HHS Research Initiative Regarding Transformations in Health and Human Services: Report of the Working Group. Transformations in Financing, Organization, and Availability of Human Services


Human-services programs currently are undergoing rapid changes in scope, content, and accessibility; and, analogous to the health-care milieu, the changes primarily involve financing, organization, and availability of services. One major contributor to the ferment is bipartisan dissatisfaction among political leaders at all levels of government regarding the effectiveness of traditional welfare modalities. Another major contributor is the drive by governments to exert greater fiscal discipline on public spending overall -- often through strategic choices that feature slower growth or even major reductions in expenditures for human services.

Welfare Reform

Income-support programs have been at the forefront of these changes. Although operational details differ significantly from state to state -- and even among communities within the same state, two themes have become prominent across the nation: (1) facilitating the movement of welfare recipients into the workforce and (2) placing explicit limits on the duration of welfare benefits.

In this spirit, the majority of states have received waivers to demonstrate welfare programs characterized by policies and procedures tailored, at least in part, to the state's priorities and resource limitations. The Department has done much to effect this devolution of policy-making responsibility -- primarily by exercising the authority provided by Section 1115 of the Social Security Act to grant waivers for state-specific demonstrations involving either the Aid to Families with Dependent Children (AFDC) Program alone or AFDC in combination with Medicaid waivers (also granted by the Department as described above) and/or food-stamp program waivers (granted by the U.S. Department of Agriculture).

Other Human Services

Important as income-support mechanisms such as AFDC and Supplemental Security Income (administered by the Social Security Administration) are in their own right, they are only part of the panoply of human services. Prime examples of other areas in which the federal government provides significant leadership and resources are the Head Start Program (DHHS), the school-lunch program (U.S. Department of Agriculture), job training (Department of Labor), and housing assistance (Department of Housing and Urban Development). For older Americans, the Administration on Aging (DHHS) serves as an advocate at the level of the federal government and supports a wide variety of programs through a national network of State Units on Aging, Area Agencies on Aging, and service providers. Critically important complementary resources come from both states and local governments as well as from churches, charities, and other private-sector entities.

The ensemble of in-kind human services, like income-support programs, also is being affected by devolutionary forces. But, in this instance, the trend is toward enhancing the policy-making roles of communities -- both local governments and not-for-profit, community-based entities. The trend is fueled both by legislative initiatives such as the Family Preservation and Support Act and by policy initiatives such as the designation of Empowerment Zones and Enterprise Communities. The resulting new arrangements are enabling local-government officials and other community leaders to explore various approaches to integrating services with a view toward enhancing effectiveness while decreasing costs.

The linkage of health services and human services -- at least functionally, if not also organizationally or administratively -- is a noteworthy feature of an increasing number of these community-level efforts. Welfare-to- work policies can succeed only if they provide effective services for preparing and connecting welfare recipients to the workforce along with necessary child care. Homeless individuals often need mental-health services or substance-abuse treatment as well as meals and shelter. Many chronically infirm or severely disabled individuals can function well outside of nursing homes only if they have ready access to assistive technology, personal care, and assisted-living arrangements in addition to health services. And better coordination of core public-health functions with Head Start, public housing, food stamps, and other human services could make the aggregate more cost- effective than the sum of the parts operating independently.

Meeting the Challenge of Change

These changes engender many challenges for policy-makers, such as the following questions:

  • What are the most effective approaches for moving families from welfare to economic independence?
  • What are the effects of different welfare reforms on the well-being of children?
  • Does welfare reform have an effect on family structure, especially on the prevalence of out-of-wedlock childbearing and single-parent families?
  • What are the most effective approaches in improving the healthy development of low-income children?
  • How does devolution affect vulnerable populations, for example, children in foster care, at-risk youth, the disabled, and racial and ethnic minorities?
  • What are the basic trends in child well-being, including child health, child abuse, social and emotional development, and readiness for school?
  • What are the basic trends in well-being of elderly individuals, especially the frail elderly?
  • Will individuals with chronic, severe physical or mental disabilities or others requiring long-term care find an augmented or diminished array of services to help them live at home or in other community-based settings?
  • Will states and local governments exploit effectively the opportunities afforded by devolution -- e.g., to tailor and integrate health/human services to meet the most pressing needs within their jurisdictions?
  • How will the consequences of devolution affect public confidence in governments at all levels?

These and related questions, like the questions highlighted in the earlier discussion of health services, make clear the need for strong, sustained efforts in research, program evaluation, and data acquisition. Section B of Appendix 1 summarizes ongoing and planned activities across the Department that offer invaluable starting points for an expanded set of studies.