In Chapters IV and V of the report, we concluded that physical and mental health problems were a major employment barrier among TANF recipients, and that these problems are most prevalent among certain sub-groups of TANF recipients, specifically those who are older, divorced or separated, and
white. In this chapter, we supplement the health findings from the surveys with data on hospital emergency department (ED) visits and hospital discharges. We compare the rates of emergency department visits and hospitalizations of the TANF caseload in South Carolina to the overall population, both in general and for specific health conditions. We also examine whether the data on emergency department visits and hospitalizations are consistent with our survey findings in terms of the sub-groups of TANF recipients most likely to have health problems.
Since 1994, the South Carolina Budget and Control Board’s Office of Research and Statistics (ORS) has partnered with the South Carolina Department of Social Services (SCDSS) in a variety of data management activities as well as in building a statistical “data warehouse”. South Carolina state agencies and private healthcare providers submit data on a regular basis to ORS, which has linked service and eligibility records over time to create an extensive database. Access to aggregate data for research purposes is provided through permission from the individual contributing agencies. SCDSS and ORS have further enhanced the capabilit ies of the state data warehouse by linking hospital inpatient and emergency department records to TANF records as part of this study.
To compile the data on TANF recipients, ORS conducted a match of open TANF cases in June 2002 against automated hospital in-patient and emergency department billing records. This match included hospital emergency department visits and hospital discharges for all persons in the TANF benefit group for the 11-month period between May 2001 and March 2002. Information was obtained on specific diagnostic categories from the emergency department admissions data and from the inpatient hospital discharge data.
Findings on Hospital Emergency Department (ed) Visits
- TANF recipients had much higher rates of emergency department use than the general population.
During the study period, emergency department use was 3.7 times greater among TANF adults than among adults in the general population (Figure VII-1).44 Emergency department visits were also more common among TANF children than among children in the general population – the rate was about 1.6 times higher during the 11-month study period.
†Rates per 10,000 TANF cases and per 10,000 South Carolina population. Data for adults aged 18-64 and children aged 1-17 visiting between May 2001 and March 2002.
- The higher rate of emergency department use among both TANF adults and children was common across many diagnostic categories.
Appendix E Figure VII-a compares TANF adults with adults in the general population for the eight most common health problems in emergency department visits, and shows that TANF adults had much higher rates of emergency department use for these diagnostic categories. Appendix E Figure VII-b shows that the rates of emergency department use by TANF children for the seven most common health problems exceeded the rates for children in the general population.
- The higher rates of emergency department use among TANF recipients may reflect problems with health care access.
Use of emergency departments for routine health care is greater when families lack health care coverage or do not have access to a primary care physician. In addition, lack of a “medical home” may result in people waiting until their health problems worsen before seeking help from emergency room personnel. Although most TANF recipients in this study were enrolled in Medicaid (and all would qualify, since TANF clients are “categorically eligible”), they may have used the emergency department for routine health care in cases where access to a health care provider who accepted Medicaid clients was a problem.
- White TANF adults had the highest rates of emergency department (ED) use.
The ED use rate for white TANF adults was 5.5 times greater than for white adults in the general population (as reflected in Figure VII-2). Among non-whites, the ratio for TANF adults to persons in the general population was almost 2.3 to 1.
A similar overall pattern was found for white and non-white children. As indicated in Figure VII-3, the rate of ED use among white TANF children was almost 2.4 times higher than the rate among white children in the general population, and the rate for non-white children was about 1.2 times higher than for non-white children in the general population.
*Rates per 10,000 TANF cases and per 10,000 South Carolina population.
†Rates per 10,000 TANF cases and per 10,000 South Carolina population. Data for children aged 1-17 visiting the ED between May 2001 and March 2002
- The higher rate of emergency department use among white TANF recipients was particularly evident in visits for mental disorders.
Figure VII-4 compares rates of emergency department visits for mental disorders for white and non-white adults. The rate for white TANF recipients was 5.7 times greater than for white adults in the general population, while the rate for non-white TANF recipients was only 1.6 times greater than for non-whites in the general population.
†Rates per 10,000 TANF cases and per 10,000 South Carolina population. Data for adults aged 18-64 visiting the ED between May 2001 and March 2002.
- The findings on emergency department use provide further evidence that white TANF recipients may have different barriers than non-white recipients.
In Chapter IV of the report, it was shown that white TANF recipients in the survey sample had significantly higher rates of physical health problems and mental health problems than black recipients. White recipients were also much more likely to be caring for a sick or disabled child or other family member. The findings on emergency department use are consistent with this overall pattern. In combination, the findings suggest that health-related problems are a more significant reason why whites enroll in TANF than non-whites. The findings also lend support to the more general conclusion that employment barriers among the TANF population may vary significantly among different sub-groups.
44 For TANF recipients, rates of emergency department use were computed per 10,000 TANF cases. Rates of use for the general population were computed per 10,000 persons in the overall population. Separate analyses were conducted for adults aged 18-64 and for children aged 1-17.
Findings on Hospitalization
- Adult TANF recipients had over twice the hospitalization rate of the general population.
Figure VII-4 shows that the rate for white TANF adults was almost 2.6 times greater than the rate for the general white adult population. The rate for non-white TANF adults was 2.2 times greater than the rate for the overall non-white population. Much of the difference was due to birth complications – the rate of hospitalization for birth complications was 11 times higher for adult TANF recipients than for adults in the general population. Pregnancy and birth complications may cause unemployment and other financial problems, bringing clients to the TANF program. In addition, the rate of hospitalization for genitourinary diseases for adult TANF recipients was nearly twice that of the rate for adults in the general population.
Hospitalization rates for TANF children were much more similar to non-TANF children than were the rates for adults. Figure VII-5 shows that the differences among subgroups of children are much less than for adult hospitalizations. While the rate for white TANF children was 25% higher than the rate for non-white TANF children, the rate for non-white TANF children was actually lower than the rate for non-white children in the general population.
Compared to the other three subgroups shown in Figure VII-6, white TANF adults had a much higher rate of hospitalization for mental disorders. Whites and blacks in the general population had approximately the same rate, which was about one-fifth that of white TANF adults. The rate of hospitalization for black TANF adults was about one-third that of white TANF adults. These findings are consistent with the survey results presented in Chapter IV of the report, showing that white TANF recipients were much more likely than black TANF recipients to report mental health problems.
†Rates per 10,000 TANF cases and per 10,000 South Carolina population. Data for adults aged 18-64 discharged from hospitals between May 2001 and March 2002.
†Rates per 10,000 TANF cases and per 10,000 South Carolina population. Data for children aged 1-17 discharged from hospitals between May 2001 and March 2002.
†Rates per 10,000 TANF cases and per 10,000 South Carolina population. Data for adults aged 18-64 between May 2001 and March 2002.
Summary and Conclusions
The findings in this chapter suggest that many TANF recipients face special health challenges, in that they experience physical and mental health problems at higher rates than the general population, and may also experience higher rates of health emergencies. The higher rate of health problems among TANF recipients appears to involve a wide range of physical and mental health conditions and is not limited to problems associated with childbirth.
The findings also suggest that white TANF recipients have higher rates of physical and mental health problems than non-whites. In addition, white TANF recipients appear to experience health problems at much higher rates than the white population in general. Non-white TANF adults also appear to experience higher rates of health problems than the overall non-white population but the difference is not nearly as great as among whites.
In combination, these findings suggest that special attention needs to be paid to physical and mental health problems among the TANF caseload, particularly among white TANF adults and children. It is possible that many white adults are on TANF primarily because of physical and mental health barriers – either their own or their children’s. Programs and services aimed at ameliorating barriers among TANF recipients should provide appropriate assessment and interventions.