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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

EXPERIENCES OF SELECTED FEDERAL SOCIAL WELFARE PROGRAMS AND
STATE LIHEAP PROGRAMS IN TARGETING
VULNERABLE ELDERLY AND YOUNG CHILD HOUSEHOLDS

December, 2008

FINAL REPORT

This document has been prepared for the Office of Community Services' Division of Energy Assistance by APPRISE Incorporated under contract #HHSP23320070081P.  The statements, findings, conclusions, and recommendations are solely those of analysts from APPRISE and do not necessarily reflect the views of HHS.

Table of Contents

I. Introduction
A.           Needs of Vulnerable Households
B.           Need for the Study
C.           Other Federal Social Welfare Programs
D.           State LIHEAP Programs

II. LIHEAP Targeting Performance
A.           LIHEAP Targeting Goals
B.           LIHEAP Targeting Rates and Trends
C.           LIHEAP Targeting Initiatives
D.           LIHEAP Targeting Issues

III. Targeting Overview
A.           Targeting Background
B.           Current Targeting Trends and Issues

IV. Analysis of Social Programs – Findings and Recommendations
A.           Overview of Method
B.           General Population Programs
C.           Programs Targeting the Elderly
D.           Programs Targeting Children

V. Lessons from Review of Other Federal Social Programs
A.           Summary of Findings on Barriers
B.           Findings on General Outreach and Intake Strategies
C.           Specific Enrollment Strategies

VI. Research on State LIHEAP Targeting Procedures
A.           Information Objectives
B.           Findings for Targeting Elderly Households
C.           Findings for Targeting Young Child Households
D.           Summary of Findings on State LIHEAP Outreach and Intake Practices
E.            Linkages between Program Design and Targeting Outcomes

VII. Recommendations
A.           Baseline Assessment
B.           General Outreach
C.           Specific Outreach and Intake Strategies

Bibliography

Footnotes

Appendix A – Survey Instrument

Listing of Tables

Table 3-1 - Federal Means-Tested Programs’ Targeting Procedures
Table 4-1 - Participation Rates for Individuals by Household Benefit as a Percentage of Maximum Benefit, FY 2005
Table 4-2 - Barriers to Medicaid Enrollment
Table 4-3 - How Respondents Learned about the Medicare Savings Programs
Table 6-1 – Outreach Through Agencies Serving Elderly
Table 6-2 – Outreach Materials Targeting Elderly
Table 6-3 – Outreach Materials with Benefit Amount
Table 6-4 – Outreach to Elderly Program Participants
Table 6-5 – Screen Programs Serving Elderly.
Table 6-6 – Special Application Period for Elderly
Table 6-7 – Special Application Requirements for Elderly
Table 6-8 – Alternative Intake Sites or Procedures for Elderly
Table 6-9 – Application Assistance for Elderly Households
Table 6-10 – Higher Benefit for Elderly Households
Table 6-11 – Outreach Through Agencies Serving Young Children
Table 6-12 – Outreach Materials Targeting Working Families
Table 6-13 – Outreach Materials Targeting Immigrant Families
Table 6-14 – Outreach to Young Child Participants of Other Programs
Table 6-15 – Screen Programs Serving Young Child Households
Table 6-16 – Special Application Period for Young Child Households
Table 6-17 – Special Application Locations for Young Child Households
Table 6-18 – Higher Benefit for Young Child Households

Listing of Acronyms

AARP....................... American Association of Retired Persons
ACF...........................Administration for Children and Families
AOA..........................Area Office on Aging
CCDF........................Child Care and Development Fund
CMS..........................Centers for Medicare and Medicaid Services
CPS-ASEC................Current Population Survey-Annual Statistical and Economic Supplement
DHHS........................U. S. Department of Health and Human Services
ED.............................U. S. Department of Education
EITC..........................Earned Income Tax Credit
FSP............................Food Stamps Program
GAO..........................U. S. Government Accountability Office
GPRA........................Government Performance and Results Act
HUD..........................U. S. Department of Housing and Urban Development
IDEA.........................Individuals with Disabilities Education Act
IRS............................Internal Revenue Service
LIHEAP....................Low Income Home Energy Assistance Program
MSP..........................Medicare Savings Program
NPE..........................Nutrition Programs for the Elderly
OMB.........................Office of Management and Budget
PART....................... Program Assessment Rating Tool
QMB.........................Qualified Medicare Beneficiary
SCHIP.......................State Children's Health Insurance Program
SIPP..........................Survey of Income and Program Participation
SLMB.......................Specified Low-Income Medicare Beneficiary
SSA...........................Social Security Administration
SSI............................Supplemental Security Income
TANF.......................Temporary Assistance for Needy Families
TRACE.....................Tracking, Referral, and Assessment Center for Excellence
USDA........................U. S. Department of Agriculture
WAP..........................Weatherization Assistance Program
WIC...........................Women, Infant, and Children Nutrition Program


 

Introduction

The Low Income Home Energy Assistance Program (LIHEAP) Statute requires that grantees “provide, in a timely manner, that the highest level of assistance will be furnished to those households which have the lowest incomes and the highest energy costs or needs in relation to income, taking into account family size” (LIHEAP Statute, Section 2605(b)(5)).  The LIHEAP statute identifies “vulnerable households” (i.e., households with at least one member that is a young child, an individual with disabilities, or a frail older individual) as one of two groups of households having the highest home energy needs.  To address that mandate, the Administration for Children and Families (ACF), which administers the LIHEAP program, has focused its performance goals and measurement on targeting income eligible vulnerable households --particularly households with at least one member 60 years or older and households having at least one member 5 years or younger. 
However, despite outreach and targeting efforts undertaken by ACF, the measured program targeting rates for vulnerable households have declined over the last three years.  The purpose of this two-phase study is to develop information that can help State LIHEAP programs more effectively target eligible vulnerable households. The first phase reviewed the experience of other Federal social welfare programs in targeting vulnerable households to assess whether they have identified strategies that are effective in reaching elderly households and/or young child households.  The second phase examined the design of the LIHEAP programs in 17 States to assess whether certain program design features were associated with higher targeting rates for vulnerable households.1

Needs of Vulnerable Households

1.  Elderly Households
A report by the Federal Interagency Forum on Aging Statistics illustrates the challenges faced by people age 65 and over (Federal Interagency Forum on Aging Statistics, 2006) regarding:

  • Poverty:  About 9.8 percent of all people age 65 and over lived in poverty during 2004.  Poverty rates were 12.6 percent for seniors age 85 and older.
  • Housing Costs: For elderly households in the lowest income quintile,(i.e., households in the bottom 20 percent of the income distribution), the percent of income allocated to housing costs increased from an average of 33 percent of income in 1987 to over 40 percent of income in 2002.
  • Chronic Health Conditions:  In 2004, 50 percent of individuals over age 65 reported having arthritis; 52 percent reported having hypertension; 32 percent reported having heart disease; 21 percent reported having cancer; and 17 percent reported having diabetes.
  • Health Care Expenditures:  For elderly households (age 65 and older) with income at or below 125 percent of poverty, the percent of income spent on out-of-pocket medical expenses increased from 16 percent in 1987 to 28 percent in 2003.

These statistics demonstrate two important challenges facing elderly households. The share of income that elderly households spend on housing costs and out-of-pocket health care expenditures has increased substantially in the last two decades.

Many research studies have found that the elderly are most at risk for adverse health impacts due to cold temperatures (Kalkstein et al. 1989).  Older individuals have the greatest risk for hypothermia because they have a lower metabolic rate that may prevent them from maintaining normal body temperatures. Certain medications make individuals more susceptible to the cold, and the elderly are more likely to take many medications.  Additionally, individuals with medical conditions, including congestive heart failure, diabetes, or gait disturbance, have an increased risk for hypothermia.  Individuals with these conditions are less able to generate heat (CDC, Morbidity and Mortality Weekly, 2005). 

The elderly also are more susceptible to heat stroke (CDC, MMWR, 1996).   The elderly are at greater risk because they have a reduced ability to control their body temperature.  The poor and the socially isolated are also at increased risk for heat-related fatality (McGeehin et al. 2000). Individuals with diseases including ischemic heart disease, stroke, or respiratory illness are at the greatest risk for heat-related death.  This is because during periods of intense heat, the stress on the cardiovascular and respiratory systems increases (Basu et al. 2002).

2.  Young Child Households
Statistics from the National Center for Children in Poverty document the economic status of children under age 6 (Douglas-Hall and Chau, 2007):

  • Incidence of Poverty:  There are about 24.4 million children under age 6 in the United States.  About 5.0 million (20%) live in families that have income at or below poverty.  About 10.4 million (43%) live in families that have income at or below 200% of poverty.
  • Poverty Trends:  Between 2000 and 2006, the number of children under age 6 who live in families that have income at or below poverty increased by 18 percent.
  • Family Structure:  Half of the 10.4 million low income children live in a family with a single parent.
  • Residential Instability:  About 22 percent of children under age 6 who live in low income families moved in the last year, compared to only 12 percent of children under age 6 in non-low income families.

Similar to the findings for elderly households, studies find that children under one year old are at risk for serious consequences from prolonged exposure to home temperatures that are either too cold in the winter or too hot in the summer.  In addition, the Children’s Sentinel Nutrition Assessment Project (C-SNAP) study (Frank, 2006) established an association between energy costs and nutrition for young children. The study concluded that “after adjustment for differences in background risk, living in a household receiving the Low Income Home Energy Assistance Program is associated with less anthropometric evidence of undernutrition, no evidence of increased overweight, and lower odds of acute hospitalization from an emergency department visit among young children in low-income renter households compared with children in comparable households not receiving the Low Income Home Energy Assistance Program.” (Frank, 2006)

Need for the Study

The LIHEAP Home Energy Notebook for FY 2006 reports that 34.4 million households were income eligible for the LIHEAP program in Fiscal Year (FY) 2006, i.e., had income at or below the Federal LIHEAP maximum income standard.  In that same year, the LIHEAP program furnished winter heating and crisis benefits to about 5.7 million households, about 17 percent of the income eligible households.  Federal funding of LIHEAP is primarily the limiting factor in LIHEAP program participation; in FY 2006, funding for LIHEAP totaled $3.1 billion, and of that amount, States furnished about $2.1 billion in heating and winter crisis benefits with an average benefit of about $368 for the heating and crisis assistance recipients

Given the limitation on Federal LIHEAP funding, the LIHEAP Statute requires LIHEAP grantees to “provide, in a timely manner, that the highest level of assistance will be furnished to those households which have the lowest incomes and the highest energy costs or needs in relation to income, taking into account family size.” (LIHEAP Statute, Section 2605(b)(5)).  The LIHEAP Statute identifies two groups of low income households as having the highest home energy needs:

  • Vulnerable Households: Vulnerable households are those with at least one member that is a young child, an individual with disabilities, or a frail older individual.
  • High Energy Burden Households: High energy burden households are those households with the lowest incomes and the highest home energy costs.

Based on national LIHEAP program goals, ACF has focused its performance goals and measurement on targeting income eligible vulnerable households and income-eligible high burden households.  However, performance measurement statistics have shown that the LIHEAP program has failed to meet performance targets during the period from FY 2003 through FY 2006.  In fact, the targeting performance measures for both elderly households and young child households declined during that time period.2

ACF needs to develop strategies that can increase the level of LIHEAP participation by vulnerable population groups.  This study researched other Federal social welfare programs that have targeted vulnerable population groups and assessed whether the programs developed outreach and/or targeting strategies that increased program participation for vulnerable households.  It also examined the design of LIHEAP outreach, intake, and benefit determination for the LIHEAP programs in 18 States to assess what design characteristics, if any, are associated with higher targeting of vulnerable households.

Other Federal Social Welfare Programs

This study of other Federal social welfare programs develops information from two sources:  a literature review and interviews with program manager contacts:

Literature Review

The primary analytic procedure employed in this study involved a literature review of outreach and targeting in a sample of means-tested Federal social welfare programs with recipiency groups similar to that of LIHEAP.  A variety of sources were consulted including: websites of the major Federal means-tested programs; websites of national organizations that study the needs of elderly households, young child households, and low income households; and academic journals.

This study included literature on the following two types of means-tested programs.

  • General Population Programs – Some programs, like LIHEAP, are available to all income-eligible households.  For these programs, the literature review looked at whether the program targeted vulnerable households and whether any national or State-level initiatives have been effective at increasing targeting of households with elderly members or young children.  It also considered whether any general outreach initiatives have increased the participation rate of households with elderly members or young children, even if the rate did not increase as much as for other types of households.
  • Targeted Programs – Other programs are only available to households with elderly members or children, including some that are only available to households with young children.  For those programs, the literature review determined whether the program has attempted to increase program participation rates and whether any specific strategy has been effective at increasing participation among households with elderly members or young children.

Program Contacts

Not all social welfare program statistics and initiatives are documented in the literature.  Once the literature review was complete, this study involved contacting the program managers of key Federal social welfare programs, including:  Food Stamps, Supplemental Security Income (SSI), Medicaid, Medicare Savings Program, State Children's Health Insurance Program (SCHIP), Women, Infant, and Children Nutrition Program (WIC), Nutrition Programs for the Elderly, Maternal and Child Health Programs, Head Start Program, and Special Education Programs to identify additional statistics and/or outreach initiatives that are not yet documented.

State LIHEAP Programs

LIHEAP statistics demonstrate that individual State LIHEAP programs vary substantially in targeting rates.3  The elderly targeting rates using State LIHEAP maximum income standards varied from a low of 31 to a high of 221 in FY 2006. (For FY 2006, the national recipiency targeting index for elderly households was 74.) The young child targeting rates for FY 2006 varied from a low of 33 to a high of 234.  (For FY 2006, the national recipiency targeting index for young child households was 115.) Since States have considerable flexibility in the design of their LIHEAP programs as LIHEAP is a block grant program, it is reasonable to consider that the higher targeting rates in some States may be associated with certain unique program design characteristics.

This study reviewed the FY 2006 targeting statistics to identify nine States that were high, moderate, and low on their elderly targeting rates and nine States with that were high, moderate, and low on their young child targeting rates.  For each group of States, researchers contacted the State LIHEAP Directors and asked questions about the design of outreach, intake, and benefit determination procedures.  The study then included analysis to assess what program designs appeared to be associated with high targeting outcomes for elderly households and what program designs appeared to be associated with high targeting outcomes for young child households.

LIHEAP Targeting Performance

This section of the report describes the LIHEAP targeting goals and the performance of the program with respect to those goals.  LIHEAP uses recipiency targeting indexes to measure the extent to which elderly households and young child households receive program benefits.  The performance goals for LIHEAP are to increase the national targeting index for elderly households and to maintain the national targeting index for young child households.  Between FY 2004-2006, targeting indexes have fallen for both groups.  In addition to the targeting initiatives undertaken by the Federal LIHEAP office, additional efforts need to be undertaken by LIHEAP grantees to improve targeting performance under the LIHEAP block grant.

LIHEAP Targeting Goals

Section 2605(b)(5) of the LIHEAP Statute requires States to provide that, “the highest level of assistance will be furnished to those households which have the lowest incomes and the highest energy costs or needs in relation to income… .”  “Highest home energy needs” refers to both high energy burden and the presence of members of vulnerable populations in the household, including young children, individuals with disabilities and frail elderly individuals (LIHEAP Statute, Section 2603(4)).

In response to the Government Performance and Results Act (GPRA) and the Office of Management and Budget’s (OMB) Program Assessment Rating Tool (PART), the LIHEAP program tracks the targeting indexes for households with vulnerable members in accordance with the statutory language and performance goal of providing services to these households at a greater rate than what they represent in the low income household population.

The annual recipiency targeting indexes measure this rate of service by dividing the percent of LIHEAP recipient households that are members of a target group by the percent of all LIHEAP income eligible households that are members of the target group and then multiplying by 100.  For example, if 25 percent of LIHEAP recipient households are elderly and 20 percent of LIHEAP income eligible households are elderly, the recipiency targeting index for elderly households is 125 (100 * (25 / 20)).  

An index above 100 means the LIHEAP program is effectively reaching the target group at a rate higher than its representation in the low income household population.  The long-term goal of the LIHEAP program set for FY 2010 is to increase the annual national recipiency targeting index to 96 for households with an elderly individual and to 122 for households with a young child.  For the purpose of this study, high, moderate, and low recipiency targeting thresholds were established.4  A State has a high elderly recipiency targeting index if the index is greater than or equal to 100, a moderate index if it is greater than or equal 80 but less than 100, and a low index if it is less than 80.  A State is considered to have a high young child recipiency targeting index if the index is greater than or equal to 120, a moderate index if it is greater than or equal 100 but less than 120, and a low index if it is less than 100. 

LIHEAP Targeting Rates and Trends

In FY 2006, the elderly recipiency targeting index at the national level was 74. This means the LIHEAP program underserves these households by providing services at a rate substantially lower than their representation in the low income household population.  This number is also a statistically significant decrease from the previous three years, during which the targeting rate for these households maintained some stability at around 79.  The goal of increasing the targeting index for households with at least one member age 60 or older to 96 by FY 2010 will require substantial and widespread initiatives designed to better inform and enroll these households.

Also in FY 2006, the young child recipiency targeting index at the national level was 115.  This means that the LIHEAP program targets these households by providing services at a rate substantially higher than their representation in the low income household population.  This FY 2006 number is lower than the benchmark young child recipiency targeting index of 122 established in 2003.  As it is unknown why this rate has declined from a high of 122 in FY 2003, there is incentive to investigate potential barriers to enrollment for these households as well as strategies to help reach the goal of 122 by FY 2010.

LIHEAP Targeting Initiatives

Section 2605 (b)(3) of the LIHEAP Statute mandates States, “conduct outreach activities designed to assure that eligible households, especially households with elderly individuals or disabled individuals, or both … are made aware of the assistance available under this title.. .”  According to the 2001 LIHEAP Clearinghouse document, Outreach and Enrollment Strategies for LIHEAP, outreach is defined as, “the various activities LIHEAP providers engage in to promote and increase program awareness with an attendant goal of increased program enrollment. Outreach may also include outreach activities designed to reach and enroll certain populations.” (NCAT, LIHEAP Clearinghouse, 2001).

The LIHEAP Model Plan asks States to report on their outreach activities by declaring whether or not they engage in the following:  providing intake through home visits; placing posters in local social service offices and articles in local newspapers; sending mass mailings to past LIHEAP recipients; and working with other low income programs to encourage referrals and generate access to target groups.  This is a somewhat varied assortment of activities, ranging beyond traditional information distribution.  This indicates that the efforts of the LIHEAP program to increase enrollment of the two target populations can, and should, go beyond the limited mandate of just increasing awareness of those groups.

In 2004, ACF initiated a nationwide LIHEAP outreach campaign focused on the distribution of OCS’ LIHEAP brochure.  ACF furnished brochures to the Administration on Aging so that they could distribute them to their network of service provider. Since this initial campaign, there have been ongoing exploratory efforts in the form of teleconferences with other agencies to learn how to effectively reach vulnerable populations.  In 2007, ACF began an ongoing collaboration with the Head Start Bureau to conduct outreach to Head Start staff at the Federal, State, and Local levels.  There is considerable room for expanding these efforts to understand how complementary programs increase enrollment and how these lessons can be applied to the LIHEAP program. 

LIHEAP Targeting Issues

Sometimes the goal of targeting vulnerable populations can be difficult when a program is faced with multiple competing constraints.  LIHEAP directors may sometimes feel these constraints make outreach a double-edged sword.  If a program engages in too much outreach, it may lead to long lines, people being turned away, smaller benefits or overworked staff.  If a program engages in too little outreach to targeted populations, it risks failing to meet the needs of the most vulnerable households.

Add to this the fact that in 2002, over 70 percent of all income eligible households contained at least one vulnerable member (APPRISE, 2004).  In a situation in which the sizeable majority of people in the general low income population are members of a targeted group, it can be difficult to understand why special efforts are needed to reach such a group —especially if that means potentially excluding nonvulnerable groups from the program.  Upon closer examination, however, certain vulnerable groups, such as elderly households, are in fact being significantly underserved; while other vulnerable groups, such as those with young children, are decreasing in relative participation.  Though the overall percentage of vulnerable households in the income eligible population is high, these groups are not enrolling in the program at levels that meet the LIHEAP performance goals.  As LIHEAP updates its performance goals, it might consider whether it is becoming more difficult to reach these targeting goals because of exogenous changes that are making it more difficult to reach the targeted populations.

LIHEAP program managers from eight States with high, moderate, and low elderly household recipiency targeting indexes were interviewed. LIHEAP program managers from nine States with high, moderate, and low young child household recipiency targeting indexes were interviewed. The interviewed program managers were from Arizona, Delaware, District of Columbia, Georgia, Iowa, Kentucky, Maine, Michigan, Nebraska, New Mexico, New York, Ohio, Rhode Island, South Dakota, Texas, Washington, and Vermont.  The researchers and ACF appreciate the responses and insights furnished by the program managers. The statements, findings, conclusions, and recommendations are solely those of analysts from APPRISE and do not necessarily reflect the views of ACF or of the responding State LIHEAP program managers.

The decline in both the elderly recipiency targeting index and the young child recipiency targeting index was statistically significant at the 95% confidence level.

See Section II.A for a definition of a recipiency targeting rate and for information on how high, moderate, and low targeting rates were assigned.

For both groups, States with targeting indexes at or above 100 are considered to be targeting the population group.  For elderly households, the States with indexes below 100 are further divided into those with indexes above the national average recipiency targeting index and those below the national average.  For young child households, the States with indexes above 100 are further divided into those with indexes above the national average recipiency targeting index and those with indexes below the national average.

Targeting Overview

This section of the report discusses targeting by other Federal social welfare programs.  It identifies how these programs define targeting and why it is important to such social welfare programs.  It examines targeting trends over the last decade.  A 2005 study by the U.S. Government Accountability Office (GAO) is particularly valuable in identifying which Federal means-tested programs consider targeting to be an important policy goal (GAO, 2005).

Targeting Background

Definition and Basic Procedures

For purpose of this study, targeting is defined as the process by which programs, according to their specified goals, attempt to provide access to services for particular population groups.  Examples of the most common target populations include households with children, elderly members, or members with disabilities.  Some programs will also target other groups such as immigrants and “able-bodied adults without dependents.”

The process of targeting involves three basic steps:

Step One:  The first step is to define a targeted group according to the needs of program and estimate that group’s participation patterns.  The participation rate is defined as the number of program enrollees belonging to the targeted group over the number of eligible people belonging to that group.5  Is that group’s participation high or low?  Has it been increasing, decreasing, or remaining stable over the years?  How does this compare with program goals?

ACF uses a LIHEAP targeting index to assess the targeting level for each household group.  The targeting index is the ratio of the percentage of LIHEAP recipients who are members of a target group over the percentage of all income eligible households that are members of the target group. The advantage of using the targeting index is that it tracks both changes in the participation rate of each household group and the share of the eligible population that group represents.  For example, LIHEAP recipient data might show an increase in the percentage of recipients who are households with elderly members, but the percent of eligible households that are elderly also might be increasing.  The targeting index accounts for both factors.

Step Two:  Once the program has an estimate of targeted group participation patterns, the second step is to explore the reasons behind these patterns.  Many programs conduct focus groups with participants and nonparticipants from the targeted population.  These focus groups elicit in-depth information on the barriers households face in obtaining access to the program.  Focus groups also provide the program with strategy suggestions for removing these barriers.  To test the significance of these barriers and strategies, programs will either conduct their own surveys or use readily available national data to develop statistical models. 

Step Three:  The final step is to report the findings of these tests and adjust program procedures as necessary and feasible.

Purpose

There are two main reasons behind tracking program targeting rates.  The first is to improve program access and the second is to improve program integrity.

Program Access
Program access means households are aware of the program, can get information on it and are able, if they wish, to enroll without too much difficulty (Bartlett et al., 2004).  There is an important distinction between this definition of access and the activities currently required by the LIHEAP Statute.  Section 2605(b)(3) of the LIHEAP Statute requires programs to make sure that, “eligible households, especially households with elderly individuals or disabled individuals, or both, and households with high home energy burdens, are made aware of the assistance available under this title.”    Program access moves beyond general awareness such as this, in order to take into account the ease of obtaining accurate information and of applying to the program.

Program Integrity
Improving program integrity is a very different, and sometimes contradictory, reason for tracking participation rates.  Program integrity is generally understood as the proportion of enrolled individuals who are actually eligible for the program.  This has received relatively more attention from Federal agencies in recent years as a result of several widespread monitoring efforts.  The Improper Payments Information Act of 2002 spurred many agencies to allocate resources toward identifying the extent of non-eligible participation.  This Act, in conjunction with OMB guidance, requires agencies to review programs and identify those with significant potential for incorrect payments in order to report those estimated payments to Congress.

These two goals may at times be in conflict.  Efforts to increase program access by casting a wider net may inadvertently decrease program integrity by encouraging the participation of those who are ineligible.  Likewise, efforts to increase program integrity by ratcheting up requirements may in fact shut out those who are actually eligible for participation.  However, there are some strategies proven to address both goals at once.  Streamlining applications, for example, can increase program access by making the application process less daunting and increase program integrity by reducing errors resulting from complex forms.  In any strategy designed to target populations, both access and integrity need sufficient consideration.

Current Targeting Trends and Issues

Trends

There is no consistent type or level of targeting across Federal means-tested programs.  Each program offers different services to low income populations; sometimes they are focused on delivering services to particular segments of the population and sometimes not.  If programs do track the participation of certain groups, they also vary on the extent of analysis and reporting.  Therefore, there is a wide span of program procedures regarding targeting ranging from some that measure, analyze and report on participation rates in detail to those that do not track participation at all.

The following table summarizes the GAO findings (GAO, 2005, p 45).

Table 3-1 - Federal Means-Tested Programs’ Targeting Procedures


Agency

Program

Estimate participation/ coverage rate?

Use as performance measure?

Include in performance report?

U.S. Department of Agriculture (USDA)

Food Stamps

Yes

Yes

Yes

WIC

Yes

No

No

U.S. Department of Health and Human Services/ Administration for Children and Families (ACF)

TANF

Yes

No

No

CCDF

Yes

No

No

Head Start

Yes

No

No

Internal Revenue Service (IRS)

EITC

Yes

No

No

HHS Centers for Medicare and Medicaid Services (CMS)

Medicaid

No

No

No

SCHIP

No

No

No

Social Security Administration (SSA)

SSI

No

No

No

U.S. Department of Education (ED)

Pell Grant

No

No

No

U.S. Department  Housing and Urban Development (HUD)

Public Housing

No

No

No

Housing Voucher

No

No

No

According to the GAO Report (GAO, 2005), USDA included program participating rates for the Food Stamps Program in its program performance report.  In addition, USDA planned to report WIC program participation rates in its upcoming program reports and HHS/ACF reported childcare coverage rates for its CCDF Biennial Report to Congress.  No other programs were found to report on program participation rates or coverage rates.
On the other end of the spectrum, the HHS Centers for Medicare and Medicaid Services (CMS), which administers the Medicaid and State Child Health Insurance Program (SCHIP), did not regularly track participation/coverage rates.  Since the GAO report, however, there have been many efforts to track SCHIP’s performance in light of congressional efforts to limit or eliminate SCHIP funding.  The Social Security Administration (SSA) did not regularly track participation rates for Social Security Insurance (SSI), nor did the Department of Education (ED) for the Pell Grant or Department of Housing and Urban Development (HUD) for the Public Housing or Housing Choice Voucher programs. 
ED and HUD did track alternative performance rates, namely “take-up”--which measures the number of those eligible applicants who received a grant--and “utilization”--which measures the number of recipients who are able to redeem their vouchers. The measure of “take-up” is appropriate for programs where all funding is not expended.  In such programs, policy analysis would look at who is eligible for the program and try to identify barriers to applying for program benefits when there are funds available.  The measure of “utilization” also is somewhat different from targeting.  In the Housing Voucher Program, some households apply for and receive vouchers, but are unable to redeem those vouchers.  For that program, the policy analysis needs to consider barriers to using the vouchers for housing that the household has selected.

Issues

The first issue to address when comparing targeting performance across programs is the difference between entitlement and non-entitlement programs.6  Faced with limited funding, non-entitlement programs necessarily have a lower coverage rate than entitlement programs.  According to the GAO, entitlement programs’ participation rates range from 50 to 70 percent, while non-entitlement programs’ coverage rates range from 10 to 50 percent of the eligible population.  Any performance goals need to consider this disparity.
The second issue affecting the analysis of targeting rates is the fact that for most programs it is quite difficult to accurately measure the eligible population.  This difficulty stems from two problems in the analysis process.  The first problem is the confusion of eligible individuals when they self-report participation in various programs.  SSA argues many survey respondents confuse SSI with Social Security, leading to significant overestimates of program participation. 
The second problem is complex program eligibility requirements that prevent analysts from accurately estimating the numbers of program-eligible households.  For example, CMS notes that eligibility rules for Medicaid and SCHIP vary across States by several criteria, including age, income, assets, and geographic area.  It is therefore difficult and expensive to conduct separate calculations for each State program.  Estimating the population eligible for the Earned Income Tax Credit (EITC) in order to create participation rates is also difficult due to the level of detail needed in the data to estimate the number of qualifying household members.
This relates to another set of problems arising from the limitations of national survey data.  The Current Population Survey Annual Statistical and Economic Supplement (CPS-ASEC) includes some demographic and program participation information, but not necessarily all that is needed to accurately estimate the eligible population.  For instance, the CPS-ASEC does not include some important assets data and leaves out individuals who are institutionalized.  The Census Bureau’s Survey of Income and Program Participation (SIPP) has more detailed information, but is designed as a panel study and is therefore more useful as an indicator of movement through a program rather than of annual participation.7  Some program estimates, such as those for the Pell Grant, must rely on limited data only available outside the confines of these two national surveys.  Research methodology can adjust for these missing data, but methodology differs among evaluating organizations leading to different estimates of program participation.


 

Analysis of Social Programs – Findings and Recommendations

This section of the report presents information on the findings and recommendations from the research on targeting in other Federal social welfare programs.  It describes the procedures used for identifying literature on targeting of elderly households and young children households, and summarizes the literature for those social programs that have addressed the issues of targeting.  It looks separately at general population programs, programs that specifically serve the elderly, and programs that specifically serve young children.  It finds that only a few programs have focused significant research efforts on program targeting.  However, the information available from those programs that have studied targeting furnishes valuable insights for the LIHEAP program.

Overview of Method

The literature review included a variety of sources, including relevant reports available online from Federal and State program websites, evaluator websites, and other complementary sources.  This search yielded a great deal of information on program targeting activities, as well as bibliographic references for other research.  The search also included accessible databases for academic peer-reviewed literature.  The academic articles were less helpful due to their focus on finding general associations between demographics and participation rates rather than exploring details of targeting strategy success and failure.
This search looked both for subject coverage across sources and lines of study within groups of sources.  For example, a wide variety of sources and programs touched upon stigma as a barrier to enrollment, but a narrower set of literature discussed the relatively new Medicare Savings Programs in order to study their immediate effects or SCHIP in order to address the possibility of continued funding.  Complying with standard procedure for a literature review, the search continued until a particular inquiry was exhausted or repeated themes in the information gathered were found.
Research focused on the major programs serving elderly households and households with young children.  The general population programs included: Food Stamps (FSP), Medicaid, Housing Vouchers, and the Weatherization Assistance Program (WAP). The programs specifically serving elderly households included: the Medicare Savings Programs, SSI, and the Nutrition Programs for the Elderly (NPE).  The programs specifically serving households with children included:  EITC, WIC, Head Start, and SCHIP.  There was a wide range in the levels of information available on these different programs.  There is very little written about some programs’ targeting activities, but a great deal on others.  This initial finding is in concert with the findings of GAO Report discussed in Section III.  The literature review found:

  • General Population Programs
    • FSP estimates a participation rate, uses it as a performance measure, includes it in its performance reports, and has a substantial body of literature exploring all the different facets of program participation and targeting;
    • Medicaid and SCHIP taken together as jointly administered programs by CMS have recently been the subject of a series of evaluations and reports.
    • The Housing Choice Voucher Program does not estimate a participation rate, but does monitor the “utilization rate,” or the rate at which voucher recipients are able to redeem benefits.  It therefore does not have an accompanying literature on participation barriers and strategies. 
    • Searches for information on WAP did not yield very much information.
  • Programs Serving Elderly Households
  • The Medicare Savings Programs, namely the Qualified Medicare Beneficiary (QMB) and Specified Low income Medicare Beneficiary (SLMB) programs, have a somewhat moderate set of studies exploring the response of the elderly population to these relatively new programs. 
  • SSI has a much smaller set of literature, likely owing to the fact that the SSA does not regularly estimate participation rates. 
  • The Elderly Nutrition Program, like the Weatherization Assistance Program, was not included in the GAO analysis and generates few studies, likely resulting from a small budget.
  • Information on the EITC participation rate was available, but there was no literature that examined the reasons for differences in participation by demographic groups.
  • WIC has limited targeting literature, likely owing to the fact that participation rates are not used as a performance measure.
  • For Head Start, very little has been written on participation rates.
  • Programs Serving Households with Children

Given these assets and limitations, the comparative analysis is focused on two programs for the general population:  Food Stamps, with analysis for both populations, and Medicaid, with analysis for children only.  The analysis also focuses on three programs targeted to households with elderly members or children, i.e., the Medicare Savings Programs, SCHIP, and WIC.

General Population Programs

Food Stamp Program

The FSP is a Federally-funded entitlement program providing low income households the means to buy food at retail stores through the use of electronic benefit cards.  The USDA administers the program and is responsible for program design, including levels of availability, eligibility and benefits.  As a means-tested program, FSP requires participants to meet certain income and resource thresholds.  Participants must also be U.S. citizens or eligible noncitizens, and all “able-bodied adults without dependents” must be employed or take part in an employment and training program.  In the late 1990s, the number of households participating in the FSP and the percent of eligible households participating declined significantly (Bartlett, 2004).8  As a result, there has been considerable research on FSP participation in the last decade.
a. FSP Participation
In 2001, the Urban Institute estimated the overall FSP participation rate to be between 46 and 48 percent.  They estimated the participation for households with elderly members to be between 27 and 28 percent and for households with children to be between 55 and 57 percent (GAO, 2005).  A recent study by Mathematica Policy Research (Wolkwitz, 2007) gives a similar overall estimate of the participation rate at about 48 percent in 2001.  The Wolkwitz paper also produced participation rates for FY 2005, estimating overall participation rates at 59 percent for households and 65 percent for individuals.
Studies agree that FSP participation rates vary by group.  Rates are highest for households on public assistance (i.e., TANF and SSI) and for households with incomes below poverty.  Rates are lowest for elderly households, eligible noncitizens, and households with earnings. (Wolkwitz, 2007)  Households applying to the program are also more likely than non-applicants to be younger, single-parent families in worse financial condition (Bartlett et al, 2004).  Wolkwitz (2007) finds that the program  reaches the neediest eligible individuals because 65 percent of all eligible individuals are being served with 80 percent of the potential benefits distributed. That means that the households who are eligible for the smallest benefits (i.e., those with the least need) are the least likely to participate.
Most households participate in the FSP as a result of either a change in income, such as a change in employment status, or a change in family composition, such as the death of a spouse.  Households will first rely on their personal networks and then use more informal social programs, such as food pantries, before turning to the FSP.  Family and friends can be instrumental in either encouraging or discouraging individuals’ or households’ participation in the program (McConnell and Ponza, 1999).
Overall, elderly households see many benefits to the program, particularly as a critical form of food and economic assistance.  By providing funds for food, the program frees up other money to pay for medical, utility, and housing expenses.  The program also allows elderly households to buy healthy food such as fruits and vegetables or ethnic items unavailable from food pantries.  Elderly individuals also appreciate the added independence that comes from being able to shop and cook for themselves rather than relying on their families (Gabor et al., 2002).
b. Barriers to Enrollment
Researchers describe five sets of barriers that eligible populations face when trying to enroll in the FSP.  Most of the findings in the literature point to barriers faced by all groups, but some specifically point to barriers faced by households with elderly members or children.9  The five main categories are:  1) eligibility rules and confusion about those rules; 2) application procedures; 3) office procedures;  4) personal feelings about the program;  and 5) lack of awareness.
i. Eligibility Rules
Many potential applicants are confused about eligibility rules (Dion and Pavetti, 2000; Gabor et al., 2002; Bartlett et al., 2004).  Eligible individuals might believe they are ineligible if they have certain assets like a bank account or car, are employed, have been denied in the past, or are not U.S. citizens.  Elderly households in particular sometimes believe that in order to receive Food stamps an applicant needs to have a child or be on TANF.  They also might believe that they have to sell their house or car or not live with their children in order to become eligible for the program.  Some of this confusion is likely due to the association of FSP with other programs through coordinated outreach efforts.  One model estimated that coordinating outreach efforts with Medicaid/SCHIP reduced the likelihood that an apparently eligible household believed it was eligible by 16 percentage points (Bartlett et al., 2004).10
Elderly households who are immigrants face an additional set of worries surrounding their own or their families’ immigration status.  Some think there is a three to five year waiting period to obtain benefits.  They might also think participation in the program will affect their eligibility or their children’s eligibility to become naturalized.  Perhaps most frightening is the prospect that if they join the program, their sponsor will have to pay all the money back or “will be damaged or hurt” For all elderly households, most information about the program circulates through family and friends, so without active intervention, there is ample opportunity for misinformation (Gabor et al., 2002). 
     
ii.   Application Procedures

The second set of barriers relates to application procedures.  Several studies show the use of identifying technology, such as fingerprinting, significantly decreases the likelihood that applicants will complete the process (Bartlett et al., 2004; Ratcliffe et al., 2007).  In fact, Bartlett (2004) estimate that fingerprinting applicants causes a 23 percentage point decrease in the number of applicants that complete the process, while Ratcliffe et al. (2007) estimate that the use of fingerprint imaging reduces food stamp receipt by 15 percent for households below 175 percent of the poverty threshold.  Studies suggest elderly individuals tend to deeply distrust this process due to a perceived loss of privacy and dignity (Gabor et al., 2002; Zedlewski et al., 2005). Even without this technology, elderly individuals feel very uncomfortable giving out their personal information such as their Social Security number, and are particularly frustrated if this information can be obtained by office staff through other means, such as, through their participation in other programs (Gabor et al., 2002).
Others point to the difficulty of obtaining multiple verification documents and the generally overwhelming amount of paperwork (Dion and Pavetti, 2000).  Elderly participants have a particularly difficult time getting documents from third parties, such as landlords or bank officials.  The complexity of the FSP medical deduction, often relevant to elderly applicants, means case workers are reluctant to process that portion of the application, leading to lower benefits.  Those elderly households with limited English proficiency face the additional barrier of poorly-done or overly-difficult translations (Dion and Pavetti, 2000; Gabor et al., 2002).
Many applicants are also dissuaded by overly personal questions on the application form and a perception that the benefit will not compensate for these difficulties.  Some elderly households argue the questions on the application for the FSP are irrelevant and designed to make the applicant feel ashamed for applying.  Interaction with office staff might add to this loss of dignity, particularly if staff are rude or acting “like it’s coming out of their own pocket” (Gabor et al., 2002, p 47). Studies argue this kind of behavior on the part of office staff can make applicants feel like they are being judged as undeserving or even criminal for receiving benefits (Gabor et al., 2002).  One study estimated that an additional positive response by a supervisor on a three response index designed to measure the positivity of food stamp office staff is associated with a 10 percentage point increase in the likelihood of application completion (Bartlett et al., 2004).  This theme carries over into the section below on stigma.
For elderly households, the primary concern is the low expected benefit coming from the program.  Many elderly nonparticipants assume they will only receive $10 a month if they already receive Social Security.  Though the actual benefit is greater than this for the average elderly applicant, this perception is a significant barrier when combined with other obstacles to enrollment.  To these households, the benefit just does not seem worth the hassle (Gabor et al., 2002; Zedlewski et al., 2005).  This barrier is reflected in the very low participation rate for individuals receiving the minimum benefit (about 15 percent), as shown in Table 2 below.

Table 4-1 - Participation Rates for Individuals by Household Benefit as a Percentage of Maximum Benefit, FY 2005


Percent of Maximum Benefit


FY 2005 Participation Rate

Minimum benefit (≤ $10)

14.8

1 – 25%

27.6

26 – 50%

51.5

51 – 75%

74.5

76 – 99%

121.2*

100%

75.7

SOURCE: Table 4 (Wolkwitz, 2007)
* Participation rates over 100 percent are due to reporting errors in the CPS.

The participation in non-entitlement programs is sometimes called a “coverage rate” (GAO, 2005) in order to acknowledge that the goal of these programs is not to reach all eligible households, but only those who can be served within given funding limits.

In an entitlement program, every household that meets the program eligibility requirements must be served by the program, no matter what the total cost.  SSI is an example of an entitlement program.  In a non-entitlement program, there is a limit to program funding.  So, households that meet the eligibility requirements can receive benefits only as long as funding is available.

A respondent to the CPS-ASEC survey is interviewed in February, March, or April and furnishes information on annual income for the prior calendar year.  A respondent to the SIPP survey is interviewed three times a year and furnishes information on monthly income for each of the previous four months.  Since participation in many social welfare programs is based on retrospective income for the last month or three months, or on prospective income for the next month or three months, the SIPP does a better job of estimating program eligibility.

The decline in both the number of participants and the participation rate was of concern to program managers.  If the number of participants had declined because fewer households were eligible for the program, program managers might have considered that a positive outcome.  However, with participation rates falling, program managers were concerned that the program was not reaching households that needed assistance.

The studies found do not distinguish in their discussion of barriers between households with older children and those with younger children.

The model parameters represent the change in the number of percentage points.  For example, in this case the change in the percentage of households that believed they were eligible for the program might have dropped from 66 percent to 50 percent, a change of 16 percentage points. 

 iii. Office Procedures
Elderly individuals face many of the same barriers in office procedures as other applicants, but often to a greater extent.  While most applicants have difficulty finding blocks of time to go through the extensive process, elderly participants must cope with the physical difficulty of waiting in sometimes excessively long lines.  Again, those elderly households with limited English proficiency face an additional barrier of being unable to find someone who speaks their primary language (Gabor et al., 2002; Zedlewski et al., 2005).
Many households experience difficulties getting themselves to the food stamp office, particularly during restricted weekday-only hours when many are at work (McConnell and Ponza, 1999; Bartlett et al., 2004).  Families with children face an additional barrier when requested to not bring children into the office, an office practice reduces the number of applicants who finish the application process by an estimated 21 percentage points (Bartlett et al., 2004).  This adds the additional expense and hassle of finding child care while attempting to access basic services.  The attitudes and behaviors of office staff also come into play in encouraging or discouraging enrollment.  Some studies discuss the importance of a household’s prior negative experiences with the program staff as dissuading it from returning to the office (Dion and Pavetti, 2000; Bartlett et al., 2004).
     
iv. Personal Perceptions

Households also carry with them strong feelings about what it means to themselves and to others to use the FSP.  Some feel that using the program means they relinquish their personal independence, a feeling only strengthened by the overly intrusive application procedures discussed above (Bartlett et al., 2004).  Others feel that using a program as charity reflects poorly upon them; they do not want to look as if they need help.  They may feel embarrassed to be seen shopping with the benefits card or want to hide their participation from friends and family (Dion and Pavetti, 2000; Zedlewski et al., 2005). 
For many seniors, the perceived loss of independence they feel that comes with enrolling in the program is again not worth the small benefit they think they would receive.  Seniors also do not want to look as if they need help after having worked and paid taxes their whole lives.  In some situations, stigma was a family concern.  If an elderly person was seen asking for assistance, the family might look bad for not being able to keep their need hidden to avoid subjecting their families to embarrassment (Gabor et al., 2002; Zedlewski et al., 2005).  However, though many studies agree stigma exists, some downplay its importance in dissuading households from actually participating in the program (McConnell and Ponza, 1999).
 v.   Awareness
A final set of barriers involves a lack of awareness (McConnell and Ponza, 1999; Zedlewski et al., 2005).  Some households do not know how to apply for benefits, while some have never heard of the program.  This was only mentioned by a few studies as an important factor in participation; however, many programs spent a good amount of time on outreach.  It is unclear whether the small effect of awareness on determining participation was a result of these outreach efforts or whether the two are unrelated, though it has been shown that employing a larger number of outreach methods increases the likelihood that a household thinks it might be eligible (Bartlett et al., 2004). 
c.   Strategies for Enrollment
This study identified four other key studies that seem to give the LIHEAP program useful information on how to increase the participation of elderly and young child households in LIHEAP.

  • Food Stamp Program Access Study (Bartlett, 2004) – This study worked directly with 109 local FSP offices to collect information on office practices, collect information on applicant and recipients households, and conduct surveys with eligible nonparticipants.
  • Food Stamp Outreach Grant Study (Zedlewski, 2005) – This study examined the experiences of 19 FSP offices that received grants to conduct outreach to low income households. The project durations varied by site from 10 months to 24 months.
  •  Elderly Nutrition Demonstrations Study (Cody and Ohls, 2005) – This study evaluated six elderly nutrition demonstrations that employed three different demonstration models: simplified eligibility, application assistance, and commodity alternative benefit.11
  • Senior Views of the Food Stamp Program (Gator, 2002) – This study conducted focus groups with eligible and recipient seniors.

The Bartlett study found that program awareness, program understanding, program stigma, and program application barriers reduce FSP participation. The first three issues can be addressed by program outreach, while the last is affected by policies implemented by the State and local FSP offices. 

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).


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.

Research on State LIHEAP Targeting Procedures

This phase of the analysis included telephone interviews with 17 LIHEAP Directors representing States with high, moderate, and low elderly targeting indexes, and States with high, moderate, and low young child targeting indexes.  The objective in surveying these States was to learn more about their program targeting designs.  The interview specifically covered outreach initiatives, intake procedures, and benefit determination formulas, particularly those methods that proved successful in other social welfare programs. (See Appendix A for a copy of the interview topic guide.)  The analysis also assessed whether there appeared to be any relationship between targeting performance and program design.

Information Objectives

The purpose of contacting State LIHEAP Directors was to get information on how they target their LIHEAP programs using outreach initiatives, intake procedures, and/or benefit determination procedures. For targeting elderly households, the literature from other social welfare programs suggests that the following procedures could be effective.

  • Outreach
    • Programs can conduct outreach through agencies that serve elderly households, including Offices on Aging and the AARP; 
    • Programs can develop outreach materials that explicitly inform elderly households that they are eligible for the program and assets such as homes and cars do not negatively impact one’s eligibility for the program;
    • Programs can give elderly households enough information on program benefits that the household will perceive it is worthwhile to complete the application; and
    • Programs can send program information to elderly households that participate in other means-tested programs.
  • Intake
  • Programs can screen elderly households that participate in other programs for eligibility for LIHEAP (e.g., SSI);15
  • Programs can establish special application periods for elderly households;
  • Programs can reduce the application requirements for elderly households that have participated in LIHEAP in prior years;
  • Programs can develop alternative intake procedures or sites for elderly individuals; and 16
  • Programs can furnish assistance to elderly individuals in completing the LIHEAP application.
  • Programs can offer higher benefits to elderly households.  As research findings indicate that elderly households are more at risk from extreme temperatures, it may be appropriate to increase benefits for elderly households to ensure that they are able to maintain adequate indoor temperatures.  At the same time, higher benefits would encourage more elderly households to apply for benefits.
  • Benefits

For targeting young child households, the literature from other social welfare programs suggests that the following procedures could be effective.

  • Outreach
    • Programs can conduct outreach through agencies that serve young children, including the Head Start Program and Community Health Centers; 
    • Programs can develop outreach materials that explicitly inform working households with young children that they are eligible for the program and that assets such as homes and cars do not preclude eligibility for the program;
    • Programs can develop outreach materials that explicitly inform immigrant households with young children that they are eligible for the program and that applying or participating does not affect one’s immigration status; and
    • Programs can send program information to young child households that participate in other means-tested programs, particularly those that furnish benefits to working households (e.g., SCHIP).
  • Intake
  • Programs can screen young child households that participate in other programs for eligibility for LIHEAP (e.g., Food Stamps, TANF, SCHIP);
  • Programs can establish special application periods for young child households; and
  • Programs can have intake at agencies that serve young children.17
  • Programs can offer higher benefits to young child households.  As research findings indicate that young child households achieve significant benefits from participation in LIHEAP, it may be appropriate to increase benefits for young child households to ensure that they are able to maintain adequate indoor temperatures.  At the same time, higher benefits would encourage more young child households to apply for benefits.
  • Benefits

In the interviews with LIHEAP Directors, these program design features were explicitly discussed.

Findings for Targeting Elderly Households

Among the States interviewed, seven had a high elderly targeting index (100 or more), five had a moderate elderly targeting index (80 to 99), and five had a low elderly targeting index (less than 80).  The following tables present information on the share of States that used each of the identified procedures that would help to target elderly households and examine whether those States with higher indexes are more likely to use the procedures.

Outreach
Program outreach has three goals:

  • Awareness – Outreach should increase the awareness of the LIHEAP program;
  • Understanding – Outreach should help a client develop a better understanding of whether his or her household is eligible for LIHEAP benefits; what the requirements do and do not include; what the effect of applying and/or participating in the program will be; and how to apply for benefits; and
  • Motivation – Outreach should help motivate a client to apply for LIHEAP benefits.

Based on the research on other Federal social programs, it was hypothesized that a State LIHEAP program could increase the effectiveness of outreach to elderly households in several ways:

  • Agencies Serving Elderly – By conducting outreach through agencies that serve elderly households (e.g., Office on Aging, AARP), a State LIHEAP program may be able to reach more elderly households and get more attention since individuals trust those agencies;
  • Materials – By tailoring outreach materials to explicitly focus on elderly households, elderly clients may be more likely to pay attention to the information furnished by the materials;
  • Benefit Amount – By including the benefit amount in the outreach materials, clients may be more motivated to apply for benefits; and
  • Elderly Program Participants – Sending outreach materials to elderly households that participate in other programs may better focus outreach efforts on households that are likely to participate in assistance programs.

Tables 6-1 through 6-4 furnish information on the findings from interviews with 17 LIHEAP programs.  It does not appear that any of the identified outreach strategies were predictors of high elderly targeting rates.
Table 6-1 shows that most States conduct outreach through agencies serving the elderly (11 of 17 respondents).  However, some States that do not use this strategy have high elderly targeting rates as well.  Moreover, most States with low elderly targeting rates do use this strategy.  Based on these interviews, there is no evidence that this strategy can increase the elderly targeting rate independent of other strategies.
Table 6-1 – Outreach Through Agencies Serving Elderly


Targeting Group

Yes

No

High Elderly Targeting

4

3

Moderate Elderly Targeting

3

2

Low Elderly Targeting

4

1

Tables 6-2, 6-3, and 6-4 show that few States have adopted the other outreach strategies recommended in the research.  Table 6-2 shows that only five States indicated they had some mention of elderly households or of issues relevant to elderly households in their outreach materials.  Table 6-3 shows that only two States reported they mention the benefit level in their outreach materials.  Table 6-4 shows that only two States reported they send outreach materials to elderly recipients of other Federal social welfare programs (SSI).  As so few States have adopted those strategies, it is difficult to assess whether they would be effective in increasing elderly targeting of LIHEAP benefits.
Table 6-2 – Outreach Materials Targeting Elderly


Targeting Group

Yes

No

High Elderly Targeting

2

5

Moderate Elderly Targeting

0

5

Low Elderly Targeting

3

2

Table 6-3 – Outreach Materials with Benefit Amount


Targeting Group

Yes

No

High Elderly Targeting

1

6

Moderate Elderly Targeting

0

5

Low Elderly Targeting

1

4


Table 6-4 – Outreach to Elderly Program Participants


Targeting Group

Yes

No

High Elderly Targeting

1

6

Moderate Elderly Targeting

1

4

Low Elderly Targeting

0

5


Intake and Benefits
Program intake and benefit determination procedures can have a significant impact on the participation of elderly households in the LIHEAP program.  The LIHEAP program can use a number of different procedures to reduce program participation barriers, reduce program participation costs, or increase program participation benefits, including:

  • Screening – Some programs screen the recipients of other programs to assess eligibility for LIHEAP and automatically enroll clients in the program;
  • Priority – Some programs give priority to the elderly by establishing a special application period;
  • Reducing Barriers/Costs – Some programs establish special application procedures for the elderly, while others conduct outreach at special sites, or offer special assistance to elderly households; and
  • Increasing Benefits – Some programs offer additional benefits to elderly households in recognition of their special needs.  This has the added benefit of increasing the motivation of elderly households to participate.

Tables 6-5 through 6-10 furnish information on the findings from interviews with 17 LIHEAP programs.  It does not appear that any of the identified intake or benefit determination strategies are predictors of high elderly targeting rates.

Table 6-5 shows that a few States screen recipients of other programs that serve the elderly.  However, States with low targeting rates are just as likely as States with high rates to use this practice.  Similarly, Table 6-6 shows that some States have a special application period for elderly households.  However, again, there is no apparent relationship between the program feature and targeting.

Source: Special tabulation of the 2008 CPS ASEC by APPRISE.

Special tabulations prepared by APPRISE from the 2005 RECS show that 93 percent of elderly households report that they never skip paying their energy bill while only 64 percent of nonelderly households make that statement.

Special tabulations prepared by APPRISE from the 2005 RECS show that elderly households with incomes below poverty have equivalent energy bills but higher energy burdens than nonelderly households.

There is an important difference between outreach to participants of other programs and screening participants of other programs.  Outreach to program participants might increase administrative costs, since it would involve mailing applications to households that might not be interested in the program or eligible for the program.  Screening of program participants might actually reduce administrative costs, since it would involve qualifying households for benefits without additional intake office costs.

As discussed in Section IV of the report, community or social groups can be effective for outreach (i.e., furnishing information about the program).  However, service agencies such as AOA offices are more appropriate for intake since elderly households would be hesitant to apply for benefits at their senior center.

As discussed in Section IV of the report, schools or community groups can be effective for outreach (i.e., furnishing information about the program).  However, service agencies such as Head Start Centers are more appropriate for intake since young child households would not to apply for benefits at their child’s public school.

Table 6-5 – Screen Programs Serving Elderly


Targeting Group

Yes

No

High Elderly Targeting

1

6

Moderate Elderly Targeting

2

3

Low Elderly Targeting

1

4

Table 6-6 – Special Application Period for Elderly


Targeting Group

Yes

No

High Elderly Targeting

2

5

Moderate Elderly Targeting

1

4

Low Elderly Targeting

3

2

Tables 6-7, 6-8 and 6-9 furnish statistics on the use of intake procedures that attempt to reduce barriers for elderly households.  Some States (6 of 17) have special application requirements for elderly households (e.g., abbreviated application forms).  However, Table 6-7 demonstrates that the availability of such procedures is not associated with a higher elderly targeting index.  Most States (14 of 17) offer alternative intake sites or procedures (e.g., mail application) for elderly households.  Table 6-8 shows that there is no difference between the high and low targeting States in the availability of these procedures.  Some States (6 of 17) offer special assistance for elderly households.  However, as seen in Table 6-9, the low targeting States are the most likely to offer this assistance.  It seems unlikely that offering assistance would reduce elderly targeting.  Rather, it is likely that other factors for the States that offer application assistance are responsible for reducing targeting of elderly households.

Table 6-7 – Special Application Requirements for Elderly


Targeting Group

Yes

No

High Elderly Targeting

2

5

Moderate Elderly Targeting

1

4

Low Elderly Targeting

3

2

Table 6-8 – Alternative Intake Sites or Procedures for Elderly


Targeting Group

Yes

No

High Elderly Targeting

6

1

Moderate Elderly Targeting

3

2

Low Elderly Targeting

5

0

Table 6-9 – Application Assistance for Elderly Households


Targeting Group

Yes

No

High Elderly Targeting

2

4

Moderate Elderly Targeting

0

5

Low Elderly Targeting

4

1

Table 6-10 furnishes statistics on the availability of higher benefits for elderly households.  About half of the States (8 of 17) have higher benefits.  However, there appears to be no relationship to the elderly targeting index.

Table 6-10 – Higher Benefit for Elderly Households


Targeting Group

Yes

No

High Elderly Targeting

2

5

Moderate Elderly Targeting

4

1

Low Elderly Targeting

2

3

Findings for Targeting Young Child Households

Among the States interviewed, eight had a high young child targeting index (120 or more), four had a moderate targeting index (100 to 119), and five had a low targeting index (less than 100).  The following tables present information on the share of States that used each of the procedures identified from the literature review that would help to target young child households and examine whether those States with higher indexes are more likely to use the procedures.
Outreach
Based on the research on other Federal social programs, it was hypothesized that a State LIHEAP program could increase the effectiveness of outreach to young child households in several ways:

  • Agencies Serving Young Children – By conducting outreach through agencies that serve young child households (e.g., Head Start, Community Health Centers, etc.), a State LIHEAP program may be able to reach more young child households;
  • Materials – By tailoring outreach materials to explicitly focus on issues for young child households (e.g., indicating that working households can receive benefits and that legal immigrants can receive benefits), those households may be more likely to pay attention to the information furnished by the materials;
  • Benefit Amount – By including the benefit amount in the outreach materials, clients that have to take time off from work to apply for the program may be more motivated to apply for benefits; and
  • Young Child Program Participants – Sending outreach materials to young child households that participate in other programs (e.g., WIC) may better focus outreach efforts on households that are likely to participate in assistance programs.

Tables 6-11 through 6-14 furnish information on the findings from interviews with 17 LIHEAP programs.  It does not appear that any of the identified outreach strategies were predictors of high young child targeting rates.
Table 6-11 shows that some States conduct outreach through agencies serving the young children (6 of 17 respondents).  However, some States that do not use this strategy still have high young child targeting rates.  Moreover, most States with low young child targeting rates do use this strategy.  Based on these interviews, there is no evidence that this strategy can increase the young child targeting rate independent of other strategies.
Table 6-11 – Outreach Through Agencies Serving Young Children


Targeting Group

Yes

No

High Young Child Targeting

1

7

Moderate Young Child Targeting

2

2

Low Young Child Targeting

3

2

Tables 6-12, 6-13, and 6-14 show that few States have adopted the other outreach strategies that recommended in the research.  Table 6-12 shows that only four States indicated that they had some mention of young child households or of issues relevant to young child households in their outreach materials.  Table 6-13 shows that only one State reported that they mention the benefit level in their outreach materials.  Table 6-14 shows that only five States reported that they send outreach materials to young child recipients of other social welfare programs.  As so few States have adopted those strategies, it is difficult to assess whether they would be effective in increasing young child targeting of LIHEAP benefits.
Table 6-12 – Outreach Materials Targeting Working Families


Targeting Group

Yes

No

High Young Child Targeting

2

6

Moderate Young Child Targeting

1

3

Low Young Child Targeting

1

4

Table 6-13 – Outreach Materials Targeting Immigrant Families


Targeting Group

Yes

No

High Young Child Targeting

0

8

Moderate Young Child Targeting

1

3

Low Young Child Targeting

0

5

Table 6-14 – Outreach to Young Child Participants of Other Programs


Targeting Group

Yes

No

High Young Child Targeting

2

6

Moderate Young Child Targeting

3

1

Low Young Child Targeting

0

5


Intake and Benefits
Program intake and benefit determination procedures can have a significant impact on the participation of young child households in the LIHEAP program.  The LIHEAP program can use a number of different procedures to reduce program participation barriers, reduce program participation costs, or increase program participation benefits, including:

  • Screening – Some programs screen the recipients of other programs to assess eligibility for LIHEAP and automatically enroll clients in the program;
  • Priority – Some programs give priority to young child households by establishing a special application period;
  • Reducing Barriers/Costs – Some programs establish special application procedures for young child households, while others conduct outreach at special sites or offer special assistance to young child households; and
  • Increasing Benefits – Some programs offer additional benefits to young child households in recognition of their special needs.  This has the added benefit of increase the motivation for working households to participate.

Table 6-15 shows that no States reported that they screen recipients of other programs that serve young child households and Table 6-16 shows that only two States report special application periods for young child households. 

Table 6-15 – Screen Programs Serving Young Child Households


Targeting Group

Yes

No

High Young Child Targeting

0

8

Moderate Young Child Targeting

0

4

Low Young Child Targeting

0

5

Table 6-16 – Special Application Period for Young Child Households


Targeting Group

Yes

No

High Young Child Targeting

1

7

Moderate Young Child Targeting

1

3

Low Young Child Targeting

0

5

Table 6-17 furnishes statistics on the use of intake procedures that attempt to reduce barriers for young child households.  Some States (7 of 17) offer alternative intake sites or procedures (e.g., mail application) for young child households.  However, there is no difference between the high and low targeting States in the availability of these procedures.

Table 6-17 – Special Application Locations for Young Child Households


Targeting Group

Yes

No

High Young Child Targeting

3

5

Moderate Young Child Targeting

1

3

Low Young Child Targeting

3

2

Table 6-18 furnishes statistics on the availability of higher benefits to young child households.  A few States (4 of 17) offer higher benefits to young child households.  In this case, the higher targeting States are more likely to offer these higher benefits.  However, given the large number of States that have a high young child targeting index but do not offer higher benefits for young children, it is not appropriate to infer that there is a causative relationship demonstrated by this table.

Table 6-18 – Higher Benefit for Young Child Households


Targeting Group

Yes

No

High Young Child Targeting

3

5

Moderate Young Child Targeting

1

3

Low Young Child Targeting

0

5

Summary of Findings on State LIHEAP Outreach and Intake Practices

In the targeting literature from other Federal social programs, one finding was clear and consistent.  The starting point for targeting any program is to create a broad-based awareness of the program through general population outreach.  Once that basic awareness has been established, the program can then apply specialized outreach that enhances the awareness and understanding of targeted groups, as well as the intake and benefit determination procedures that lower the barriers to participation experienced by targeted groups. 
The interviews with State LIHEAP programs asked whether the State had an explicit outreach plan and an explicit outreach budget.  All respondents reported having a basic outreach plan as outlined in the State Plan submitted to ACS.  In all cases, respondents reported that their outreach plan was modeled on what was required by the Federal Statute.  Some respondents reported that they had delegated responsibility for outreach to the local agencies because they find it more appropriate to have the agency tailor the outreach to the population they serve.  No respondent reported having an explicit outreach budget that was reviewed annually to assess its effectiveness in reaching vulnerable households or other outreach targets.  The research finds that States could do more to increase overall program awareness and could implement more direct outreach to targeted groups.
However, many respondents noted that their LIHEAP program is already oversubscribed.  They recognize the need for improving outreach, but were hesitant to aggressively reach out to the low income population for fear that their program would run out of funds early in the heating season.  Without a higher level of program awareness, it is difficult for LIHEAP programs to increase the level of applications by targeted groups (i.e., elderly households and young child households), even if more directed outreach to targeted groups is conducted. 
The research finds that some States have implemented procedures that are designed to reduce program application barriers for elderly and young child households.  However, in the research, there was no consistent relationship between States that implemented procedures and States with high recipiency targeting indexes.  This does not necessarily mean that the recommended barrier reduction measures (e.g., conducting outreach at agencies that serve elderly households or young child households) are not effective.  Rather, it is possible that such measures have an incremental impact on targeting, and that other factors are responsible for the dominant targeting outcome.

Linkages between Program Design and Targeting Outcomes

As part of the interviews, State LIHEAP program managers described LIHEAP program design elements in their State that have an impact on program targeting.  Some of these program design elements appear to have a significant impact on program targeting results.  Examples include:

  • Elderly Household Application Period with Outreach – A number of States have a special application period for elderly households.  However, in one State, extensive outreach is conducted during this early application period.  During a recent program year, about 55 percent of LIHEAP benefits were distributed before the program was opened to other types of households.  That State has a high elderly targeting index and a low young child targeting index.
  • Focus on Other Programs’ Eligibility – During the LIHEAP season, one State program manager reports that the State has a policy of reviewing all applications for other programs to determine whether the household is also eligible for LIHEAP.  That State has a high young child targeting index and a low elderly targeting index.
  • State Office Application Processing – One State program manager reports that all LIHEAP applications are completed at the local level, but processed by the State LIHEAP office.  Many different types of agencies, including local community-based organizations, Head Start programs, and AOA offices are given the opportunity to submit applications for their clients.  That State has a high elderly targeting index and a high young child targeting index.
  • Intensive Outreach – One State not interviewed for this research had a significant increase in its elderly targeting index in the last three years.  That State recently implemented a ratepayer funded low income energy assistance program that was directly linked to the LIHEAP program.  When it was determined that participation of elderly households in the program was low, there were intensive outreach efforts to low income elderly households.  That outreach appears to be associated with the increase in the targeting of elderly household by the State LIHEAP program.
  • State Income Tax System – One State reported that their LIHEAP benefits are distributed through the State personal income tax system.  That State has a moderate elderly targeting index and a high young child targeting index.  Significant outreach for the Earned Income Tax Credit has raised participation of working households with children to very high rates across the country.  Such households also would benefit by receiving LIHEAP by completing their tax returns.  Low income elderly households, on the other hand, might not even need to file taxes.  So, they would not be as likely to receive LIHEAP benefits.

These examples make it clear that changing LIHEAP program recipiency targeting rates will require not only general improvement in the outreach and intake procedures, but also specific changes in the way that certain programs are designed if the program design is working contrary to targeting objectives established by the State.  Examples include:

  • During LIHEAP season, one State reviews all program applications to assess whether the household is eligible for LIHEAP.  Since relatively few elderly households have active program applications, the State has a low elderly targeting index.  To increase the elderly targeting index, the State might need to implement a countervailing design feature that identifies elderly households who are in need of energy assistance.  
  • One State distributes 55 percent of its LIHEAP funds during the special elderly household enrollment period.  In order to increase its young child targeting rate, the State might need to include young child households in that special enrollment period.

By applying effective outreach strategies, working to lower program intake barriers, and being alert to program design elements that target one type of household, States can improve their elderly and young child recipiency targeting indexes.

Recommendations

In FY 2006, the national targeting indexes for households with elderly members and households with young children were lower than they were when the baseline was established in 2003.  ACF is interested in making information available to State LIHEAP program administrators on how they can increase their targeting rates for these households.  Based on findings from this research, this study recommends that State LIHEAP Directors who wish to increase targeting to either or both of these groups adopt the following strategy.

  • First, they need to measure their current rate of targeting and examine in what ways their existing program design, outreach, and intake strategies are linked to the targeting outcomes. 
  • Second, they need to increase the general awareness of their programs through a general outreach campaign. 
  • Third, they need to adopt specific outreach and intake strategies that transform the general awareness of LIHEAP into actions by targeted households that result in receipt of program benefits.
  • Finally, they need to measure the outcomes of their actions in terms of program targeting for vulnerable households.

Only systematic efforts on the parts of State LIHEAP program managers are likely to have a significant impact on vulnerable household targeting levels for the LIHEAP program.

Baseline Assessment

The starting point for any grantee that is interested in increasing targeting households with elderly members and/or households with young children is to assess how current practices relate to current outcomes.

  • Targeting Index – ACF can furnish grantees with information on the elderly targeting index and the young child targeting index for the most recent year for which States have submitted a Household Report.  Alternatively, ACF can furnish grantees with information on the number of income eligible households by vulnerable group and State can compute targeting indexes for heating assistance using information from their LIHEAP program management databases.
  • Outreach Practices – Grantees need to take stock of their existing outreach procedures.  Specific questions include:
    • General Awareness – What types of general awareness outreach is being conducted by the grantee?  Is there any information on who that outreach is targeting?
    • Specific Awareness – What types of targeted outreach are being conducted by the grantee?  Is there any information on the effectiveness of that outreach?
    • Content – Is there anything in the outreach plan the explicitly addresses issues that may be relevant to elderly households or young child households?
  • Intake Practices – Grantees need to examine their existing intake procedures.  Specific design issues include:
  • Application Periods – Are there special application periods for vulnerable households?
  • Application Options – Are different methods of completing the application available?
  • Application Support – Is application assistance, including on a one-on-one basis, available to targeted households?
  • Benefits – Are special benefit levels set for targeted households?

For each grantee, the combined set of outreach and intake procedures is likely to be responsible for the current targeting outcomes. However, the program director also must be alert to special factors that are unique to the grantee’s program that have an influence.

General Outreach

The literature from both FSP and SCHIP indicates it is important to establish a basic level of awareness of the program to serve as a foundation for the more targeted outreach activities.  All of the interviewed State program mangers indicated that they had an outreach plan and that outreach was conducted at the start of each program year.  However, while many respondents to the survey indicated that they thought additional outreach was needed to increase awareness, they were hesitant to fund more outreach when their programs only have funding to serve 10 percent to 50 percent of income eligible households.

At a minimum, it would be appropriate for those State LIHEAP program managers that delegate outreach responsibilities to local intake agencies to conduct a more intensive review of the individual methods and materials used by those agencies.  By establishing a consistent message across agencies they would have more ability to ensure that the general outreach materials do not deter elderly or young child households from participating.  Further, by making sure that intake agencies are partnering with other appropriate community-based agencies on outreach, they can make sure that their program message is reaching targeted households.

Specific Outreach and Intake Strategies

Once grantees are confident that a basic level of awareness has been established, grantees can work to establish additional specific outreach strategies that would increase awareness, understanding, and action among targeted groups.
Specific outreach strategies include:

  • Agencies Serving Targeted Households – By conducting outreach through agencies that serve targeted households, a State LIHEAP program may be able to reach more of the targeted households and receive more attention because individuals trust those agencies;
  • Materials – By tailoring outreach materials to explicitly focus on the targeted households, targeted clients may be more likely to pay attention to the information furnished by the materials;
  • Benefit Amount – By including the benefit amount in the outreach materials, clients may be more motivated to apply for benefits; and
  • Targeted Program Participants – Sending outreach materials to targeted households that participate in other programs may better focus outreach efforts on households that are likely to participate in assistance programs.

Specific intake strategies include:

  • Screening – Some programs screen the recipients of other programs to assess eligibility for LIHEAP and automatically enroll clients in the program;
  • Priority – Some programs give priority to the targeted households by establishing a special application period;
  • Reducing Barriers/Costs – Some programs establish special application procedures for the targeted, while others conduct intake at special sites or offer special assistance to targeted households; and
  • Increasing Benefits – Some programs offer additional benefits to targeted households in recognition of their special needs.  This has the added advantage of increasing the motivation of targeted households to participate.

Based on the individual experiences of the interviewed State LIHEAP programs, some more specific actions that might be effective include:

  • Centralized Application Systems – While local intake agencies do an important job of working with individual clients on applications, it also may be appropriate to establish a centralized State-level system to process certain kinds of applications. Two of the interviewed States had success with processing applications at the State LIHEAP office to enable certain groups to better access to program enrollment.
  • Special Application Periods – While some States have special application periods for elderly households, few have such periods for young child households.  Special application periods help to target specific groups, but also can reduce office waiting times for elderly and young child households, both of which have difficulty with crowded offices.
  • Year Round Application Periods – In general, special application periods are one or two months prior to the opening of the general LIHEAP program.  However, if a State had a centralized processing option, it could take LIHEAP applications throughout the year for elderly and young child households.  In particular, as most elderly households consistently pay their energy bills, a year-round application period with a once a year payment might give elderly households the benefit they need while also ensuring that they are able to apply for benefits whenever a caseworker identifies the need for the program.

Each grantee is likely to find that some of the identified strategies are already in place.  What is most important is to assess what is and is not being done to target vulnerable households, and then implement procedures that address the missing targeting elements.

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Frank, Deborah A. et al., “Heat or Eat: The Low Income Home Energy Assistance Program and Nutritional and Health Risks Among Children Less Than 3 Years of Age, Pediatrics, 118:1293-1302, 2006
Gabor, Vivian et al., 2002, “Seniors' Views of the Food Stamp Program and Ways to Improve Participation: Focus Group Findings in Washington State”, Economic Research Service, E-FAN-02-012, June.
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Footnotes

  1. LIHEAP program managers from eight States with high, moderate, and low elderly household recipiency targeting indexes were interviewed. LIHEAP program managers from nine States with high, moderate, and low young child household recipiency targeting indexes were interviewed. The interviewed program managers were from Arizona, Delaware, District of Columbia, Georgia, Iowa, Kentucky, Maine, Michigan, Nebraska, New Mexico, New York, Ohio, Rhode Island, South Dakota, Texas, Washington, and Vermont. The researchers and ACF appreciate the responses and insights furnished by the program managers. The statements, findings, conclusions, and recommendations are solely those of analysts from APPRISE and do not necessarily reflect the views of ACF or of the responding State LIHEAP program managers.
  2. The decline in both the elderly recipiency targeting index and the young child recipiency targeting index was statistically significant at the 95% confidence level.
  3. See Section II.A for a definition of a recipiency targeting rate and for information on how high, moderate, and low targeting rates were assigned
  4. For both groups, States with targeting indexes at or above 100 are considered to be targeting the population group. For elderly households, the States with indexes below 100 are further divided into those with indexes above the national average recipiency targeting index and those below the national average. For young child households, the States with indexes above 100 are further divided into those with indexes above the national average recipiency targeting index and those with indexes below the national average.
  5. The participation in non-entitlement programs is sometimes called a “coverage rate” (GAO, 2005) in order to acknowledge that the goal of these programs is not to reach all eligible households, but only those who can be served within given funding limits.
  6. In an entitlement program, every household that meets the program eligibility requirements must be served by the program, no matter what the total cost. SSI is an example of an entitlement program. In a non-entitlement program, there is a limit to program funding. So, households that meet the eligibility requirements can receive benefits only as long as funding is available.
  7. A respondent to the CPS-ASEC survey is interviewed in February, March, or April and furnishes information on annual income for the prior calendar year. A respondent to the SIPP survey is interviewed three times a year and furnishes information on monthly income for each of the previous four months. Since participation in many social welfare programs is based on retrospective income for the last month or three months, or on prospective income for the next month or three months, the SIPP does a better job of estimating program eligibility.
  8. The decline in both the number of participants and the participation rate was of concern to program managers. If the number of participants had declined because fewer households were eligible for the program, program managers might have considered that a positive outcome. However, with participation rates falling, program managers were concerned that the program was not reaching households that needed assistance.
  9. The studies found do not distinguish in their discussion of barriers between households with older children and those with younger children.
  10. The model parameters represent the change in the number of percentage points. For example, in this case the change in the percentage of households that believed they were eligible for the program might have dropped from 66 percent to 50 percent, a change of 16 percentage points.


 

  1. USDA funded these demonstration projects with six States that participated for a two-year period.
  2. Source: Special tabulation of the 2008 CPS ASEC by APPRISE.
  3. Special tabulations prepared by APPRISE from the 2005 RECS show that 93 percent of elderly households report that they never skip paying their energy bill while only 64 percent of nonelderly households make that statement.


 

  1. Special tabulations prepared by APPRISE from the 2005 RECS show that elderly households with incomes below poverty have equivalent energy bills but higher energy burdens than nonelderly households.
  2. There is an important difference between outreach to participants of other programs and screening participants of other programs. Outreach to program participants might increase administrative costs, since it would involve mailing applications to households that might not be interested in the program or eligible for the program. Screening of program participants might actually reduce administrative costs, since it would involve qualifying households for benefits without additional intake office costs


 

  1. As discussed in Section IV of the report, community or social groups can be effective for outreach (i.e., furnishing information about the program). However, service agencies such as AOA offices are more appropriate for intake since elderly households would be hesitant to apply for benefits at their senior center.
  2. As discussed in Section IV of the report, schools or community groups can be effective for outreach (i.e., furnishing information about the program). However, service agencies such as Head Start Centers are more appropriate for intake since young child households would not to apply for benefits at their child’s public school.

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Appendix A
Survey Instrument


 

General Outreach Procedures

Does your program have an outreach plan?
Does your program have an outreach budget?

  • Program Outreach – Do any recipients of other programs receive direct mail outreach (e.g., TANF, Food Stamps, SSI)?
  • Recipient Outreach – Do prior year LIHEAP recipients receive direct mail outreach?
  • What other outreach is conducted?
    • PSAs?
    • CAPs?
    • Other?

Targeted Outreach Procedures

  • Does your state have an explicit plan for reaching out to elderly households (60+) or young child households (<6)?
  • Elderly Outreach – What type of outreach (if any) do you conduct through agencies that specially serve the elderly?
    • Office on Aging?
    • AARP?
    • Other?
  • Elderly Materials – Do you have any outreach materials targeted to elderly households?
  • Young Child Outreach – What type of outreach (if any) do you conduct outreach through agencies that serve young children?
  • Head Start?
  • Community Health Centers?
  • Schools?
  • Other?
  • Young Child Materials – Do you have outreach materials targeted to young child households?
  • TANF?
  • Food Stamps?
  • SSI?
  • State Partnerships – What other state-level partnerships have been developed with other agencies?
  • eligibility of elderly households?
  • eligibility of working households?
  • eligibility of young children?
  • eligibility of legal immigrants?
  • asset exclusions for cars, homes, and savings?
  • the benefits amounts?
  • Local Partnerships – What other local partnerships have been developed with agencies?
  • Eligibility / Benefit Information – Do outreach materials explicitly include reference to . . .?

Intake Procedures

  • Automatic Screening – What programs are screened for LIHEAP eligibility (e.g., TANF, Food Stamps, SSI)?
  • Special Enrollment Periods – What groups, if any, are able to apply during special enrollment periods?
  • Special Applications – What groups, if any, are given a special intake form that is designed for them?
  • Special Eligibility – What groups, if any, have special eligibility standards?
  • Previous Recipients
    • Do you send applications to recipients from the prior year?
  • Intake Procedures – What are available intake procedures?
  • Mail?
  • Internet?
  • In-Person?
  • Other?
  • County/Local Welfare Office?
  • Local Community Action Program (CAP) Office?
  • Agencies Serving Elderly – Office on Aging, AARP, Community Health Center?
  • Agencies Serving Young Children – Head Start, Community Health Center?
  • Other Agencies?
  • Utilities?
  • Other?
  • How many in-home visits were conducted by intake staff last year?
  • How many off-site sessions were conducted by intake staff last year?
  • What are the referral mechanisms that lead to home visits?
  • What do you do to try to reach remote areas?
  • Intake Sites – Which are used as intake sites?
  • Site Visits

Benefit Procedures

  • In addition to income, household size, and fuel type does your benefit determination procedure explicitly take into account the following factors?  The household’s . . .?actual energy bill?
  • actual energy burden?
  • status as an elderly household?
  • status as a young child household?