Since the late 1990s, policymakers and advocates for the poor have called for streamlined programs, better caseworker training, enhanced program management, and expanded public education to reduce barriers to participation (O’Brien et al. 2000; Shahin 2009; Waters Boots 2010). In response, the federal government began mounting efforts to reduce or eliminate barriers to program application and participation. For instance, the Social Security Administration and Veteran’s Administration instituted electronic application systems and the U.S. Department of Agriculture developed an online tool that individuals and families can use to determine their potential eligibility for SNAP. A collaborative effort of 17 Federal agencies launched in 2002 what is now benefits.gov, an effort to provide citizens with easy, online access to government benefit and assistance programs. And, several agencies offered states flexibility in relaxing program eligibility policies and procedures.
Most recently, the Economic Recovery and Domestic Poverty Task Force of the President’s Advisory Council on Faith-Based and Neighborhood Partnerships made the following four recommendations for a “streamlined, people-centered multiple-benefit access system based in the community” (President's Advisory Council on Faith-Based and Neighborhood Partnerships 2010):
- Create a taskforce to streamline and consolidate eligibility and application processes
- Expand single-site, multiple-benefit access programs
- Invest in the development and distribution of software applications to facilitate access to multiple benefits through online applications
- Create incentives for state and local governments to maximize program participation among low-income populations and to promote multiple-benefit access through faith- and community-based organizations
As part of the Affordable Care Act (ACA) signed into law in March 2010, DHHS—in consultation with the Health Information Technology (HIT) Policy Committee and the HIT Standards Committee—offered recommendations which “seek to encourage adoption of modern electronic systems and processes that allow a consumer to seamlessly obtain and maintain the full range of available health coverage and other human services benefits.” The recommendations are guided by the notion that “the consumer will be best served by a health and human services eligibility and enrollment process that:
- Features a transparent, understandable and easy to use online process that enables consumers to make informed decisions about applying for and managing benefits;
- Accommodates the range of user capabilities, languages and access considerations;
- Offers seamless integration between private and public insurance options;
- Connects consumers not only with health coverage, but also other human services such as the Supplemental Nutrition Assistance Program (SNAP) and the Temporary Assistance for Needy Families (TANF) program; and
- Provides strong privacy and security protections” (DHHS 2010).
In addition to federal agency efforts, states, localities, and private organizations that serve low-income populations have mounted their own responses. These different federal, state, and community efforts intervene at different stages of the process program applicants and participants go through—from learning about and applying for benefits, to going through an eligibility determination and enrolling in programs, to taking the necessary measures to remain on benefits. In rural communities, coordinated benefits access efforts have been seen as a means to address impediments to services for rural individuals and families, such as lack of public transportation, persistent poverty, and limited access to resources. At the same time, many of these efforts have been implemented in urban settings with high concentrations of low-income populations. Some efforts depend heavily on information systems technology, and some do not. Figure 1.1 illustrates the range of these efforts, and they are discussed briefly in the paragraphs below.
Learning about benefits. Benefits access efforts that provide information about different types of benefits are designed both to inform potential applicants about existing benefit programs and to dispel myths about the stigma—perceived or real—associated with program participation. Examples include marketing campaigns that consist of television, radio, newspaper or other printed advertisements and/or varied types of printed distribution materials such as flyers, brochures, postcards, or envelope/paycheck stuffers. Telephone hotlines providing resource and referral information also fall into this category. Many efforts at this stage also rely on the web to disseminate program descriptions, instructions on how and where to find more information and apply for benefits, and lists of other resources. Federal agencies, states, localities, and private organizations have used this type of outreach to educate potentially eligible families and individuals.
Applying for benefits. Efforts that intervene at this stage focus on making it easier for individuals and families to submit applications for benefits. Some benefit providers have attempted to make the process easier by combining program applications (thus reducing the time and effort required of the applicant), extending office hours, or implementing call centers to enable applicants to provide information and have questions addressed more conveniently. Some providers reach out to prospective clients by distributing and accepting applications at convenient community locations. Private nonprofit and for-profit organizations conduct this type of outreach as well, and they also may help individuals and families complete applications and compile the necessary documentation. Efforts at this stage can rely on electronic data exchange or data matching to identify a target group of individuals or families who are enrolled in one or more programs but not in others for which they are likely to qualify. Public and private entities may do the matching, but public agencies must supply the data.
Public and private organizations have also used the Internet to bring people into a program or programs. For example, online screeners and benefit calculators with interactive software help people assess their eligibility for programs and estimate their benefits. In some cases, people can fill out applications online, print them, and then deliver them to the program office(s). In others, online program applications may be submitted electronically, relieving the pressure of relying on mail delivery or delivering applications to programs offices that are not conveniently located or open during convenient times. Many efforts offer some combination of the above.
Determining eligibility and enrolling in benefits. Initiatives at this stage aim to speed up the eligibility determination and enrollment process in order to reduce the potential for attrition before people are certified for benefits. Attrition tends to occur at a few critical points in the eligibility determination process. Typical examples include failure to attend a required in-person interview or failure to provide documentation for the information on an application.
The shaded boxes in Figure I.1 on page 4 illustrate the types of efforts included in, and excluded from, the scan. Included are three distinct types of web-based technologies that help people apply for at least two federally-funded programs in which they do not currently participate:
- Screeners/benefit calculators that provide information to potential applicants
- Online applications that must be printed and delivered to relevant program office(s)
- Online applications that may be submitted electronically
Public agencies have attempted to address this problem by changing their policies and processes. With respect to policies, for example, some agencies have waived interview requirements or replaced a required in-person interview with a required telephone interview. Process changes have taken two forms. First, agencies have shifted their workflow and redefined staff roles to maximize productivity and to reduce processing time. Some have done this through specialization of staff roles and/or the institution of call centers. Second, agencies have used technology to obtain data more quickly and to reduce the burden on applicants. For instance, one agency may exchange data with another in order to directly certify individuals and families for certain programs based on their enrollment in others. Data exchange also can be used to verify eligibility information for one set of programs based on documentation provided for others. In addition, technology in the form of systems integration can facilitate enrollment by allowing electronic application data to be automatically transferred into a program’s eligibility and benefit determination system. Without this capability, program staff must re-type application data (whether submitted in hard copy or electronically) into the
Taking necessary steps to remain on benefits. In most programs, participants are certified to receive benefits for a certain period of time after they enroll. Once that period ends, they must provide documentation to the agency to prove that they are still eligible for benefits. In SNAP, for instance, the standard certification period is 6 or 12 months, and for Medicaid, it is 12 months or less. However, participants do not always take the necessary steps to recertify, either because they are not aware that they need to or because it is burdensome to acquire and submit the documentation. Access efforts at this stage are therefore designed to help individuals and families keep their benefits by reducing or simplifying the recertification requirements. Some are policy changes. For instance, agencies have extended the certification period for some programs or aligned certification periods across programs. Other efforts affect processes—for instance, enabling participants to report changes and re-certify for benefits through call centers or online. More progressive efforts involve “passive renewal,” whereby agencies send recertification forms to participants and inform them that their eligibilitywill be automatically renewed unless they respond. Such efforts are increasingly prominent in Medicaid and CHIP.