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Improving the Delivery of Key Work Supports

Policy and Practice Opportunities at a Critical Moment

For more than 15 years, federal and state governments have been working together in earnest to simplify enrollment in public benefit programs.  Their work has been driven by the fact that the share of people who participate in public programs has not kept pace with the need; by a desire to make full use of the federal resources available for low-income residents; and by the need to create more effective and efficient government services.

These efforts have been successful in many ways.  In some form or another, most states have embraced increasing access and simplifying policies, particularly in federally funded programs like Medicaid and SNAP (formerly Food Stamps).  They have streamlined processes, made procedures more client-friendly, reduced paperwork, and sought to increase outreach to potentially eligible people.  As a result, millions of low-income individuals who might not have obtained work supports now do.  This achievement is no small feat.

And yet, the work is far from complete.  Often there is little coordination or seamless service delivery across programs (as opposed to within a single program).  Further, although some states have coordination policies on the books, too often the on-the-ground procedures needed to operationalize these policies are not in evidence.  In addition, few if any states have an effective, data-based system for determining whether families are in fact connected to the full range of programs for which they qualify. 

Failure to Coordinate Across Programs Creates Problems for Families and States

Lack of cross-program coordination can undermine the impact of in-program efforts and significantly decrease agency efficiency.  It also reduces overall support for families.  Because they must navigate a complex and inefficient web of systems, families often are unable to secure the full package of benefits for which they are eligible. 

Consider a family with low earnings that is eligible for children’s health coverage [1], SNAP, and child care.  In many states, despite the fact that these programs often serve the same families and require very similar enrollment information, a struggling family would have to apply and renew benefits via three separate processes that are not synchronized in any way.  Further, busy state workers in these three programs will spend time duplicating each others’ efforts.

Without some level of coordination among programs, states’ efforts to support struggling families are effectively stalled.  And this is a particularly bad time to be stalled.  Millions of Americans live in households whose earnings are not enough to get by.  In 2009, nearly 46 million people (1 in 7 Americans) lived in a working family with cash income below 150 percent of the federal poverty line ($32,931 for a family of four).  The recent economic downturn has significantly exacerbated this problem, with more and more people streaming into public agencies to get help. 

Even when the economy improves, the demand for services and supports will continue.  The health care reforms enacted in 2010 will expand Medicaid coverage to approximately 16 million additional people, beginning in 2014.  Many of these individuals will also be eligible for, but not participating in, human services programs such as SNAP or child care.  At the same time, shrinking state budgets will continue to put enormous pressures on agencies to do more with less.  Already 44 states have projected budget gaps that total $125 billion for fiscal year 2012, and the projected gap is likely to grow and extend into future years.[2]

Thinking Outside the Box

In response to these challenging circumstances, a number of states have been shifting the paradigm under which they work: instead of focusing narrowly on enrollment — i.e., what can we do to maximize participation in a particular program? — they have broadened their sights to consider how they can be operationally smarter and maximize their effectiveness.  Rapidly advancing technology and committed leaders who bring high expectations for what government can accomplish have helped the cause.  Building on 15 years of experience with SNAP and children’s health insurance enrollment efforts across the country, these states are launching new, more comprehensive efforts to rethink their policies, redesign their work processes, take full advantage of technology, and use data to guide their improvements in enrollment, retention, and service delivery. 

This paper lays out the particulars.   In the areas of policy, procedure, and data utilization, it shows why coordination among programs is critical and how to overcome its inherent challenges.  Moving from theory to practice, it provides a catalogue of specific options states can pursue and reviews some best practices.  While the paper focuses primarily on how states can better coordinate Medicaid and SNAP, it also offers examples of how to include TANF, child care, and other programs in the effort.  With this information as a guide, state agencies providing key critical work supports to families in need can substantially streamline and improve the way they conduct their business. [3]

In This Report

  • The big picture.   Why this work is so vital, what past efforts at improving enrollment practices have accomplished, and how the current economic climate creates even more urgency to finish the job.
  • Key considerations.   A review of some of the overarching challenges in this work, the role of health care reform, as well as specific recommendations about where to start. 
  • Policy options.  A catalogue of policies that can help states expand eligibility, increase participation by eligible people, provide seamless enrollment across programs, expedite the application process for both families and workers, and increase retention and speed renewal. 
  • Procedural and systems options.    How states can use case management, verification procedures, technology, staff training, forms, and other systems to support coordination among programs.
  • Data utilization options.   Strategies for using program data to assess the effectiveness of current and new policies and procedures.
  • Additional resources.  A brief bibliography of research and reports that offer additional information.

Instead of organizing the paper by type of intervention (i.e., policy, procedures, and data, as is presented here) another way to think about program improvements would be in terms of where in the eligibility process the change occurs (i.e., efforts to bring eligible people to the front door, efforts to reduce and to streamline verification burdens, efforts to help eligible people retain benefits rather than churn on and off, and so forth.)  Table 1 summarizes the paper’s major recommendations organized by steps in the application and eligibility process, including reviews and redeterminations.

Table 1:
Options For Coordinating Across Programs
Methods Covered in This Paper
Overall Performance
Reaching eligible families with full package of benefits X       X  
Interaction with health reform X        
Process redesign        
  Process mapping (also see )     X    
Workload management changes such as universal caseloads, task model, centralized units, improved policy materials and training     X   X  
Using technology to enhance access and process management     X   X  
Diagnosing process strengths and weaknesses     X   X  
Leadership (overall vision plus ensuring that changes happen down the line) X   X   X    
Role of program integrity   X      
Customer service (notices, forms, surveys)     X   X  
Specific Steps in the Process
Bringing eligible families to the “front door” Expand eligibility, provide multiple access points and seamless enrollment, improve cross-program eligibility screening, etc.   X   X    
Limiting in-person requirements Adopt telephone interviews, online applications, etc.   X   X    
Reducing documentation requirements or sharing verification Eliminate documentation requirements, improve cross-program sharing of information, administrative verification, etc.   X   X    
Improving change reporting rules Limit changes that must be reported, establish call centers, give families online or telephone access to their case information   X   X    
Simplifying renewals / Improving retention of benefits Coordinate renewals and change reporting, focus on reducing churning, etc.   X   X   X  
Using data to provide feedback loop Use data to assess implementation on churning, program overlap, workload measurements, etc.       X  

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End Notes

[1] Throughout this paper the term “children’s health insurance” includes Medicaid coverage for children and the Children’s Health Insurance Program (CHIP), as distinguished from “family health coverage,” where the parents in a low-income family also qualify for Medicaid coverage.  Typically states’ income limits for health coverage for parents are much lower than for children.  When health reform is implemented Medicaid income limits for adults will rise to at least 138 percent of poverty.

[2] Elizabeth McNichol , Phil Oliff, and Nicholas Johnson, States Continue to Feel Recession’s Impact, Center on Budget and Policy Priorities, January 21, 2011.

[3] The paper focuses on the package of benefits for working families (and families with unemployed workers).  States also serve childless adults as well as seniors and people with disabilities in many of the same programs.