clSR8152 west 57th streetNew York, NY 10019-3310phone 212 8415200fax 212 956 8020http://www.casacolumbia.org
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`Board of Directors
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`E. BurkeKenneth I. ChenaoltJames DimonMary FisherBetty FordDouglas A. FraserDonald R. KeoughLaSalle D. L&all, Jr., M.D.Manuel T. Pacheco, Ph.D.Nancy ReaganE. John Rosenwald, Jr.George Rupp, Pb.DMichael P. ScholhofThe National Center onAddiction and Substance Abuseat Columbia University
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`andPresident
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`Joseph A. Califano, Jr.Chairman
`James
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`Barbara C. Jordan (1936.1996)Frank G. Wells (1932.1994)
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`S u b s t a n ce A b u s e a n d
`W o m e n o n W e l f a r e
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`June 1994
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`CFAD VI 1026-0001
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`Board of Di,rectors
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`Joseph A. Califano, Jr.Chairman and President of CASAJames E. BurkeChairman of the Partnership for a Drug-Free AmericaKenneth I. ChenaultVice Chairman, American Express CompanyJames DimonPresident, Chief Operating Officer and Director of Travelers GroupMary FisherFounder of Family AIDS NetworkBetty FordChief Executive Officer of the Betty Ford Center in Ranch Mirage, CaliforniaDouglas A. FraserProfessor of Labor Studies at Wayne State University (former President of UnitedAuto Workers)Donald R. KeoughChairman of the Board of Allen and Company Incorporated(former President of The Coca-Cola Company)Lasalle D. Leffall, Jr., M.D., F.A.C.S.Charles R. Drew Professor of Surgery, Howard University HospitalManuel T. Pacheco, Ph.D.President of The University of ArizonaNancy ReaganFormer First LadyE. John Rosenwald, Jr.Vice Chairman of The Bear Stearns Companies Inc.George Rupp, Ph.D.President of Columbia UniversityMichael P. SchulhofBarbara C. Jordan (1936-1996)Frank G. Wells (1932-1994)
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`This report was prepared by JefJrey C. Menill, Vice President for Policy and Research at CASA; Kimberley
`S. Fox, Senior Program Manager: Jennifer C. Friedman, Research Associate and Gerald E. Pulver, Data
`Manager. The report was funded by core grants from the Carnegie Corporation of New York and the Ford
`and Robert Wood Johnson Foundations. Data analysis was done by CASA’s Substance Abuse Data Analysis
`Center made possible by a grant from The Henry J. Kaiser Family Foundation.
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`Copyright 0 1994 by The National Center on Addiction and Substance Abuse at Columbia University
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`CFAD VI 1026-0002
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`4/W
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`THE AFDC I’OPULATION AND SUBSTANCE ABUSEThe Aid to Families with Dependent Children (AFDC) program provides financialsupport primarily to low-income women and their children.In 1993, 14.2 million individualsreceived AFDC, comprising 4.5 million families. Two-thirds, or 9.5 million, of the recipientsare children, representing 13 percent of all children in the United States.The AFDC populationis 38 percent white and 38 percent black, with Latinos making up most of the remaining 24percent.Almost 90 percent of the adults on AFDC--more than 4 million--am women?BACKGROUNDSubstance abuse and addiction is Public Health Enemy Number One in America.The grim reality, shrouded for so long in our individual and national self-denial, is that anymeaningful reform of our health care, criminal justice or welfare systems must mount an allfronts attack on all substance abuse--legal and illegal drugs, alcohol, and tobacco.The central missions of the Center on Addiction and Substance Abuse at ColumbiaUniversity (CASA) are to inform the American people of the social and economic costs ofsubstance abuse and its impact on their lives; to find out what works for whom in preventionand treatment; and to encourage all individuals and institutions to take responsibility forcombatting substance abuse.This study is one in a series examining the costs of all forms of substance abuseto our society.We have already published reports on the costs of substance abuse, to theMedicaid and Medicate programs and the impact of substance abuse on college campuses.’This report examines the extent of substance abuse in the AFDC population and its implicationsfor welfare reform.
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`CFAD VI 1026-0003
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`The total cost of AFDC in 1993 was 22.2 billion dollars, including 12.2 billionfederal dollars. AFDC recipients are automatically eligible for Medicaid, and their coverageunder this program costs an additional 36 billion dollars.The combined AFDC cash paymentsand related Medicaid costs approached 60 billion dollars in federal and state expenditures in1993.Overall, 28 percent of adult individuals receiving AFDC abuse or are addicted todrugs and alcohol,* a higher rate than the 20 percent of people in a comparable age group notreceiving public assistance.3Since almost 90 percent of adult AFDC recipients are female, thisreport focuses on this population.***Women receiving AFDC are nearly twice as likely to abuse or be addicted toalcohol and illicit drugs than women not receiving AFDC (27 percent comparedto 14 percent).**** 37 percent of AFDC women 18 to 24 years of age abuse or are addicted toalcohol and drugs.
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`l Alcohol abuse is &fined as drinking 5 or more drinks in one sitting, two or more times
`in a month. Drug use is defined a& having used illicit drugs in the past year.
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`Among adult male ARDC recipients, 34 percent admit using either illicit drugs or alcohol
`or both, compared to 27percent of men not on public assistance.
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`The
`*** The analysis of AFDC “women” includes females 18 years of age and older.
`analysis of Al?DC “mothers” includes females over the age of I4 with at least one living
`biological child.
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`CFAD VI 1026-0004
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`0Mothers receiving AFDC are three times more likely to abuse or be addicted toalcohol and drugs than mothers not receiving AFDC (27 percent compared to 9percent).The substance abuse problem in AFDC is not confined to alcohol or one type ofdrug.Women receiving AFDC are almost twice as likely to use cigarettes, alcohol, marijuanaor cocaine as women not on public assistance.50 percent smoked cigarettes inthe last month, compared to 29 percent of non-AFDC women.Among women on AFDC:12 percent consumed five or more drinks in one sitting at least two times in thepast month, compared to 6 percent of non-AFDC women.23 percent used’an illicit drug in the past year, compared to 12 percent of non-AFDC women.17 percent used marijuana in the past year, compared to 8 percent of non-AFDCwomen.34 percent of AFDC mothers who abuse illegal drugs also abuse alcohol,compared to 17 percent of non-AFDC mothers.-3-
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`CFAD VI 1026-0005
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`These statistics provide an overall picture of the extent of the problem.However,two-thirds of the AFDC women who reported using these substances also admitted that they usethem regularly. *0Of AFDC women reporting two or more binge drinking episodes in the lastmonth, almost 80 percent admitted binging at least once a week.oOf those who reported using illicit drugs in the last year, more than half (54percent) admitted that they use drugs at least once a month.Almost one-thirdadmitted weekly use.The numbers reported here underestimate the extent of the substance abuseproblem in two ways: the information is self-reported, and people are generally reluctant toadmit to alcohol or drug abuse and addiction; and, even if people do report using drugs oralcohol, they may not want to admit that they used them frequently.Other studies of the AFDCpopulation in specific states confii that substance abuse is a major problem.Pregnancy and Substance Abuse in AFDCDrug, alcohol, and tobacco use by a pregnant woman affects the newborn childas well as the mother.The 1993 CASA study of the impact of substance abuse on Medicaid
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`’ Regular use is defined as at least one binge drinking episode per week and/or the us of
`an illicit drug on a monthly or more frequent basis.
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`CFAD VI 1026-0006
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`hospital costs estimated that caring for drug and alcohol-exposed infants accounts for more than6 percent--or 2 billion dollars--of all Medicaid expenditures on inpatient hospital care in 1994.Several states have conducted urine toxicology screening ,on pregnant women onwelfare at the time of delivery.The most extensive data has been collected by the state ofCalifornia. The California data reveal that 13.4 percent of pregnant women receiving publicassistance have positive urine tests for alcohol or drugs (other than tobacco) at the time of theirdelivery, and 1.8 percent test positive for cocaine.These estimates are low because alcohol and drugs can only be detected in urinefor a period of seven days after use.Thus, if a woman used drugs more than a week beforedelivery, traces of the drug would not be captured in a urine test.However, new research onmeconium--an infant’s first stool--can detect the mother’s drug use during the prior six to eight weeksIn a South Carolina study,”both meconium and urine tests were conducted ona sample population. The meconium test found nearly eight times as many women testingpositive for cocaine, and three times as many for marijuana, than did the urine test alone.Extrapolating these ratios to results from urine tests done on a larger population in SouthCarolina-and to the California urine testing results--yields much higher rates of substance useamong pregnant women.Using this form of extrapolation, we estimate that:014 percent of the pregnant women on public assistance in the California study,and 11 percent of pregnant women on Medicaid in the South Carolina study,would test positive for cocaine use.
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`CFAD VI 1026-0007
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`0More than 16 percent in South Carolina would test positive for one or moreillegal drugs.oNationwide, 200,000 drug-exposed babies would be born annually to mothers onAFDC.Tbe Impact of Substance Abuse on WelfareFor some AFDC recipients, dependency on drugs or alcohol may have led to jobloss and, ultimately, to welfare dependence.For. others, drug and alcohol abuse may makemoving from welfare dependency to self-sufficiency virtually impossible.Half of all AFDC recipients spend less than two years on welfare.”For thosewho are on welfare for longer periods, substance abuse is a major impediment to getting off.A study of 25 state AFDC offices by the Inspector General of the Department of Health andHuman Services found substance abuse to be among the most frequently identified functionalimpairments preventing AFDC recipients from leaving welfare and successfully completing jobtraining program. It is difficult to deter&e the exact proportion of the AFDC population that eitherinitially applies for, or continues to receive, public assistance as a result of substance abuse.But, even if AFDC dependence is attributable to substance abuse in ‘only 15 percent of the caseswhere substance abuse exists, the cost to the AFDC program would be more than 1 billiondollars in cash assistance in 1994.Substance abuse also has a significant impact on Medicaid costs for treating bothwomen’s health problems and adverse birth outcomes.Forty-two percent of AFDC mothers
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`CFAD VI 1026-0008
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`continue to smoke during pregnancy.Smoking, as well as cocaine use, results in low birthweight babies, premature delivery, and other pregnancy complications. For adverse birthoutcomes alone, if 11 to 14 percent of pregnant women on welfare test positive for cocainenationwide,* the 6 percent of Medicaid hospital expenditures for birth complications attributableto substance abuse may be closer to 10 percent, or 4 billion dollars, in 1994. These costs areonly a small portion of the total dollars spent on alcohol- and drug-exposed infants, many ofwhom are sentenced to a lifetime of dependence and poverty.The cost of caring for a childseriously impaired by substance abuse from birth to the 18th birthday is estimated at $750,000in medical care, special education and social services alone.CONCLUSIONThe most important question in the debate over welfare reform is how to helpindividuals on AFDC to become self-sufficient so that they can get off the welfare rolls.Atleast 1.3 million adult welfare recipients currently abuse or are addicted to drugs and alcohol.Welfare agencies identify substance abuse as one of the most serious barriers to becoming a partof the work force. Currently, the Job Opportunity and Basic Skills (JOBS) program (aneducation, training and employment program to help AFDC clients avoid long-term dependence)requires states to serve only 20 percent of the AFDC population. As a result, states havelatitude to exclude identified substance abusers from participation. Indeed, as part of theeligibility process for JOBS, more than half the states ask specifically about substance abuse andview this problem as a barrier to training and employability.
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`’ Based on projecting the data
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`the California and South Carolina studies (see above).
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`-7-
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`CFAD VI 1026-0009
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`from
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`Job training, literacy skills, and health care are all important elements in makingthe transition to self-sufficiency.But, in order to reduce welfare dependence substantially,substance abuse treatment, including aftercare, must also be a critical element of any meaningfulwelfare reform plan. Without this, it will be impossible to train the 1.3 million recipients withdrug or alcohol problems so that they can obtain and hold jobs.-8-
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`CFAD VI 1026-0010
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`References1. The prior reports are: The Cost of Substance Abuse to America’s Health Care Svstem,Report 1: Medicaid Hosoital Costs (1993), The Cost of Substance Abuse to America’sHealth Care System. Report 2: Medicare Hospital Costs (1994), and Rethinking Rites ofPassage: Substance Abuse on America’s Camouses (1994). They can be ordered fromthe Center on Addiction and Substance Abuse at Columbia University.2. U.S. House of Representatives, Committee on Ways and Means, Overview ofEntitlement Programs: 1993 Green Book: Background Material and Data on Programswithin the Jurisdiction of the Committee on Wavs and Means (Washington, DC: U.S.Government Printing Office, 1993).3. Data on tobacco, alcohol and drug use. in this section generated from: NationalHousehold Survev on Drug Abuse: 1991, conducted by the Substance Abuse DataAnalysis Center (SADAC) at the Center on Addiction and Substance Abuse at ColumbiaUniversity.4. Laurence Slutsker, Richard Smith, Grant Higginson, and David Fleming, ‘RecognizingIllicit Drug Use by Pregnant Women: Reports from Oregon Birth Attendants,” AmericanJournal of Public Health 83, no. 1 (January 1993): 61-64.5. U.S. Department of Health and Human Services, Office of Inspector General, FunctionalImpairments of AFDC Clients (Rockville, MD: U.S. Department of Health and HumanServices, 1992).6. Constance Weisner and Laura Schmidt, “Alcohol and Drug Problems among DiverseHealth and Social Service Populations,”American Journal of Public Health 83, no. 6(June 1993): 824-829.7. Susan Zurivan and Geoffrey L. Greif,“Normative and Child-Maltreating AFDCMothers,” Social Casework: The Journal of Contemporarv Social Work (February 1989):76-84.8. William A. Vega, Amanda Noble, Bohdan Kolody, Pat Porter, Jimmy Hwang, andAnthony Bole, Profile of Alcohol and Drug Use during Pregnancy in California. 1992:Perinatal SubstanceExposure Studv: General Report (Sacramento: California Departmentof Alcohol and Drug Programs, 1993).9. William A. Vega, Bohdan Kolody, Amanda Noble, Jimmy Hwang, Pat Porter, AnthonyBole, and Juanita Dimas, profile of Alcohol and Drue Use during Pregnancy inCalifornia. 1992: Perinatal Substance Exposure Survev: Scientific Reoort (Sacramento:California Department of Alcohol and Drug Programs, 1993).-9-
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`10. South Carolina State Council on Maternal, Infant and Child Health, fl91 South CarolinaPrevalence Studv of Drug Use among Women Giving Birth (Columbia, SC: Offtce of theGovernor, 1991).11. U.S. House of Representatives, Committee on Ways and Means, op. cit.12. U.S. Department of Health and Human Services, Office of Inspector General, op. cit.13. U.S. General Accounting Office, Drug-Exposed Infants: A Generation at Risk(Washington, DC: U.S. General Accounting Office, 1990).14. Ibid.15. U.S. Department of Health and Human Services, Office of the Inspector General, op.cit.
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`CFAD VI 1026-0012
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