Monitoring Outcomes for Former Welfare Recipients: A Review of 11 Survey Instruments

Publication Date

Aug 10, 1999

Paper presented at the
National Association for Welfare Research and Statistics (NAWRS)
39^th Annual Workshop in Cleveland, Ohio

By
Julia B. Isaacs
Director, Division of Data and Technical Analysis
Office of the Assistant Secretary for Planning and Evaluation (ASPE)
U.S. Department of Health and Human Services (HHS)
http://aspe.hhs.gov/hsp/index.htm

The views expressed in this paper are those of the author
and should not be construed as representing the views of the
Department of Health and Human Services, or any office therein.

Introduction

With welfare caseloads dropping dramatically in the past four years, there has been increased public interest in an apparently simple question: what is happening to families who leave welfare? Do they get jobs? What is their economic status? How are their children faring? To answer these questions, the Department of Health and Human Services (HHS) awarded grants to 14 states and large counties to track and monitor outcomes for families leaving welfare.⁽¹⁾ The purpose of this paper, and of this panel presentation, is to examine the survey instruments used by these fourteen grantees in their studies of welfare “leavers.”

In this first paper, I examine the instruments from a crossproject perspective. After an initial overview of the 14 projects and the research topics they address, the majority of the paper examines the actual wording of survey items across eleven different instruments. A sample of only five selected outcomes — food stamp receipt, health insurance coverage, food insecurity, health status/access to health care, and knowledge of Medicaid and food stamp eligibility — were selected for this in-depth analysis.⁽²⁾ Additional outcomes — employment and earnings, barriers to employment, the financial situation of those not employed, and child wellbeing — are discussed by the other co-presenters in this panel, although not from a crossproject perspective.

The crossproject review of instruments in this paper may serve different functions for different audiences. Researchers who are currently designing surveys of leavers may pick up some interesting examples of survey items and reflections on the differences caused by variations in wording of items. For the grantee researchers who are in the midst of analyzing results from the field, the review may provide some aid in “benchmarking” their survey findings to findings in other localities. That is, if a state finds that X percent of its leavers answered a certain question, it is important to know whether any other state or national surveys asked the same question, so that the state’s results can be compared to some benchmark. Analysts who are interested in examining findings across studies can benefit from a better understanding of the comparability of different instruments. Apparent differences between State A and State B may be partially caused by differences in the design of survey items.

Those anxious to know more about the wellbeing of former recipients may be disappointed because this review does not report actual findings. It does, however, provide some preview of the types of information that will be available over the next year, and thus some indication of the extent to which states are asking questions that will provide information needed for policy decisions. Finally, those in HHS, USDA, and other organizations that have provided sample survey items or technical guidance to the grantees may benefit from learning the degree to which researchers have incorporated various survey items in their instruments.

Overview of HHS-Funded "Leavers" Studies

All 14 of the studies funded by the Department of Health and Human Services, Office of Assistant Secretary for Planning and Evaluation (ASPE), are using a combination of linked administrative data sets and surveys of former recipients to monitor the economic status and general wellbeing of families leaving welfare. At this point (July 1999), most grantees are about half way through their projects; and six have released interim reports based on administrative analyses of an early cohort of leavers. Most grantees define this early cohort as those that ceased receiving cash assistance in late 1996 or early 1997, as states were beginning to implement the Personal Responsibility and Work Opportunities Act (PRWORA). Grantees are still working on their administrative analyses of later cohorts of leavers (e.g., those leaving in late 1997, 1998 or early 1999), and on collecting and analyzing survey data for these later cohorts. Although a number of states have released reports based on statefunded surveys of leavers, most of the HHS-funded surveys are still in the field. Final reports, which will combine analyses of linked administrative data with findings from surveys of former recipients, are scheduled for completion at various times over the next twelve months, depending on the schedule of the individual grantees.

As stated above, each grantee is fielding a survey to gather information about the overall wellbeing of families leaving welfare. Although research proposals ranged across grantees, most grantees proposed surveying a sample of between 600 and 1200 former recipients, at a point between 4 to 12 months after exit from cash assistance.⁽³⁾ With one exception, grantees are conducting mixed mode surveys, consisting of telephone interviews for the majority of households, supplemented by in-person follow-up for those who cannot be reached by telephone. Most surveys are expected to take 20-40 minutes. In this short time period, grantees are planning to ask questions across a broad array of topics, including employment and earnings, program participation, health insurance, child wellbeing, barriers to selfsufficiency, etc.

One key challenge has been the design of a survey instrument to gather information across this broad array of topics, within the constraints of a timelimited telephone interview. One potential solution to this challenge would have been to design a single survey for use across multiple sites. Such an approach would have had the advantage of providing common measures for crossstate comparisons and the development of a national picture of welfare leavers.⁽⁴⁾ It was rejected early in the design of the project, however, because of its disadvantages, particularly in the current era of devolution of welfare policy making to the state and local levels.

One disadvantage of a nationally designed survey is that it might not address questions of most policy relevance to a particular state. For example, a state with a fullfamily sanction might want to ask different questions than a state with a partial sanction. Second, a national study would not be as effective in building state and local capacity for ongoing TANFrelated research to support state and local policy development. Finally, the consensus process for working with multiple states to develop a single instrument would likely be quite lengthy, with additional time required for official clearance of a national survey instrument by the Office of Management and Budget (OMB). A lengthy research process, however, conflicted with the desire of both Congress and state and local policy makers to know as soon as possible what was happening to families leaving welfare.

In sum, the Department of Health and Human Services decided to award grants that provided each research team with considerable flexibility in designing its own research project, including its own survey instrument. At the same time, Federal staff worked to encourage some degree of comparability of outcomes across states, within the constraints of a tight time schedule and limited resources. Steps taken to facilitate comparability included: holding an initial planning meeting in November 1998; establishing of an electronic “listserve” for discussion among researchers; developing consensus on a common definition of the “leavers” study population;⁽⁵⁾ developing guidance on a proposed set of nine commonly reported administrative outcomes for leaver studies;⁽⁶⁾ and, of most relevance for this paper, disseminating resources on surveys, including examples of survey items.

As shown in Table I, grantees were provided with paper copies of, or website addresses for, selected components of the Census Bureau’s Survey on Income and Program Participation (SIPP) and Survey on Program Dynamics (SPD), the USDA’s “Food Security/Hunger Core Module,” the Urban Institute’s “National Survey of America’s Families (NSAF), and other selected survey items. Some of these items were distributed in a resource book provided to all participants at the first grantee meeting, others were the subject of presentations at that same meeting, mailed to all grantees, or discussed over the listserve, primarily in December 1998 and January 1999.

Table I. Dissemination of Survey Items

Survey	Topic Area(s) Disseminated	Resource Book	Presentation	ListServe	Mailed
Census Bureau’s Survey of Program Dynamics (SPD)	Employment and earnings	X	X
Census Bureau’s Survey of Program Dynamics (SPD)	Training	X	X
Census Bureau’s Survey of Income and Program Participation (SIPP)	Training	X	X
USDA’s Food Insecurity Module in CPS	Food Security	X	X	X
Urban Institute’s National Survey of America’s Families (NSAF)	Insecurity/Deprivation (6 items)		X
	Child Well-Being (Sections C and N)			X
	Health (Sections B, E, and F)			X
	All			X
MDRC’s Urban Change	All				X
State and Local Area Integrated Telephone Survey (SLAITS)	Health			X
	Child Care			X
	Child Well-Being			X
Abt’s Family Transition Program	Employment and earnings	X	X
South Carolina Survey	Insecurity/Deprivation	X	X
Draft items developed by Mary Ellen Colten at U. Mass, Boston	11 items on Domestic Violence			X

Notes:

Resource Books with photocopies of surveys and other technical assistance items were distributed to all 60 participants at November grantee meeting.
Presentations were made at the November grantee meeting, on topics such as measuring employment and earnings, measuring insecurity/deprivation, and measuring child well-being.
The List-serve was used to disseminate web-site addresses and text of surveys, as well as to facilitate discussion among researchers.
MDRC mailed copies of the Urban Change survey to each of the 14 grantees.

Given the nature of the grants, and the limited amounts of technical assistance provided on surveys, one might expect that each grantee would develop quite different surveys. On the other hand, there was sufficient sharing of questionnaires and discussions on the listserve that one might expect some areas of similarity. Most of the rest of this paper reviews specific items to get some sense of the similarity and dissimilarity in the grantees’ survey instruments. Before doing so, however, I provide a brief overview of the types of research topics included in the grantees’ study designs.

Research Topics in the Leavers Studies

In their research plans, all grantees proposed to collect survey information about employment and earnings, household income, program participation, and child and family wellbeing. There were differences in emphasis, however, as some grantees proposed asking extensive questions about employment and training services, others focused on collecting detailed information on household income across all household members, and still others wanted to ask extended questions on child wellbeing. A brief overview of the questions addressed in the survey instruments is provided below, with questions grouped into nine topical areas for ease of presentation.⁽⁷⁾

Employment and earnings

Almost all grantees ask survey questions about wage levels, hours worked, and types of jobs or occupations. In addition, 10 of the 14 grantees include questions on fringe benefits, and several include questions about jobrelated training, as shown in Figure A-1.

Figure A-1. Employment and Earnings.

Case closures and recidivism

Many (9 of 14) grantees ask questions about reasons for case closure and most also ask about reasons for return to TANF (Figure A-2).

Figure A-2. Case Closures and Recidivism.

Other income supports

All grantees proposed questions about financial assistance from family members, with 13 of 14 also asking specifically about child support. As shown in Figure A-3, many grantees also include questions about income from food stamps, SSI, housing assistance, and the Earned Income Tax Credit (EITC).

Figure A-3. Other Income Supports.

Health Insurance

Most grantees also include questions about Medicaid and employerprovided health insurance on their surveys (see Figure A-4). Ten of the fourteen grantees plan to include specific questions about health insurance coverage for children, and two include specific questions about use of the Children’s Health Insurance Program (CHIP).

Figure A-4. Health Insurance.

Child Care

Most (12) of the grantees proposed including survey questions about the child care used by families after they leave welfare. Typical questions focus on the type of provider used, child care costs, and the parents’ awareness and use of subsidies. Half (7) of the grantees also ask parents about their perceptions of child care quality (see Figure A-5).

Figure A-5. Child Care.

Child Well-Being

Most grantees proposed including some type of survey questions about children’s living arrangements and/or interactions with the child welfare system. Nine grantees also plan to examine some measure of child health status (typically through a survey question), seven grantees plan to ask questions about children’s school attendance, and five grantees plan to include questions addressing child behavior, as shown in Figure A-6.

Figure A-6. Child Well-Being.

Barriers to Self-Sufficiency

All grantees proposed to examine barriers to selfsufficiency (see Figure A-7). Primarily through survey questions, grantees will be gathering data about such subjects as disability, maternal depression, substance abuse, illiteracy, domestic violence, and lack of education/skills. Most include specific questions about barriers related to lack of transportation and lack of child care.

Figure A-7. Barriers to Self-Sufficiency.

Deprivation/Insecurity

As shown in Figure A-8, for the most part, grantees are planning to use survey questions to query whether former recipients encounter severe problems in meeting basic needs. These include issues associated with hunger, access to health care, use of emergency services, and housing problems (homelessness, lack of money to pay rent, or living with relatives).

Figure A-8. Deprivation/Insecurity.

Other Research Topics

Half of the grantees are surveying former recipients about their attitudes toward TANF or welfare reform. Additionally, Figure A-9 shows that five are surveying former recipients about their attitudes toward work. Many grantees also are including survey questions to probe for recipients’ awareness of transitional child care (TCC) benefits and transitional Medicaid benefits. Finally, 12 of the 14 grantees are surveying individuals that leave TANF about changes in household compositions after program exit, such as birth of a new child. Over half explicitly ask about changes in marital status and half ask questions about changes in household residence.

Figure A-9. Other Topics.

Review of Survey Instruments

Whereas all fourteen grantees were included in the overview of research topics and Figures 1-9, a total of 11 instruments are included in the tables and analyses in the remainder of this paper. There are only 11 instruments in this review because two grantees — Cuyahoga County and Los Angeles County — are sharing the same survey instrument,⁽⁸⁾ and two grantees — Massachusetts and New York — were still in the process of drafting instruments as of July 1999. Of the eleven instruments, six are clearly written as Computer Assisted Telephone Interviews (CATI) and the other five do not appear to be so, at least not from the versions shared with the author. An average interview length is provided for half the surveys; these averages range from 15 minutes (South Carolina) to 45 minutes (Missouri), with others at 20-30 minutes, 35-40 minutes, and 40 minutes. An annotated list of the eleven survey instruments is provided in Appendix I.

Most of the 11 survey instruments have 6 to 12 sections, spanning the breadth of topics discussed above. For this analysis, I identified all questions which address the following outcomes: food stamp receipt; health insurance (including Medicaid receipt); food insecurity; access to health care and health status; and knowledge of transitional benefits. Each of these five outcomes is discussed in turn below, with Tables II – VI providing summary information about each outcome, and Appendices II – VI providing actual wording of survey items for these five areas.

Food Stamp Receipt

Ten of the eleven instruments ask questions about food stamp receipt. Five of these simply ask one question, such as “does your family currently receive food stamps?” and five ask additional questions, including whether food stamps continued after the household left cash assistance; if not, why not; and the amount of food stamps received. Illinois asks two additional questions not seen on other surveys: whether or not the former recipient has applied for food stamps since leaving TANF, and if not, why not. The Georgia survey does not appear to ask any questions about food stamp receipt, presumably relying on administrative records for this information. Illinois and Georgia are shown in the first and last columns, respectively, of Table II-A, which shows the types of questions asked by each grantee.

Table II-A: Receipt of Food Stamps


Received food stamps (now/last month)	X	X	X	X	X	X	X	X				8
Received food stamps (within last 6 months or any time since TANF exit)	X			X					X	X		4
Continued to received food stamps (when left TANF)		X	X									2
Why not get food stamps	X	X	X	X								4
Amount received (last month)		X⁽²⁾	X		X							3
Total Number of Questions	5⁽¹⁾	4	4	3	2	1	1	1	1	1	0

Notes:
1. The Illinois survey also has two additional questions, “Have you applied for food stamps?” and “If not, why not?”
2. Arizona asks about amount of Food Stamps received Dec. 1997 (last month of TANF Receipt) and last month.

The exact phrasing of questions about food stamp receipt varies across three dimensions:

Time Period of Receipt. Eight questionnaires ask about receipt this month (or last month); four ask whether the family has received Food stamps at any point in the last six months, or roughly equivalently, since leaving TANF; and two ask if the family continued to receive food stamps when it exited from TANF. (See Table II-A).
Definition of Family or Household. Four instruments ask if “you or anyone else in your household” or “you or someone in your home receives food stamps”; two instruments make reference to “you and your immediate family,”⁽⁹⁾ and the remaining four speak more generally of “you and your family,” or sometimes just “you” with an implicit reference to the family. (See Appendix II for exact wording of the food stamp receipt questions).
Context of Question. Finally, while some surveys ask about “income from food stamps” along with a list of other income sources, others ask about “getting or using” food stamps along with a list of benefits/services, and a few ask about food stamps as a completely separate topic.

Though these phrasing variations may not make a large difference, one might expect slightly larger measures of receipt when measured over a sixmonth as opposed to a onemonth period, and larger measures of receipt when including food stamps received by any member of the home or household.

In addition to questions about food stamp receipt, eight instruments include questions about the Women, Infants, and Children (WIC) Supplemental Nutrition program and six ask about children’s receipt of school lunches (see Table II-B). A few also ask questions about the school breakfast or summer feeding programs. In addition, though not shown in Table II-B, ten of the eleven instruments ask questions about nongovernmental assistance, such as meals or food from shelters, food kitchens, or food banks (see Appendix IV-B).

Table II-A: Receipt of Other Federal Nutrition Benefits


Receive WIC	X	X		X	X	X	X	X		X		8
School Lunch	X	X				X		X		X	X	6
School Breakfast								X			X	2
Summer Food Program						X		X		X		3
Total Number of Questions	2	2	0	1	1	3	2⁽¹⁾	4	0	3	2

Notes:
1. The Missouri survey has an additional question, “Did you ever hear of the government’s WIC program?”

Health Insurance Coverage

Grantees ask many more questions about health insurance coverage than about food stamp receipt, reflecting the greater complexity of the subject. As shown in Table III, grantees are asking between five and ten questions about health insurance, with the questions falling into five general areas:

Do you have health insurance coverage?
What type of coverage do you have?
Are you enrolled in Medicaid?
Do you participate in an employer health plan? and
Why don’t you have ... [Medicaid/employer/any health insurance]?

Most of these health insurance questions are asked twice, both with regard to the leaver herself, and with regard to her children (denoted with a “C” in Table III). Though not shown in the table, one survey (Cuyahoga/L.A.) also asks about coverage for the leaver’s spouse/partner, and another (Wisconsin) asks all health insurance questions about each member of the household, allowing different responses for various adults and children (see Appendix III for detailed wording of health insurance questions).

Coverage and Type of Care. The first two types of questions are the most common, with eight of the eleven instruments specifically asking whether the respondent has health insurance coverage (now or last month), and all but one asking about type of coverage (see Table III). Note that this latter question, “type of coverage” question overlaps with the other questions, since Medicaid, employer health plans, and in some cases, no insurance, are among the eight or so types of care listed as possible responses. One grantee, the District of Columbia, specifically probes, “So are you/all your children uninsured?” if the respondent replies “No,” to the question about whether she has any health insurance coverage. Another grantee (Florida) asks what type of health insurance is used to pay for most of the respondent’s medical care, taking into account the possibility of more than one health plan.
Medicaid Receipt. Seven grantees ask specific questions about Medicaid receipt, in addition to listing “Medicaid” as one response to the question about health insurance coverage. Questions focus on current Medicaid receipt, or receipt after exit from cash assistance, with two grantees (Arizona and Cuyahoga/L.A.) asking about receipt in both time periods. Grantees generally ask about Medicaid coverage separately for the adult and for the children in the household, with some grantees (e.g., Cuyahoga/L.A., South Carolina, Wisconsin) allowing for situations where some children are covered by Medicaid and others are not covered.

Table III: Health Insurance

Questions
What type of health care coverage? (Choices include... Medicaid, employer, etc)	X C		X C		X C	X C	X C	X C	X C	X C	X C	9
Any current health care insurance?	X C	X C	X C	X C	X			X C	X C		X	8
Currently enrolled in/receive Medicaid?		X C		X C	X						X C	4
Continue to receive Medicaid after left cash assistance?		X C		X C		X C		X		X C		5
Does your employer OFFER...health plan?	X		X				X					3
Do you ENROLL/PARTICIPATE IN employer health plan?	X C	X C	X C			X C	X					5
Do you GET a health plan or medical insurance from your employer?				X C	X C			X C				3
Why (main reason) not covered?			X C	C	X C				X C			4
Why not enrolled/continue to get Medicaid?	X C	X C				X C						3
Why not participating in employer health plan?	X						X					2
Other Questions (see below)						X C	X C		X	C		4
Total Number of Questions	10	10	9	9	8	8	7	7	7	6	5

Notes:
X = Question asked of adult; C = Question asked about children in household.

Food Insecurity

Food insecurity differs from the other four outcome measures in this review, because a “core module” of questions on food security/hunger was distributed to all grantees. This module was developed by a collaboration of Federal agencies and academic researchers, fielded in the April 1995 Current Population Survey (CPS) Supplement, and analyzed in a series of USDA reports released in September 1997.⁽¹⁰⁾ Researchers from the U.S. Department of Agriculture encouraged the incorporation of this new set of questions in the leavers’ surveys, disseminating copies to all grantees and discussing it at the grantee meeting and through the listserve.

From the beginning, grantees were uncertain that they could incorporate the full set of 16 questions, four of which have multiple parts. USDA researchers, on the other hand, urged grantees to include all questions in their leavers’ surveys, because the full set of questions can be combined into a single overall measure of food security, drawing on 18 items from the 16 questions.⁽¹¹⁾ They were reluctant to promote a reduced form of the 18-item scale, arguing that the module was shorter than it seemed, since many questions are skipped if the household responds “no” to the initial screening questions. Inclusion of the full 18-item scale would also allow comparison to other surveys incorporating these items, such as the Survey on Program Dynamics (SPD). Grantees were concerned, however, that the questions seemed repetitive.

In the end, none of the grantees included the full core module with its 21 items (the 18-item scale plus a 3-item introductory screener). As shown in Table IV, the highest number of items included in a leavers’ study instrument was seven items, in the Cuyahoga/L.A. instrument. Three grantees — Arizona, South Carolina, and Wisconsin — ask only question (although they ask it about two time periods, while on welfare and since exit). The average grantee included 3.3 items. Although most (86 percent) of these items were drawn directly or with slight modifications from the USDA Food Security/Hunger Core Module, they were selected across the breadth of the survey instrument.

Table IV: Food Insecurity

Questions												Other
#8. Cut size of or skip/meals () #8a. How often ()	X X	X	X		X X		X					O N O N	5 2
#1. Food adequacy; #1a. Why not enough food #1b. Why not kinds of foods wanted	X		X X X	X					X			O S	4 1 1
#3. Food did not last (*)	X			X	X		X					O N	4
No way to buy food (not from USDA)						X		X		X	X		4
#4. Not afford balanced meals (*)	X	X		X								O	3
#2. Worried about food running out				X	X							N	2
#12. Adults not eat full day #12a. How often		X	X										2 0
#14. Children ever skip meals; #14a. How often		X				X X							2 1
#13. Ever cut size of children's meals		X											1
#16. Any children not eat food for day		X											1
#10. Eat less than felt should (*)	X											O	1
#9. Ever hungry (*)	X											O	1
Satisfaction with food [not from USDA]								X					1
#5. Relied on low-cost foods													0
#6. Not afford balanced meals (children)													0
#7. Children not eating enough													0
#11. Lost weight													0
#15. Children ever hungry													0
Total Number of Questions	7	6	5	4	4	3	2	2	1	1	1

Notes:
(*) Indicates on USDA short (6-item) scale.

Other: N - National Survey of America's Families; O - Child Outcomes Project; S - SIPP.

Note: Arizona, Illinois, South Carolina, and Wisconsin ask each question twice (period on welfare, period off welfare)

The most common question, asked by five grantees, is #8 in the USDA instrument (shown in Appendix IV-A), concerning whether adults in the household had cut the size of meals, or skipped meals because there was not enough money for food. Two grantees ask a follow-up question (#8a) about frequency of cutting the size of or skipping meals.

Another two grantees (Washington and Missouri) ask questions about meals being cut or skipped by children (#13, #14, #14a). Both previous research and analysis of the 18-item scale indicate that households tend to reduce food intake by adults before they reduce food intake by children and so reductions in meal sizes or meals by children is a greater sign of food insecurity and hunger. In fact, the items used by Washington and Missouri are used in the 18-item scale to distinguish households with “severe” hunger from households with “moderate” hunger.⁽¹²⁾

The questions about adults cutting the size of or skipping meals, #8 and #8a, are two of the six items included in a short (6-item) version of the USDA scale. This scale was included in the grantees’ resource books, but was not discussed much at the grantee meeting or the listserve, where the discussion focused on the full scale. This was perhaps unfortunate, because it turns out that the short scale is being used by four of the five states involved in the HHSfunded “Project on StateLevel Child Outcomes,” a project that adds child outcome measures to existing welfare reform evaluations.⁽¹³⁾ Moreover, three of the six items in the short scale also are included in the Urban Institute’s National Survey of America’s Families (NSAF), which reports outcomes related to welfare reform in 13 states as well as on a national basis.⁽¹⁴⁾ If grantees had known of its widespread use, they might have focused more attention on it. Instead, some dismissed it, because all six questions ask about adult rather than child experiences of reduced food intake and hunger, giving it the appearance of being illsuited for studies of families with children. In fact, the six questions about adult experiences with hunger can be used in households with children, because hunger in such households is likely to first show up as reduced food intake among adults, as discussed above. Another possible concern about the 6-item scale is that it cannot distinguish between households with “moderate” hunger and those with such “severe” hunger that children are affected. The latter group is relatively rare, however, and so may be difficult to identify accurately without use of the full 18-item scale.

Another common question, included in four leavers’ surveys, is #1, which asks about food insufficiency, that is, whether the household has enough food to eat and enough of the kinds wanted. A followup question probing for reasons for food insufficiency is asked in one survey (San Mateo). This question and its followups are not included in the short 6-item version, nor are they strictly part of the 18-item scale. The question is, however, is included in the Survey of Income and Program Participation, the Survey of Program Dynamics, and other national surveys, and has been used to measure food insufficiency over a 20-year period.

Two other common questions are #3, which asks whether the family found that the food that they bought just didn’t last, and #4, which asks whether the family found it could not afford to serve balanced meals. Four grantees, the Child Outcomes Project, and the NSAF are fielding #3, and three grantees and the Child Outcomes project are fielding #4. Both these questions are in the short (6-item) versions of the food security scale.

Other questions drawn from the Core Module were asked by one or two grantees, including:

Whether the respondent worries about food running out (#2, asked by two grantees);
Whether adults in the household skipped food for a day (#12, asked by two grantees);
Whether the adult experienced hunger (#9, asked by one grantee and the Child Outcomes project and part of the short scale);
Whether the respondent felt there was not enough food (#10, asked by one grantee and the Child Outcomes project and part of the short scale); and
Whether children in household skip food for a day (#15, asked by one grantee).

Six items in the Core Module (#5, 6, 7, 11, 12a, and 15) were not asked by any grantee.

Finally, four grantees asked a question that was not directly from the USDA scale, namely, “was there a time when you had no way to buy food?” First used in the South Carolina survey, this question has been picked up by Wisconsin, Missouri, and Florida. If respondents answer yes, South Carolina and Wisconsin ask the respondent to state whether this occurred while the family was on welfare, or since exit. Florida also asks a question not included on other surveys concerning satisfaction with foods eaten by the household. The wording of these items is shown in Appendix IV-B.

Note that even when four or five grantees do ask the same general question about food insecurity, there may be variations which make it harder to make crossstate comparisons. The most important of these concerns time period. Although some grantees ask about food insecurity “during the past twelve months,” as in the Core Module, others ask over a 6-month time period, a 30-day time period, or the varying period since exit from TANF. Four grantees (Arizona, Illinois, South Carolina, and Wisconsin) ask the respondent to compare food insecurity in the 6-month or longer period since exit from welfare with food insecurity while on welfare. While this question gets directly at an issue of great interest to policy makers, it is not clear if respondents can accurately recall hunger experiences across two different 6-month time periods.

Only five food insecurity questions were asked by three or more grantees. These questions include three questions from the short version of the USDA scale (#8, #3, #4 ), one other question from the full core (#1), and a question not found on the USDA module (the South Carolina question). Four items were asked by two grantees, eight items by only grantee (including the Florida item not from the USDA module), and six items were not asked by any grantee. Overall, items on the short scale were asked by more grantees than other items in the full module: the 6 items on the short scale were asked by an average of 2.7 grantees, and the 15 other items from the Food Security/Hunger Module scale were asked by an average of 1.4 grantees.

In sum, comparisons of food insecurity across leavers’ studies will be limited by wording variations, and even more by the fact that grantees chose food insecurity items from across the broad array of 21 different items provided in the full USDA Food Security/Hunger Module. Opportunities will exist, however, for comparisons of food insecurity among leavers to food insecurity among more general national and state populations, given the inclusion of the short or full versions of the USDA module in such surveys as the SPD, NSAF, and welfare reform evaluations involved in the Project on StateLevel Child Outcomes.

Access to Health Care and Health Status

Grantees did not ask as many questions about access to health care and health care status as they did about food security. Four grantees did not include any questions, four asked only question, and three asked three to five questions, as shown in Table V.

Table V: Access to Health Care and Health Status

Questions
Was anyone in your home sick or hurt or in need of doctor, but could not afford to get medical care?	X X C		X X	X	X	X	X					6
Satisfaction with quality of health care		X C										1
Health status	X C	X C	X									3
Total	5	4	3	1	1	1	1	0	0	0	0	0

X = Question asked of adult; C = Question asked about children in household.

Notes:
Florida asks this type of question three times:

If could not afford care since left TANF;
If need medical care and unable to obtain it at the present time; and
If children in need of medical care at present time.

The Cuyahoga/L.A. survey asks two questions, first whether unable to go see doctor or hospital because of lack of money or medical insurance, and second, whether unable to see dentist.

The most common question related to whether or not there was somebody in the home who was ever sick or hurt but unable to afford to get medical care. Six grantees asked a version of this question, which is asked in the National Health Interview Survey (NHIS), the Survey of Income and Program Participation (SIPP), and other national surveys. Five asked whether this had occurred “since leaving TANF.” In some cases this time interval may be four months, in other cases, nine to twelve months, depending on the timing of the survey interview relative to TANF exit in the various studies. The sixth grantee, the Cuyahoga/L.A. survey explicitly asks whether the adult or her children or spouse/partner have been unable to see a doctor or go to the hospital in the past twelve months. This has the advantage of being similar phrasing as in the NHIS and the SIPP, and so can be more easily compared. As in the SIPP, the Cuyahoga/L.A. survey repeats the question with regard to seeing a dentist. Two grantees (South Carolina and Wisconsin) ask about lack of access to needed health care during the time period the former recipient was on welfare, as well as since exit from welfare.

In Florida, the general question about not being to afford medical care when sick or hurt is supplemented by two later questions: whether the respondent needs medical care and cannot obtain it at the present time, and whether children are unable to obtain needed medical care at the present time. It will be interesting to learn how these “current time” questions fare.

Three grantees ask about health care status. Florida and Cuyahoga/L.A. use the same wording as in National Health Interview Survey and the Survey on Income and Program Participation, that is, “would you say that in general your health is excellent, very good, fair or poor?” Illinois asks how satisfied or dissatisfied the respondent is with her personal health and physical condition, and that of her children. Illinois also asks about satisfaction with the quality of the health care that the family can afford, and further, whether the respondent thinks, in terms of medical care for her children, she is better off, worse off, or about the same as when she left welfare. Finally, although not included in this analysis, a number of surveys include questions about personal or child health disability or sickness that may pose barriers to employment.

Knowledge of Medicaid and Food Stamp Eligibility

The final outcome measure included in this analysis concerns the former recipient’s knowledge of her potential eligibility for Medicaid and food stamps. Preliminary findings from administrative data and statefunded surveys of leavers suggest that relative low percentages of leavers — in some cases less than 50 percent — are receiving Medicaid or food stamps. This is a puzzling finding, given that many families who leave TANF are expected to be eligible for these programs, because of their relatively lowpaying jobs and low family income. Furthermore, all families leaving because of employment should qualify for transitional Medicaid assistance during the first six months after an exit. In order to better understand, and eventually, address issues of nonparticipation among this seemingly eligible population, many leavers’ surveys include questions about clients’ knowledge of their entitlement to benefits.

As shown in Table VI, seven instruments include questions that probe for respondents’ knowledge of their eligibility for Medicaid, their children’ eligibility for Medicaid, and their family’s eligibility for food stamps. Of the seven questions about Medicaid, five ask, “Did you know that... (you may be eligible, your children may be eligible, working adults are eligible, children are eligible)?” The Georgia instrument asks a somewhat broader question, “Once you leave TANF, do Medicaid benefits end?” The Illinois survey asks about the client’s perception of her specific eligibility, “Did you think you would be eligible to get a Medicaid card...?” In addition to asking about knowledge of eligibility rules, two surveys ask whether the former recipient received information from the welfare office about Medicaid.

Table VI: Knowledge of Medicaid and Food Stamp Eligibility

Questions
Did you know that you [adults who work] could/may continue to be eligible to get Medicaid after leaving TANF? YOUR CHILDREN...		C X	X C	X	C	C X						5
Once you leave TANF, do Medicaid benefits end?*							X					1
Did you think you would be eligible to get a Medicaid card after you left cash assistance? Children?	X C											1
Did caseworker tell you/did you receive info from welfare office letting you know about Medicaid eligibility for you (your children)	X C			C								2
Have you ever heard of the Children's Health Initiative Program?					C							1
Did you know that you can/ may/might continue to get food stamps after leaving TANF?		X	X			X						3
Did you think you would be eligible for food stamps after you left cash assistance?	X											1
Did caseworker tell you/did you receive info from welfare office about food stamps?	X			X								2
Total Number of Questions	6	3	3	3	2	2	1	0	0	0	0

X = Question asked of adult; C = Question asked about children in household.

* An additional survey not included in this review, an IRP survey of families applying from and/or diverted from cash assistance in Milwaukee asks a somewhat similar question, “Can someone receive Medicaid without participating in W-2?” The question is repeated with “food stamps” substituting for “Medicaid.”

Similar questions are asked about food stamp eligibility and information at welfare offices, although these questions are not as common as the questions about Medicaid eligibility. Though not included in this analysis, many surveys also include questions about recipients’ knowledge of eligibility for child care subsidies. (See Appendix V for a complete listing of the questions on knowledge of Medicaid and food stamps).

With regard to the questions about Medicaid eligibility, it seems to me that the question, “did you know that people like you are eligible for Medicaid...” is a “loaded” question, and thus not as meaningful as a more neutral question about eligibility rules, like the example in the Georgia survey. If someone were to ask me if I knew that the Federal government (my employer) provided a particular brand of health insurance or a particular kind of life insurance, I would likely answer yes, not wanting to admit that I do not recall the details of the ½" thick pile of papers on benefit options that I plowed through on my first day of employment. However, if one were to ask me more neutrally, does the Federal government offer X to its employees, I might be more likely to respond honestly that I do not know. Perhaps researchers might want to consider the potential merit of rewording questions about Medicaid eligibility, to bring them more in line with the more neutral wording of the Georgia example.⁽¹⁵⁾

Conclusion

One of the goals of this paper has been to investigate the extent to which the HHSfunded grantees developed common measures to track the economic and noneconomic wellbeing of families leaving welfare, and the extent to which they developed dissimilar items. Summing up what was found in each of the five outcomes:

Almost all (10 of 11) instruments ask questions about food stamp receipt, with these questions varying somewhat in terms of the time period of receipt and the definition of family or household receiving the benefit.
All surveys include questions about overall health insurance and Medicaid receipt (either through specific questions and/or through questions about type of coverage), for both the adult respondent and her children. In addition, eight include questions about employer health plans, although these are not strictly comparable because of the potential difference between employers offering such coverage and employees actually enrolling in the plan.
Although all 11 instruments ask at least one question about food insecurity, these questions are drawn from the broad array of 21 different questions or follow-up questions included in the USDA Food Security/Hunger Core Module. Only five specific questions are asked by three or more grantees.
Seven surveys ask about access to health care and/or health status, with six of these asking about whether the household could not afford to get needed medical care.
Seven instruments include questions about Medicaid eligibility and information, with five also asking about food stamp eligibility and information.

In general, there was some degree of common measures, in the sense that many outcomes were measured across five or more instruments. For example, eight instruments ask about food stamp receipt in the current (or most recent) month, nine ask about types of health insurance coverage, five instruments ask if adults in the household cut the size of or skipped meals, six ask whether anyone in the household has been in need of medical care but unable to afford it, and five ask if the respondent knew she were eligible for Medicaid.

There are, however, differences in the wording of questions. Generally, these differences include variations in the time period measured (one month, six months, 12 months, the {X}months since TANF exit), whether the outcome was measured for the respondent, her children, her family or her whole household, and the context for the question (i.e., placement in the questionnaire, tone of the lead-in to the question, content of the immediately preceding questions).

In the area of food security, there was the possibility for incorporating identical, or at least very similar, questions across many different surveys, because all grantees were provided with a common module of questions. However, the overall length of the module — 16 questions with 21 items when counting multiple part questions — diminishes its usefulness as a common module for the leavers’ studies. Grantees are asking an average of only 3.3 items, and these items are drawn across a broad array of the 21 items. Of these 21 items, only 4 are found in 3 or more leavers’ surveys, 4 are found in two surveys, 7 are in just one survey, and 6 are not in any leavers’ survey. Grantees also are asking 2 questions not found in the USDA core module.

In hindsight, and with the benefits of this analysis, it is clear that more attention should have been focused on the short (6-item) version of the USDA food insecurity scale, the version used in the Project on StateLevel Child Outcomes and also, in part, in the National Survey of America’s Families. There would have been much more commonality in food security measures if grantees had been encouraged to draw from a pool of 6 items rather than a pool of 21 items.

In my role of coordinating technical assistance on the survey questions and other aspects of the leavers studies, I have sometimes felt caught in the middle, between grantees who want one or two questions to measure a certain outcomes, and experts in a particular area who propose a “core set” of 10 to 20 or more questions. The tensions experienced in the area of food insecurity were also evident in such outcomes as child care, child wellbeing, and other measures. On the one hand, I understood the arguments of content area experts, who, after careful analysis and sifting through of dozens of questions, produce a core set of questions that they do not think can be reduced further without compromising the validity of the measure. (In the case of food security, 58 questions were tested in a food security supplement and numerous factor analyses were conducted before the core module was boiled down to 16 questions and an 18-item scale). On the other hand, I understand the pressures on researchers conducting leavers studies to ask a minimal set of questions about each outcome measure. One lesson from this analysis, I believe, is that if the experts are unable to develop a condensed version of their outcome measures, each leaver study will develop its own condensed measure. At least that is what has happened in the area of food insecurity.

Although the 1998 round of HHSfunded leavers’ studies are mostly in the field at this point, the question of developing short measures of food insecurity or child wellbeing or other important outcomes is still quite relevant. States across the country are continuing to design and conduct studies of families leaving welfare. Moreover, my office is awarding additional grants to states and large counties within the next few weeks, to fund further studies of welfare outcomes. Although the second round will focus on families formally or informally diverted from welfare before entry, rather than the traditional “leavers,” the same questions are likely to be asked with regard to employment outcomes, program participation, and family and child wellbeing. I plan to use the results of this analysis in my work with the next round of HHSfunded grantees, as we work together to move closer toward the longterm goal of developing more common outcome measures to monitor the status of families affected by welfare reform.

Footnotes

1. The 14 grantees are: Arizona, District of Columbia, Florida, Georgia, Illinois, Massachusetts, Missouri, New York, South Carolina, Washington, Wisconsin, Cuyahoga County (OH), Los Angeles County (CA), and a consortium of San Mateo, Santa Clara, and Santa Cruz counties in California.

2. It was difficult to choose outcome measures for this analysis. The food security measure was chosen in order to examine how grantees responded to an 18-item food insecurity module that was developed by the U.S. Department of Agriculture (USDA) and disseminated to all grantees. The other outcome measures were selected partly as a complement to the food security measures and partly as a result of the high levels of attention being focused on issues of Medicaid and food stamp receipt.

3. Proposed sample sizes are much smaller — 300 to 330 — for three grantees (Cuyahoga County, Los Angeles County, and the District of Columbia). Two grantees, Florida and Georgia, proposed much larger sample sizes (15,000 and 7,800, respectively). Also note that one grantee — Missouri — proposed interviewing recipients a full 24 months after exit.

4. For discussion of the difficulty of making crossstate comparisons in the absence of common measures, see the General Accounting Office report, Welfare Reform: Information on Former Recipients’ Status, GAO/HEHS-99-48 (April 1999) and the Urban Institute issue brief, Where Are They Now? What States’ Studies of People Who Left Welfare Tell Us, a product of Assessing the New Federalism, Series A, No. A-32 (May 1999).

5. After extended discussion, all grantees came to agree on a common definition of leavers as cases that leave cash assistance and remain off cash assistance for a minimum of two months. Initially, some grantees had wanted to limit the study to those families that remained off welfare at the time of interview (as much as ten to twelve months after exit). This approach, however, severely limits our understanding of why some families are successful in remaining off welfare while others return to the rolls. Other grantees wanted to look at cases that closed for one month and then re-opened, because of the policy interest in understanding the effects of fullbenefit sanctions. Many “one-month” closings, however, are exits due to administrative churning, rather than “true” exits. The two-month definition was developed as a compromise.

Note that two states — Arizona and New York — plan to study “one month and longer” leavers, but will conduct analyses of the subgroup of “two-month” leavers in order to increase comparability across studies. Also note that while some grantees limit the study population to singleparent cases, some include two-parent cases and a smaller number include childonly cases. In most cases, however, all grantees are reporting at least some findings for the “singleparent two-month leavers” that are common across all studies.

6. More information about the guidance on administrative data outcomes or the electronic list serve for leavers researchers is available from the author at julia.isaacs@hhs.gov.

7. Further information about both the administrative and survey data in these topical areas is provided in Appendix A of ASPE’s Interim Status Report on Research on the Outcomes of Welfare Reform, posted on the ASPE/HSP web site at http://aspe.hhs.gov/hsp/hspwelfare.htm.

8. Cuyahoga and Los Angeles are two of the four sites in MDRC’s Study of Devolution and Change (Urban Change) and both sites are using the same instrument and similar analyses.

9. The Wisconsin survey explicitly defines immediate family, stating, “For the purposes of the next few questions, family members include only your children and your spouse, or the parent of at least one of your children.” The Cuyahoga/L.A. survey asks, “Did you receive any food stamps” and “Did anyone else in your immediate family receive food stamps?”

10. In particular, see Price, Hamilton, and Cook, Guide to Implementing the Core Food Security Module. Alexandria, VA: U. S. Department of Agriculture (September 1997).

11. During discussions of the food security questions at the first grantee meeting, there was some confusion between the 18-item scale and the questionnaire, which is numbered from #1 – #16. The 18-item scale is built on Questions #2 – #16 from the core module, including three follow-up questions (#8a, #12a, and #14a). The first question, a threepart question, is not used in the 18-item scale, but is included in the core module because of its in past surveys and its potential as a screener for the other questions.

12. The full 18-item scale has been used to classify U.S. households into four categories: food secure, food insecure without hunger, food insecure with moderate hunger, and food insecure with severe hunger.

13. Connecticut, Florida, Indiana, and Iowa are using the 6-item scale, as well as Question #1 from the 1997 version of the module. Minnesota, the fifth state involved in the operational phase of this project, is simply fielding Question #1.

14. The 13 states in the National Survey of America’s Families include Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin. Researchers from Child Trends worked on the food insecurity and other child outcome measures in both the Child Outcomes Project and the NSAF.

15. An additional survey not included in this review, an Institute for Research on Poverty survey of welfare applicants in Milwaukee, asks families, “Can someone receive Medicaid (food stamps) without participating in W-2 [state name for TANF]?” This seems to me to be another example of a more neutrally phrased question.

Appendices

Appendix I: Survey Instruments Included in Review

Arizona Department of Economic Security, “1999 ADES Welfare Exit Study,” (April 1999).

15 pages. Drafted by Research and Reporting Office of Maricopa County. Drawn from previously tested and developed modules as much as possible. Pilot tested (60 complete interviews) in March 1999.

Cuyahoga County and Los Angeles County, MDRC, “TANF Leavers” CATI instrument (summer 1999).

Computer-assisted telephone interview, estimated 35-40 minutes. Focuses most heavily on employment, household composition and income, and also touches on such issues as respondent participation in training/education programs, educational attainment, material hardship, reasons for leaving welfare, health care coverage, and child care. English and Spanish versions.

District of Columbia: The Urban Institute, “D.C. TANF Leavers Questionnaire,” (draft as of 7/99).

Computer-assisted telephone interview; 80 items across 6 topics: work behavior; personal family characteristics; sources of support; hardship; health insurance; and leaving TANF. Note that the Urban Institute also designed the National Survey of America's Families (NSAF).

Florida: Survey Research Library, Florida State University, “Welfare Survey,” Revised 4/28/99.

Computer-assisted telephone interview. Some questions, particularly health questions, same as in the Florida Behavioral Risk Factor Questionnaire, allowing comparisons to entire population of Florida.

Georgia: Unnamed survey instrument.

Computer-assisted telephone interview. Includes strong focus on child well-being including child care arrangements and involvement with absent father as well as measures of parenting and home environment. Also gathers data on employment and income of former recipients, family economic status, and experience with and understanding of welfare reform. A number of survey items drawn from the PSID or the PSID Child Development Supplement.

Illinois: University of Illinois - UIS and UIUC for Illinois Department of Human Services, “TANF Closed-Cases Telephone Interview Instrument Version #8, December 1998 Closures (6/15/99).

Survey instrument based on earlier state survey, with modifications based on discussions with ASPE staff and representatives from other 13 projects funded by ASPE. Interviewer tells respondent the interview should take 20 to 30 minutes.

Missouri: Macro International, Inc., Survey of Welfare Leavers in Missouri, CATI/CAPI Questionnaire and Coding Specifications: March 12, 1999.

Computer assisted. If respondent asks, the interviewer is instructed to say the survey usually takes about 45 minutes to complete. The questionnaire was developed by Midwest Research Institute (MRI). It includes 151 items, covering 10 topic areas: work effort, earnings and other income, welfare recipiency status, use of food stamps, emergency assistance, and WIC; training; education; health insurance coverage; child care; housing and residential mobility; and household composition. Questions were drawn primarily from NSAF and two MDRC surveys (Minnesota FIP and Vermont Welfare Restructuring Program 42-Month follow-up Survey). For more information, see MRI's The Study of Families Formerly Receiving AFDC. Interim Report: 1999 Survey (May 3, 1999). Those interested in receiving a copy of the 79-page survey may contact MRI at 816-753-7600, ext. 1169.

San Mateo: Batelle Memorial Institute Centers for Public Health Research and Evaluation, Prepared for the SPHERE INSTITUTE, “The Bay Area Family Well-Being Survey: A Study for Welfare Leavers and Housing Assistance Recipients in San Mateo, Santa Clara and Santa Cruz Counties.”

29 pages, 109 items. Interviewer tells recipient it is a 40-minute interview.

South Carolina Department of Social Services, Division of Quality Assurance, “Review of Closed Family Independence Cases.” Version used for Cases closed October through December, 1997.

Questionnaire designed by Donold Klos. Surveys have been administered to five quarterly cohorts of leavers; surveys for cohorts 2-5 are nearly identical. New version of survey (prepared with ASPE grant) will be mostly the same as this survey. 12 pages, 45 items. Average interview takes 15 minutes. For more information, see South Carolina DSS, “Survey of Former Family Independence Program Clients: Cases closed during October through December, 1997, (2/22/99).”

Washington State, “Survey of TANF Exiting Clients, April-May 1999.”

Survey was based in large part on the state's prior TANF exit surveys. 16 pages, 30 items. Contact for survey portion of the project is Jean Du at 360-413-3063 or dujm@dshs.wa.gov.

Wisconsin Department of Workforce Development, “Review of W-2 Cases with no Cash Assistance for at least 2 months” (Version 6/2/99).

Draws heavily on South Carolina survey. Separate survey administered to those that returned to W-2 by time of survey.

Appendix II: Food Stamp Receipt

State	Food Stamp	Amount of Food Stamps	WIC, School Lunch
Arizona	201a. Did you (or your family) continue to receive Food Stamps? 201b. Why didn't you receive Food Stamps after you stopped receiving Cash Assistance? [in series of questions about income received by household last month] 413. What about Food Stamps? Did you receive Food Stamps last month?	313. What about Food stamps? How much did you receive in Food Stamps in December 1997? 413. If received last month, How much?	121, 161. Did you receive WIC Supplemental Nutrition Benefits? 122,162 Was your child(ren) on the free or discount school lunch program? (Asked first during 6 mos before exit, and then mos since exit)
Florida	Q62. I would like you to tell me whether you or someone in your home currently receives any of these (or has received any of these in the past 6 months)? Food Stamps?		Q68. WIC Supplemental Nutrition benefits? Q69. School lunch program? Q70. Summer feeding program for children?
Georgia			Does [child/name] eat breakfast at school/day care/nursery school] under the Federal School Breakfast program? Does [child/name] receive free or reduced price lunches under the FSLP during the school year?
Illinois	VIII-1. Various areas of your family's life since you left TANF...First, let's talk about Food Stamps. Since you left welfare, have you ever received food stamps? VIII-1A Do you get food stamps now?	(If received since left, but not now): VIII-1A1 Why don't you get food stamps now? (If not received: Have you applied for food stamps since you left welfare in [month]? Why haven't you applied for food stamps?	VIII-12. For each, I'd like you to tell me whether you or someone in your household got the benefit or service (Asked during 6 mos before exit, and then mos. since exit) WIC Supplemental Nutrition benefits, school lunch program
Missouri	First, during {prior month} did you or anyone else in your household receive Food Stamps?		Have you ever heard of the government's WIC program, that is Women, Infants, and Children Nutrition program? Do you or does anyone else in your household currently receive WIC assistance?
South Carolina	39. Now I will read you a list of benefit programs and types of support and I'd like you to tell me whether you or someone in your home gets this. Is anyone in your home getting Food Stamps?		WIC Supplemental Nutrition benefits? School lunch program? Summer feeding program for children?
Wisconsin	Next I will read a list of benefits, services, and types of support. I would like you to tell me whether you or a family member in your home receives it. For the purpose of the next few questions, family members include only your children and your spouse, or the parent of at least one of your children. 81. Are you or your family receiving any of the following? A. Food stamps?		81.1 Are you or your family receiving any of the following? B. WIC? C. Charitable food through meal programs, food pantries or shelter? 81.2 During the past year, did anyone in your family get help from A. Summer Food Service program for children. B. Free and reduced school lunch program. C. School breakfast program.
Washington	In the last 6 months, have you used any of the following resources/services? a) Food stamps? Etc.
Cuyahoga & LA	E9. In [prior month] did you receive any Food Stamps? I3c. Did anyone else in your immediate family receive Food Stamps? W11. When you left cash welfare benefits did you still receive food stamps? W11a. Why did you stop receiving food stamps? (Record verbatim)	E10a. During {prior month} how much did you (he/she/they) receive in Food Stamps? If unknown, Do you think it was closer to $100, $200, $300, $400 or $500 or more?
San Mateo	67. In the past month, did you or anyone else in your family receive income from...(c) food stamps.	How much did you or your family receive in total during [prior month]	(d) WIC?
D.C.	C1. Is anyone from your home getting.... Food Stamps? C2. At any time since [date of exit] have you or someone else in your home received..... Food Stamps? C3a. You say that no one in your household has received food stamps since [date]. Why not?		C1. WIC Supplemental Nutrition benefits? C2. Ditto since date of exit.

Appendix III: Health Insurance

State	Health Insurance	Why not covered?	Medicaid/Type of Insurance	Employer
Arizona	204. Are you currently covered by Medical Assistance (AHCCCS), do you have other health insurance coverage for yourself, or are you currently uninsured? 207. Ditto children.	203a. Why didn't you continue to get Medical Assistance (AHCCS) after you stopped receiving Cash Assistance? 206a. Ditto children.	203. Did you continue to receive Medical Assistance (AHCCS) for yourself after you stopped receiving Cash Assistance? (Also see 204 to left). 206. Ditto children.	[204] Is this (other) health insurance coverage through your employer or your spouse's employer (Coded as otheremployer, othernot employer) [207]Ditto children.
Florida	Q85a. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMO's, or government plans such as Medicaid? Q88a. Do your children have any kind of health care coverage?	Q85b. What is the most important reason that you do not have coverage? Ditto children.	Q62. I would like you to tell me whether you or someone in your home currently receives any of these (or has received any of these in the past 6 months)? Medicaid? Q86. What type of health care coverage do you use to pay for MOST of your medical care? Q88b. What type of health care coverage do you use to pay for most of your child's medical care?	Q9. Do/did you get any of the following benefits from your employer (or most recent employer)? [want to know if offered, not what employee taking advantage of] A health plan or medical insurance for you? A health plan or medical insurance for your children?
Georgia	Qing. Do you currently have health insurance for yourself? Do the children in your household currently have health insurance? When did you last have insurance for the children? (Within the last 6 mos, 6mos - 1 yr, 1-2 yrs, more than 2 yrs, DK, No Answer). What was the insurance ? (Medicaid, Peach care, employer provided insurance)		Qins1. Are you enrolled in Medicaid, Medicare, an employer provided plan, or one you pay for on your own? Are the children enrolled in Medicaid, Peach care, .......	Please tell me if the child's absent father has done any of the following...paid for dental or insured medical expenses? Paid for child's medical insurance?
Illinois	VIII-5. Not counting Medicaid, do you have health insurance for yourself? Ditto, kids.		VIII-2. Now let's talk about Medicaid. Since you left welfare, have you ever received a Medicaid card for yourself? Do you have a medicaid card for yourself now? Why don't you have a Medicaid card for yourself? VIII-2D Have you applied for a Medicaid card for yourself since you left welfare in [month] Why haven't you...Ditto all for kids, asking about "Medicaid or KidCare card"	Do you have this health insurance through your employer or your spouse's employer? If no: What kind of program covers you? Ditto children.
Missouri	See question I.3 to left; "no insurance coverage during prior month" is one of eight items. I5. Since you left AFDC on {date} have there been any periods of time when a child living in your household did not have medical coverage, including Medicaid? I6. Ditto, YOU.	See items to right on why participating in employer health plan.	I.3. There are many kinds of health insurance plans. [for each person in H.H., for prior month] please tell me which kind of health insurance each person has. Next, what kind of health insurance coverage does [each person in H.H.] currently have? (List of 8 types, including: 3. Medicaid or Medicaidpaid HMO	F16. Did your employer offer any of the following benefits to you? C. A health insurance plan? E. Dental benefits? I.1. Earlier you said your employer offers a hp. Do you participate in that plan? Which of the following statements most clearly describes why you do not participate in your employer's health plan? (Read list of 5 items: not need, premium too high, don't like, preexisting cond, other health insurance, other). Note that I3. to right include health insurance offered by current or former employer; by spouse's current or former employer.
South Carolina	40. Do you or other people who live with have some kind of health insurance that will pay all or some of the medical bills? Insurance includes Medicaid.		39. Now I will read you a list of benefit programs and types of support and I'd like you to tell me whether you or someone in your home gets this. Is anyone in your home getting Medicaid? 40a. What kind of medical coverage? How many people under 18 years are covered? How many 18 years or older are covered?	40b. Is this private insurance from an employer, do you pay for it all yourself, or what?
Wisconsin	1j. Does person have health insurance (y/n)? [asked for each person in current H.H.]	1k. If no ins., why not?	1I. Health insurance type? (Interviewer codes Medicaid, medical assistance, Title XIX or Healthy Start as 1)[each person]	1m. If private ins. who pays premium?
Washington	E12. Do you have any health care coverage for yourself, including DSHS medical coupons? E23. Do any of your children have health care coverage or insurance, including DSHS medical coupons?	E22. What is the main reason that you are without any health coverage? E25. Ditto children	E14. Next I am going to read a list of types of health care coverage that people may have. As I read each one, please tell me whether you have this type of health care coverage. (2^ND item: .... Medicaid / medical coupons / healthy options) What is the primary type of health care coverage for each of your children (different answer for up to 4 kids)	B14. Does your employer offer health care plan? B15. Were/are you actually enrolled in your employer sponsored health care plan? B16. Ditto children. E15. Type of care includes: .... My employer / union sponsored plan. E24. Type of primary healthcare coverage for children includes employer sponsored plan
Cuyahoga & LA	H1a. In [prior month] were you covered by any health insurance plan? H2a. Ditto spouse / partner. H3. Thinking about the children who were not covered by Medicaid / Medi-Cal, were all of them covered by some other health plan, some covered, none?	H3b. What is the main reason your children who are not covered by Insurance are not covered by Medicaid / Medi-Cal? (Write down verbatim)	H1. In [prior month] were you covered by Medicaid / Medi-Cal? Probe: Did you have a valid Medicaid / Medi-Cal card? H2. Ditto spouse/partner. H3. Thinking about all your children under 18 who lived with you in [prior month], were all of your children covered by Medicaid / Medi-Cal, were some of them covered, or were none of them? W12. When you left cash welfare benefits did anyone in your family continue on Medicaid (Medi-Cal in LA survey)? Did your children continue on Medicaid (Medi-Cal)	LF17. Do/did you get any of the following benefits from your employer? C) a health plan or medical insurance for you? D) ... for your children?
San Mateo	Is your child(ren) currently covered by a plan that helps pay for their/his/her medical care, such as Medi-Cal or Medicaid, Healthy Families, which is sometimes called "Medi-Cal for Kids," a private insurance plan, such as a plan provided by an employer or one you pay for yourself, or some other government health plan, such as Champus or Medicare? (Answer for each child) 86. Are you yourself currently covered by any sort of plan that helps pay for your medical care, such as Medicaid or private health insurance?		What type of medical insurance plan is {each child} currently covered by? Is it... a) Medi-Cal or Medicaid, b) Healthy Families, which is sometimes called "Medi-Cal for Kids," c) a private insurance plan, such as a plan provided by an employer or one you pay for yourself, or d) some other government health plan, such as Champus or Medicare? (Answer for each child) 86a. Ditto, you. 95. When you stopped receiving cash aid in (exit month), did the county welfare agency or another government agency ... d) continue to provide you with health insurance?	Current/just before you left does/did this job provide you with... c) a health plan or medical insurance for yourself? d) A health plan or medical insurance that covers children?
D.C.	E2a. Do you have any health insurance coverage? E2b. So are you uninsured? E3. Do any of your children... E3a. So all your children are uninsured?	E2c. Why aren't you enrolled in Medicaid?	E2a. What is the source of your health insurance coverage? E3b. What are the sources of health insurance coverage for your children?	A 10. Do you receive health insurance through (your employer, union, temporary agency, or contract company) Does your (employer, union, etc) offer health insurance to any of its (temporary) employees? Cold you begin this plan if you wanted to? Why aren't you in this plan? Why can't you be in this plan? Does your (employer, union, etc) pay for all, part or none of the insurance premiums? E1. Are any of your children covered under your health insurance policy through your employer?

Food Questions

Appendix IV-A: Food Security/Hunger Core Module: 3-Stage Design, With Screeners (7/28/97)

Questions, by #, in Core Module	Grantees	Grantee Adaptions:
#1. Which of these statements best describes the food eaten in your household in the last 12 months, that is, since (current month) of last year: We [always] have enough to eat and the kinds of food we want We have enough to eat but not always the kinds of foods we want Sometimes we don't have enough to eat; or Often we don't have enough to eat (Don't know or refused)	Arizona, Georgia, Cuyahoga & L.A. San Mateo, Other: CO, S	AZ: And, during those 6 months, was there ever a time when you or your family did not have enough to eat? Child Outcomes/SIPP: Which of these statements best described the food eaten in PRIOR MONTH/last 4 months?
#1a. Here are some reasons why people don't always have enough to eat. For each one, please tell me if that is a reason why YOU don't always have enough to eat. [Read list. Mark all that apply.] Not enough money for food; Too hard to get to store; On a diet; No working stove available; Not able to cook or eat because of health problems. #1b. Same question about why people don't always have the kinds of food they want or need. Last two responses changed to: Kinds of food (I/we) want not available; Good quality food not available.	San Mateo (#1a and 1b)
Intro to #2 (*) Now I'm going to read you several that people have made about their food situation. For these statements, please tell me whether the statement was OFTEN true, SOMETIMES true, or NEVER true for your household in the last 12 months, that is,	Georgia, Washington, Other: CO, N	GA: For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household over the past 12 months. WA: In the last 6 months, if at all, how often have you experienced any of the following problems? since last (name of current) month.
#2. The first statement is "we were worried whether our food would run out before we got money to buy more"	Georgia, DC, Other: N
#3. (*) The food that we bought just didn't last, and we didn't have enough money to get more.	Georgia, DC, Illinois, Cuyahoga/LA, Other: CO, N	Illinois: [During this time period] was there ever a time when the food you bought....(asked about last 6 months before exit, and also about 5-7 mos since exit).
#4. (*) We couldn't afford to eat balanced meals.	Georgia, Washington, Cuyahoga/LA, Other: CO	WA: (6 mos): Not enough money to provide balanced meals for the family
#5. (*) We relied on only a few kinds of low-cost food to feed our children because we were running out of money to buy food.
#6. We couldn't feed our children a balanced meal, because we couldn't afford that.
#7. Our children were not eating enough because we just couldn't afford enough food.
#8(*). In the last 12 months, since XX, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?	Illinois, D.C., Washington, Cuyahoga/LA, San Mateo, Other: CO, N	Ill: [During this time period] Was there ever a time when anyone in your family ever cut the size of meals or skipped meals because... (asked about last 6 months before exit, and also about 5-7 mos since exit). WA: (6 mos): Cut the size of meals because... (Separate question:) Skip meals because.... (See below on adults vs. children) SM: In the last month, did anyone skip any meals because there wasn't enough food, or money or food stamps to buy food?
# 8a (*). How often did this happen - almost every month, some months but not every month, or only 1 or 2 months?	Cuyahoga/LA, DC, Other: CO, N
#9 (*). In the last 12 months, were you ever hungry but didn't eat because you couldn't afford enough food?	Cuyahoga/LA Other: CO	CY: Since your welfare benefits ended last month, were you ever hungry but didn't eat because....
#10(*). In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money to buy food?	Cuyahoga/LA, Other: O
#11. In the last 12 months, did you lose weight because you didn't have enough money for food?
#12 In the last 12 months, did you or other adults in your household ever not eat for a whole day because there wasn't enough money for food?	Washington, San Mateo	WA: Going without food all day because there was no money to buy food. SM: In last month, were there days when your H.H. had no food, or money or food stamps to buy food?
#12a. How often did this happen - almost every month, some months but not every month, or in only 1 or 2 months?
#13. In the last 12 months, since XX of last year, did you ever cut the size of any of the children's meals because there wasn't enough money for food?	Washington	Did this (cutting meal size) happen only to adult members of your family or both adults and children?
#14. In the last 12 months, did any of the children ever skip meals because there wasn't enough money for food?	Missouri Washington	MO: During last month...... How many days did this happen during [last month].. WA: Did this (skipping meals) happen only to adult members of your family or both adults and children?
#14a. How often did this happen - almost every month, some months but not every month, or in only 1 or 2 months?	Missouri
#15. In the last 12 months, were the children ever hungry but you just couldn't afford more food?
#16. In the last 12 months, did any of the children ever not eat for a whole day because there wasn't enough money for food?	Washington	Did this (not eating for a day) happen only to adult members of your family or both adults and children)
Other Items, Not from USDA Food Security/Hunger Core Module		FL: Was there ever a time when you could not afford to buy food? MO: Was there a time when you/your household was unable to bun enough for its/your needs. SC: Was there ever a time when you had no way to buy food? (No, yes, on welfare, after welfare) WI: Was there a time when you had no way to buy food? (No, yes, on welfare, after welfare)

Appendix IV-B: Food Insecurity

State	Food Insecurity	Non-Governmental Food Assistance
Arizona	USDA Food Security item #1 (adapted) 118, 157. And, during those months/this period was there ever a time when you or your family did not have enough to eat? (No, Yes, don't remember, Refused) Asked twice, last 6 mos. before exit i.e., July 97-Dec97, and months since exit (Jan 98) when NOT receiving TANF]	129. 169. Did you receive meals or food from shelters, food kitchens, or food banks? Asked twice, last 6 mos before exit, and months since exit when not receiving cash assistance.
Florida	Q53. Was there ever a time when you could not afford to buy food? (From a list of things that may have happened to you since you left WAGES) Q91. Final questions ask how satisfied you are these days with various things. The food your household eats? Very sat., satisfied, dissatisfied, very dis.	Now I would like to know whether you have received any of the following after leaving WAGES.. Q81. Food pantry? Q82. Food kitchen?
Georgia	5 USDA Food Security items (#1: enough food to eat; #2: worried about food would run out before we got money to buy more, #3: food we bought just didn't last, #4: couldn't afford to eat balanced meals).	Qmode9. When you did not have enough money to buy food, what did you and your family do- go hungry, get meals or food at a shelter or kitchen, get food from a church, from friends or relatives, or some other way.
Illinois	2 USDA Food Security items (#8: cut size/skip meals; #3: food we bought just didn't last)	VIII-12. For each, I'd like you to tell me whether you or someone in your household got the benefit or service (Asked during 6 mos before exit, and then mos. since exit) 15. Gifts of money or food from family or friends, 16. gifts of money or food from your church, 17. meals or food from shelters, food kitchens, or food pantries
Missouri	2 USDA Food Security items (#14 & 14a, children skip a meal for a day, and how often) and H2. During [prior month] was there a time when your household was unable to buy enough food for its needs?	H3. Did you get help when your household was unable to buy enough food for its needs? H4. Why didn't you get any help? H5. Who did you get help from? (Select all that apply: family or friends, church, synagogue, or other religious organization; community programs, such as a food bank or soup kitchen; government program; other)
South Carolina	16. Was there ever a time when you had no way to buy food? (No, yes, on welfare, after welfare)	17. When you did not have money for food, what did you and your family do? (Interviewer do not read responses; check all that apply; probe: Code as: went hungry; got meals or food at shelter/food kitchen/food pantry; got meals/food/money for food from church; were given food or money for food by friends, relatives; other)
Wisconsin	37. Was there a time when you had no way to buy food?	37.1. When you did not have enough food, what did you and your family do? 81.1 Are you or your family receiving any of the following? C. Charitable food through meal programs, food pantries or shelter
Washington	6 adapted from USDA Food Insecurity items (#8: Cut size of meals, #13: happen only to adults or both to adults and children; #8: Skip meals; #14: happen only to adults or both to kids and adults? #12: Not eat for a whole day; #16 happen only to adults or both to adults and children)	In the last 6 months, have you used any of the following resources/services? ... b) food banks h) Assistance from charitable organizations?
Cuyahoga/LA	7 USDA Food Insecurity items (#8: cut size/skip meals; #8a, how often did this happen; #10: eat less than felt should; #9: hungry but didn't eat; #3: food we bought just didn't last; #4: couldn't afford to eat balanced meals; #1 Enough food to eat, enough but not always the kinds).	Did you or anyone in your immediate family get food from a church, food pantry, foodbank or any clothing from a church or other charitable organization in [Last month.]?
San Mateo	5 USDA Food Security Items (#1,1a & 1b: Enough food to eat & why; #12 adapted, days when H.H. had no food, or money or food stamps to buy food? #8, adapted: In the last month, did anyone skip any meals because there wasn't enough food, or money or food stamps to buy food?)	82. Possible reasons why people don't always have the kinds of food they want or need]. A) not enough money b) hard to get to store c) on diet; d) kinds of foods you want not available, e) good quality food not available. 83. Ditto for reasons why not enough to eat: a), b), c) as above, d) no working stove or refrigerator; e) not able to cook because of health problems
D.C.	USDA Food Security Items #2: worried about whether food would run out; #3 Food we bought didn't last; #8 cut size/meals; #8a how often cut size/meals

Note: Item #s refer to the "Food-Security/Hunger Core Module: 3-Stage Design, with Screeners" USDA, Food and Consumer Services (7/28/97). See Appendix IV-A.

Appendix V: Access to Health Care and Health Status

State	Access to Health Care	Health Status
Arizona	156. During the last year, when you were not receiving Cash Assistance, was there a time when you, or anyone else in your household, did not get needed medical treatment because you could not afford it?
Florida	Q52. Was somebody in your home ever sick or hurt when you could not afford medical care? (From a list of things that may have happened to you since you left WAGES) Q87. Do you need medical care and cannot obtain it at the present time? Q89. Do your children need medical care and cannot obtain it at the present time?	Q83. Would you say that in general your health is excellent, very good, good, fair, poor, DK, NA? Q84. How about your children's health?
Georgia
Illinois	IX-2. H. How satisfied or dissatisfied are you with... the quality of the health care that you and your family can afford (very satisfied., somewhat sat., somewhat dissatisfied., very dissatisfied)	IX-2. F. How satisfied or dissatisfied are you... with your personal health and physical condition. (very satisfied., somewhat sat. , somewhat dissatisfied., very dissatisfied). G. What about the health and physical condition of your child or children? XI-4c. In terms of medical care for your children, do you think you are better off, worse off, or about the same as when you left welfare in MONTH?
Missouri
South Carolina	15. Was somebody in your home ever sick or hurt when you could not get medical care? (No? Yes? On welfare? Off welfare?)
Wisconsin	35. Was somebody in your home sick or hurt when you could not afford to get medical care (n, yes, on TANF, off TANF)
Washington
Cuyahoga/LA	H6. Has there been any time in the past twelve months when you or your child(ren) (or your husband/partner) needed to see a doctor or go to the hospital but didn't go because you didn't have money or medical insurance? H8. Ditto "see a dentist"	H5. Would you say that in general your health is excellent, very good, good, fair, or poor (DK, R)
San Mateo
D.C.	D14. Was someone in your home ever sick or hurt when you could not get medical care? [since leaving TANF]

Appendix VI: Knowledge of Food Stamp and Medicaid Eligibility

State	Knowledge of benefits (Food Stamps)	Knowledge of benefits (Medicaid)
Arizona	When you stopped receiving Cash Assistance in January-98, did you receive information from DES letting you know that you might be able to continue to receive Food Stamps?	Did DES let you know that you might still be eligible for Medical Assistance (AHCCS) for yourself when you stopped receiving cash assistance? Did you receive information from DES, letting you know that your child(ren) might still be eligible for Medical Assistance, when you stopped receiving ...
Florida	Q37. Did you know that you may continue to get Food Stamps after leaving WAGES?	Q38. Did you know that YOUR CHILDREN may continue to get Medicaid after leaving WAGES? Q39. Did you know that ADULTS may continue to get MEDICAID after leaving WAGES?
Georgia	Now, we'd like to ask you a few questions about how welfare works in Georgia. We want to learn how well people understand the new rules. ... qmode3. Once you leave TANF, do Medicaid benefits end?
Illinois	VIII-1B Did you think you would be eligible to receive food stamps after you left cash assistance? VIII-1C. Did your case worker or someone else from the welfare office tell you that you might be eligible for food stamps after you left welfare cash assistance?	VIII-2B Did you think you would be eligible to get a Medicaid card for yourself after you left cash assistance? VIII-1C. Did your case worker or someone else from the welfare office tell you that you might be eligible to get a Medicaid card for yourself after you left welfare cash assistance? Both questions repeated, asking about "Medicaid or KidCare card"
Missouri		I.7. Do you think a child of yours could receive Medicaid benefits even if you were not receiving cash assistance from the State's AFDC or TANF program? Have you ever heard of the Children's Health Initiative Program or MC+ Program?
South Carolina	42. There are some benefits that people can continue to get even if they are no longer on welfare. I need to ask if you know about these. First, Did you know that you may continue to get Food Stamps after leaving welfare?	43. Did you know that children may continue to get Medicaid after leaving welfare? 44. Did you now that adults who leave welfare to work may continue to get Medicaid?
Wisconsin	There are some benefits that you may still be eligible for after you leave W-2. The next few questions will ask whether you've heard about these benefits or not. Did you know that after W-2 you may be eligible for Food Stamps?	Did you know that after W-2 your children may continue to be eligible to get Medicaid? ... adults who work may be eligible to get Medicaid?
Washington
Cuyahoga/LA
San Mateo
D.C.

Note: Another survey not included in this review, a study of families diverted from TANF in Milwaukee, asks, "Can someone receive Food Stamps without participating in W-2? And "Can someone receive Medicaid without participating in W-2?

Topics

Welfare, Welfare Reform, & TANF