amend AFDC regulations to expand the list of medical providers able to verify incapacity (106 C.M.R. Section 301.600(F)). ii) Expand criteria in state AFDC regulations (106 C.M.R. Section 303.330) for parental incapacity to include the broadest acceptable under federal standards. - 12 - 2. PROBLEM: Unemployed Parent/Work History Standard ; Other than incapacity, all other two-parent families are required to verify work history via proof of receipt of Unemployment Compensation (or potential receipt) or six quarters (3 month periods) of actual work or participation in WIN demonstration programs including the Employment and Training Program. Young, teenage parents in particular have great difficulty in providing an adequate work history due to their age and legal prohibitions against work. Refugees as well (those who are not eligible for special Federal Refugee Assistance due to refugee status or length of time in the country) have difficulties verifying work performed in their country of origin. Failing to establish the work history, families are denied benefits or get aid eventually from state funded General Relief (GP) but often only after weeks of delay before receiving assistance. (In combination with those families unable to prove incapacity, Massachusetts aids approximately 1,620 families on GR who have been found ineligible for AFDC, according to the Department's FY '87 Budget Bequest.. In addition, many families denied or terminated from AFDC go without any alternative assistance because they are unaware of the difference between AFDC and General Relief eligibility criteria.) RECOMMENDATION ; (a) Federal Law : i) Amend 42 USC Section 607(b), (c) and (d) to provide for more flexible criteria for establishing work history such as a family's willingness to register with the state's training or employment programs, ii) Alternately, amend this section to allow young parents to prove work history through past high school attendance or vocational school training (outside of WIN). - 13 - (b) State Policy : DPW regulations should be examined and amended to (i) expand possible verifications of work history (106 C.M.R. Section 303.340) particularly for refugees and others whose "work history" was performed in another country, or (ii) implement regulations (106 CMR Section 301.100 et seq.) and systems to ensure an automatic transition to GR benefits retroactive to the date of AFDC application if AFDC is denied, and administer a comprehensive public welfare program providing a range of services to all recipients, as required by M.G.L. c.18 Section 2. 3. PROBLEM : Pregnant Women : Although Chapter 398 of the Acts of 1984 (State legislation amending M.G.L. c.118 Section 2) extended AFDC benefits to pregnant women throughout their pregnancies, current DPW policy is to require married pregnant women residing with their spouses to verify the "deprivation factor" (proof of incapactiy or work history). Many young married couples are denied AFDC during pregnancy even though they have no income and do not qualify for GR based on pregnancy. This type of policy encourages the break up of marriages in order for the woman to become eligible (a similar effect that Congress recognized prior to establishing AFDC for two-parent families). In addition, in cases where the "deprivation factor" is; met and the pregnant woman is eligible, the couple receives only a one person grant for the two persons even though the spouse has no income. RECOMMENDATIONS : a) Federal Law : Amend 42 USC Section 606(b) to provide AFDC to all financially eligible pregnant women (regardless of "deprivation factor") from the onset of pregnancy, therefore providing states with financial reimbursement for all three trimesters. - 14 b) State Law : i) Amend the state statute (118 M.G.L. Section 2) defining eligible pregnant women to include all pregnant women regardless of categorical eligibility (see 118E M.G.L. Section 1 as sample language) but using AFDC financial criteria, ii) Amend state statute (M.G.L. c.118 Section 2) to allow the financially needy spouses of pregnant women to be included on the grant. (For the last trimester, federal reimbursement may be available if the spouse is considered an "essential person" (45 CFR Section 233.20 (a)(2)(vi)). (c) State Policy : Amend state regulations (106 C.M.R. Section 303.110) to allow all financially eligible pregnant women to receive benefits. 4. PROBLEM : Child Support : Single parents are required to cooperate with the Title IV-D agency, currently the Child Support Enforcement Unit (CSEU) of the DPW, in establishing paternity and pursuing support as a condition of receipt of AFDC (Part D of the Social Security Act, 1975). The recipient assigns the right to child support payments to the DPW which then attempts to collect the support owed (Appendix D) . The recipient is entitled to the first $50 of any child support collected by the DPW each month. This $50 pass-through is not counted as income for AFDC or Medicaid continued eligibility but is counted in Food Stamps (106 C.M.R. 363.220). The largest single issue in child support is how the amount of child support due is determined: whether the current child support collected should be just enough to get the family off of welfare or whether the current child support should be sufficient to allow the single parent to provide adequately for her family. It is equally important to ensure that child support is applied - 15 - to current support before billing a parent for any arrearage due to DPW. A second problem arises when DPW uses the child support mechanism to recover an arrearage (such as maternity medical expenses incurred on behalf of a pregnant woman from the father who is now living with the family and attempting to support the child on a current basis). In addition, there are many problems in establishing paternity in cases where applicants are fearful of physical or emotional trauma from the absent parent if he/she is contacted, especially where spouse abuse or rape is alleged. Requirements of unnecessary verification of evidence or the failure to protect information regarding the address of the parent seeking support are other common problems. Further ones arise when payments of the $50 are not promptly passed along because there have been poor records kept of the child support payments. In addition, when and if the child support payments exceed eligibility limits for AFDC, a gap between DPW's terminating the payments and transferring them directly to the recipient can cause undue hardships. RECOMMENDATION : The Child Support Act which passed in July, 1986, addresses many of these problems. Additional recommendations should be devised after careful monitoring of the implementation of this law. 5. PROBLEM : Children 18-21 in School : Due to OBRA cuts in 1981, "dependent children" and their parents are eligible for AFDC only until the child's 18th birthday or in some cases to age 19 If the child will graduate high school by that time. Prior to OBRA, federal reimbursement - 16 - was available for full AFDC benefits to the family through the 21st birthday of the child if s/he continued their education in high school or college. During those years, Social Security was similarly available to children in college or high school whose parents were disabled, deceased or elderly. The state statute (118 M.G.L. Section 1, as amended by Chapter 424, Section 2 of the Acts of 1982) provides "GET" benefits (Grant for Education and Training) of only $84.00 per month to the child while in high school, with no AFDC for the parents nor any continuation of AFDC while the child is in college. Current policy discourages students from finishing school, particularly economically disadvantaged students who drop out to take a job to support the family. Parents who may be in the middle of an employment or training program sponsored by E.T. lose their E.T. placement and must often interrupt their training, applying in some cases for GR months later. RECOMMENDATION : a) Federal Law : Amend federal statute (42 U.S.C. Section 606(a)) to return AFDC eligibility to pre-OBRA policies allowing both children and parents to receive AFDC until the child turns 21 while in high school, vocational school and college. b) State Law : i) Amend state statute (118 M.G.L. Section 1) to provide full AFDC and E.T. benefits to the parent(s) as well as the youth during his/her 18-21 year period including the provision that a child or parent must be allowed to complete an E.T. program or training if begun prior to the date of termination of benefits, ii) Alternatively, amend state statute (118 M.G.L. Section 1) allowing dependents in college - 17 - (18-21) who are not GET eligible to be Included In AFDC grant as "essential persons" In addition to other dependent children. (Note: this policy has been adopted by other states such as New York and Michigan. Federal reimbursement is available if implemented according to 45 C.F.R. Section 233.20(a)(2)(vi) . ) B. FINANCIAL ELIGIBILITY ISSUES The amount of cash assistance for different families on AFDC, both working and non-working, is a complex and confusing challenge to anyone trying to evaluate the adequacy of welfare allowances in any state. The Social Security Act governing AFDC only requires that: 1) each state establish its own "Standard of Need" for the cash grant, defined simply as that level essential to basic existence, and 2) each state set its benefit level as a proportion of its "Standard of Need." The federal "poverty level," by which many assistance programs are judged, was first established in 1965, using an amount which is three times that needed for the "Thrifty Food Plan" as set by the U.S. Department of Agriculture. This food plan, however, is intended to cover the needs of a family only while it is in an emergency or temporary situation and is not sufficient for a nutritionally sound diet. Forty- eight states have set their Standard of Need below this "official poverty level;" in one-third of the states, the Standard of Need is more than 50% below the poverty level and in another third, it is in the 50-60% range. Nor do the states have to set their benefits at this Standard of Need. Many states have been setting the Standard of Need just above or equal to - 18 - the level of benefit set by the state. As of July 1, 1986, the MA FY '87 budget set the Standard of Need at the benefit level. The 10% AFDC COLA and the $15.00 rent supplement are a step towards closing the gap between these basic benefits and the poverty level. The value of other benefits are often included in attempts to prove that AFDC recipients have adequate incomes to provide for their families. Food stamps, housing subsidies, school lunches and day care are often used for this purpose along with Medicaid. Housing subsidies, of great value for those fortunate to find apartments within the guidelines, are of no use to AFDC recipients on long waiting lists. In addition, Medicaid coverage should not be counted as income for AFDC recipients just because the working poor often do not have medical insurance. Instead, to help the non-welfare poor, income eligibility should be expanded to enable them to receive Medicaid. 1. PROBLEM : Definition of Poverty by Federal Government ; The insistence of the U.S. Government in setting a level for poverty which is substantially below the amount necessary to feed and house a family is an almost impenetrable barrier to all attempts to provide AFDC families with a livable level of cash assistance. In fact, it was 16 years ago, in 1970, when Massachusetts last provided benefits slightly above the poverty level. Today, an AFDC family can purchase only 60% of the food and services it could buy in 1970. The dramatic increase in use of food pantries and shelters for the homeless in part is attributable to the plight of AFDC and GR recipients who are unable to make their welfare checks last for the month. - 19 - FECOMMENDATION ; Congress must be called upon to redefine the terms of the level of poverty, using the U.S. Bureau of Labor Statistics "Lower Budget Level" which provides for a more adequate food budget and for regional differences in living costs and then multiplying this by four. This figure should then be required as the federally mandated "Standard of Need" for the entire country and increased annually by an amount equal to the Consumer Price Index or by further increases in the poverty level guidelines, whichever is greater. 2. PROBLEM : Inadequate Grant Levels : AFDC grants in Massachusetts are 63% of the federal poverty level often causing many of the 164,000 children and 73,000 single parents (women) in Massachusetts to go hungry, become homeless and lose hope in their futures. In Massachusetts, the real dollar value of AFDC benefits has declined by 33% since 1970. For a family of three, AFDC grants are 37% below the federal poverty level. For working recipients, after the first 4 months of employment virtually every dollar of earnings is counted against the AFDC grant causing a dollar for dollar reduction if not termination in benefits. It is up to the state to determine and pay the basic grant and need standard. The federal government reimburses approximately 50% of this amount. RECOMMENDATION t a) Federal Law ; Adopt a federal minimum standard nationwide to provide an adequate benefit level and give states incentives (through an increased federal reimbursement rate) to increase benefits. - 20 - b) State Law : Amend M.G.L. c.118 Section 2 and M.G.L. c.117 Section 1, bringing both AFDC and General Relief grants up to at least the federal poverty level. It will take 3 to 4 years of (25%+) increases in the DPW AFDC (4403-2000) and General Relief (4406-2000) budget line items to reach the current federal poverty levels. 3. PROBLEM: AFDC Work Disincentives : On the Federal level, the Omnibus Reconciliation Act (0BRA) and Deficit Reduction Act (DEFRA) significantly restructured the way income is treated for purposes of AFDC eligibility for those working poor including: a) creating an eligibility standard (originally 150% of the state need standard, raised by DEFRA to 185%) which, prevents financially needy working poor from receiving AFDC to supplement their income and often from receiving Medicaid; b) destroying the $30 and 1/3 work incentive by limiting it to 4 months; c) defining work expense deduction standards which do not allow for the costs of earning income; d) deeming the income not actually contributed by non-legally liable persons ( e.g . , stepparents, siblings, alien sponsors and grandparents); and e) counting past income for current eligibility (retrospective budgeting). These changes constituted very significant and regressive anti-work and anti-family financial measures and resulted in substantial losses of benefits and case closings nationwide, including 26,000 cases closed in Massachusetts. In response to the federal cuts and restrictions, the primary "solution" would be to rescind those aspects of OBRA and DEFRA that have continually penalized the AFDC population since 1981. Short of adequate federal changes, the state can also pick up many of those harmed by federal policies through the state General Relief program. - 21 - Current AFDC criteria discourage and penalize AFDC recipients from seeking and maintaining gainful employment : (a) Working recipients are barred from receiving any AFDC benefits if their monthly gross (before taxes or deductions) exceeds 185% of the AFDC needs standard, even if they would qualify for AFDC after allowable deductions and disregards (including childcare). For a family of three with a single working parent, 185% of the Massachusetts AFDC needs standard is approximately $880.60 per month ( gross income) or only $52.00/month over the poverty level. (b). Working recipients are allowed only four months worth of the full "work incentive" deduction. This is a disregard of $30.00 plus 1/3 of earned monthly income for the four month period as an "incentive." For an additional 8 months, only the $30.00 deduction is allowed. (Prior to OBRA in 1981, both the "$30 and 1/3" disregard were allowed indefinitely while the single parent worked until income with deductions exceeded the grant . ) (c) No deductions against monthly earned income are allowed for the actual costs of employment except childcare. A standard monthly deduction of $ 75.00 total earnings is allowed from the gross income for taxes, transportation, uniforms, union dues, and health care expenses. For a woman with a full-time minimum wage job ($3.55/hr.) and one dependent, $75 represents barely 50% of her taxes only. After the $30 and 1/3 disregard expires, - 22 - women actually lose money working. Nationally the minimum wage has remained at $3.35/hr. since 1981 while the cost of living has risen 26%. (d) A maximum deduction of up to $160/month (which is limited to $1.00 per hour per child) is allowed for child-care expenses regardless of whether the child care costs exceed $160/month. (e) "Net" income (gross less the $75.00 deduction and childcare up to $160) is measured dollar for dollar against the AFDC grant level. (f) Recipients of General Relief ( e.g . , two parent families where one is working full time but with inadequate income) are similarly penalized by many procedures identical to the above. RECOMMENDATION : a) Federal Law ; i) Amend 42 U.S.C. Section 602(a)(18) to remove the 185% eligibility cap (returning to pre-OBRA) . This would allow the working poor to qualify for an AFDC supplement claiming all work-related expenses (childcare, taxes, etc.) against their gross income, ii) Amend 42 U.S.C. Section 602(a)(8)(A) to restore the full $30 and 1/3 disregard indefinitely until the recipient earns enough to exceed the basic grant above the disregard, iii) Alternatively, amend 42 U.S.C. Section 602(a)(8)(A) to: a) allow a standard $75.00 deduction from the net income (after taxes), b) provide the recipient an opportunity to exceed the standard $75.00 deduction if s/he verifies expenses above that amount, and c) allow the recipient to deduct for actual childcare expenses with no cap. - 23 - b) State Law : i) Amend M.G.L. c.118 Section 2 (and c.117 Section 1 for GR recipients) to provide for an AFDC need standard which is at least 25% above the AFDC payment standard, creating a work incentive for employed applicants, ii) Amend M.G.L. c.117 Section 1 (General Relief) to define available earned income as net income (after taxes) with allowances for actual work-related expenses and an allowance for the $30 and 1/3 earned income work incentive. (Current language in the statute regarding "available income" may in fact be sufficient, requiring only an amendment to the General Relief regulations.) A. PROBLEM: Loss of Income : As a condition of eligibility, recipients who work (or receive other monthly income such as Unemployment Compensation) are required to report earnings monthly. The budget for their cash assistance is based on income received in the month that was two month's earlier ("retrospective budgeting"). Recipients who lose earnings for any reason (reduction in hours, wages, etc.) in the intervening period are not entitled automatically to a supplemental payment. It is only authorized if the family knows enough to specifically ask for it, and then it is delayed further if the family is not able to reach the worker immediately. Obviously, those least able to help themselves ( i.e ., those who are functionally illiterate, mentally disabled, not fluent in the English language) will be the ones deprived of this needed benefit. RECOMMENDATION : a) State Law : Amend M.G.L. c.118 Section 2 to require automatic issuance of a supplemental payment when the family experiences any loss - 24 - of income due to retrospective accounting. This is a federally reimbursable option which the state agency has been slow to implement. Only 4.4% of the recipients who are entitled to supplemental payments currently receive them ( i.e . , an average of 175 recipients per month out of an eligible population of 4,000). 5. PROBLEM : Deeming of Step-parent, Grandparent, Sibling and Alien Sponsor Income ; OBRA and DEFRA implemented the concept of income "deeming," which means counting as available to a family or individual the income of a non-legally liable relative whether or not it is actually available to the family. Because of OBRA in 1981, thousands of mothers with dependent children who remarried lost the AFDC which they had previously been receiving for their children (as well as any assistance from the Child Support Enforcement Unit to enforce support obligations of the absent father) because of the deeming of the new husband's income even though he had not adopted her children. This policy resulted in many marriages breaking up and now discourages many low-income couples from remarrying. This year, DPW will be required to implement "grandparent deeming" (a DEFRA change), requiring grandparents to support the child of a teen parent who lives with them instead of providing AFDC for the baby as is currently the case. Many parenting teens may leave their parent's homes due to this policy because of the financial pressures on the family or tension over the question of whether the grandparents of the baby wish to support their teenager's baby. This year also, DPW will be required to implement the OBRA/DEFRA requirements of "alien sponsor deeming," counting the income of the individual or - 25 - family that sponsored the alien, regardless of whether the alien receives any support from the sponsor (or even can locate the sponsor to request support) . In addition, DPW will be required to implement the DEFFA requirement that income such as Social Security benefits or child support paid on behalf of one child be deemed to other siblings (including half-brothers and sisters) in the family. In all these deeming cases, there is no legally enforceable way in Massachusetts to require the person whose income is being deemed (stepparent, grandparent, sibling, or alien sponsor) to actually pay support or become otherwise legally liable for the needy family or child. In addition, the deeming provisions require that the stepparent, grandparent, sibling or alien sponsor's income be evaluated a_s ^j[ the individual and their dependents were living on public assistance , at an AFDC needs standard well below the poverty level. The income is further evaluated in ways similar to but less adequate than even the AFDC earned income calculations (i.e. gross income less a standard $75.00 deduction which is prorated according to hours, a maximum $160.00 cap on child care but no earned income incentive). The difference above the AFDC need standard is then "deemed" available to the step-child, grandchild, siblilng or alien. This type of deeming not only ignores the fact that the money may not actually be available to the needy child but also fails to allow amounts of income adequate for the other family members to subsist. - 26 - Some of those denied or terminated from AFDC may be eligible to receive state funded General Relief benefits. However, the transition to GR is not automatic, and many who don't know that GR does not have similar deeming requirements often do not apply. Those who do apply for GR receive benefits substantially lower than the AFDC levels since the maximum GR grant is 10-15% lower than the AFDC grant for same sized families. Additionally, the GR program decreases benefits further in a "shared living arrangements" reduction which results in a grant 50% less than that available for AFDC recipients. (This policy puts the GR recipient in a Catch-22 of not being able to live alone due to an inadequate grant but then losing almost 40% of the grant if s/he shares an apartment with others.) Finally, many are denied GR because the GR asset limit is only $250.00 for an individual or $500.00 for a family, while AFDC allows for an asset limit of $1,000.00 for individuals (a child, pregnant woman, etc.) or family. RECOMMENDATIONS : a) Federal Law : i) Amend 42 U.S.C. Section 602(a)(31), (38) and (39), eliminating the provision of stepparent, grandparent, sibling, and alien sponsor deeming, ii) Alternatively, at a minimum, allow for the federal poverty level to become the threshold before any income is considered "deemable" towards stepchildren, grandchildren, sibling, or aliens, iii) Additionally, allow all of the work-related expenses (the full $75.00 standard deduction and the $30 and 1/3 work-related disregard) to be used in measuring income of the stepparent, grandparent, sibling, or alien sponsor. - 27 - b) State Law : Amend M.G.L. c.117 Section 1 creating parity between General Relief and AFDC benefits so that the basic grant and asset limits are identical for needy same-sized families and individuals (as proposed in Senate bill No. 258, 1985). c) State Policy : i) Amend state GR regulations (106 CMP Section 313.720) eliminating the reduction in basic benefits between full and shared living arrangements. This will also require an increase in the GP account (line item 4406-2000). ii) Amend the AFDC regulations (106 CMR Section 302.130) requiring workers to conduct an automatic determination of GP. eligibility if AFDC is denied or terminated due to the "deeming" provisions. This recommendation is consistent with the recommendation under Categorical Eligibility Issues (A, 2b) requiring the Department to administer a comprehensive welfare program as required by M.G.L. c. 18 Section 2. C. BENEFITS ISSUES : In addition to the basic cash grant and Medicaid, AFDC offers recipients a few additional benefits to supplement the basic grant at times of emergency, the birth of a child or for school clothing. Federal law provides federal reimbursement to states to provide certain of these additional benefits if they do not otherwise duplicate provisions in the grant. Among the additional benefits available are: 1) An annual clothing allowance for dependent children which is given out in September only so that new recipients must wait from one to eleven months to take advantage of this benefit (this year's allowance was increased to $150 per child). - 28 - 2) A one time payment of $125.00 for a crib and layette for a newborn who is added to the AFDC grant. 3) A monthly child support pass-along of $50 if child support is paid regularly by an absent parent directly to a court. 4) A one time Burial Expense up to $1,100. 5) A one time Transportation cost for recipients needing to move out of state (under special circumstances). 6) Supplemental payments : Available only to recipients who work and who must file a written monthly report of income. If this income (based on the previous two months income) has gone down, they may be eligible for a Supplemental Income Payment while awaiting an increase in AFDC if_ the recipient knows to apply for the payment. 7) Family Reunification Benefit ; If a child is voluntarily placed in temporary custody by the Department of Social Services, the family can continue to receive AFDC for up to 6 months after the child leaves and for 3 months prior to the anticipated return. (This benefit is not available to families whose children have been removed because of a finding of child abuse.) 8) Employment and Training benefits (See section on Employment and Training ) . 9) A monthly rent supplement of $15 for those not living in public or subsidized housing was passed in the FY '87 budget (line item 4403-2000 DPW) and has recently been approved by the Federal government. 10) Emergency Assistance : Emergency Assistance (EA) (42 USC Section 606(e)(1)) can play a large role in filling the gap in a family's struggle to meet living costs on an AFDC grant (which is currently 37% below the poverty line) and facing exorbitant housing costs. It is a program of temporary assistance for eligible low income families as well as for AFDC recipients in crisis situations. Under the federal 50% matching program for reimbursement, low income children under 21 and their caretaking relative as well as pregnant women may qualify if the family: a) has a combined income below 185% of the "Eligibility Standard" for the state (in Massachusetts, this is $879 for a family of three) and assets less than $1,000, b) has not received EA in the last 12 months, c) has a specific and urgent need for one or more of the covered services, d) does not have a family member in the household who has refused the Employment and Training program. - 29 - Services available under EA include (106 CMR Section 309.040 & 050): a) payment of up to 4 months rent and utility arrearages to prevent eviction or fuel/utility shut off. b) one month's security deposit, one month's rent, and moving expenses to help homeless families find housing. c) up to 90 days lodging in a hotel/motel if homeless and there is no shelter alternative with relatives, friends, or charities. d) specified limited replacement costs for household goods, . clothing and appliances in disasters (fires, floods), and $100.00 towards appliance repair. The application process requires independent documentation of all income and resources, plus written proof in case of fire by the fire department and a home visit by the DPW staff, copies of repair estimates, eviction notices and utility shut-off notices. Costs of EA have risen from $7.5 million to $34 million between FY '83 and FY '86 and are projected to increase beyond $34 million due to homelessness. The charges that this cost increase comes from inappropriate use and repeated unnecessary applications are hard to substantiate in the face of the well documented large numbers of low income and AFDC families experiencing hardships due to rapidly rising rental costs, evictions because of condo conversions, and the high costs of utilities. To prevent eviction and to avoid the cost of emergency hotel/motel housing, Chapter 450 of the Acts of 1983 (amending, among other statutes, M.G.L. c. 18, Section 2(D)) was passed to eliminate restrictive caps on payments for rent and utility arrearages, advance rents and security deposits and for hotel/motel stays. Furthermore, it statutorily authorized EA for the prevention of homelessness in order to "prevent destitution or to provide living arrangements in the home" (M.G.L. c.18, Section 2(D)). For FY '87, the DPW received approximately $33.5 million for the program plus $7.1 million in emergency Section 707 housing certificates targeted for the homeless population living in hotels/motels. The EA appropriation falls $5.6 million short of that which was requested for the FY '87 year. 1. PROBLEM : Clothing Allowance : The new annual clothing allowance has been available to recipients for the past 5 years. It is currently - 30 - $150.00 per child once a year (average of $12.50/month) , having just been increased by $25/year in the FY '87 budget. The grant amount is barely enough to provide a child with a warm winter coat and boots, to say nothing of sweaters, slacks, warm shirts and shoes. The parents of children are not eligible for a clothing allowance, nor are pregnant women. RECOMMENDATION : a) State Law : Increase line item 4403-2000 to include an increase in the clothing allowance to $350 with an annual cost of living adjustment and to include parents and pregnant women as recipients. 2. PEOBLEM: Maternity and Infant Benefits: A pregnant woman receiving AFDC is eligible for $75.00 for a crib and $50.00 for a layette for a newborn. This benefit is not provided automatically to recipients; women must know enough to ask for it (the same as for supplemental payments). Additionally, the crib and layette amounts also have not been increased since at least 1978. Further, pregnant women are not eligible for maternity clothing allowances (as noted in problem 2 above), nor are there any allowances for special maternity diets (both of which are provided to AFDC women by some other states and both of which are federally reimbursable) under 45 CFR Section 233.90(c)(2)(iv). For the few pregnant women in the General Relief program, this would be a state expense. RECOMMENDATION : a) State Law : Amend M.G.L. c.118 and M.G.L. c.117 and/or increase line items 4403-2000 and 4406-2000 to provide for special maternity benefits (clothing and special diet) for pregnant women. - 31 - b) State Policy : Amend state regulations 106 CMR Section 305.600 (AFDC) and 106 CMR Section 313.260 and .270 (GR) to increase the allowances for cribs and layettes and to automate the issuance of these benefits to women who request AFDC for their newborns. 3. PROBLEM : Emergency Assistance : The Emergency Assistance program in recent years has become the only place to turn for families threatened with homelessness. The recent increase in use of the program has been due to the expansion of the program through the Homelessness Act (Chapter 450 of the Acts of 1983), the substantial loss of affordable housing in Massachusetts and the inadequacy of the basic AFDC grant which is currently 37% below the poverty level. While Emergency Assistance (EA) provides some very basic benefits for a family threatened with homelessness (as listed previously), there are a number of benefits not provided which homeless families require in relocating. Examples include: emergency shelter beyond 90 days, last month's rent, furniture storage beyond 30 days, replacement of furniture lost due to homelessness, initial utility service charges, basic household supplies and food staples for the homeless who locate a new home and housing search services for all EA homeless families (limited housing search is available through EOCD) . In addition, the furniture and appliance amounts (available only to disaster victims) have not been increased since 1977. By including these improvements in the EA state plan, federal reimbursement would be available. RECOMMENDATION : a) State Law: i) Amend M.G.L. c.18 Section 2(D) to include in the - 32 - Emergency Assistance program additional basic relocation benefits for families needing emergency assistance such as last month's rent, furniture storage beyond 30 days, furniture replacement for the homeless and additional emergency shelter, ii) Increase also 4403-2000 to provide funds for these new benefits and to increase the amounts available for furniture and appliance replacements (in disaster and homeless situations) . PART TWO GENERAL RELIEF I. INTRODUCTION General Relief (GR) Is a fully state-funded program of financial and medical assistance for people in Massachusetts who are not covered by federally assisted programs such as Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI). The vast majority of the GR caseload consists of single individuals and married couples with no dependents. In order to be eligible for GR, individuals must be "unemployable" according to the Department of Public Welfare's definition. A small percentage of the GR caseload consists of two-parent families with dependent children who do not qualify for AFDC. According to the DPW's FY '87 Budget Request, there were 23,998 individuals and 1,620 families receiving General Relief benefits at the end of 1985. Fifty percent of all GR recipients are women . GR provides financial and medical assistance to eligible recipients. The monthly benefit as of July 1, 1986, for an individual living alone is $268.90 (without a rent allowance); for those sharing expenses with another it is $178.40; and for a homeless individual who is categorically eligible (or someone with no shelter expenses), the monthly benefit is $82.10. In addition, a special monthly rent supplement of $15 has been - 34 - approved for individuals and families who are not in public or subsidized housing. The maximum basic grant of $431.00 for a family of three is 10% below the AFDC grant for a family of the same size and 43% below the federal poverty level (Appendix E). General Relief medical assistance provides medical coverage for most non-hospital medical services needed by the GR population. Free hospital care to GR recipients is guaranteed through a recent amendment (Chapter 347 of the Acts of 1984) to the free care provisions of Chapter 6A, Section 51 of the General Laws ("Chapter 372"). In order to qualify for GR, the countable resources of the individual must be less than $250.00 (or $500.00 for a family). From 1934 until 1975, the Commonwealth was obligated by law to "support all poor and indigent persons residing therein, whenever they stand in need of relief or support." In 1975, at the behest of the Governor, the legislature passed a bill that changed the wording of the law so that the Commonwealth is only obligated to support "residents. . . found by the (Welfare) department to be eligible for such assistance in accordance with this chapter." The legislation further instructed the Department that "A person who has no dependent children and who is determined by the Department in accordance with its regulations to be employable shall not be eligible for assistance under this Chapter." This change was made during a deep economic recession in Massachusetts in May of 1975 when the unemployment rate was 12.6% and the GR caseload was 47,694 persons. Up to 17,000 unemployed persons were terminated from GR or denied benefits due to the cutbacks. Up until 1975, the General Relief program had been a safety net for all individuals, unemployed or - 35 - non-employable, who were without any income, had inadequate resources or lacked access to other forms of public assistance (e.g., Unemployment Compensation, AFDC, SSI). Following the cutbacks, the Department began determining eligibility based on the limited criteria of individuals being "employable" or "non- employ able." II. CATEGORICAL ELIGIBILITY ISSUES Since 110 employable individual without children is eligible to receive GR in Massachusetts, the DPW's definition of employability is crucial in determining who may receive GR. Currently, the Department allows only persons who fall in the following categories to receive GR: 1. mentally or physically incapacitated, 2. required to care in the home for an incapacitated adult or child, 3. vocationally disabled clients with the Massachusetts Rehabilitation Commission, 4. ex-offenders who have spent at least 60 days in penal institutions (benefits for 60 days only), 5. full time high school students (college students are ineligible for GR by statute), 6. over 65 and awaiting SSI benefits, 7. 45 years of age or older with little or no work history and actively seeking employment with the Division of Employment Security (targeted towards displaced homemakers), 8. residents of an alcoholic or drug halfway house or treatment center, or halfway house for individuals released from state mental hospitals or schools for the retarded (eligible only for a personal needs allowance). - 36 - In 1983, the legislature passed legislation removing the "fixed abode" or permanent address requirement (Chapter 450). This prevented persons who met both the categorical and financial eligibility requirements for the General Relief program from being denied benefits if they lacked an address. Although this change removed a substantial barrier to the program, the homeless are still required to secure a medical report or prove one of the other categories of "non-employ- ability." 1. PROBLEM : Non-Employable Person : There are thousands of financially needy individuals (predominantly under age 45) that sociologists and social service agencies would categorize as not employable due to their lack of skills and education or lack of work in their area of training. However, several groups of individuals have been identified who are clearly not employable but are either not currently GR eligible or face long delays and barriers to establishing eligibility: a) Battered Childless Women : DPW estimates that approximately 200 battered women with no dependents are in need of basic cash benefits in Massachusetts. Many end up among the homeless after exhausting their stay at a shelter for battered women. Or, because of waiting lists at shelters, their only alternative is to become homeless after leaving their batterer. b) The Homeless : Although Chapter 450 of the Acts of 1983 removed the address requirement from the GR program, homeless persons must still meet one of the eight categories of persons - 37 - considered to be not employable. Non-existent, inadequate or delayed medical reports verifying incapacity are the most common problems encountered by GR applicants. Of the 10,000 homeless persons throughout the state, DPW estimates based on a Shattuck Shelter study that 7,000 of the 10,000 homeless in Massachusetts currently receive no assistance, such as basic cash, medical and training benefits. c) Deinstitutionalized Persons : Current Department policy denies GP to residents of state mental or public health institutions, including a personal needs allowance available to other institutionalized persons such as nursing home patients. Persons awaiting discharge from an institution are often unable to apply for GR until actually released which delays receipt of any benefits for 2-4 weeks. Further, these persons are not automatically eligible unless they meet one of the eight non-employable categories listed above. Some of these categories require the same medical verification referred to above. Of the 800 monthly non-elderly adult discharges from state mental hospitals, DPW estimates that 250 deinstitutionalized persons are released each month (or 3,000 each year) with no income or resources (such as SSI or other disability benefits) or other basic education and training services to help transition back into communities. d) Ex-Offenders : GP. benefits are currently available to ex-offenders for 2 months only, leaving most financially needy 38 - individuals released from prison little time to complete any type of meaningful Employment and Training (ET) program. In addition, youth released out of the custody of DYS are not included in the Department's definition of "ex-offenders." Many of these youth, therefore, are released without transitional income or education and training services, e) Participants of Drug, Alcohol and Vocational Rehabilitation Programs ; Individuals who have been recently addicted to drugs or alcohol and who are actively seeking rehabilitation are not eligible for GR unless able to verify medical incapacity. Additionally, persons in vocational rehabilitation programs not sponsored by the Massachusetts Rehabilitation Commission ( e.g . , Department of Mental Health vocational rehabilitation placements) are not independently eligible for GR. These unemployed participants in need of employment and training services are often barred from basic GR benefits during critical periods of their rehabilitation unless an available physician is willing to verify incapacity. Lack of basic resources often undermines the rehabilitative progress, causing individuals to drop out of their programs. For all the individuals above, particularly the homeless and deinstitutionalized, the inability to verify medical incapacity is the single most difficult problem encountered. According to DPW statistics, between July 1984 and April 1985, 4,110 GR applications were denied due to "lack of verification." Over half of these denials were attributable - 39 - to lack of medical verifications due to the refusal of doctors to accept Medicaid, fill out forms, or schedule timely appointments for GR applicants. Even for those medically able to work, deinstitutional- ization, battering, release from prison, and homelessness are times of crisis and disorientation which inhibit an individual's ability to acquire and maintain gainful employment. RECOMMENDATIONS : State Law ; i) Amend M.G.L. c.117 Section 4 fully restoring GR benefits to all individuals in financial need in the Commonwealth (pre-1975 standards), ii) At a minimum, amend M.G.L. c.117 Section 4 to provide General Relief transition benefits (including Employment and Training) for a minimum of six months to persons who are homeless, deinstitutionalized, battered, ex-offenders (including DYS youth) as well as participants of drug, alcohol and vocational rehabilitation programs (See Senate No. 628 and House No. 3003, 1986). This would also involve increasing line items 4406-2000, 4406-5000 and 4407-1010. State Policy ; i) Amend the state regulation to improve verification procedures for medical incapacity, including broadening the scope of medical signers to allow professionals other than physicians to verify medical incapacity (106 CMR Section 312.520). Remove the requisite secondary medical diagnosis confirming drug and alcohol incapacities (106 CMP. Section 312.200). 2. PROBLEM - Individuals Institutionalized in State Mental Hospitals, Individuals who are patients in state mental hospitals are not currently eligible for the General Relief personal needs allowance ($60.00/month) - 40 - which .is available to residents of nursing homes, chronic hospitals, residential treatment centers, intermediate care facilities and public medical hospitals. Patients of mental health facilities who have no outside source of income must do without the basic personal needs items that make life in such institutions more bearable including newspapers, toiletries, snack food, personal phone calls, and field trip expenses. In addition, GR recipients who are admitted on a short term basis ( e.g . , for 60 days, observations, etc.) to mental hospitals immediately lose their General Relief benefits upon institutionalization. If their stay results in prolonged institutionalization, they may lose their apartment or room in the community and be discharged to join the ranks of the homeless. RECOMMENDATIONS : State Law ; Amend M.G.L. c.117 Section 1 to allow residents of state mental hospitals to receive personal needs allowances and GR recipients who are temporarily institutionalized to continue full GR benefits for maintenance of their home during institutionalization (similar to the Family Reunification Benefits concept). State Policy ; Amend GR regulations defining disqualified individuals (106 CMP. Section 312.090 and 313.730(C)) and temporary absence (106 CMR Section 312.080) to meet the needs of the mentally ill who are institu- tionalized either on a temporary or long-term basis. III. FINANCIAL ELIGIBILITY ISSUES General Relief has always been the step child to the AFDC program, in part, perhaps, because It is ineligible for any federal financial - 41 - reimbursement. GR recipients historically have been denied the cost of living adjustments that AFDC recipients received in the 1980' s. They are also restricted by resource limits that are 50-75% lower than those allowed for AFDC families of the same size, denied the same criteria as AFDC for treatment of earned and unearned income, and subject to major reductions in benefits if sharing expenses with others. In addition, GR recipients are not eligible for the federal Medicaid coverage (unless under 21 years of age) but rather receive the more limited state funded medical coverage. 1. PROBLEM: Inadequacy of Grant Levels : GR .benefits are currently 43% below the federal poverty level and 10-15% below even the AFDC grant level for families of the same size. The disparity between these two programs grew during the early 1980' s when GR recipients were left out of the small cost of living adjustments issued to AFDC recipients. GR recipients are further penalized in their efforts to avoid homelessness by sharing expenses with another family or individual, losing 30-40% of their GR grant regardless of actual expenses (an individual on GR receives $178.40 if sharing expenses with another, regardless of shelter costs). Homeless individuals who are categorically eligible (such as the incapacitated) receive a total of $82.00 per month for food, clothing and personal needs such as transportation, phone calls and over-the-counter medications. RECOMMENDATION : State Law : i) Amend M.G.L. c.117 Section to establish GR benefits at a minimally adequate level (e.g., the federal poverty level), and further - 42 - mandate that GP benefits be established at the same level as the AFDC grant for the same-sized family (See S.258, 1985). ii) Increase the GP budget line item (4406-2000) to achieve parity in the GR program, increase grants for individuals in shared living arrangements to the full GP benefit level and increase the monthly minimum grant for the homeless. 2. PROBLEM ; Unrealistic Resource Levels : Compared just with AFDC, the resource level the state allows of $250 for an individual and $500 for a family on GR is 25-50% of the $1,000 limit in resources allowed individuals and families in the AFDC program. It is 15-30% of the $1,500 Food Stamp resource limit and 3-12% of the Medicaid resource limits of $2,000 and $3,000. Although all basic needs entitlement programs are designed to be benefits of last resort, in federal programs, Congress has historically recognized that the poor should not be forced to become so impoverished that they have no possibility of keeping a few savings to help them in emergencies. The state, on the other hand, has not increased these resource limits since the early 1970' s. RECOMMENDATION : State Law ; Amend M.G.L. c.H7 Section 1 to establish a resource limit at least at parity with the AFDC $1,000 resource limit. State Policy ; Amend Department regulations (106 CMP. Section 313.301) providing for an asset limit minimum of at least $1,000. The state statute currently gives the Department the authority to establish financial eligibility criteria including resource limits. - 43 - 3. PROBLEM: Tnequi table Treatment of Income : Again, unlike the AFDC program, the General Relief program does not currently allow a "$30 and 1/3" work incentive deduction for those employable individuals ( e.g . , parents in two parent families) who have earned income. Additionally, the Department calculates earned income using only the standard $75.00 deduction against gross monthly income without allowing for taxes, transportation, uniforms, union dues or any other expenses that the parent may incur in the cost of earning the income. There is no separate higher need standard comparable to the AFDC program nor currently any allowance for childcare deductions. Other disparities exist between programs in the treatment of non-countable income. RECOMMENDATIONS t State Law : Amend M.G.L. c.117 Section 1 to define countable income as including all mandatory payroll deductions (taxes, etc.) and work-related deductions (see M.G.L. C.118E Section 10 for sample language) and allow the extended earned income incentive ($30 and 1/3) that is recommended for AFDC recipients. State Policy : Amend Department regulations regarding the treatment of earned income (106 CMP. Section 313.470) and non-countable income (106 CMR Section 313.530) to resolve the problems listed above. IV. BENEFIT ISSUES In addition to basic cash assistance, General Relief offers other benefits for special needs situations. These benefits include: - 44 - 1) Clothing allowance (Sept. only) of $115. 2) Crib and layette for newborns (total of $125). 3) Funeral and burial expenses ($1,100 maximum). 4) Transportation costs for recipients needing to leave the state (under certain conditions'* . ^ * 5) Emergency Relief (similar to Emergency Assistance for families but excluding emergency shelter for childless individuals) . 6) Employment and Training benefits for recipients able to participate in the program. 7) Medical care (does not include hospital services and has other limitations). 8) A monthly rent supplement of $15 for those not living in public or subsidized housing was passed in the FY '87 budget (line item 4406-2000 DPW) . Many of the recommendations effecting similar special benefits under the AFDC program should be implemented here as well. 1. PFOBLEM: Medical Assistance : The GR Medical Assistance (GP-MA) program, funded 100% by the state, has had a history of under funding and limited services. Until the FY '85 budget, the CR-MA program provided only a few services including a narrow scope of medications, with no transportation reimbursement nor any services provided In hospitals. Chapter 347 of the Acts of 1984 amended the hospital cost-containment law (Chapter 372) to provide access to hospital services for the GR population. Although a checkerboard approach to health care, GR recipients for the first time are able to access hospital care provided a physician will accept GR-MA and treat the patient. Problems over hospital compliance with the - 45 - Chapter 347 amendments continue as there are questions as to whether this population has any entitlement to hospital care. In addition, unlike Medicaid, GR-MA Is not available to persons who are slightly over income for GP . There is no process for becoming eligible for GR-MA as in the AFDC-MA program by "spending down" income to the GP level in order to receive coverage. Low income childless individuals (who are not elderly, blind or totally disabled so as to be Medicaid eligible) are denied access to any form of medical care beyond the emergency room if they are slightly over income for GP. RECOMMENDATIONS: State Lav : i) Amend M.G.L. c.6A Section 51 to continue guaranteed hospital access to the GP. population, ii) Expand GP-MA budget line item (4406-5000) to include services not currently available such as hospital based community health centers (if not part of free care services), adult day health services, intermediate care facilities for the mentally retarded, long term care services, etc., similar to Medicaid, iii) Amend M.G.L. c.117 to provide for GR-MA "spend downs" for individuals and families slightly over-income for GR. 2. PROBLEM : Family Reunification Benefits : Unlike AFDC, the GR program does not continue basic assistance for a 6 month period to families whose children have been placed temporarily in DSS foster care. Although only 1,620 families currently receive GR, the small percent of families who may be in need of Family Reunification Benefits to avoid homelessness during the temporary absence of the child are currently ineligible. - 46 - RECOMMENDATION : State Law : Amend M.G.L. c.117 Section 1 to provide Family Reunification benefits parallel with those currently available in the AFDC program. This will involve an increase in the GR budget line item (4406-2000) as well. PART THP.FF MFPICA7P T. INTRODUCTION The continued increase in medical costs in the United States is receiving major attention throughout all corners of industry and government, both state and federal. For those with little or no health insurance, an accident or a major illness for a family member can quickly drop that family from a moderate standard of living into poverty and invoke an application for AFPC or G? . For poor women who are household heads with growing children, the spectre of not being able to have access to health rare is a continuing nightmare. At the same time, while medical costs have been escalating (with an increase of 50% in the Consumer Price Index for the cost of medical care items from 1980-1985 alone), the number of Americans who are going without health insurance has grown significantly. Unemployed workers, low-wage and part-time workers, and the countless numbers of discouraged workers outside the work force have neither the means nor the access to join an affordable group health care plan. Today, 35 million people - 152 of the population - are without health insurance, representing a 25% increase since 1977. Medicaid currently covers only 52% of the poor, compared with 65% in 1976. Children are the hardest hit. They constitute 40% of all the poor, and only one-third have Medicaid coverage. - 48 - In Massachusetts, 665,000 people (13? of the population) were without health insurance in 1983. Approximately one-third of these are in families with income three times the poverty line or above. But half of all the uninsured are living in families below or just above the poverty line. The largest group is children under 19 years (221,000), while 38% are uninsured adults. Tt is the working poor who have been the major victims of health care cutbacks and the decrease in funding for neighborhood health centers which has taken place following 0BPA (Omnibus Reconciliation Act of 1981). Today, the federal government pays more for health care for the middle and upper classes in the form of tax deductions than it pays for medical care for the poor. Deductions for health care for these groups cost the government $29 billion in lost revenues in 1982. This was $8.2 billion more than the total bill for Medicaid, which was $20.3 billion. Tn addition, the government spent $57.4 billion on Medicare for the elderly and disabled in 1985. II. MEDICAID The medical program for the poor, Medicaid, was established in 1965 as Title XX of the Social Security Act. It is jointly funded by the federal and state governments, but administration is under state control. The stated goal of the federal act is to provide "necessary and high quality medical care to the financially and medically needy." The state must comply with federal regulations mandating basic coverage and income guidelines in order to receive federal reimbursements, which total roughly 50? of the cost of eligibile services. - 49 - It is important not to confuse the two federal programs which provide support for medical care nationally, MEDICAID and MEPICAPF ♦ The latter, Medicare , is a federally-funded medical insurance program for individuals over 65 who are recipients of Petireroent Benefits under the Social Security program or who are specifically eligible as "disabled" persons. Medicare has two parts. Most recipients of Medicare are entitled to "Medicare A" without paying a premium. This covers hospital care and limited nursing home care following a required hospitalization, but there are increasingly costly deductibles and co-insurance with this coverage. "Part B" covers the physician's services, but again there are regular deductible fees for the recipient to pay. One of the most serious drawbacks to Medicare is that it doesn't pay for regular prolonged nursing home care, whereas Medicaid does. This has led to the hotly debated "spend-down" practice enabling persons above Medicaid income limits to "spend-down" their income to meet Medicaid eligibility guidelines. MFDICATP , funded by a combination of federal and state funds, is the largest single item in the state's budget, costing over $1.2 billion in FY '86. It covers health care costs for the AFDC population, SSI and certain medically needy populations. Under federal guidelines, the state is mandated to cover the costs of inpatient and outpatient care, skilled nursing home care, physician and licensed psychologist care, laboratory and radiology services, home health care and basic dental and preventive health care for children. In addition, Massachusetts has opted to provide 30 optional services including prescribed drugs, intermediate - 50 - nursing home care, adult day care, mental health care and transportation to medical services. The reasons for the high costs of Medicaid are poorly understood by the general public, which tends to blame AFDC families for the size of the Medicaid budget. The DPW adds to this myth by listing the average cost of care for an AFDC family at $3000 instead .of the median cost of $900. (In the DPW FY '87 Budget Narrative, it subsequently documents that the cost of a small number of seriously ill AFDC recipients skews the average . ) The lion's share of the Medicaid budget goes to support care for the elderly and the institutionalized. While 65% of Medicaid recipients are AFDC children and their single or unemployed parents, their share of the cost only totals 25% of the budget. The elderly and disabled, who make up 35% of the caseload, account for 75% of the costs. The projected breakdown of expenditures for FY '87 is as follows: Amount % of Total Long term care $645.3 million 52% Acute hospital care $243.5 million 20% Outpatient care $118.1 million 10% Physicians $ 60.0 million 4.9% Drugs, home health care, . . dentist and miscellaneous $128.2 million 13.9% (see Appendix F for a further anyalysis of the FY '86 caseload.) Cost control was the main thrust of the Department of Public Welfare's FY '87 budget narrative. Reducing the error rate is mandated by the federal government to avoid fiscal sanctions; and the state error rate is currently at 1.2%, down from 6.6% in FY '84. - 51 - This year's priority measures for the state administration include: a) improving the quality and access to care, b) further reducing costs by controlling inappropriate provider claims, c) reviewing rate setting decisions, d) insuring that services are actually needed ("second opinions"), and e N implementing the "Third Party Liabi lity" program which recovers costs from recipients who are found to be carrying private health insurance. Tn addition to Medicaid the DPW is responsible for three other health care accounts. Medical Assistance for Mental Health is a separate account established in 1980 to fund the Department of Mental Health's program of community-based mental health and mental retardation services (which is beyond the scope of this report). In addition, DPF administers General Pelief /Medical Assistance, a totally state-funded program which is more fully covered in Part Two of this report. General Pelief /Medical Assistance pays for most non-hospital medical services for some 25,000 individuals and families. Hospital benefits are provided under Chapter 347 passed in 1985 which amended Chapter 372 to provide free, hospital care. One very important program mandated by the federal government, as an amendment passed by Congress in 1967 to Title XIX of the Social Security Act, requires states to include preventive and curative services to children under age 21. This program, called Early and Periodic Screening , Diagnosis and Treatment (EPSPT), requires every state with a Medicaid program to provide ^PSDT services to all children eligible for Medicaid. Unlike Medicaid, EPSDT not only reimburses for services but - 52 - requires that states ensure the provision of these services. Massachusetts has named its EPSDT program Project Good Health (PGH) and is operating under a court order from the VEGA suit in 1978 to improve services and access for all eligible children. Project Good Health (PGH) is designed to detect medical and dental problems before they become chronic or cause permanent damage. A mandated screening program must include regularly scheduled diagnostic tests including health history, physical examination, developmental assessment, immunizations geared to a child's age, nutritional assessment, vision and hearing testing, and appropriate laboratory studies (including testing for lead^. PGH is required to inform all AFPC families and other Medicaid- eligible children about all PGH. services. PPT-7 must ensure that PGH children are receiving the proper follow-up on diagnoses and treatment and notification of schedules for further periodic screening. That PGH is cost effective has been demonstrated by national studies showing that EPSDT participants have Medicaid costs (including administrative costs) which are 17, lower than those incurred by non-participants. In this past 1986 fiscal year DPW worked cooperatively with the Department of Public Health to administer the Healthy Start Program now (for FY '87) the total responsibility of DPH. DPW also administers the Food Stamp program which is available to other low-income people as well as AFPC recipients. - 53 - II. ELIGIBILITY REQUIREMENTS Medicaid is a federally funded program restricted to those eligible categories of low-income individuals who can meet strict categorical and financial requirements. The federal government reimburses states for approximately 50% of the costs according to specific formula. (For those not eligible for Medicaid under Massachusetts regulations, the state provides state funding for non-hospital based services for General Relief participants, mental health and limited free care reimbursement for hospital costs.) The following are the Medicaid eligible categories: 1) Medicaid/Old Age ; Covers those individuals over 65 years of age who are financially eligible (including those eligible with a "spend down"). Elders receiving SSI (Supplemental Security Income) are automatically eligible for Medicaid. 2) Medicaid/Disabled and Blind ; Covers those individuals who are disabled (a substantial and severe disability lasting a minimum of 12 months or ending in death) or blind and financially eligible (including those eligible with a "spend down"). Disabled and blind individuals receiving SSI are automatically eligible, as well as certain former SSI recipients transitionally employed. 3) Medicaid/AFDC-Related ; For families receiving AFDC. It is also for pregnant women and families over income or resources for AFDC but financially eligible for Medicaid (including those eligible with a a "spend down"). Parents of children must meet the - 54 - "characteristics" of an AFDC family ( e.g. , single parents or two-parent families complying with the "deprivation factor" as explained in the AFDC section) in order to be eligible for Medicaid. Pregnant women are eligible regardless of the "deprivation factor." Families terminated from AFDC due to earnings or child support may also receive continued Medicaid (usually either a 4 or 9 month period) as transition coverage. 4) Medicaid/Under 21 ; Available to children and adults under 21 years of age who are otherwise financially eligible (including those eligible with a "spend down"). For children under 18 living with parents, all parental income is considered in determining eligibility. Assuming an individual or family meets one of the "categories" above, the Medicaid program financial eligibility levels are still, for families, 15 to 23 percent below the federal poverty level. Using the figures in the FY '87 budget appropriation (133.3% of the AFDC standard), for a family of three the Medicaid income level is now $641.00 per month or $7,692 per year, 16% below the Federal Poverty Level and 33.3% above the AFDC level for a family of three. Families and individuals that exceed the Medicaid income levels may nevertheless be eligible as long as they "spend-down" their income to the Medicaid level, paying for a share of their medical bills calculated for a six month period. They essentially are forced to reduce their income to the Medicaid level just to receive basic medical care for themselves and their children. In - 55 - addition to the income criteria, individuals and families must have resources below $2,000.00 (individuals) and $3,000.00 (two persons plus $100.00/per dependent) in order to qualify. The people not eligible for Medicaid include: a) childless individuals between the ages of 21 and 65 who are not totally disabled or blind (according to the stringent SSI standards); b) parents (over 21 years of age) in two-parent households who work more than 100 hours per month; c) unemployed or underemployed parents who lack a work history; d) the working poor (including single-parent families) whose income or assets may be over the Medicaid standards but who are still poor. A. CATEGOPICAL ELIGIBILITY ISSUES 1 . Health Coverage for Pregnant Women and Adolescents : Overview Since 1981, the Medicaid program has provided Medicaid coverage to financially eligible pregnant women (Chapter 351 Section 172 of the Acts of 1981, amending 118E M.G.L. Section 1). However, there remain two groups of pregnant women who are ineligible for Medicaid: women whose monthly income is above the low Medicaid levels and pregnant teenagers living with parents who may be unwilling to apply for Medicaid or whose income creates financial ineligibility for the teen. Women whose income is slightly above the poverty level ($5,360 per year for a single person, $7,240 per year for a couple) are often ineligible for Medicaid and may not seek or are denied access to medical care due to an inability to pay - 56 - ( e.g . , inability to meet the Medicaid "spend-down") . Pregnant and parenting teens may similarly be denied access to medical care if living at home. Pecent studies have shown that basic prenatal care reduces the incidence of infant mortality. Low weight babies (under 5 1/2 pounds) are 50 times more likely to die and are more prone to illness and chronic disability. In Massachusetts, 13. 2% of young mothers under the age of 16 and 8.7% of mothers 16 to 17 years gave birth to low weight infants. Studies in Massachusetts also indicate that prenatal care is cost effective. For every dollar spent, approximately four to six dollars is saved in hospital costs associated with low birth weight problems. According to the report by Marion McCarthy, April, 1986, Pregnant and Parenting Teenagers in Massachusetts for the Massachusetts Caucus of Women Legislators' Task Force on Pregnant and Parenting Teens, there were 7,016 births to teenage mothers or 29.3 per thousand teens in 1984, reported to be an increase of 97 births over the previous year. Additionally, teens suffer twice the normal risk of complications in pregnancy and delivery than older women, have a greater likelihood of anemia, toxemia, premature births, and often do not seek prenatal care. According to a 1984 study by the Department of Public Health, financial barriers were the most commonly cited obstacles to prenatal care, as indicated by 72% of those who responded to the survey. The consequence of inadequate prenatal care and the poverty implications for the Commonwealth as well as for the personal lives of all of these women (often young, single and without education or skills) has 'been frequently cited. 57 - 1 . PROBLEM ; Health Coverage for Non-Medicaid Eligible Pregnant Women : Due to the Medicaid financial eligibility levels still being below the. poverty level, many working poor pregnant women are unable to access basic medical care beyond maternity care (through Healthy Start) during the course of their pregnancy. In the FY '87 budget the Medicaid financial eligibility standard was, for the first time, raised to the federally allowable maximum (133.3% of the AFDC need standard). This increase will cover some of these women who would be eligible for Healthy Start and shift half the cost of their care to the federal government. However, there are thousands of working poor women who will still be ineligible for Medicaid, foregoing medical treatment or receiving only maternity care (although not other necessary care) through Healthy Start. There also remains the question of the permanence of both the 133.37 Medicaid increase budget item and the Healthy Start budget item. RECOMMENDATIONS ; State Law ; i) Amend M.G.L. c.llBE, Section 1 to permanently set the standard for medically needy persons at no less than 133.3% of the state's AFDC Standard of Need. ii) Amend the state statute (under Chapter 111 of the M.G.L.) establishing the Healthy Start program as an entitlement program for all eligible pregnant women, setting the income levels at no less than 200% of the federal poverty level, and providing comprehensive medical care for all medically necessary services during the course of pregnancy as well as necessary post-partum care and at least one pediatric ambulatory visit for the newborn, iii) In addition, - 58 - continue to provide sufficient funding in the state budget (line item 4513-1005 fDPH)) for maternity c .ve; and increase the funding to provide comprehensive medical care for all Healthy Start eligible women throughout the course of their pregnancy. The DPP. projects that more than 4,500 eligible women will request Healthy Start benefits this year. 2. P ROBLEM : Medical Coverage for Pregnant and Parenting Minors : In 1972, the state legislature recognized that certain groups of minors were at high medical risks, particularly pregnant and/or parenting ones. The legislature futher recognized that these minors would forego needed medical care if parental consent was required. As a result, Chapter 112 M.G.L. Section 12F was amended to allow minors to consent to their own medical care (excluding abortions and sterilizations) without their parents' consent or financial liability. Although these minors now have the statutory authority to seek and consent to their own medical care, lack of resources to pay for the care undermines the original intent of the law, creating problems for minors. On the one hand, they have the right to consent to the^'r care; but on the other hand they cannot pay for it. Healthy Start, if sufficiently funded, is one option for some financially eligible minors, although it would be 100% funded by the state. In addition, last year Chapter 715 of the Acts of 1985 was enacted requiring that private health insurance coverage must include maternity care of dependents of beneficiaries. This closed the loophole slightly but not enough. Pregnant and /or parenting minors who live with their parents who do not have private health insurance or wbo are afraid to - 59 - discuss their medical needs with their parents are still confronted with the fact that they are not independently eligible for Medicaid. Beyond basic access to medical care, the problems associated with teenage pregnancy require more extensive attention. Again, according to the Task Force on Pregnant and Parenting Teens, 2,550 teenage mothers in Massachusetts are single heads of households; and 82% of teenage women who gave birth at age 16 (or younger) were daughters of teenage mothers. This alone can continue the cycle of poverty. Also, those teenagers (both sexes) eligible for Medicaid through their parents often do not receive information on basic health services or a copy of their own Medicaid card to access their own medical care. RECOMMENDATIONS : i) Amend state law (118E M.G.L. Section 10) to allow pregnant and/or parenting minors to establish eligibility for Medicaid without deeming of parental income if their parents do not know about or have refused to pay for their medical care (see House No. 5437 and Senate No. 1927, 1986). ii) Establish Healthy Start as an entitlement program (under Chapter 111 of the M.G.L. as recommended in problem 1 above), iii) Amend state law (under Chapter 111 of the M.G.L.) to establish a coordinating council to study and develop model programs for health care and health promotion for adolescents (House No. 5662, 1986). iv) Expand the scope of obstetric, gynecological and other family planning services available in the Medicaid program for all pregnant women to the fullest extent allowed under the Comprehensive Omnibus Reconciliation Act (COBRA: Public Law 99-272, Section 9501). This should include providing outreach for family - 60 - planning and other medical services to adolescent recipients of AFDC and Medicaid, including those who are dependents in AFDC and Medicaid households through the Project Good Health program.. 3. PROBLEM : Medicaid Ineligibility Due to "Double Counting" of Income : When families with a disabled parent apply for Medicaid, they have a right, under federal law, to divide the family into two "assistance units," one to include the disabled parent and the other to include the other parent and children. Using this approach, each assistance unit is entitled to a separate financial eligibility determination; and the disabled person will be judged as a single person with an income limit of $440 to qualify for Medicaid. The DPF, however, adds the income of the disabled parent and the other parent's assistance grant together and uses this total to determine each assistance unit's eligibility, in effect "double counting." This method frequently causes the family's income to exceed the limit, disqualifying them completely from Medicaid; or the disabled person may decide to forego medical treatment in order to remain living with his/her family. RECOMMENDATION : Amend the state statute M.G.L. C.118E, Section 1 (See Senate No. 622, House No. 3733 of 1986) to require that the DPW count income only once for use between the two assistance units. A portion of the combined income would be assigned to the disabled person (at the SSI or Medicaid standard for one person, whichever is lower), and the remainder would be assigned to the other assistance unit for eligibility purposes. - 61 - 4. PROBLEM ; Coverage for People Between 60-65 Whose Income Exceeds the G? Limit : Medicaid is not available to many individuals such as displaced homemakers, widows and early retirees. Without the resources to obtain the necessary medical coverage, they are forced to go without care. RECOMffENDATION ; Amend the state statute M.G.L. C.118E, Section 1 (See Senate No. 639, House No. 371 3 of 1986) to require the state to extend Medicaid eligibility to this group of older people. It would be a limited expansion of Medicaid but one which is critical to a very vulnerable group of poor women. B. FINANCIAL ELIGIBILITY ISSUES 1. PROBLEM ; Eligibility Standard for Medicaid : For the first time, the state budget (FY '87) provided for a Medicaid eligibility level at 133.37 of the AFPC need standard. For many of the low income working poor who lose AFPC due to employment secured on their own or through ET, the Medicaid increase provides a minimum safety net of medical security. Nevertheless, the Medicaid levels are still 15-23% below the federal poverty level; and the budget item needs to become a permanent component of the Medicaid program. RECOMMENDATION ; Amend Chapter 118E, Section 1 to set the standard for medically needy families of two or more at not less than 133.3% of the state's AFDC Standard of Need (cf Appendix E for a chart of these figures). In - 62 - addition, raise the AFDC Need Standard (as recommended under AFDC, Section B, Problem 3, Recommendation b) so that the Medicaid standard can increase for working poor families. 2. PROBLEM : Expanding Coverage to Include More Low-Income Families and Those Who Lose Coverage Because of Loss of Employment or a Spoused Income ; This issue is one of the most important and troublesome ones effecting all low and many moderate-income families - the inability to pay for the cost of medical coverage if it is not provided by an employer. Bills are filed annually in Congress to address this situation. In a recent development, the Budget Reconciliation Act of 1986 requires that employers continue to offer health coverage to terminated workers for 18 months and to their divorced, separated or widowed spouses and dependent children for up to three years if the family breaks up. The coverage must be requested, and the employer can charge 102% of the premium to cover the extra expenses of billing the employees directly. (It is somewhat akin to Chapter 414 of the Massachusetts General Laws (1984) providing coverage to spouses following divorce or separate support judgments without additional premiums or additional physical exams for a period to be specified in the judgment.) RECOMMENDATIONS : a) Federal Law : i) One direct and permanent approach is to have Congress raise the Standard of Need and the level of poverty guidelines, as has already been proposed in this report under AFDC, and then mandate Medicaid coverage at 185% of the Standard of Need, ii) Two bills which were considered by Congress in 1986 had bipartisan support and would have - 63 - provided relief for several subsets of people now lacking medical coverage : o) HP 4630 and S 2333 (1986) provided coverage for all pregnant women and infants up to one year; o> HP 4742 and S 2402, 2403 (1986), the "Access to Health Care Act," included a mandate to set up insurance pools for the chronically ill and uninsurables, required the provision of essential health care for all poor and gave tax incentives to small employers to provide health insurance to their employees. These bills should be refiled for the next Congressional session. b) State Law : i N The state is urged to consider legislation to provide coverage for catastrophic illness for the poor and uninsurable similar to Rhode Island's, or to extend Medicaid to cover more low income poor along the lines of California's "MediCal" coverage, ii) Support the passage of H.4916 (1986) which would extend Medicaid benefits for one year after recipients have entered the work force if health insurance is not provided by their employer or have DPW co-pay these benefits. To be eligible, the recipient's income during that year could not exceed 200% of the national poverty level, iii) Support continuation of the existing Study Committee on Health Care Financing and Delivery Reform, with a four year time line to establish a plan to insure the un- and under-insured. c) State Policy : The state should encourage the speedy implementation of the new federal law extending health coverage for terminated workers and their families. A monitoring system should be developed to ensure that those entitled to receive these benefits do so. - 64 - 2. PPOBLEM: One Month Spend-Down : For those families who are medically needy hut whose income exceeds the AFDC or SSI limits, medical assistance is available only after incurring medical expenses equivalent to a "spend-down" amount. A "spend-down" amount is the amount of monthly income a family has which is over the level set for the standard of need for that size family. Currently, DPW requires that people incur liability for medical expenses for a total of six times the spend-down amount. This imposes a severe hardship on many low-income families. For some, it is impossible to find the money to pay their bills; or they must decide whether to choose living costs or medical expenses. A last resort is admission to institutional care for which the state legislature amended the law to require a one month spend-down. RECOMMENDATION : Amend state statute Chapter 118E, Section 10 to eliminate the requirement that a person must incur six times the spend-down amount before medical coverage is provided. Medical assistance would then be available in any month in which a person's medical expenses were equal to their one month, spend-down. C. ACCESS TO MEDICAL CAFE AND SERVICES 1) PPOBLEM : Today, Many AFDC Families and SSI Recipients Cannot Get Care Because Many Health Care Providers Do Not Accept Medicaid Patients . Providers protest that the fees for services have been set too low by the state and that the lag time for receiving payments is too long. Others add that they cannot absorb the income loss caused by the 65 - high number of missed appointments they fee] this population incurs. In addition, neighborhood health centers are closing due to cutbacks in operating funds caused by the 1981 OBPA cuts. Health Maintenance Organizations (HMO's) have also been slow to contract with DPW to accept Medicaid. Traditionally, recipients have resorted to outpatient departments and emergency rooms when other care was difficult to obtain. This approach has become very expensive as hospitals have had to increase their fees substantially to meet deficits. One approach which has been in bill form since late 1984 would make participation in Medicaid a condition for licensure for physicians in this state. This proposed legislation was derailed last year to give the Massachusetts Medical Society an opportunity to show that it could persuade enough doctors to open their practices to Medicaid recipients to satisfy the need. Advocates have been disappointed in the result of this effort and continue to press for the passage of the "Medicaid Access" bill. The DPW has attempted to encourage more Medicaid providers by addressing physician complaints about paperwork, audit procedures and claim processing time. An increase in fees has provided some expansion in the numbers of primary care physicians and pediatricians willing to accept Medicaid, but shortages still persist in other specialties in some areas of the state. RECOMMENDATION ; i) Amend state regulations to require that those private health plans and Health Maintenance Organizations (HMO's) who contract with the state to provide health coverage for state employees accept contracts for groups of Medicaid patients. - 66 - ii) Continue to develop ways to attract more doctors to accept Medicaid patients as well as to press the Massachusetts Medical Society to increase its own efforts along these lines, ill) If such efforts do not produce the desired outcomes, Medicaid participation could be attached to licensing requirements as now is in effect for Medicare, as the "Medicaid Access" bill is currently again before the legislature. Other proposals being discussed include requiring participation in Medicaid as a condition for admitting privileges in hospitals or when hospitals request license renewals, transfers or expansion under Determination of Need regulations, iv) Support is needed through the budget so that DPW can proceed with its Health Choices for Families initiative. This will change the existing Medicaid program from a predominately fee-for-service system to one offering three different plans for health coverage. This will offer an alternative to the expensive practice of using private doctors and outpatient departments. These plans are: o Coordinated Health Program : A single primary heath care provider, such as a Health Maintenance Organization, neighborhood health center, or physician, would be responsible for all necessary health services; o Private Insurance Plan : The state would negotiate with private health insurers such as Blue Cross or Prudential Care for health care plans; - 67 - o Revamped Fee-for-Service Basic Medicaid ; Continued full coverage of existing services with increased quality control and utilization control measures. This approach which offers Medicaid-eligible families a choice (similar to the approach used by employers) will result in better medical care and major savings in cost overruns. At the same time it will preserve the federal directive that Medicaid must offer the poor a choice of quality medical care programs. v) Support House No. 5265, 1986, which directs EOFS to establish a pilot program for the enrollment of Medicaid recipients in these types of private insurance plans, vi) Review future legislation regulating hospital reimbursement to ensure that it does not impede access to health care. 2. PROBLEM ; Inadequate Health Services for Adolescents : In addition to pregnancy coverage, adolescents tend to have the most problems in getting access to available health services. A study by the national Children's Defense Fund gives evidence of the increasing number of unrecognized and/or untreated health impairments ranging from vision and hearing losses to chronic illnesses to serious mental problems among adolescents. Such conditions are even more likely to go unnoticed among low- income teens. Project Good Health (PGH\ described earlier in this section, is one approach to this problem. PPW has made efforts to enroll more providers willing to perform the required complete PGH health screenings. In FY '85, the number of providers increased to 547, representing a 39% - 68 - increase over FY '84. This resulted in an increase in the number of children and youth covered, from 55,573 in FY '84 to 86,765 in FY '85. The goal for FY '86 was 120,000. The challenge to the DPW is to continue this promising record, while ensuring that complete screenings are followed up with the necessary diagnosis and treatment plans. FGH has been shown to be cost effective by national studies documenting that EPSDT (national name for PGH) participants have medical costs which are 7% lower than non-participants. RECOMMENDATION : i) Implement the recommendations of the Advisory Task Force on Health's January 1985 Report to the DPW Commissioner, ii) Expand the scope of obstetrical, gynecological and family planning services to pregnant and parenting teens through the PGH program (which may be broader than otherwise provided for Medicaid eligible teenagers), iii) Restructure the PGH program to improve supervision of the field staff, increase referrals to PGH and create standards for programs similar to those set by ET. PART FOUP EMPLOYMENT AND TRAINING I. INTPODUCTION The predecessor to the Massachusetts Employment and Training Choices Program (ET) was the nationally mandated Work Incentive Program (WIN), established as part of the 1967 amendments to the Social Security Act. Since 1971, all AFDC recipients with no preschool children at home and no barriers to prevent them from being away from home have been required to register with the state's employment security program, participate in job training and/or job search and accept any employment offered them. Under WIN, participants were also eligible for support services, such as child care and transportation. The WIN program was always over-enrolled by AFDC recipients eager to get off welfare; but a lack of funding, a poor job market, and perfunctory efforts by many welfare departments led to its being considered as almost a complete failure. In 1981, through the OBRA (Omnibus Reconciliation Act), President Reagan mounted a major effort to institute compulsory workfare programs (in which recipients would be required to work off their grant in public service jobs if there were no other employment available). States were also permitted to set up demonstration projects to study a variety of employment and training reforms in an effort to reduce welfare rolls. In these demonstrations, there have been a number of different combinations - 70 - of job search and placement programs with or without training; but all are coupled with "workfare" for those who can't find work. In workfare, recipients are required to "work off" their grants at the minimum wage in a public service job. These programs are all mandatory; and the recipients are required to participate as directed, or they will lose their share of the grant. The ET program in Massachusetts has received wide acclaim for its success in reducing the number of AFDC and GR recipients by placing them in permanent jobs. ET is different from the demonstration programs in other states in that, without coercive measures, it emphasizes a wide choice of approaches to job training, adult literacy and job placement accompanied by support services for mothers of young children in the form of day care and transportation. The ET approach requires that all eligible recipients register for the program, come in to meet with an ET worker for appraisal and learn about the various choices (See Section III). For recipients who do not follow through on recommendations, ET staff will continue to maintain contact and call them back to review the options. As it is, however, there are already so many recipients signed up on waiting lists for slots in the various programs that ET opts to put its resources with these recipients. Many are volunteers, in that the age of their children exempt them from mandatory registration. In FY '86, 44% of the participants were mothers with children under six. The ET program has been widely publicized as a remarkable success story by placing welfare recipients in permanent jobs and reducing the - 71 - welfare caseload. In the first 20 months, 23,000 recipients were placed in either full time or part time jobs, saving the Commonwealth an estimated $69 million and reducing the caseload from 89,000 in October 1983 to 85,000 in FY '86. Eighty-four percent of those who obtained full-time jobs and were able to leave welfare were still off welfare a year later. Critics have challenged that these recipients may already have been readily employable and did not need ET. However, statistics on the ET program do not include any AFDC recipients who obtain jobs on their own without registering for ET. Others question why the AFDC caseload has not continued to decline in recent months. In answer, the DPU had already warned that the caseload might very well level off and increase because of 1) the enrollment of an estimated 1000 pregnant women newly eligible for AFDC due to an extension of benefits throughout pregnancy and 2) the increase in the number of mothers of children who have never been married, who have fewer work skills and may require longer ET placement efforts to assist them in obtaining jobs. Most evaluations to date are in full agreement that the goals of the program are correct, the support services are critical to its success, and that ET should be continued with the goal of placing more recipients in jobs at higher wages so that they can become self-supporting. II. REGISTRATION FOR ET All recipients of public assistance must register for and participate in ET unless they have been determined to be exempt as follows: o a person under 16 years of age, - 72 - o a person 16-19 attending full-time secondary school or vocational training not provided through a college, o a person 65 years of age or older, o a person physically or mentally incapacitated for 30 days or more, o a person temporarily ill for less than 30 days, o a caretaker required at home for an impaired household member, ■ o a parent of a child under six years providing full-time care except for certain designated absences from the child (such as Head Start), a parent attending a full-time educational program or working while the child is in day care, o a parent if there is another parent in the home already working or registered for ET, o a person working in part-time employment of designated hours and weeks* o a person who would have to travel in excess of 2 hours to the nearest ET site, exclusive of time necessary to take the child to school or child care site, OR, o a pregnant woman. Verifications of the above exemptions are required, including written statements from physicians, school authorities, etc. Participation is mandatory for all two-parent families and mothers of teenage children. Clients who do not respond to a first notice for interviews are recontacted with a special "marketing" approach. Prior to the passage of the FY '87 budget, pregnant and parenting teens living with parents whose income exceeded AFDC limits were ineligible for ET services. However, the Caucus, working closely with advocates, was successful in extending ET eligibility to this group of teen parents. The Administration has since promulgated regulations, which will go into effect November 1. - 73 - III. PARTICIPATION IN ET The initial step is for the ET participant to meet with an ET worker to develop an individualized "employment plan." These meetings take place in all of the 60 welfare offices statewide and offer the following options: 1) Appraisal : The ET worker determines the recipient's financial situation, his/her educational and employment background, need for support services (day care and transportation), and then reviews the various "choices" available to the recipient. 2) Employment Plan : This plan is drawn up cooperatively by the worker and the recipient, who then is permitted to pursue only those choices consistent with the "Employment Plan" as specified. The plan sets goals, timetables and specific possible ET programs and support services necessary to help the client fulfill the goals. The participant must be given a copy of the plan and may ask for a "Career Assessment" before signing it. 3) Career Assessment : This a free counseling session held with a trained professional who has contracted with the DPW to provide this service. Every recipient should be urged to take advantage of this service which can offer additional guidance. If the counselor is skilled and independent of the DPW, this session can help resolve any problems that may arise if the recipient and the worker disagree on the Employment Plan. 4) Educational Programs : a) Basic Education participants are among the least job ready. However, in the first program review, of those who had worked in - 74 - the first 20 months of ET, the average wages were $5.25 an hour, 44% had been on AFDC 5 years or more, and 64% were-non white. Adult literacy and English as a Second Language are important components of this section; b) Advanced Education participants are those with educational skills but few vocational skills. As a group, they have been found to be less likely to have had recent work experience. 5) Supported Work ; This is designed for those with little or no work experience (to date 83% have high school diplomas). In this program, the state contracts with non-profit agencies to place participants in supervised paid jobs. Most of the participants do not receive any cash assistance as long as they are in this placement if their pay exceeds 185% of the welfare limit . There is no guarantee that a permanent job can result even though the participant's job performance is satisfactory. This can present problems if the employer decides not to keep the participant. 6) Skills Training ; This component is available both through the Job Training Partnership Act (JTPA), Bay State Skills Corporation (BSSC), and other contracted programs. Ninety percent of the recipients placed in this category have worked before, and over 50% have held jobs recently. Those in the non-JTPA programs, however, were less likely to have worked before and have been on welfare longer. 7) Division of Employment Security (PES) Individual and Group Job Search ; Thirty-five percent of all those placed during the first 20 months of ET were placed through the DES Individual Job Search program - 75 - and 11% through the Group Job Search. This program Is operated by the DES under an interagency performance contract with the DPW. After initial meetings with a DES counselor, participants are expected to look for work independently using the Job Bank , the DES listing of available jobs. The DPW acknowledges that, in the first 20 months of ET, the participants were somewhat more job ready than the rest of the AFDC recipients. A greater proportion (87%) had had previous work experience than the AFDC population as a whole (73%). One group, the AFDC - Unemployed Parents clients, were mainly men with previous work employment; and they benefited in a relatively short time. Other findings in the DPW's own evalulation which have bearing on predictions of long-range effects for assisting AFDC mothers to become self supporting include: 1) Long-term clients and minorities have had as much, or even more, success in finding jobs as other participants, although minority wages were lower. Recent data indicate that the wage gap between minorities and whites is closing. 2) More than 3/4 of the ET placements were full time with an average hourly wage of $5.11. 3) The latest data on ET from July 1, 1985 to April 1, 1986 shows average wages of $5.33 (See Appendix G) . 4) The average monthly grant savings for a job obtained through ET is $219. The DPW estimates that this translates into a savings of $67 million in recipient grant reductions and case closings in the first 20 - 76 - months. With additional savings from Food Stamps, Medicaid, and with State/Federal tax revenue, the total net savings amounts to $107 million. IV. SUPPORT SERVICES FOR ET The most important key, perhaps, to ET's success is the provision of support services to the large number of AFDC mothers. Since the inception of the WIN program in 1967, AFDC mothers have demonstrated their eagerness to work but have lacked adequate child care and transportation. If they did find a job, they quickly discovered that the costs of these services plus the loss of Medicaid and reduction in Food Stamps led to a net overall loss in take-home pay, leaving them with less money than they had in the grant. Very rarely was there any possibility of getting health insurance coverage to replace Medicaid. The services offered to ET participants include: 1) Voucher day care: The ET Choices program has contracted with the Department of Social Services to admininster day care vouchers which are good for up to 12 months after the AFDC case is closed due to the ET participant becoming employed. The voucher covers the cost of day care on a sliding scale with the participant paying from $2-$5 per week per child. Babysitting or "neighborhood care" is also available for 1-4 months at $1.00 an hour if no licensed child care is available with the voucher. The cost of operating and providing the voucher child care program for approximately 5,250 children was estimated to total $18,000,0000 during FY '86, according to DPW's budget narrative for FY •87; - 77 - 2) Medicaid coverage is available for A months after employment begins if the wages cause the recipients to be over-income for AFDOMedicaid eligibility, and there is no job-related health coverage: 3) If the recipients are still on a partial AFDC grant because of low wages, they will receive the deduction of $30 per month plus 1/3 of the wages and be provided with Medicaid for A months (if no health coverage is available through the employer). At the end of A months, when they lose the 1/3 deduction, they can still receive the Medicaid coverage for 15 months if they are otherwise below the 185% cut-off for income; A) Transportation costs are available to all participants for up to $10 a day. 1. PROBLEM: The Average Wage Level ; For full-time ET placements in the most recent data, the average wage is $5.16 an hour. This amount is not sufficient to enable an AFDC family to become self-supporting. The DPW is well aware of the problem of low wages and the dilemma of having to continue to subsidize support services for most of the ET placements. The DPW claims that 75% of ET participants have been placed in full-time employment at starting salaries of $10,000. It ignores that, for a family of four, this amount is $1,000 below the Poverty Income Guidelines. An analysis of the budget of a working mother with two children in 198A on a $9,000 income done by the Massachusetts Human Services Coalition shows that her expenses leave her over $150 in the red every month. According to the recent evaluation by the DPW's research - 78 - division, full-time placements through DES are doing somewhat better with an average hourly pay of $5.30. For JTPA placed jobs, it is $5.52; and for BSSC the hourly average pay is up to $6.25. RECOMMENDATION : a) Federal Level: i) Raise the minimum wage (which was last increased nationally five years ago) to a level which would allow a full-time worker to earn at least the federal poverty level; and review this figure annually, adjusting it to correspond to, at a minimum, increases in the Consumer Price Index, ii) Provide tax incentives to businesses to participate more broadly in on-site or other employer supported day care and. employee health coverage in order to address the loss of benefits, day care and health coverage at the federal level, iii) Increase the ceiling on Medicaid to 185% of the Standard of Need (as opposed to the 133.3% currently allowed) to enable lower income workers to keep this coverage (see Medicaid recommendations), iv) Return to the pre-OBRA regulations permitting AFDC recipients to continue to deduct the $30 and 1/3 of their wages until their net income exceeds the value of their grant (also, see section on "Uork Disincentives" in the AFDC chapter), v) Provide a payment standard which is, at a minimum, 100% of the federal poverty level; and provide a need standard which is, at a minimum, 25% above the poverty level (see AFDC recommendations). b) State Level ; i) Encourage DPtf to keep its commitment to hold ET contractors accountable for increasing wage levels and to provide them with incentives to place clients in higher paying jobs, ii) Increase line items 4407-1000 and 4407-1010 for educational programs and - 79 - training, iii) Establish a floor on wages for ET participants, iv) Support DPW's efforts to provide assistance to those placed in jobs to help meet health insurance costs and "deductibles." (In their FY '87 budget request PPW proposed a new program of health coverage for ET graduates whose jobs do not include medical benefits. Called "FT Health Choices," this item was not approved by the Legislature.) Additionally, support the passage of H.4916 which would extend Medicaid benefits for one year after a recipient enters employment (See Medicaid - Section B). 2. PPOBLEM : Minority Participants are Underrepresented, and Their Wages are Lower ; Thirty-six percent of the AFDC caseload are minorities, but only 28% of the ET participants are. They are also underrepresented in placements, and their wages are lower. Recent data documents improvement in placements: for Blacks, from 12.3% to 16.8%, and for Hispanics from 15.4% to 16.8%. Wages have also risen by 7% and 16% respectively. RECOMMENDATION ; Increase the outreach to minorities, increase access to basic education and adult literacy and put more emphasis on appropriate and thorough career appraisals. Some of this will require additional funding (DPW 4407-1000); some will require improved training of staff as well as monitoring of contractors. 3. PROBLEM ; A Shortage of Voucher Day Care, and Low Wages for Neighborhood Day Care Providers : Efforts to increase the number of day care vouchers have been well publicized. Current estimates by DPW predict a shortfall of approximately $6. 5- 7m in the Voucher Day Care account (4400-1009) for FY '87 due to increased enrollment in the ET - 80 - program. Recipients are required to use these vouchers only in licensed child care centers, but the reimbursement rate to the centers is not keeping up with the rising fees the centers must charge. The alternative, the rate for local unlicensed neighborhood care or babysitting, is so low as to be almost useless. RECOMMENDATIONS : i) Efforts must be stepped up to increase the number of licensed child care providers, ii) The rate of reimbursement for vouchers must be raised, iii) Additional funding for the voucher day care account must be made available to cover the projected deficiency. 4. PROBLEM : FY '87 Funding for ET ; Recent federal cutbacks in funding for WIN and JTPA (Job Training Partnership Act) programs, along with level funding in the state's FY '87 budget, have left DPW with less money than anticipated for the current year's ET program. This deficiency has effected new initiatives targeted at pregnant and parenting teens, adults in need of literacy services, displaced homemakers, and others. Without additional monies for FY '87, these programs will not be implemented. RECOMMENDATION t Support efforts to provide additional funding for the ET program (line item 4407-1000) for FY '87. 5. Additional Recommendations to Improve ET Eligibility and Insure Continued Employment for Those Placed : a) Provide ET allowances for books and supplies (in part made necessary to offset reductions in Food Stamps because of educational loans). In addition, such financial aid should be disregarded in determining eligibility for transportation allowances. - 81 - b) Expand higher education opportunities through both the ET Employment Plans drawn up for recipients and increased scholarship aid for part-time students. c) Provide for ET coverage of a parent or child to continue until completion of the job placement or graduation in those cases where a family loses AFDC eligibility because of a child turning 18. PART FIVE A SPECIAL PEPOPT ON HOUSING 'Almost every day someone comes into the church and talks about being evicted, often after 10-20 years in the same place." (community worker in East Boston) 83 - I. INTPOPUCTION Few would argue that the housing crisis falls heaviest on the low-income working poor and those on public assistance. For single women with one or more children, the scarcity of affordable rental housing can become a nightmare in which the vision of having to place their children in foster care or enter a shelter is all too real. For low-income families, finding rental housing may mean facing the exhausting job alone of: 1^ searching want ads and following up every lead day and night; 2) applying for rental certificates and grappling with the administrative red tape of providing documentation of income eligibility if the family needs financial assistance; 3) getting one's name on several waiting lists; 4) approaching prospective landlords with one or more children in tow; and then 5) trying to find an apartment which, for those with rental certificates, meets regulations for sanitary codes, number of bedrooms and rent ceiling, to say nothing of location, transportation access and/or proximity to day care and job site if the mother is working. Discrimination is widespread against single women, especially those of color, those with children, and those on public assistance. Pregnant and/or parenting teens needing their own housing most often find this intolerance extends to their age. Lastly, if the mother is on public assistance and is unable to get a rent certificate or use it, her chances of finding an apartment which won't take over 75% of her monthly allowance is about as good as winning the "Instant Game." Massachusetts already has an impressive three years of trying to play catch-up with a housing shortage that became a hidden time bomb in the - 84 - late 70' s and early 80' s when the federal cutbacks collided with the baby boom, an Increasing divorce rate and postponement of marriage. Condo conversions and loss of single-room occupancy units also were major contributors to the housing shortage for low-income tenants. The state responded first in 1983 by declaring homelessness the number one priority and passing "The Act to Prevent Homelessness," Chapter 450. This act increased assistance to homeless and potentially homeless individuals and families by expanding eligibility for General Relief and increasing financial assistance for rent emergencies and emergency shelter. In addition, the legislature passed the "Act to Control Condo Conversions" which provided a one-year notification period before conversions could take place and which could be extended to two years for low-income, elderly and the handicapped. To address the supply problem, Massachusetts passed two major bond and public housing programs in 1983 and 1985, and the legislature is currently working on a third series of housing bills. Still, with the latest shortfall in new housing estimated to be 72,000 units, and with 250,000 families across the state currently in need of affordable low-income housing, immediate as well as long-term measures are desperately needed to address what clearly is the worst housing crisis since the end of World War II. II. THE EXTENT OF THE HOUSING CRISIS Housing production in Massachusetts has fallen 72,000 units behind the need in the last five years. In the spring of 1986, vacancy rates in - 85 - rental housing were at an all time low, with less than 1% in Boston, 1.17. in Barnstable, 1.5% in Springfield, and 0% in Burlington,. In addition: 1) More than 10,000 families/individuals were homeless in Massachusetts last year, with female-headed households the fastest growing segment. 2) 242,659 families (17%) and 109,872 (15%) elderly either pay more than 25% of their income for rent, live in substandard housing, or live in overcrowded housing. 3) 63% of families on AFDC pay 75% of their income in rent. 4) Emergency Assistance provided to low income families has risen from $7.5 million in FY '83 to $34 million in FY '86, due to expanded coverage for low income families struggling with increased housing costs, evictions and gentrif ication. The need for "Affordable Housing" is acute across the. state. It can mean different styles according to a family's income and location needs. Economists define affordable housing as that costing 25% of one's income while the federal government continues to use 30%, which leaves proportionately less for other living expenses: 1) In 1970, low-income households ($3000-$ 7000 income) were paying 25% of their income for rent. Today, such households pay 75% of their income for rent; 2) For the poorest families (eg. a family of three on AFDC who receives $5,712 annually) even 10% of one's income will not leave enough for food, utilities and other expenses. Affordable housing is extremely scarce for low-income families in all- urban areas for a number of different reasons, among which the following are major factors: 1) Arson, abandonment, demolition, condominium conversions, and reduction of new public housing construction have seriously depleted the supply: a) between 1980-1984, 12,462 units were converted to condominiums for investment interests, - 86 - b) 6,500 rooming house units were lost to "higher economic usage" in the last 20 years, c) 4,000 units have been lost due to arson and abandonment, d) the major builder of public housing, the federal government, has decreased its input of low-income housing nationally from 15,300 units in 1979 to A, 800 in 1985. 2) New construction has not kept pace with the need In Massachusetts (figures from EOCD) : 1980-1985 Per Year Units needed: 210,000 35,000 Units built: 137,000 22,900 (all price ranges) Shortfall: 72,600 12,100 3) A shortage of available land specifically for low-income housing. 4) Changes In family patterns have increased the demand for housing: a) an increased number of elderly live alone, b) increases in divorce and separation produces many more single-headed households, c) "baby boom generation" (ages 25-40) now house hunting, d) in Boston, the population has increased from 563,000 to 621,000 in the last five years. 5) The percentage of housing units in Boston renting for less than $300/month declined from 13? to 2% between 1982 and 1984. - Pents statewide are rising at an annual rate of 30-46%. 6) The average monthly rent for a 2-bedroom apartment in 1986: At 30% of income, Pent would require : Boston. . . . . $863 $34,520 annually Springfield $463 18,520 Barnstable $569 22,760 Lawrence-Haverhill $803 32,170 Pittsfield $441 17,640 III. HOUSING OPTIONS FOP AFPC/LOT-7 INCOME FAMILIES Rental assistance is an option for only 30% of families because of the shortage of certificates and discrimination experienced by many - 87 - families trying to use them. To get a certificate, families must put their names on waiting lists for either or both federal and state public housing units and put their names on a separate list for the federal and state rent certificates. The table below indicates the limitation of this type of housing. It lists the total number of public housing units in Greater Boston cities for the fall of 1985, the number of certificates available for use in the open housing market and the number on the waiting lists in the beginning of 1986. For example, the cities noted below showed : # Certificates # People on # Units Available Waiting Lists Boston 13,000 5,000 18,042 Maiden 1,372 513 1,389 Quincy 1,561 738 2,906 Walt ham 779 517 807 The FY '87 budget included additional rental certificates (see Section VII, #3). For those without rent certificates, or who are unable to find housing with one, the following options exist: 1) Find an apartment in the private market, paying far more than 25-30% of their income for rent. - 63% of AFDC families pay 75% of their income for rent. 2) Double up with family or friends. This creates over-crowding, stress and high risk for eviction by landlords or because of violation of local housing codes. - 64% of families on AFDC who required hotel/motel housing were homeless because of overcrowding or the inability to meet rent payment s . 3) Live in abandoned housing. 4) Live in a transitional family shelter if room is available. 5) Be placed in a hotel/motel unit: 334 families were in hotels/moLels in January 1986. 6) Become actually homeless - live in a car or on the street. - 88 - IV. THE DIFFERENCE BETWEEN PUBLIC HOUSING, SUBSIDIZED HOUSING AND RENT CERTIFICATES o Public Housing can be either federally or state funded, but it is owned and operated by a "Local Housing Authority" (LHA) . Included are Veteran's Housing (occupied by many non-veterans), family, elderly, handicapped and scattered site housing. o Subsidized Housing is privately owned mixed-income housing which has been built with low-cost loans through either federal or state programs and which allow some units to rent at below market rates. Examples include the federal Section 236 and Section 221(d)3 programs and Massachusetts Housing Finance Agency projects. Some units in these projects often also have "deep subsidies" allowing qualified tenants to pay 25-30% of their income for rent. o Rent Certificates are designed to supplement public housing programs by providing subsidies to low-income families for private market rentals. Only units which comply with stringent "Fair Market Rent" ceilings set by either the state or federal government and meeting code and family size standards are eligible for rent certificates. These programs include the federal Section 8 Existing Housing program and the state Chapter 707 program. V. ELIGIBILITY FOR HOUSING ASSISTANCE A. Income and assets o The income and assets of a family (or individual) must be - 89 - below a ceiling set for the particular program, geographical area and family size for entry into the housing unit, o For the federal programs, the income ceiling is 50% of the area's median income; for the state, the ceiling is 80% of the area median income, o Examples for two selected sites for a FAMILY OF THREE: Program Federal Public Housing or Section 8 Certificates Income Ceiling for entry: Income at which tenant loses subsidy: Fair Market Rent ceiling: (2 BR, family of three) % of income tenant pays: Boston Springfield $15,300/yr $26,800/yr $670/month $12,350/yr $18,400/yr $460/month 30% State Public Housing or Chapter 707 Rent Certificates Income Ceiling for entry: Income at which tenant loses subsidy: Maximum Allowable Rent ceiling: (2 BR, family of three) $18,612/yr $30,192/yr $629/month $15,552/yr $22,896/yr $477/month % of income tenant pays: 25% 25% - 90 - B. HOW THE SUBSIDIES WOFK o IN PUBLIC HOUSING, the family pays its portion of the rent directly to the Local Housing Authority, and the, LHA subsidizes the rest with federal or state funds. For rent certificates, the tenant pays his/her portion of the rent to the landlord; and the LHA pays the balance to the landlord. o If the family income increases, the portion paid increases until the 25% or 30% subsidy equals the gross rent charged for the unit. At this point, in federal public housing, the family has a one year grace period to find other housing. However, the family may not be denied a lease renewal based on income unless the LHA has identified a similar rental unit at the same rent or it is required by local law to proceed with eviction. In a private rental, the family may remain, paying full rent if the landlord agrees. The certificate is released for someone else. o If the tenant has to pay for part or all of the utilities, an allowance is made according to LHA guidelines. o IN PUBLIC HOUSING, when a family meets the criteria below (lowest waiting list number, priority guidelines, size of family), the family is shown the vacant unit. If they are unwilling to accept the unit, they must reapply for and go to the bottom of the waiting list. o WITH RENT CEPTIFICATES , the family meeting the criteria below looks for an apartment under the following restrictions: - 91 - a) The certificate is good for 60 days, with two 30-day extensions; but it must then be turned back to the LHA if no apartment is found; b) Most certificates are restricted to the city/town covered by the LHA or a specific regional area; c) The unit must be the size designated for the number in the family; d) The rent cannot exceed the fair market rent (FMF) for the area for the specified number of bedrooms; e) The LHA must inspect and approve the unit for rent, size and sanitary code: f) The landlord must agree to accept Section 8 or Chapter 707 funding; g) If the certificate is returned, the family must sign up again for the waiting list. C. PRIORITY AND /OP PPFFERENCE ON WAITING LISTS Federally subsidized units have two emergency priorities: national disaster and a government action (which is defined under federal rules). Homelessness can qualify for emergency placement at the option of the LHA with HUD approval. State subsidized units will have new tenant selection emergency priority regulations in early December: 1. homelessness due to natural forces (fire, flood, etc.), 2. homelessness due to public action (slum clearance, urban development, etc. N , 3. homelessness due to public action, i.e., code violations, 4. emergency cases, as established by the LHA (they must define and include: homelessness as a result of economic forces, abuse, and medical emergency), - 92 - 5. transfer for good cause (from one public housing unit to another). Preference categories are also established for state-subsidized housing: - local veteran, - non-local veteran, - local resident, - other applicants. If the LHA has an affirmative action plan, minority applicants receive preference according to the guidelines for affirmative action set by the specific LHA. When a public housing unit or certificate becomes available, it goes to the appropriate size family with the lowest waiting list number and preference rating. (Any "barrier^free" unit is offered to any handicapped person qualifying for such a unit.) 1. PROBLEM : There is a Shortage of Public Housing in the State : a) There are 81,436 federal and state funded public housing units in Massachusetts (some of which are presently uninhabitable) . b) Much of the federal public housing is 30-40 years old, no longer meets sanitary codes (outdated electric and plumbing systems), needs major repairs and/or is vacant. - in Boston in 7/85: 13,000 units were habitable, 2,079 units were vacant and 38% of the occupied family units did not meet sanitary codes. c) Only 30% of all AFDC families in Massachusetts live in subsidized housing. For Boston, this percentage is 23%. - 93 - Lists: PROBLEM : AFDC Families Do Not Receive Preferences on Waiting a) AFDC families in need of financial assistance to secure housing are not automatically entered onto waiting lists. b) In August, 1985, 4,200 AFDC families were on the waiting list for Boston public housing. In the first 8 months of 1985, only 170 AFDC families moved into public housing. At this rate, it would take 17 years to place all the families on that list in public housing - not to mention future applicants. c) No preference is given to applicants according to the size of their income, although AFDC families are at the lowest end of the income scale of eligible applicants. d) Finally, federal guidelines for public housing have promoted specific tenant selection patterns for the purpose of encouraging a broad range of income and avoiding a concentration of low-income and "deprived families with serious social problems." While this goal may be acceptable when housing supplies are adequate, the current shortage of housing units for low-income families must be the determining factor in who should have access to public housing. 3. PROBLEM : There Are Not Enough Rental Certificates to Meet the Demand . There were approximately 38,000 Section 8 federal rent certificates and 8,500 "707" state rent certificates as of 12/85. However, due to the fact that these certificates are only valid below the specified rent ceiling (or Fair Market Rent), AFDC recipients and all others eligible to receive them have great difficulty in using them: - 94 - a) Rental certificates are being returned to the Local Housing Authorities at the rate of 75% to 80% because rental housing cannot be found, b) In Boston, prior to the July 1986 increases in the present Fair Market Rents, only 1.8% of the available rental units fell within this ceiling. RECOMMENDATIONS: IMMEDIATE AND SHORT-TERM STEPS : 1. Prevent Further Loss of Housing for Low-Income Families : a) Strenghten regulations relating to condo conversion. b) Provide loans for low-income tenants to buy apartment houses cooperatively (to prevent further outside investment buyers). c) Increase subsidies to rehabilitate current housing stock. d) Provide mortgage subsidies to enable renters to buy homes. e) Address the lead paint problem more aggressively to meet code. f) Expand EOCD's budget to increase its capability to oversee housing programs and work with LHA's. 2. Improve Access to Current Housing Stock and Stabilize Occupancy : a) Increase AFDC/GR allowances so recipients have more money to meet the cost of housing. b) Simplify procedures for getting onto waiting lists and update them regularly. c) Increase the number of certificates and funding for the Chapter 707 program. d) Raise the Maximum Allowable Rent ceiling for 707 certificates. - 95 - e) Increase EOCD's program for outreach to educate landlords on 707's. f) Increase efforts by MCAD to prevent discrimination in all areas with documented housing shortages. 3. Improve Services to Families Facing Housing Problems ; a) DPTf should develop a program to review housing needs for incoming AFDC families, using trained housing specialists. (Homeless families now receive similar assistance.) b> Assist Emergency Assistance recipients with a similar program. c) Provide day care and transportation for families facing emergency housing searches. d) Continue, expanding as needed, the Housing Services Program which EOCD provides jointly with DPW to give tenants assistance in mediating disputes with landlords as well as counseling on budgeting and tenants' rights. e) Encourage, with contracts if required, the work of Legal Services and community advocacy agencies which provide support and legal representation in landlord/tenant disputes and eviction proceedings. FECOMMENPATIONS : LONG-TEPM MEASUPES TO INCREASE THE HOUSING SUPPLY : 1. Support current as well as future bills and budget requests to increase housing construction targeted for low- and mode rate- income housing as well as innovative programs such as the Housing Trust Fund - 96 - (Senate Bill No. 1648, 1986), transitional housing, and SRO's (Single Room Occupancy) . 2. Increase the ratio of low-income units in both the SHARP and TELLER programs to 50%. (Currently it is 25% for SHARP and 20% for TELLER.) 3. Increase the number of units planned for Chapter 705 Public Housing. 4. Provide money to assist low-income tenants in buying foreclosed and distressed properties. 5. In rural areas, assist mobile home owners on leased land to purchase the land, preventing its sale to developers for other purposes. 6. Become familiar with advocates' project to petition the General Court to pass a Const itutuional Amendment which states that all citizens have, among other rights, the right "... .of occupying habitable and affordable non-transient housing. ..." (Further information can be obtained by contacting the Massachusetts Right to Housing Project at 523-6400.) VI. WHAT THE FEDERAL GOVERNMENT IS NOT DOING TO ADDRESS THE HOUSING CRISIS The new tax reform law will have a major impact on developers as they will no longer be able to sell tax benefits to raise equity. While there is still a very minor tax credit for low income housing, tax accountants feel it is basically unworkable. Massachusetts was, however, able to retain credits for previously agreed to MHFA-backed mortgages and SHARP loans. The future for all housing (new construction, rehabilitation, etc.) appears to be poor. - 97 - The federal government, once the major source of public housing funds, is pulling out of the public housing business. Funding for all HUD Assisted Housing Programs has been reduced by $1.8 billion, down from $9.3 in FY f 86 to $7.5 in FY '87. In 1983, a voucher program was initiated, similar to Sec. 8, but for current housing stock only. Vouchers have only a five year commitment, unlike Sec. 8 which has a 15-20 year commitment. They also can be used for units which exceed the Fair Market Rent, although they only cover up to 30% of an individual's adjusted income. The President attempted to eliminate all Sec. 8's for FY '87, replacing it with a total of 50,000 vouchers nationwide. Fortunately, Congress was able to block this from happening. The FY '87 HUD budget: 1) Increases vouchers by 15,548 units (up from 34,452 in FY '86 to 50,000 in FY '87) to be used only with current housing stock; 2) Sec. 8 existing housing stock program is decreased by 20,624 units (from 30,624 in FY '86 to 10,000 in FY '87); 3) Also decreased is the Sec. 8 moderate rehab, program, down 2,070 units (from 9,570 in FY '86 to 7,500 in FY '87). In total, the FY '87 HUD budget for assisted housing (including elderly housing not noted above) is down by 6,630 units (from 86,130 in FY '86 to 79,500 in FY '87). VII. WHAT THE STATE IS DOING TO INCREASE SUPPLY 1) The Housing Bill of 1983 provided for the following units now beginning to come into the market: - 98 - - 2600 low-income units, - 3380 mixed-income units, 25-30% to be low-income, - 3500 "707" rental certificates, - A800 moderate-income mortgage units, - 400 units for mentally retarded as part of the consent decree. 2) The 1985 Housing Bill included: - 1400 units of scattered site housing ($101 million), - 800 units for special need population ($30.3 million), - $91.5 million for renovation of existing state-assisted housing, - $35 million for renovation of federally-assisted housing, - $20 million for Community Development Action Grants to promote home ownership opportunities. 3) The FY '87 budget provides for: 1) $15/month rent supplement for AFDC and GR recipients not in public or subsidized housing; 2) 1200 emergency rental certificates (707's) primarily for AFDC recipients housed in hotels/motels; 3) At least 2,250 new rental certificates (707's) for AFDC recipients receiving Emergency Assistance; 4) $22 million ceiling for the SHARP (State Housing Assistance for Rental Production) program, with priority for projects that: a) set aside more than 25% of their units for low-income families; b) have the greatest number of three or more bedroom units; c) are located in economically distressed areas. - 99 - 5) $8.5 million for funding the MA Housing Partnership Fund (1985 housing bill); 6) $1.09 million for the Abandoned Housing program, including $275,000 for an anti-arson program; 7) Funding for joint efforts between the Executive Office of Communities and Development and the Department of Social Services to develop transitional housing programs for special populations (such as the homeless, teen oarents, battered women, and older adolescents). These programs will include social services as well as employment and training services. A family or individual's stay in such a program will last anywhere from 6-24 months, depending upon need. 4. There are currently two major housing initiatives before the Legislature: a) Senate Bill No. 2144 - Housing Production and Services Package : This bill includes state funding, raised through bonds, for: - Chapter 705 Family Housing $100m - Renovations for federal housing owned by LHA's $75m - Removal of asbestos in housing projects $10m - Child care facilities at LHA developments $4m - Disposition of federal housing owned by LHA's $5m - Housing Innovations Fund for alternative forms of housing 5 10m - 100 - An Urban Development Action Grant program will also be provided by this legislation, funded at $60 million. And $5 million will be targeted for a cooperative housing program through the Massachusetts Landbank . b) House Bill No. 6420 - Homeownership Opportunity Program : This is a supplemental appropriation for FY '86, requesting $45 million for EOCD's Homeownership Program which would provide for low interest rate mortgages so families earning below $30,000 could afford to buy a home. Poverty Appendix A Percentage of Children in Poverty, by Family Structure and Race, 1959-1984 Family Type Hispanic Black White Total Female-headed Families 1959 1969 1979 1980 1981 1982 1983 1984 Z change 1959-1979 Z change 1979-1984 n/a 81.6 64.6 72.2 n/a 68.2 45.2 54.4 62.2 63.1 38.6 48.6 65.0 64.8 41.6 50.8 67.3 67.7 42.8 52.3 71.8 70.7 46.5 56.0 70.6 68.3 47.2 55.5 71.0 66.2 45.9 54.0 -22.7 -40.2 -32.7 14.1 +4.9 +18.9 +11.1 All Other Families 1950 1969 1979 1980 1981 1982 1983 1984 n/a 60.6 17.4 22.4 n/a 25.0 6.7 8.6 19.2 18.7 7.3 8.5 22.9 20.3 9.0 10.4 24.5 23.4 10.0 11.6 27.8 24.1 11.6 13.0 27.2 23.7 12.0 13.5 27.5 24.3 11.0 12.5 % change 1959-1979 Z change 1979-1984 +43.2 -69.1 +29.9 -58.0 +50.7 62.1 +47.1 All Families Combined 1959 1969 1979 1980 1981 1982 1983 1984 Z change, 1959-1979 Z change, 1979-1984 n/a 65.5 20.6 26.9 n/a 39.6 9.7 13.8 27.7 40.8 11.4 16.0 33.0 42.1 13.4 17.9 35.4 44.9 14.7 19.5 38.9 47.3 16.5 21.3 37.7 46.2 17.0 21.8 38.7 46.2 16.1 21.0 __ _ -37.7 -44.7 -40.5 39.7 +13.2 +41.2 +31.3 Source: National Center for Health Statistics. CHILDREN'S DEFENSE FUND Earnings Percent of Workers Paid on an Hourly Basis Earning the Minimum Wage or Less in 1979 and 1984, and the Percent in 1984 Earning Less Than $4.00, the Inflation-Adjusted Value of the 1979 Minimum Wage of $2.90 per Hour Race, 1979 1984 1984 Sex, $2.90 $3.35 Under & Age or Less or Less $4.00 Group Hourly Hourlv Hourlv Total 13.3 11.0 21.1 Male 7.7 7.5 14.3 Female 20.2 14.8 28.4 White 12.8 10.7 20.5 Black 16.9 13.5 24.7 Age 16-19 37,3 38.5 65.3 Male 29.5 32.9 58.1 Female 45.9 44.1 72.5 White 36.3 37.6 64.9 Black 48.7 50.1 70.3 Age 20-24 13.7 14.3 28.5 Male 8.3 10.6 21.6 Female 20.6 18.7 36.5 White 12.9 13.6 27.1 Black 19.2 20.6 38.9 Age 25-up 8.4 6.2 12.8 Male 3.3 3.1 6.2 Female 14.6 9.5 19.8 White 7.7 5.7 11.9 Black 12.8 9.0 17.9 Appendix B Children's Defense fund Appawdlx C Poverty Rates for Men and Women Over Age 45 in 1984 Poverty Rate (%) 15 H Women 10 5 Men • 1 1 | i 45-54 55-59 60-64 65+ Age Group Source: Census Bureau. P-60. No. 149. Earnings of Year Round Full-Time Workers in 1984 Dollars (Thousands) 30 25 20 15 10 I- 5 - 25-34 ± J. 35-44 45-54 Age Group Source Census Bureau, Unpublished Data. Current Population Survey. March 1965 Men Women 55-64 65< Appendix V z o 2. cr-o 5 o Failure to Appear In Court o §o — a> 3 W C » a a t 0> O O c < O " o » g» 2 » 3 S w » > -n 5* o si z2 "§|c 3. 5 = «» 2.*< > <: S c | 5 3 << > a- M o 3 ■o 3 O o & O c S 3 > ■n O o o at o O o 3 O — e> 3 £ c • n a Z o O c w < o ■ c a» n "=• 5 a 2 a. 3 5" 3 . s > 3 2" 2i — o » ■ 2 M 3 3 o t» - «? Parent Dead acltated, or ■rcerated o X F D (/> C "0 "D o m z n 3} O m m z H m 5otM.ce: CPW Budget Request W 87 INCOME/PAYMENT STANDARDS ****>** Effective 7/1/86 It AFDC/RRP/GET % V (t ASSISTANCE UNIT ELIGIBILITY NEED/PAYMENT SIZE STANDARD $57535 STANDARD 1 $311 2 72850 394 3 880.60 476 4 1028.60 556 5 117845 637 6 1332.00 720 7 1481.85 801 8 163355 883 9 178155 963 10 193140 1044 INCREMENTAL 155.40 84 J *x ASSISTANCE UNIT SIZE 1 2 3 4 5 6 „ INCREMENTAL TABLE A $268.90 350.00 431.00 512.10 593.20 674.20 81.10 GR TABLE B $178.40 259.40 340.50 421.60 502.60 583.70 81.10 TABLE C $60.00 TABLED $82.10 163.20 244.20 325.30 406.40 473.20 81.10 r J NUMBER OF PERSONS T" 2 3 4 5 6 7 8 9 10 V* EACH ADDITIONAL PERSON MA INCOME STANDARDS $451 533 641 741 850 966 1075 1183 1291 1391 + 116 "\ MAPNA $60 J ?napaA:•:■:•:•¥•:• ¥:¥: : :¥v':x : : ; ¥:¥x¥:¥x¥: X;X;X;X;X;X; x¥;¥ : :X>:X¥: x¥:¥x¥:¥x. ■xx-xxx-x ¥:%¥:¥:¥:¥: 3,000 3000 2900 2100 *ar\r ) 1,500 1500 900 900 800 400 1 X;X>;X;XvX; 600 '•.'"••' •'■' PH| AFDC SSI-A SSI-D MA- MA- AFDC UN21 | | Average cost per case [~~j Median cost per case MA- OAA MA- DA Source.: VP6I Budge* Reijueii FV'«7 ET JOBS AND WAGES Appendix. G Distribution of Jobs 1% 3% 4o/o 5% 6% 6 0/0 7% 9o/o 12o/o 18 0/0 29% 100% Occupation Farming, Fishing, Forestry Transportation Processing Sales Machine Trades Construction Professional/Managerial Benchwork Packing/Handling Service Clerical Total/ average Average Hourly Wage $4.93 $6.39 $4.70 $4.91 $5.66 $6.92 $7.22 $4.80 $4.62 $4.73 $5.30 $5.33 Data from Division of Employment Security Job Development and Placement Services only, July 1, 1985 through March 31, 1986. 5/86 - 108 - BIBLIOGRAPHY Two references are of particular note in the list below: The first is LITTLE MAX: Creating Maximum Benefits for Children, Elderly, Poor and "Disabled" People , published by the Massachusetts Poverty Law Center. It is a unique and valuable reference for anyone requiring a comprehensive and readable analysis of the many Intricate regulations covering all the programs available to the poor. The second reference is "The Budget Request FY '87 Narrative" released by the Department of Public Welfare on January 22, 1986. This 535 page report is much more than a list of fiscal line items requested for FY '87. It provides comprehensive background information and detailed explanations of problem areas plus proposed future initiatives on programs serving the poor. Included are a number of excellent charts and graphs. 1. Bane, Mary Jo, and Elwood, David, "Dynamics of Dependency: The Routes to Self Sufficiency", Urban Systems Research and Engineering, Inc., Cambridge, MA, June 1983. 2. Budgets for FY '87, including The Governor's Budget Recommendations, House and Senate Ways and Means, Ch. 206 of 1986, and The Poor People's Budget (Meredith Associates and the MA Poverty Law Center) . 3. Center for Budget and Policy Priorities, "Smaller Slices of the Pie: The Growing Economic Vulnerability of Poor and Moderate Income Americans", Washington, D.C., 1985. A. Corporation for Enterprise Development, "Investing the Poor Communities", Washington, D.C., 1985. 5. Danzinger, Shelden and Gottschalk, David, "Work, Poverty and the Working Poor", prepared for presentation to the Subcommittee of the U.S. House Committee on Government Operations, Dec. 12, 1985 6. Ford Foundation, "A Working Paper: Women, Children, and Poverty in in America", New York, New York, January 1985. 7. Harrington, Michael, New American Poverty , Penguin Books, 1984. 8. Interfaith Action for Economic Justice, "End Results: Impact of Federal Policies since 1980 on Low Income Americans", prepared by the Center for Budget and Policy Priorities, Washington, D.C., 1984. -109 - 9. Kluver, Jean, "ET: Workfare Under Another Name or a Stepping Stone to Self-Sufficiency? " American Friends Service Committee, Cambridge, MA, March 1985. 10. Maged, Gladys and Spriggs, Marshall T. , " Little Max: Creating Maximum Benefits for Children, Elderly, Poor and "Disabled" People , Massachusetts Poverty Law Center, Boston, MA, 1986. 11. Massachusetts Department of Public Welfare, Boston, MA, 1986 a) Budget Request FY '87 Narrative, January 22, 1986. b) "Facts About Welfare: Being Poor in Massachusetts", 1985. c) An Evalulation of the Massachusetts Employment and Training Choices Program, FY '84 - FY '85, prepared by the Office of Research, Planning and Evaluation, January, 1986. d) "Increasing Enrollment in Project Good Health: A Report to the Commissioner", prepared by the Office of Research, Planning and Evaluation, January 1985. 12. Massachusetts Human Services Coalition, "Up the Down Escalator: State and Federal Programs - the Impact on Families", 1982-1984, Boston, MA, 1985. 13. Massachusetts Law Reform Institute, Legislative analyses and Fact Sheets prepared by the staff for the 1985 and 1986 legislative sessions. 14. Mead, Lawrence, Beyond Entitlement: The Social Obligations of Citizenship , New York, Free Press, 1986. 15. Piven, Frances F. and Cloward, Richard A., Regulating the Poor , New York, Random House, 1972. 16. Sidel, Ruth, Women and Children Last: Plight of Poor Women in Affluent America , New York, Viking, 1985. 17. Statewide Advisory Council, MA Office for Children, "Growing Up Poor in Massachusetts: Children and the Poverty Gap", Boston, MA, 1986. 18. U.S. General Accounting Office, "An Evaluation of the 1981 AFDC Changes: Initial Analysis", Washington, D.C. 1984. 19. U.S. Buerau of Census, Current Population Reports and Data from the 1980 Census. 20. Source material for the special report on the housing crisis included interviews with officials from the U.S. Department of Housing and Urban Development, Massachusetts Executive Office of Communities and Development, Departments of Public Welfare and Social Services, studies by the Citizen's Housing and Planning Association, Massachusetts Association of Mental Health and the Boston Housing Authority, in addition to references above and numerous newspaper articles from the local press and the New York Times.