Experiences of Selected Federal Social Welfare Programs and State LIHEAP Programs in Targeting Vulnerable Elderly and Young Child Households
Other SCHIP outreach solutions to increase enrollment include: traditional pamphlets and posters, television and radio advertising, toll-free numbers, and websites. Additionally, some programs encourage private organizations to join in the outreach campaigns. These programs appeal to companies to contribute to advertising costs and to disseminate information on company materials such as grocery bags, diaper boxes, toothbrushes, and pharmaceutical products. These outreach campaigns are taking place in both English and Spanish, sometimes accompanied by promotional materials. Though school-based mass mailings or inserts in registration packets have regularly shown high success rates, one Missouri program combining SCHIP and Medicaid outreach saw a 70 percent increase in enrollment after a multifaceted campaign targeting malls, Wal-Marts, hospitals, and clinics. One of the more interesting attempts to reach fathers of uninsured children in Massachusetts involved a community-based organization raffling off a chainsaw at the local dump every Saturday (National Health Policy Forum, 1999; Wegener, 1999).
Studies show that families do learn about the SCHIP program through these many outlets, but the key factor in making the decision to enroll children is one-on-one contact with trusted people. The 2005 congressionally-mandated evaluation of the SCHIP program found that when participants were asked which source was most important in their making the decision to enroll, health care providers were most important (22 percent) followed by public agencies (20 percent) friends and relatives (18 percent) and school contacts (17 percent) (Woolridge et al., 2005). This distinction between awareness and decision to enroll is an important one to make when looking to increase participation rates of targeted groups. Aside from this evaluation, most of the efforts discussed above have been subject to little pretesting or follow-up research. However, similar to strategies to increase Medicaid enrollment, they are a direct response to barriers proven to be significant and therefore deserve careful consideration.
As the SCHIP program has matured and the fiscal environment has tightened, States have learned what efforts are successful and have tailored their approaches accordingly. Early campaigns were aimed at creating broad awareness of SCHIP. Over time, States became engaged in a learning-by-doing approach to refine their outreach initiatives and have adapted their outreach campaigns to close the gaps in enrolling hard-to-reach populations by modifying their target populations, messages, methods, organizational strategies, and emphasis. As a result, they shifted from broad efforts intended to establish name recognition to more targeted approaches directed at families who were eligible but not enrolled (Williams and Rosenbach, 2007).
Irvin et al. (2006) tests an approach to detecting links between SCHIP enrollment and outreach. The method is designed to detect and explain any notable gains or “outbreaks” of enrollment at both the State and Local levels. The State-level analysis assesses quarter-by-quarter changes in the number of new SCHIP enrollees. The local-level analyses identify outbreaks that may occur at particular times and in particular locations within a State, controlling for economic and sociodemographic factors. Once the outbreaks have been identified, the design then uses qualitative information from stakeholder interviews and various sensitivity analyses to determine whether the outbreaks can be linked credibly to specific outreach activities or changes in enrollment policies. The Statewide outreach campaigns associated with enrollment increases were Statewide “Back-to-School” campaigns and spillover effects to the traditional Medicaid program in Kentucky, media exposure and improved access to program information and applications in Georgia, and expanded eligibility criteria and simplified application requirements in Ohio. Local-level analyses suggested that successful strategies were comprehensive, multifaceted, and well focused. These strategies were implemented by a variety of organizations including providers, county social service offices, community-based service organizations, and faith-based groups.
Women, Infants, and Children Nutrition Program
WIC is a Federally funded non-entitlement program providing supplemental foods, nutrition education, health screening and service referrals to low income and nutritionally at risk households. WIC participants must be pregnant, breastfeeding, or non-breastfeeding postpartum women; infants up to age one; or children up to age five.
a. Participation Rates
The National Research Council estimates WIC’s coverage rate in 1998 as 51 percent. The Urban Institute estimates a rate of between 51 and 55 percent for all eligible infants and children overall. The coverage rate is higher for infants, at 79 to 93 percent, presumably because they receive larger and more comprehensive benefits. Children aged 1 to 4 are covered at a rate of 41 to 45 percent. The coverage rate for pregnant women has ranged from 64 percent in 2001 to 77.6 percent in 1998; and 69 percent of those eligible participated in 2003. A smaller proportion of eligible breastfeeding women participate in WIC compared to postpartum women who do not breastfeed; however, the proportion of eligible breastfeeding women who participate has increased over time, reaching a high of 67.4 percent in 2003. The coverage rate for postpartum women has ranged from a low of 56.7 percent in 1994 to a high of 81.9 percent in 1998; nearly 78 percent in 2003. (FNS, 2006)
b. Barriers to Enrollment
Less work has been done to study enrollment barriers and strategies for the WIC program than for the preceding programs. Many of the barriers that are discussed in reference to the WIC program have been discussed earlier in this report. Participants have a difficult time getting to the WIC clinic, and once there, they are waiting too long to be helped (Cole et al., 2001). As far as application procedures are concerned, States that require proof of income and have generally stricter program rules have lower participation rates (Bitler et al., 2002).
c. Strategies for Enrollment
The main finding shown to increase participation in the WIC program is one-on-one contacts with trusted information sources, similar to findings from the SCHIP program. Cole et al. (2001) argue that friends, family members, and health care professionals are the largest source of referrals to the program, with program advertisement having only a marginal effect. However, within the advertisement category, print ads were more effective than electronic ads.
Special Education Programs
The Individuals with Disabilities Education Act (IDEA) ensures services to children with disabilities throughout the nation. IDEA governs how States and public agencies provide early intervention, special education, and related services to more than 6.5 million eligible infants, toddlers, children, and youth with disabilities.
Infants and toddlers with disabilities (age birth to 2 years old) and their families receive early intervention services under IDEA Part C. Children and youth (ages 3-21 years old) receive special education and related services under IDEA Part B.
a. Participation Rates
The cornerstone of IDEA is the provision that all disabled children are assured the "right to a free appropriate public education” which is comprised of “specially designed instruction at no cost to parents or guardians”. The IDEA mandates a "zero reject" principle, which means that all eligible disabled children need to be identified and enrolled in the program.
b. Strategies for Enrollment
According to IDEA, States must develop and implement a comprehensive child find system that includes both State efforts to identify and locate eligible children and procedures that parents and professionals can use to refer children to early intervention or special education.
The Tracking, Referral and Assessment Center for Excellence (TRACE) aims to identify and promote the use of evidence-based practices and models for improving child find, referral, and the early identification of infants, toddlers, and preschool children with disabilities or delays as eligible for participation in IDEA Part C early intervention programs or Part B preschool special education programs. A study at TRACE examined 38 studies that investigated factors that make outreach to physicians and other primary referral sources likely to be most successful. Findings showed that four sets of factors proved most important for successful outreach:
- Building rapport and establishing credibility with physicians and other primary referral sources;
- Highlighting and repeating a focused message about the benefits of making a referral to the physician and his/her patients;
- Using concise, graphic written materials that describe the services the physicians and children will receive; and
- Making repeated follow-up visits to reinforce referrals, answer questions, and provide additional information.
Repeated follow-up visits were so important that, if not done, the other factors didn’t matter (Clow et al., 2005).
Other studies at TRACE found that providing regular feedback to primary referral sources is more likely to result in sustained referrals (Dunst et al., 2006). Tailoring printed materials targeted to a specific audience that includes a message that is especially relevant to that audience can help improve child find and increase referrals from primary referral sources (Dunst and Hamby, 2006).
Although these strategies are successful in identifying and enrolling a rare population of children in the special education programs, they are mostly not applicable to the LIHEAP program.
Lessons from Review of Other Federal Social Programs
The experience of other Federal social programs in targeting households with elderly members and/or young children furnishes extensive information on the barriers to program enrollment and the strategies that most effectively address those barriers.. Barriers include lack of awareness of programs, lack of understanding of programs because of complex eligibility rules and confusion about those rules, and procedural barriers associated with application procedures and office procedures.
One set of proposed strategies involves improved outreach activities that make target populations aware of the program, give them a good understanding of program benefits and application procedures, and reducing the stigma associated with applying for benefits. The second set of proposed strategies involves changes that make it easier for programs to enroll targeted households and for targeted households to complete applications and obtain benefits. While some of the strategies may involve additional administrative expenses, many involve changes that are expected to be cost neutral or might even reduce program administrative costs.
Summary of Findings on Barriers
All households face the same set of barriers to participation in public assistance programs. To participate in a program, a household must be aware that the program is available, must understand the program well enough to perceive that they might be eligible, must decide that the program benefits are greater than the personal and social cost of applying, and they must successful complete the application process. However, the research from other social welfare programs illustrates that those barriers manifest themselves in different ways for elderly households and young child households.
For elderly households, the research appears to show that the program participation barriers are most significant for households that have not previously made use of public assistance programs. For such households, a number of factors contribute to a lack of awareness and/or understanding of program benefits.
- Programs Targeting Households with Children – Since many programs explicitly target households with children (e.g., TANF, WIC, SCHIP), some elderly households perceive that a household without children is not eligible for the benefits provided by programs.
- Changes in Income Status – Some elderly households did not qualify for program benefits when they were working. If retirement or the loss of a spouse reduces household income enough that the household is now be eligible for benefits, it may take a significant amount of outreach to make the household aware that they are now eligible for benefits.
- Assets – Many low-income households have assets (e.g., a house or a car) that they perceive would make them ineligible for program benefits.
All of these factors can reduce the likelihood that an elderly household would perceive that it is eligible for benefits and/or make them feel that other households need the benefits more than they do. They also increase the stigma that elderly households must overcome to participate in social welfare programs.
The application barriers for an elderly household relate to the general challenges faced by elderly households. An elderly household may have difficulty getting to a program intake site, may have difficulty with crowded waiting rooms, and may be confused about where to get the necessary information or how to complete forms.
For young child households, the barriers may be somewhat different. Increasingly, low-income young child households are employed. Of the 6.4 million young child households that were income eligible for LIHEAP, over 90 percent report that they had wage income of some type.12 Specific information barriers for young child households include:
- Income – Many households believe that having wage income makes them ineligible for public assistance benefits.
- Assets – Like elderly households, many low income working households have assets such a home or a car that they may perceive make them ineligible for public assistance benefits.
- Immigration Status – If a working young child household is a legal immigrant, the household might perceive that participation in a public assistance program might affect its immigration status.
For a young child household that is working, it may be difficult for them to get time off from work to apply for benefits. If the young child household is not working, it may be difficult to bring the child to the program intake site or to get childcare.
These barriers are particularly relevant to the LIHEAP program. For most State LIHEAP programs, there is limited funding and the program tends to only be available for part of the year. If program awareness and application barriers are higher for elderly households and/or young child households than for other types of households, it will be difficult for LIHEAP to target benefits to vulnerable households, since it cannot restrict benefits to nonvulnerable households.
Findings on General Outreach and Intake Strategies
Make eligibility and other program rules clear and consistent
Many studies argue non-enrollees in social programs are unclear about whether or not they qualify for assistance. One of the main reasons for this confusion is that a household may be eligible for one public assistance program, but not for another. Even more importantly, a household who has previously been denied program benefits may be made eligible by changes in income status or changes in program eligibility criteria. For that reason, it is very important for each public assistance program to make it clear who is eligible for the program.
There are a number of reasons why these concerns are particularly relevant to LIHEAP programs. Households who live in subsidized housing sometimes have their utilities paid by other program funds. Some States have different application procedures and benefits for households with heat included in rent. So, it is important for a LIHEAP program to do whatever possible to clarify and simplify program eligibility requirements.
Reduce stigma and increase awareness through new messages and targeted outreach
Research shows elderly households are uncomfortable with several aspects of receiving assistance. They worry about losing a sense of independence and feel it reflects poorly on them to be receiving what they consider a “handout.” New messages about assistance can change these perceptions by focusing on the ways in which program participation can enable seniors to free up funds for healthy living or how program funds are deserved after a lifetime of working hard to make a living. There will be a greater likelihood of success if these messages about LIHEAP are delivered in a context separate from other assistance programs carrying a greater level of stigma, for example at senior social clubs rather than TANF offices.
Additionally, coordinating outreach activities with specialized groups helps to reach new households. For households with young children, this includes schools and day care centers, as well as immigrant organizations, faith-based institutions, and small business associations. This helps to not only gives access to targeted populations, but also to reduce any welfare stigma associated with an assistance program.
Above all, seniors respond best to one-on-one contact with personal contacts and care professionals. Rather than focusing on widespread mass mailings or media advertising campaigns, LIHEAP should encourage the already existing network of care professionals, peer leaders, friends, family, and community organizations to help make the people they serve aware of the LIHEAP program. This effort can include incentives to individuals to refer friends to the program. Any method of encouraging word-of-mouth about LIHEAP will find the most success among elderly households.
Simplify application procedures and furnish application assistance
This is a consistent finding across all programs: simplifying the application process increases eligible participation. This includes shortening the form, making questions less intrusive, requiring less document verification, and allowing categorical eligibility. While program managers will find that certain requirements are important to maintain program integrity, most social welfare programs have found that they can make changes that reduce client burden without compromising program integrity.
Application assistance is also helpful for all families, but particularly those with limited English proficiency. Some studies argue increased technology can help with this process, such as allowing online applications; while others argue face-to-face time is still key for successful enrollment. If programs allow mail-in, telephone, or online applications, hotlines greatly help with providing needed information or assistance.
Elderly households would especially appreciate large print or perhaps a separate form with only questions relevant to them. Application assistance has also proven to be especially effective in encouraging elderly households to complete the enrollment process. While increased technology may help enroll some populations, it can be especially difficult for elderly households who should be allowed to submit all materials in the more trusted paper form. State LIHEAP programs are free to create their own application procedures, so there is plenty of room for creative strategizing as some State models demonstrate.
Since LIHEAP is not an entitlement program, it must contend with limited funding. However, episodic or seasonal application procedures can be very frustrating for elderly households and low income families who do not make the deadline. The current system of one-time payments (with perhaps one or two additional payments for crisis and cooling assistance) could perhaps be modified for elderly and young child households.
Make the program more accessible through greater office flexibility and resources
Working families need flexible office hours. They also need to be able to bring their children into the office. A “family friendly” LIHEAP office would allow parents to schedule appointments in the evenings and on weekends, and make parents feel comfortable in bringing their children to these appointments to avoid the additional expense of day care.
The research also shows that program intake staff can have a big impact on how clients perceive the program. “Pro-participation” attitudes can help parents feel like they are welcome in the office, and can more help make the enrollment process more smooth and efficient. The LIHEAP program could also benefit from informing caseworkers at community organizations, including clinics, schools, malls, day care centers, and social clubs about the programs so that they can furnish reliable information and possibly application assistance to households.
It is often quite difficult for elderly households relying on public transportation to visit program offices. Once there, they may confront long lines while waiting for service. Increasing the number of office staff would enable intake to occur at “outstations” across rural counties or in various urban neighborhoods.
Staff training on elderly sensitivity and the hiring of older case workers can also help seniors feel more comfortable applying for LIHEAP assistance. It is important to keep face-to-face contact for these meetings, as elderly individuals can be intimidated by automated phone systems and online procedures.
Specific Enrollment Strategies
Increasing the Targeting Index for Elderly Households
OCS has set a performance target of increasing the LIHEAP Recipiency Targeting Index for low income elderly households. This can only be accomplished if individual LIHEAP grantees adopt strategies for increasing the enrollment of low income elderly households. Based on the information summarized above, this study identified a specific set of program outreach and enrollment characteristics that can be expected to better achieve that end:
- Outreach – Grantees need to conduct LIHEAP program outreach to ensure that more eligible elderly households are aware of the program, understand that they are eligible for the program, and understand that the benefits, including reducing health and safety risks, are significant. The literature review shows that this can best be accomplished by conducting outreach through organizations that are trusted by elderly households and using materials that are specific to the circumstances of elderly households. Examples of possible senior service organizations are Area Offices on Aging and the AARP. Materials designed for elderly households might specifically refer to income requirements for one and two person households. They might explicitly give examples of the kinds of assets that are allowable under the program. They also might furnish a number of assurances/clarifications regarding there being no need to pay back benefits or that receipt of LIHEAP does not affect their status for other assistance programs;
- Application Period – Since elderly households consistently pay their energy bills13, they are less likely to apply for benefits at the start of the heating season to get service restored or to be threatened with service termination for nonpayment of high winter bills. As a result, those elderly households that need assistance (i.e., have high energy burden but not high arrearages) may find that benefits are no longer available when they become aware of the program and decide to apply. It may be appropriate to establish a special benefit period (preenrollment period) for elderly households. Alternatively, grantees could allow service organizations that serve elderly households to accept LIHEAP applications throughout the year and thereby build up the applicant pool for elderly households;
- Application Procedures – Grantees might make it easier for elderly households to apply for LIHEAP by developing special application forms for households that contain only elderly individuals or elderly couples. By doing so, they could eliminate many questions that are not relevant to such households and thereby make the whole process less intrusive and time consuming for elderly households. Grantees also might partner with senior service organizations to either assist elderly households in completing forms or to certify elderly households for eligibility. Recent FSP literature suggests that simplifying applications and furnishing application assistance is particularly important for households with individuals that are age 70 or older;
- Recertification Procedures – Many elderly households are on fixed incomes and therefore remain eligible for LIHEAP benefits from year to year. For such households, it may be appropriate to have special intake procedures that ask the household to update information furnished in the previous year, rather than require the household to complete a new intake form. By retaining those elderly households that have enrolled in LIHEAP previously, it may be easier for grantees to increase the total number of elderly households receiving LIHEAP; and
- Benefits – In general, elderly households are smaller than nonelderly households. If a State uses a benefit matrix that includes household size, it is possible that elderly households get lower benefits than nonelderly households.14 A LIHEAP grantee may be able to encourage more elderly households to participate in the program by increasing benefits for elderly households taking into account needs that are especially significant to elderly households, such as medications and other medical expenses.
Such practices are likely to increase the total number of elderly households successfully applying for LIHEAP and increase the total population of elderly household recipients over the long run.
Increasing the Targeting Index for Young Child Households
OCS has set a performance target of maintaining the level of the LIHEAP Recipiency
Targeting Index for young child households. However, over the last several years, the share of young child households participating in the program has declined. This study hypothesizes that this decline has occurred because more young child households are leaving public assistance and becoming working low income households, and that some income eligible young child households are legal immigrants who worry that applying for public assistance can affect their immigration status. To reverse this decline, grantees will need to reach out to working low income households that have children:
- Outreach – Grantees need to conduct LIHEAP program outreach to make low income young child households aware of the program, understand that they are eligible for the program, and understand that the benefits are significant. From the literature review, it appears that this can best be accomplished by conducting outreach through organizations that are used by such households, including Head Start programs and community health centers. Materials designed for working young child households might specifically refer to any work-related expenses that are deducted from gross income prior to eligibility determination. Such informational materials might give explicit examples of the kinds of assets that are allowable under the program, including cars and homes. Recent SCHIP analysis suggests that, when there is broad awareness of the program, targeted outreach campaigns can be very effective in reaching population groups that are participating at lower rates. To the extent that the recent declines in targeting indexes among young child households relate to changes in the demographics of those households (i.e., more working families and/or more recent immigrants), targeted outreach to those groups might help to reverse the decline in the targeting index;
- Application Period – In recognition of the special needs of these households, grantees might offer a special pre-enrollment period, particularly so that households with young children can avoid the long lines that might accompany the start of the LIHEAP enrollment period; and
- Application Procedures – Grantees might make it easier for young child households to apply for LIHEAP by identifying special times of the day or special days of the week when child care is available, to make the process easier for both the applicant and the intake worker. Alternatively, grantees might send the intake worker on location to a day care center or community health center.
Such initiatives might reverse the decline in the rate at which young child households apply for LIHEAP and receive benefits.