Supporting Working Families by Holding States Accountable: New Ideas from the Work Support Strategies Initiative


Giving children a good start in life is a widely held goal for Americans of all political parties. With recent Census figures showing 20 percent of children living in families whose income is below the federal poverty level ($18,769), and another 22 percent living just above the poverty level in families struggling to make ends meet, the need is certainly there. But even Governors who understand the urgency may worry that the costs of reaching 15 million poor children are daunting and impractical.

That’s where a new report from the Work Support Strategies initiative comes in. The report, by Urban Institute researchers, highlights an idea that is practical, well-supported by evidence, and costs states little or nothing: improving children’s health and nutrition by connecting them and their parents to the benefits—largely federally funded—that they are already eligible for but not receiving. When children get help through these programs—Medicaid or CHIP and the Supplemental Nutrition Assistance Program or SNAP (formerly food stamps)—they are healthier in childhood and as adults, do better in school, and have better employment and earnings records.   Children also benefit when their parents get help; for example, when parents have health insurance, their children go to the doctor more

The report finds that even though this strategy seems like a no-brainer, there is plenty of room for improvement. Providing a baseline look at enrollment in Medicaid and SNAP before the implementation of the Affordable Care Act, the report finds that more than 25 million children and 9 million parents nationwide were jointly eligible for the two programs. But evidence from five states suggests that only about two-thirds of those jointly eligible were getting both. 

These gaps are not about choices of what income level to cover but about whether states are successfully implementing the choices they have made. For example, Illinois, which has made inclusive policy choices (for instance, by offering health insurance to parents with incomes above the poverty level even before the Affordable Care Act), reported that about 20 percent of children and 60 percent of adults who were jointly eligible did not receive both benefits in 2011. South Carolina, a state with far more restrictive policy choices (for example, a lower Medicaid eligibility level for parents), reported quite similar numbers in 2011—about 25 percent of children and 45 percent of adults who were jointly eligible did not receive both benefits. This means that in 2011, many children and parents who were eligible to get health and nutrition help didn’t get it because of barriers such as overloaded local offices, outdated eligibility systems, overly complex applications, and lack of information.

Both South Carolina and Illinois decided to take action to change these results, as part of their participation in the Work Support Strategies (WSS) initiative. One important step is to take advantage of the information that states already have about children and parents from the programs in which they participate. For example, South Carolina used “express-lane enrollment” to add Medicaid coverage for more than 80,000 children who were previously receiving just SNAP, using the information that the government already had on file for them rather than asking parents to provide the information all over again and overwhelming state caseworkers with additional paperwork.Illinois used a federal option to express enroll about 40,000 adults who were receiving SNAP benefits into Medicaid under the Affordable Care Act. Both states, along with the other Work Support Strategies states (Colorado, Idaho, North Carolina, and Rhode Island), are also streamlining local office processes and improving computer systems to increase families’ participation, both at initial application and when they need to renew their eligibility, allowing families to get and keep the help for which they are eligible.

Another key factor is simply to begin tracking whether eligible children and families are receiving the benefits and services for which they are eligible, as the WSS states did for this report. Advocates should seize the opportunity showcased in the report to hold states accountable not only for good policy – but also for real-life results. Federal agencies also should consider state performance in an integrated way, perhaps by conducting an annual assessment of states’ success in delivering help to children, families, and individuals who are eligible for both programs

State leaders in WSS have also found extra benefits to taking on this challenge. Reducing the burden on families usually also means reducing the burden on state workers—as one state told us, every piece of paper that a family is required to bring in is a piece of paper a worker has to process. And from the perspective of a state trying to boost participation in one program—say, health insurance—families who are already receiving help from another program are “low-hanging fruit,” a lot easier to find and enroll than families who haven’t connected to any help yet. But most of all, states say the motivation for their changes is their belief that children and families will be healthier, and parents will be more stable at work and better placed to move up, when the full package of supports is in place.

The opportunities to make a difference for children are enormous. Just to give a sense of scale, fully 42 percent of Texas’ children were eligible for help with both nutrition and health in 2011, as were 44 percent of Florida’s children, and 34 percent of California’s children. Reaching these children with health and nutrition support that can make a lifetime’s worth of difference isn’t about policy or politics but about basic good government – setting a goal, sticking with it, and taking the myriad steps that make policy work in practice. This report shows a path for governors, their executive branch leaders, and state legislators to make a measurable difference for hundreds of thousands of children and their parents.