An intensive survey of more than 2,400 low-income families in three U.S. cities shows that one side effect of welfare reform is that more families are going without health care coverage as they move into the workforce, something Congress had hoped to avoid.

"Work is basically a health insurance risk factor," said Ronald Angel, a professor and health policy analyst at the University of Texas' Department of Sociology and Lyndon B. Johnson School of Public Affairs and lead author of the study, which is part of a larger four-year welfare reform study coordinated by Johns Hopkins.

As part of the 1996 welfare reform legislation, Congress separated Medicaid from cash assistance payments, opened eligibility and provided additional federal funding to help states make sure people moving from welfare to work didn't suffer a loss of health insurance.

But based on the data from Boston, Chicago and San Antonio, as families move from welfare to work, they are losing Medicaid health care coverage, and private employer health care coverage is not filling the gap.

"The message that's being sent is, if you're poor and want health insurance coverage, don't get married. And don't leave welfare for work," said Andrew Cherlin, the Benjamin H. Griswold III Professor of Public Policy at Hopkins and the coordinator of Welfare, Children and Families: A Three-City Study. "So we have to ask ourselves," he said, "are these the signals that we want to be giving to the working poor population?"

Angel said the problem is that while Medicaid was separated from cash assistance, the program continued to be administered out of the same welfare offices. Application procedures can be complex and confusing. For Mexican-Americans, language and other barriers get in the way.

Based on the survey results, however, where you live also plays a role, as the states of Illinois and Massachusetts are doing a better job than Texas of helping provide Medicaid coverage to their low-income residents.

Of those people who should be eligible to receive it, a far higher percentage in Boston than in San Antonio were receiving it, Angel said.

"Many children who qualify for Medicaid are not enrolled," the report states. "Possible barriers to enrollment may include misinformation or misunderstanding concerning the connection between Medicaid and the receipt of TANF [Temporary Assistance for Needy Families], a complex application process that differs from state to state, or fears concerning citizenship and immigration status."

Low-income Mexican-American families were the least likely to be covered by health insurance in the three cities surveyed, Angel said. A full 27 percent of the Mexican-American children in the survey had no health insurance, compared to 9 percent of the children who were non-Hispanic whites and 8 percent who were African-American.

Health insurance coverage for Mexican-Americans was "lower everywhere," Angel said. "It probably has something to do with citizenship issues, but we can't prove it or document it for sure." Other possible barriers include language and transportation, he said.

The complete report can be found at the Three-City Study Web site http://www.jhu.edu/~welfare/index.html.