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LIHEAP Research Experiences of Selected Federal Social Welfare Programs and State LIHEAP Programs in Targeting Vulnerable Elderly and Young Child Households

Published: December 1, 2008
Audience:
Low Income Home Energy Assistance Program (LIHEAP)
Category:
Publications/Reports, Research, Case Studies

With respect to outreach, the Bartlett study found:
 

  • The more FSP outreach and the more different modes of FSP specific outreach conducted by an office, the higher the level of program awareness and correct understanding of the Food Stamp Program. There was no specific method or specific organization that proved most effective.  Rather, getting the program message out through many different sources appeared to be the most effective.
  • In contrast, coordinated outreach with Medicaid appeared to reduce awareness of the FSP and understanding of the FSP requirements.  The author hypothesizes that the coordinated outreach “dilutes” the FSP message.

There are some challenges for the LIHEAP program in making use of these findings because the LIHEAP program is trying to increase participation of specific groups, rather than the overall program participation.  However, it is useful to know that this study found that outreach to specific groups or through specific organizations was not the determinant in overall program awareness and understanding by those groups.
With respect to local office practices, the Bartlett study found:

  • Elderly households are concerned about the accessibility of the FSP office, particularly the location of the office and the distance traveled.   However, once they have begun the application process, elderly households have the highest probability of completing the application.
  • Households with children are discouraged from applying for the program if the local office is not “child friendly.”  Moreover, households with children are the least likely to complete an FSP application once it has started the process.

The Zedlewski study found that FSP outreach grant recipients made use of funding for both general outreach procedures and special outreach experiments. With respect to general outreach, the study found:

  • Mass Marketing - These techniques were not effective in increasing the number of FSP applications.
  • Technology – The Internet appeared to be a useful tool for furnishing information to clients potentially interested in the program. These tools were particularly valuable for rural clients that live a long distance from intake agencies.
  • Community Groups – Partnering with community groups, including both furnishing access to clients and assisting with implementing outreach initiatives, yielded the highest level of referrals.

The elderly and the working poor were the hardest groups to reach.  If one wants to target those types of households, it is important to reach out to the community organizations that serve those households.

  • Elderly – For this group, it is important to work directly with senior service providers, i.e., the Office on Aging.  Community-based organizations that serve the general low income population are not as effective at serving seniors as those organizations that are more focused on the needs of seniors.  Conducting outreach at churches and other organizations that seniors frequent is sometimes not effective because the seniors would not want to express a need for services in front of their community members.
  • Children – For working poor households with young children, community health centers appeared to be good partners for outreach.  Schools did not perform very well because low income households with children are less likely than other parents to attend school-based meetings or to make use of materials sent home from the schools.

These grant recipients also found that prescreening applications for eligibility (i.e., estimating the benefit during the initial intake visit) was effective, as was including information about the benefit level in outreach materials.
The Cody and Ohls study found that the most effective elderly nutrition demonstrations were those that could either lower the costs of applying or increase the benefits of participating.  The simplified eligibility and application assistance demonstration models worked primarily through reducing the application burden.  Seniors who were interviewed and participated in focus groups as part of the evaluation furnished substantial evidence that, without the demonstrations, their costs of applying outweighed the program benefits.

The demonstrations attracted disproportionate shares of seniors at the older end of the age distribution.  Older seniors are more likely to have cognitive or physical limitations that increase the burden of applying for benefits.  In the application assistance demonstration sites, demonstration households were much more likely to have a household member over age 70 than nondemonstration households.  A similar pattern was observed in the commodity sites for the households containing an elderly member over 70.  There also was some evidence in the simplified eligibility demonstrations that those households attracted by the demonstrations were more likely to contain individuals over age 70.

Seniors interviewed or participating in focus groups as part of the evaluation had extremely positive assessments of the demonstrations.  In simplified eligibility and application assistance demonstrations, seniors appreciated having minimal interaction with local FSP offices.  Seniors in the application assistance demonstrations also reacted positively to the personal assistance and to the “respect” that they received from the application assistants.

The Gator study focus group findings support many of the lessons learned from the prior studies.  Seniors perceive that program benefits are too low, that they are not eligible, that the applications are too complicated, and that the office is uncomfortable.  By giving seniors information about the benefit level, prescreening them for eligibility, offering application assistance, and offering program enrollment through other avenues, FSP offices could substantially increase the participating of elderly households in the Food Stamp Program.

Medicaid

Medicaid is a Federally and State funded entitlement program providing health insurance coverage for low income households. The United States Department of Health and Human Services (DHHS) administers the program and, along with State providers, is responsible for program design.  States have wide leverage in establishing eligibility rules, services provided and administration procedures.  Policies within each State vary greatly and can prove to be quite complex.
a. Participation Rates
The GAO report puts the overall participation rate for Medicaid in 2000 at between 66 and 70 percent.  Children participate at a higher rate of 74 to 79 percent; whereas, adults and the elderly participate at 56 to 64 percent and 40 to 43 percent respectively.  This estimate does not include those individuals who are living in institutionalized housing.  Unfortunately, rates of program participation over time were not available due to inconsistent methodology from one year to the next.
b. Barriers to Enrollment
There are three main sets of barriers eligible populations face when trying to enroll in Medicaid.  As in the research on the FSP, most of the findings in the literature point to barriers faced by all groups, but some point to barriers faced specifically by households with children.  The three main categories are:  1) confusion about eligibility; 2) application procedures; and 3) personal feelings about the program.
i. Eligibility Rules
As mentioned above, the rules concerning eligibility are quite complex.  This translates to confusion among both potential beneficiaries and case workers about whether individuals are eligible for the program.  In part this is because eligibility guidelines for Medicaid are different from those for TANF and FSP benefits.  Households that are not eligible for TANF and FSP may be eligible for Medicaid  benefits, but are likely to perceive that they would not be eligible (GAO, 2005).

ii. Application Procedures
Once eligibility is established, application procedures often stand in the way of successful enrollment.  According to a recent study by the Kaiser Commission on Medicaid and the Uninsured, over 70 percent of those who were unable to complete their Medicaid applications said this was primarily due the excessive difficulty of obtaining required documentation (Bartlett et al., 2004).
iii. Personal Perceptions
Recent study on barriers to participation in Medicaid has also focused on personal feelings about the program.  Stuber et al. (2000) discuss three primary kinds of stigma in relation to the program.  “Welfare stigma” is the kind that makes beneficiaries feel badly about themselves if they participate or worry that others (friends or family) will look down on them for participating.  “Treatment stigma” occurs when potential enrollees feel they will be treated poorly by office staff, including feeling probed or humiliated by the process of applying for the program.  The third type, “provider stigma”, is a fear that doctors will not accept program participants or will not treat them as well as they treat those who are not participating in Medicaid.
With specific reference to children, “welfare stigma” can affect parents’ decision to enroll in Medicaid, particularly if they have to visit a welfare office to do so.  Stuber et al. (2000) found 42 percent of parents of Medicaid-eligible uninsured children would be more likely to enroll if they did not have to visit a welfare office.  “Treatment stigma” also matters in reference to the site of application.   Survey respondents who visited a welfare office in order to apply for Medicaid were twice as likely to report poor treatment and feelings of discomfort as those who went to another location to apply for the program (Stuber et al., 2000; Bartlett et al., 2004).
A survey of participants and nonparticipants (Stuber et al., 2000, p 11) found these barriers had varying effects on enrollment.  Five specific variables were significant in predicting whether a survey respondent was eligible but not enrolled in Medicaid.
Table 4-2 - Barriers to Medicaid Enrollment


Barrier

Parameter
Estimate

Standard
Error

P-value

Odds Ratio

Confused about who can apply

.57

.30

.050

1.8

Belief that one must be on welfare to get Medicaid

.56

.26

.030

1.7

Application is long and complicated

.61

.23

.010

1.8

Must answer unfair personal questions

.77

.26

.003

2.2

Doctors do not treat people with Medicaid equally

.51

.26

.050

1.7

The first two variables above show survey respondents who were confused about eligibility rules were about 1.8 times more likely to be eligible but not enrolled than those who did not express this problem.  Those claiming the application was long and complicated were also more likely to not be enrolled.  Respondents expressing a fear of treatment stigma, that they would have to answer unfair personal questions, were 2.2 times more likely to not be enrolled. Those expressing a fear of provider stigma, that doctors would not treat them as well because they were Medicaid beneficiaries, were 1.7 times more likely to be eligible but not enrolled in the program.
c. Strategies for Enrollment
Many agencies have tried specific strategies in response to these barriers.  Some develop programs to educate both potential beneficiaries and office staff about eligibility requirements.  This is occurring through both outreach campaigns focused on reducing confusion and staff training to help intake workers understand the complexities in determining eligibility.  Outreach at schools, clinics and special events is specifically designed to reduce confusion among parents with uninsured children.  To close the loop on some who may have been wrongly excluded, one location offered $20 gift certificates to families who reapplied after losing benefits (Bartlett et al., 2004).
To reduce application barriers, some programs accept mail-in applications and have simplified their forms.  As mentioned above, welfare stigma is somewhat eased by moving the site of application to a nontraditional location, such as a health center, community clinic, hospital, school or child-care center.  To ease fears of treatment stigma, these programs also eliminated all unnecessary and potentially humiliating questions, such as those asking about how applicants handle their money, about their drug or alcohol use, and details about their sex lives (Stuber et al., 2000).  Though the studies arguing for these changes have not yet subject them to intensive evaluation, their direct response to proven barriers suggests they might be effective solutions.
While all of these approaches are likely to increase participation, there was not specific discussion in the literature of how to increase participation for elderly households or those with young children. 

Programs Targeting the Elderly

Medicare Savings Programs

The Medicare Savings Programs (MSP) are a set of programs providing low income aged and disabled populations relief from expenses and services left uncovered by Medicare.  These expenses and services include premiums, deductibles, coinsurance, outpatient prescription drugs and nursing home care.  There are five ways that beneficiaries can qualify for these programs, though the literature primarily focuses on two primary categories: Qualified Medicare Beneficiary (QMB) and Specified Low income Medicare Beneficiary (SLMB).  Individuals qualifying as QMB must have incomes below 100 percent of the Federal Poverty Level and resources not in excess of twice the SSI limit.  For these individuals, State programs pay Medicare Part B premiums as well as deductibles and coinsurance.  State programs also pay the Medicare Part B premiums for individuals qualifying as SLMB, or those with incomes up to 120 percent FPL and resources that do not exceed two times the SSI limit (Perry et al., 2002; Haber et al., 2003).
a. Participation Rates
According to recent studies, one-half to two-thirds of all eligible Medicare beneficiaries are covered by these programs.  This number is increasing over time, with varying enrollment among the specific qualifying categories and among States.  Higher coverage rates for the QMB program support the argument that the most vulnerable groups are being targeted.  Research has found enrollees have higher rates of service than eligible non-enrollees, though it is not clear whether those enrolled are sicker or whether enrollment increases service use (Haber et al., 2003).
b. Barriers to Enrollment
Overall, studies report that participants in the MSP are highly appreciative of the programs and have some opposition to large-scale change.  However there are clear avenues for improving access for low income seniors.  Potential enrollees in the MSP face some of the same barriers to enrollment that they face in the FSP.  Individuals are often not aware of the program, confused about eligibility and program rules, are dissuaded by difficult application and office procedures, and hold strong feelings about what it means to participate in the programs.
i. Awareness
Despite efforts at outreach, most non-enrollees State that no one has ever discussed the programs with them, much less talked to them about whether they might qualify.  This is particularly a problem for those seniors living on their own and not in communal housing.  Not only does this bring them into less contact with designated officials, it can mean less contact with other seniors who are participating in the programs.  If seniors do know about the program, they often lack the knowledge of where to go to enroll.   Some assume they need to go to the social services office, while others think it is AARP or local religious institutions.   Friends and family who remain the most trusted source of information are underutilized in these efforts (Perry et al., 2002).
ii. Eligibility Confusion
Without needed education, many eligible individuals make decision on the basis of information available.  Many Medicare beneficiaries do not enroll in the programs because they assume they will not qualify for them, believing their incomes are too high for the threshold.  Others believe they would have to diminish their assets in order to qualify, including selling their homes or reducing their savings.  For others, eligibility is more a matter of perception.  Their understanding of the program is to provide assistance to those they see in common images of “poor people”, primarily mothers with young children.  They do not see themselves in that category and therefore do not even consider whether they might in fact be eligible.  An additional barrier is the fear of needing to pay back assistance received.  In a recent study, close to 20 percent of eligible non-enrollees were concerned with State recovery (Perry et al., 2002; Haber et al., 2003).  Once program rules are explained, interest in the program rises substantially.
iii. Application Procedures
A third set of barriers includes difficult application and office procedures.  Focus group respondents report feeling like the application is invasive and that their personal lives are being “violated” in order to enroll in the program.  Similar to findings for the FSP, seniors perceive questions as being designed to catch them in an act of dishonesty, as if they were trying to get away with something.  More practical concerns include irrelevant questions, such as those about pregnancy, or an overall form that is too long, repetitive, and in print too small to read.  Respondents also report difficulty getting to the office to enroll (Perry et al., 2002).
iv. Personal Perceptions
Seniors also carry with them strong feelings about what it means to participate in the MSP.  Many express worries that being on the program connotes a loss of independence.  Others comment that taking care of themselves is a point of pride, particularly after having worked all their lives.  They believe it reflects poorly upon people to accept what they consider a “handout”.  They also worry about being treated poorly by office staff, who can sometimes present themselves as rude, cold, and suspicious.  All of these factors combine to making some seniors reluctant to ask for help (Perry et al., 2002).  However, Haber et al. (2003) argues seniors actually want the assistance and enroll because they feel they deserve it.  These two findings suggest avenues for re-imaging the program in order to make it appealing to seniors.
c. Strategies for Enrollment
Studies have explored how best to conduct an effective outreach campaign to encourage senior enrollment.  Survey respondents clearly report that the most effective method of distributing information to seniors is through one-on-one communication.  Advertising through the media or printed materials are less effective in encouraging seniors to enroll.  The following table from Haber et al. (2003) summarizes the significant findings from a 2002 analysis of enrollees and non-enrollees.

  Table 4-3 - How Respondents Learned about the Medicare Savings Programs


Of those who heard about the program, what percent learned from each of the following sources?

Enrollees

Non-enrollees

Social worker/Health care professional

50.0%

10.2%

Visit to community agency

39.5%

16.5%

Printed materials

30.5%

52.5%

Radio/TV

18.9%

43.8%

Of those seniors who were eligible, those who enrolled were much more likely than those who did not enroll to have heard about the program through a social worker, health care professional, or visit to a community agency.  Those who did not enroll were significantly more likely to have heard about the program through printed materials and radio or television advertising.  These findings are further supported by the fact that many respondents reported enrolling in the programs after they moved into subsidized housing where they are in frequent one-on-one contact with health care professionals.  These findings also point to the potential for encouraging doctors and nurses to be involved in outreach by talking to their patients about the programs when they come in for appointments (Perry et al., 2002; Haber et al., 2003).
The most important finding regarding application procedures is that two-thirds of enrollees received assistance in completing their application, either from friends and family, social workers, or offices where they received the application.  Other practical suggestions from survey respondents include using bigger print and shortening the application, creating a separate form for seniors that eliminates irrelevant questions, and making sure verification requirements are clearly explained.  Respondents also suggest cutting down on the number of required in-person visits to ease transportation hassles.  Program rules could also be modified to ease assets tests for eligibility, encouraging seniors to apply who might have thought their assets put them beyond threshold.  Marketing could also help to clarify that the program allows participants to keeps assets and some income, thereby encouraging those to apply who might not think they are eligible  (Perry et al., 2002).
To counter negative feelings about the program, one concrete suggestion is to move the application site to some place other than the welfare office in order to diminish the stigma of program assistance as a “handout”.  Survey respondents also suggest revamping the image of the program by developing a new advertising campaign.  Messages for this campaign could emphasize that it is for seniors who have worked hard all their lives and now deserve some extra help.  The campaign could also emphasize that the program covers needed services, such as medication and glasses, that the application process is convenient, and that help is available to complete it (Perry et al., 2002). 


USDA funded these demonstration projects with six States that participated for a two-year period.

Programs Targeting Children

SCHIP

SCHIP is a Federally and State funded non-entitlement program that is similar to Medicaid but expands health insurance coverage to children whose families have income above the limits set for Medicaid. The U.S. DHHS administers SCHIP and, along with State providers, is responsible for program design.  States have the authority to determine how they might best use SCHIP funds.  They may expand Medicaid eligibility, create an entirely separate program, or do some combination of those two options.
a. Participation Rate
GAO puts the overall coverage rate for SCHIP in 2000 at between 44 and 51 percent.  The GAO report argues that there have been significant increases in enrollment since 2000, but because information on the eligible population is not readily available it is unclear what influence this increase has had on the coverage rate.  Kenney and Cook (2007) estimated the coverage rate to be about 29 percent, or 3.9 million children in 2005.
b. Barriers to Enrollment
Many of the same barriers faced by general population programs are also faced by SCHIP.  These include difficult application procedures, confusion about eligibility, office procedures, and treatment stigma.  Welfare stigma is less of an issue for those agencies that create SCHIP programs that are separate from Medicaid.  Some of the difficulty with application arises from the fact that SCHIP is not an entitlement program and therefore must negotiate limited funding over the fiscal year.  Non-entitlement programs that cope with this issue by creating limited or episodic enrollment periods may run into situations where families who are entitled to benefits may very well not be able to receive them if the program is not in season or has run out of funds.  This may create frustration and confusion among low income households in the service area (Perry and Paradise, 2007).
i. Application Procedures
Application procedures that require extensive documentation are also very difficult for those households that may be unwilling to hand over important items such as original birth certificates without a guarantee that they will be returned.  Obtaining other documents can also be extremely taxing in certain situations.  Some focus group participants said that States require single mothers to ask for child support from their child’s father before they can enroll, which is difficult to do for those who may not know who the father is or be able to contact him (Perry and Paradise, 2007).  Other programs require proof of income, which is difficult to obtain for cash workers who do not get check stubs or who are hesitant to ask employers to fill out the verification of income form (National Health Policy Forum, 1999; Perry and Paradise, 2007).
ii. Eligibility Confusion
Many parents are confused about whether or not they are eligible for the program (Woolridge et al., 2005).  Those who apply and are rejected believe they can never apply again, even if their income changes.  Immigrant households with children face an additional set of worries surrounding their or their families’ immigration status.   Studies show Latino families fear enrollment in SCHIP might put their family members who are in the country illegally in jeopardy of being deported.  One family in particular was told by a lawyer that participation would “go against them”.  Other immigrant households fear their own immigration status will be threatened or they will have to pay back all of the benefits received (National Health Policy Forum, 1999; Perry and Paradise, 2007).
iii. Office Procedures and Perceptions
Office procedures and treatment stigma are also issues for those who are considering enrolling their children in SCHIP.  Office hours limited to traditional working hours make it very difficult for working parents to make in-person interviews.  Latino survey respondents also cite the need for access to culturally-competent caseworkers who can educate and assist them.  These needs overlap with concerns over treatment stigma.  For some applicants, culturally insensitive questions combine with the perception that case workers are rude or dismissive.  The fear of being “debased” during the application interview keeps parents away from the SCHIP enrollment office (Perry and Paradise, 2007).
c. Strategies for Enrollment
SCHIP programs have been very creative in attempting to reach out to eligible families.  They tackle not only those barriers discussed above, but also issues of program coordination and outreach to new households.  To address the issue of limited and episodic enrollment, studies suggest creating continuous enrollment schedules.  They also suggest simplifying the enrollment process by requiring less documentation or allowing online or mail-in applications.  To help with eligibility confusion, California uses a central facility to process applications for Medicaid and SCHIP so families do not have to figure out which one they fit in.  Ideally, States could simplify income eligibility to a consistent percentage, but this runs into the issue of different States counting different types of assets in their income calculations (National Health Policy Forum, 1999; Perry and Paradise, 2007).
Changing office procedures can also help relieve barriers parents face when enrolling their children in SCHIP.  Some agencies provide hotlines in several languages that give application assistance and information about eligibility without requiring a trip to the office.  Other offices have extended hours on weekdays or are open on weekends to accommodate working parents’ time constraints.  Some States place “outstation workers” at a variety of locations, including hospitals, schools, housing authorities, fast food restaurants, shopping malls, day care centers, community clinics, and mobile health vans.  These outstation workers are an important connection to many vulnerable children, including those who are Native American or immigrants, those who are experiencing homelessness, or those who are living in rural areas (National Health Policy Forum, 1999; Wegener, 1999).
In order to increase enrollment, SCHIP programs also engage in a variety of creative coordination and outreach efforts.  These programs work with schools, community-based, and faith-based organizations.  Community Action Agencies connect SCHIP programs to organizations that are particularly important in rural communities, such as Future Farmers of America, 4-H clubs, home extension clubs, and farming or ranching associations.  Working with small business associations is a way to reach working parents who are self-employed or employed in small businesses that do not offer private health insurance coverage.  Many SCHIP programs have found success coordinating with other public assistance programs to reach eligible children, such as WIC, the Child Support Enforcement program, the school lunch program, subsidized childcare, and Head Start.  It is important to keep in mind that some public assistance programs such as Medicaid do carry a fair amount of stigma, so partnering with these programs, while improving access, might in fact decrease the appeal of the SCHIP program (National Health Policy Forum, 1999; Wegener, 1999).