Work Support Strategies was a multiyear, foundation-funded initiative to help eligible low-income families get and keep the full package of work supports, particularly the Supplemental Nutrition Assistance Program, Medicaid/Children's Health Insurance Program, and child care assistance. Through grants, expert technical assistance, and peer learning, the initiative helped Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina reform, modernize, align, and integrate the systems delivering work support programs to increase families' well-being and stability. This brief summarizes the changes the states made, the outcomes of those changes, and what we learned from their experiences.
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Millions of working parents qualify for food, medical, and child care assistance that can help them support their families. When parents receive the full package of supports they qualify for, it can stabilize their work lives and promote the health and well-being of their children. However, accessing these supports can be difficult or confusing. Through the Work Support Strategies (WSS) initiative, six states addressed this challenge.
WSS was a multiyear, multistate, foundation-funded initiative to help low-income families get and keep the full package of work supports for which they are eligible. It was grounded in research that suggested that working families who get and keep core work support programs (Medicaid and the Children’s Health Insurance Program [CHIP] and nutrition and child care assistance) are then better able to stabilize their lives, advance their careers, and raise their children (Mills, Compton, and Golden 2011). Yet the research also showed that many eligible families did not receive help, partly because of barriers in cumbersome state systems. Inefficient, outdated technology and archaic business processes burden the families seeking support and are costly to state and local social services agencies. Unsatisfied with the status quo, 27 states applied to participate in WSS.
Nine states were competitively selected to participate in a planning and design year in 2011, and six (Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina) continued to an implementation phase that ran from 2012 through 2015. Through grants that gave states the capacity to focus on service delivery issues, expert technical assistance, and peer learning, the initiative helped these states reform, modernize, align, and integrate the systems delivering work support programs to increase the well-being and stability of families. States focused particularly on the Supplemental Nutrition Assistance Program (SNAP), Medicaid (including CHIP), and child care assistance through the Child Care and Development Block Grant. Some states included additional programs as part of their WSS effort.
The WSS states aimed to improve operational efficiency and customer service while improving family well-being. Diverse politically, geographically, and in administrative structure, they shared a common commitment to devote time, resources, and political capital to reforming work support programs. They sought to streamline and integrate service delivery, implement 21st-century technology, and apply innovative business processes to improve administrative efficiency and reduce the burden on states and working families, all toward the goal of increasing participation and retention.
This brief provides an overview of the changes the WSS states made, the outcomes of those changes, and what we learned from their experiences. Findings from the WSS evaluation are based on analyses of hundreds of individual and group interviews conducted during annual site visits to the six states in the planning and implementation phases; hundreds of quarterly reports, planning documents, and other written materials submitted by the states; other documents obtained through secondary sources; state administrative data tracking key outcomes over time; and additional data from client experience surveys and client focus groups conducted by the evaluation team in selected states. The brief summarizes information that is presented in greater detail in several other publications from the WSS initiative and evaluation.1
What Changes Did the WSS States Make?
WSS states made interrelated changes to their technology systems, policies, and business processes. At the beginning of the WSS initiative, state work support programs varied in integration from totally separate applications, caseworkers, or processes to integrated applications with one set of workers handling multiple programs. Recognizing the interconnected nature of family needs, states made changes to improve cross-program integration so eligible families could more easily access multiple work supports. Changes to individual programs and program integration were guided by a focus on serving families through improved customer service and administrative efficiency. These changes were not easy, and some reform attempts were successful only after states learned from initial mistakes.
Improved Customer Service through Faster, Easier Access to Work Supports
Rather than merely complying with federal requirements to deliver work supports within specified time frames, WSS states considered the customer’s point of view and found ways to ease the application process. In some cases, clients are now able to receive benefits on the same day they apply. And nearly all WSS states expanded options for clients to apply online or by phone, reducing the need for clients to visit an office and easing access for people with health or transportation challenges or who work during office hours.
New and Updated Technology
Each state implemented new technology or updated existing technology to deliver services more efficiently. Before WSS, several states’ eligibility systems (the main computer systems for entering and tracking benefit information) had been in place for decades. These legacy systems were typically slow, inefficient, and cumbersome to reprogram to support new policy changes or procedures. Technology limitations in some states required clients to provide the same paper documentation multiple times for different programs, and clients could have difficulty getting information about their benefit status from agencies. Several states struggled to pull timely and accurate data out of their existing systems or produce reports from raw data for use in management and decisionmaking.
States believed the use of technology to automate some administrative tasks and improve efficiency would give frontline workers more time to support customers, ensure consistency in determinations across workers and offices, and reduce errors. They also saw that technology could support efforts to improve cross-program integration and how customers access multiple programs. They envisioned using technology to share information more easily across government departments, track service delivery, and reduce the need for multiple office visits with multiple documents.
WSS states made three primary types of technology changes:
- States implemented new eligibility systems or made key improvements to existing systems. Some states built integration into new eligibility systems to help clients apply for multiple benefits through a single process.
- States developed online applications and websites (customer portals) through which applicants can be prescreened for eligibility, apply for benefits, find information on their benefit status and use, report status changes, submit documents, and receive assistance through online chat.
- Almost all states implemented lobby management technology to maximize efficiency and minimize wait times by providing information about client queues that allows managers to reallocate staff as needed. This information also helps clients decide if they should stay or need to come back at another time.
In addition, states implemented other important technology changes, such as electronic data verification, which speeds up application and renewal processes, and document imaging systems, which more information on how the WSS states used technology to improve the delivery of work supports, see Loprest, Gearing, and Kassabian (2016).
States frequently faced challenges as they implemented new technology. Because of ACA requirements, changes were rolled out under very tight timelines just as states were dealing with a surge of new applications. Problems arose with incomplete or limited functionality, delays in development leading to limited time or less-than-ideal conditions for training staff, and technology glitches. In some cases, these resulted in significant backlogs in processing applications and occasional reports of lost applications or paperwork. States mitigated these challenges by implementing larger or more complex system changes in phases, even delaying additional phases until initial issues were addressed. States also used planned workarounds—procedures staff could use when intended procedures did not work or were not yet available. Planned workarounds prevented workers from creating their own individual workarounds, which could lead to errors and inconsistencies.
Streamlined and Aligned Policies
WSS states made several policy changes to streamline access to SNAP, child care, and Medicaid. To streamline operations, state policy changes in SNAP and child care reduced the use of face-to-face interviews, simplified eligibility and verification requirements, and lengthened certification periods. Several states realized they were requiring clients applying for child care subsidies to provide detailed documentation of their work schedules, which is not mandated by federal law. Eliminating this requirement saved time for both clients and caseworkers. The ACA also required all states to make changes to Medicaid that eliminate asset tests for most applications and provide 12 months of eligibility.
States also sought to align policies across work support programs to reduce administrative burdens on families eligible for more than one program. States established processes for cross-program review of new policies, aligned the timing of benefit redeterminations so families could renew benefits for two or more programs at the same time, and used electronic data to autoenroll SNAP recipients in Medicaid. By streamlining and aligning policies—or as an interviewee in one state put it, “reducing duplicative requests for the same paperwork”—states found they could improve outcomes for workers and clients. For more information on how WSS states changed policies to streamline access to work supports, see Isaacs, Katz, and Kassabian (2016).
Improved Business Processes
States made changes to their business processes, updating their methods for greeting customers, accepting applications, making eligibility determinations, and processing changes and renewals. Frontline workers and supervisors worked with business process specialists to identify inefficiencies in their workflow and implement new ways of organizing the work. As a result, states changed the layout of lobbies in local offices, reallocated work, eliminated unnecessary steps, and made other changes to streamline and simplify their operations. Idaho reorganized several lobbies to include private stations within the main lobby for interviews, small, private spaces where clients can have phone interviews when local office staff are too busy, and special counters for express transactions (e.g., dropping off paperwork or reporting an address change).
States also integrated business processes across programs. Idaho, Colorado, and Illinois had integrated service delivery processes for SNAP and Medicaid before the WSS initiative began, but each state took the opportunity to further integrate program processes. Rhode Island, South Carolina, and some counties in North Carolina each established a goal of integrating the intake process for customers seeking assistance through multiple programs—a concept referred to as “no wrong door”—and ultimately having “universal workers” who can process applications and other transactions for multiple programs. For more information on how the WSS states improved their business processes for delivering work supports, see Hahn et al. (2016).
Joint Consideration to Technology, Policy, and Business Process Changes
States often found that changes to one aspect of service delivery affected or influenced another. State leaders described the importance of strategically addressing the interplay of policy, business process, and technology barriers as they worked to implement their visions of service delivery. State policy staff usually participated in design sessions for new eligibility systems to ensure that new technologies were as compatible as possible with existing policies and planned policy changes. Policy staff often worked alongside operational staff to set policies for business improvement pilots or write new policies to fit new business procedures. Illinois changed its policy on verifying citizenship, allowing the state to eliminate a citizenship form that had slowed processing of benefit applications. Likewise, redesign of business processes sometimes called for changes in technology, and access to improved technology could spur changes in business processes. The development of a single computer system to handle all of Rhode Island’s social service programs facilitated the shift to an integrated business process using universal workers.
What Outcomes Did the WSS States Acheive?
WSS states had ambitious goals for streamlining access to work supports. Though all demonstrated progress toward those goals, some states achieved greater results than others. Many states made strides toward some goals while falling short or even losing ground on others. Some states also struggled to assemble data that would allow for tracking progress on particular measures, as discussed earlier. States continue to make technology, policy, and business process changes, and it could be some time before these yield measurable results.
Still, by the end of the WSS period, most states were able to provide faster service and improve access to SNAP and Medicaid/CHIP. Some had also made progress in reducing the incidence of families temporarily losing work supports due to procedural issues, known as churn. For more detailed information on the results of these efforts, see Isaacs, Amin, and Katz (forthcoming) and Loprest, Lynch and Wheaton (2016).
Each of these outcomes has positive implications for family well-being. According to client experience surveys conducted in three WSS states, clients who experienced shorter wait times in offices or on the phone reported more positive experiences overall and identified shorter waits and faster benefit delivery as the potential customer service improvements most important to them. In addition, more than half of respondents in each of the three states said they experienced emergencies or problems (e.g., loss of job, loss of car, not enough food, or loss of housing) while applying for or redetermining eligibility for benefits, and more than half said these problems could have been avoided or mitigated if they had received benefits sooner.
Because families applying for cash, medical, food, or child care assistance typically need assistance right away, WSS states aimed to reduce the time between application and receipt of benefits while maintaining accuracy and integrity. State efforts to speed up benefit delivery were further motivated by new federal requirements and concerns about improving efficiency for workers. Most states improved the speed of benefit delivery, but improvements were not uniform and marked by periods of slower issuance during rollout of new technology and business process systems.
The most dramatic and consistent changes were in the percentage of applications processed on the same day they were received, as shown in figure 1. The percentage of same-day SNAP applications processed in Rhode Island increased from 10 percent in mid-2011 to 30 percent in early 2015. In Colorado, this number more than doubled, from 15 percent in winter 2013 to 32 percent in summer 2015. Illinois also saw notable improvement in same-day service, from 13 percent in 2012 to 21 percent in 2015. Idaho already provided same-day service to 71 percent of SNAP applicants before WSS but saw a small increase to 72 percent by the end of the initiative.
It is unlikely that same-day service increased in North Carolina during the WSS period given that the state experienced a substantial backlog of applications while implementing a new eligibility system, but the state reports improvements in overall processing time. It is also unclear whether same-day service increased in South Carolina, but the state did see an increase in the percentage of cases processed within 10 days, from 36 percent to 40 percent (data not shown).
States also measured progress and performance using average days needed to process an application. In the four states tracking SNAP applications this way, noticeable net improvement was observed over the course of the project. Two states were particularly successful: in Rhode Island, the average days needed to process dropped from 10 to 5, and Idaho saw its average time decrease from 2.4 days to 1.6 days. Average processing times also dropped in Illinois, from 16 days to 13 days, and in South Carolina, from 21 days to 17 days. Comparable data were not available for Colorado or North Carolina. This measurement tends to be sensitive to periods of backlogged applications because the average rises when many cases take much longer than 30 days to process. Several WSS states experienced backlogs during rollout of new business processes, technology systems, and the new health insurance exchange subsidies. Backlogs in SNAP were generally resolved by the end of the WSS period, but Medicaid backlogs took longer to resolve in some states and were still problematic in 2015.
Access to a Package of Work Supports
Though families typically seek assistance because of a specific urgent need, low-income families usually need food, health care, and possibly other supports to achieve stability over time. WSS states aimed to improve the extent to which these families receive the full package of work supports for which they are eligible. The WSS evaluation team tracked the joint program participation rate—a measure of the extent to which individuals who are eligible for both Medicaid/CHIP and SNAP receive both benefits—in the five states that provided data (Colorado, Idaho, Illinois, North Carolina, and South Carolina). Four of the five states made substantial progress toward increased joint participation between 2011 and 2013. We measure change through 2013 because this was the last year before implementation of some of the biggest changes included in the ACA, which could have significant effects on joint program participation rates. Focusing on 2011–13 allows us to track whether WSS activities were associated with increases in joint participation rates. We cannot definitively attribute changes (or lack thereof) in these joint participation rates to activities undertaken during the WSS initiative. However, given the stated goals of WSS states, these results suggest state efforts helped improve access to the combined set of benefits.
As shown in figure 2, increases in joint program participation rates were substantial in three states: Colorado (73 percent to 87 percent), Illinois (70 percent to 78 percent), and South Carolina (73 percent to 81 percent). The increase in Idaho was smaller (from 93 percent to 96 percent) as the state’s initial rate was already high. North Carolina’s joint participation rates were fairly stable and showed a slight decrease for nonelderly individuals. Separate examination of rates for children and nonelderly adults reveals that observed increases in joint participation rates occurred in both age groups.
A common problem among benefit programs is churn, the temporary loss of benefits by eligible families, who must then reapply for services. This most often occurs during renewal, but it can occur any time clients must meet a procedural requirement. Churn can destabilize low-income families and adds to agency workload, as it is typically more time-consuming to process a new application than to renew an existing case.
WSS states took steps to reduce procedural churn. Only two states, however, had sufficient data to allow us to observe whether churn rates actually declined, and results were mixed.
The most striking positive results were for the Medicaid program in Idaho, where procedural closures were nearly eliminated through a combination of changes, including using existing electronic data to redetermine eligibility passively and automatically for a subset of cases with limited sources of income. The number of Medicaid renewals closed for procedural reasons dropped from an average of more than 1,500 per month in state fiscal year 2011–12 to an average of 35 per month in 2014–15 (figure 3). There were so few procedural closures in 2014–15—only 0.2 percent of all cases up for renewal—that the churn rate dropped to near zero. Idaho’s SNAP program had only modest reductions in churn, and the child care assistance program actually experienced an increase in churn, despite state efforts to improve renewal procedures.
Churn results in Rhode Island also were mixed. The state adopted longer certification periods for its child care program, which was expected to reduce the number of families cycling on and off the program because most churn occurs at recertification,. Data confirmed this to be true. However, despite the efforts of a new statewide recertification unit, Rhode Island outcome data reveal an increase in SNAP churn at recertification. No change was observed in SNAP churn at the time of interim reporting, when families report any changes to their status. As a result of this finding, the state subsequently disbanded the recertification unit. The lack of results for SNAP in Rhode Island and child care in Idaho show that addressing churn is not easy, and it is important to track progress to ensure that efforts have the intended effect.
What Did It Take to Make Changes to Access and Integration?
States faced numerous challenges in their attempts to make meaningful and lasting improvements in the delivery of social services, according to both career civil servants within government and constituents outside government. Frequent turnover at the highest levels of state government, complex and entrenched bureaucracies, limited funding for social and health services (and related hiring freezes), and lengthy processes for changing laws and regulations can make it difficult to improve services and service delivery for working families seeking assistance. Multiple external pressures—from stakeholders, the federal government, the courts, state legislature, and others—created countervailing demands that either stymied change or led to contradictory mandates without a clear overall direction.
Despite these many challenges, states strategically seized opportunities to overcome obstacles and move in new directions. Their experiences show that large-scale change required leadership and vision, an outlined strategy to realize the vision, stakeholder cooperation and changes in agency culture, and use of data for planning and accountability. The structure of the WSS grant also provided resources and helped keep focus on the ambitious goals of the initiative (see box 2).
Leadership and Vision
Active leadership from high-level agency officials involved not only practical leadership but also each leader’s personal passion for implementing a shared vision and commitment to continuous improvement. Leaders driving the vision behind WSS changes typically were directors of state health and human services agencies, and cabinet secretaries had at least periodic direct involvement. A Colorado leader recognized the effect of leadership’s passion and vision on others: “Most people go into the work because they have some sense of a higher desire to help.” Reminding staff of this mission motivated and “refueled” them during the hard work of implementing changes.
WSS leaders persevered in the face of competing priorities and other challenges and emphasized continuous improvement as they tried to achieve both quick wins and lasting, large-scale changes in the delivery of social services. Agency staff frequently found it challenging to work on program simplification and alignment with all the other demands on their time. Resources such as staff time and the attention of leadership had to be divided between meeting ACA requirements under tight timelines and developing new technology systems. But even as states encountered these challenges and the growing pains of upgrading technology, they remained motivated by the strong vision of reducing unnecessary work for staff and making a measurable difference in customers’ lives. For more information on how leaders in two WSS states drove changes in state government, see Hahn et al. (2015).
Stakeholder Cooperation and Changes in Agency Culture
No leader can make change happen alone. To overhaul policies, technologies, and business processes, state WSS leaders needed buy-in and cooperation from many government and community partners. Engaging these constituencies required building relationships and establishing structures for ongoing coordination.
Because separate agencies or offices oversee different work support programs, changing policies, technologies, or business processes to promote integration of these supports required collaboration among state health and human services agencies and close communication with IT developers (whether internal or vendors), data management divisions, and other entities.
County and local offices are integral to implementing changes in policies, technologies, and business processes, so states found it useful to involve county and local office administrators, frontline workers, and supervisors in developing the changes. States provided them with extensive training on new policies and processes with an emphasis on improved customer service.
States also drew on consultations with community stakeholders to discuss agency goals, priorities, and changes to policies and processes.
Some states made considerable efforts to connect with the federal agencies administering SNAP and Medicaid to discuss where federal policies appeared to diverge and to ask for changes to facilitate better program integration.
Strategy to Realize the Vision
The structure of the WSS initiative required states to approach their goals with a deliberate strategy. During the 2011 planning year, states received $250,000 grants, expert technical assistance, and peer support from other states. With these resources, states defined their visions, performed intensive diagnostic self-assessments, explored options for business process improvements, established leadership structures, and developed data-driven action plans to address changes in policy, technology, and business processes (Golden 2013).
States developed purposeful structures and methods to manage the implementation of their reform strategies and ensure ongoing alignment with their visions and strategies. In each state, WSS project managers—state employees and/or outside contractors from consulting firms or local universities—helped prioritize WSS activities, bring groups together, set deadlines, facilitate communication among different departments or agencies, and keep states moving forward on their action plans. States also convened cross-agency work groups or committees to advance WSS goals and work on policy changes. Many states convened ad hoc work groups with state, county, and/or community stakeholders to augment work on a particular task. In other cases, work groups were part of a more formal or long-term institutional structure.
Use of Data for Planning and Accountability
Throughout the initiative, WSS management and technical assistance (TA) teams encouraged and assisted states in their efforts to collect, analyze, and use data to assist in policy development and management of business process changes. Some states were more successful than others in having both the human and technological capacity to identify, track, understand, and react to new information. Data helped Colorado and Idaho identify where change was needed, set priorities, and monitor progress. Idaho, which had already implemented a new eligibility system for SNAP and Medicaid, invested state resources to build a longitudinal data mart and further enhance their capacity to extract and use information from its Idaho Benefits Eligibility System. States encountered problems, to varying degrees, defining and accessing meaningful metrics for their business processes or interpreting the data they did have. Although each state prioritized easier access to data for decisonmaking, some are only beginning to see dividends from this work as systems are still being rolled out. Illinois, Rhode Island, and North Carolina processed some cases in their old systems and some in their new systems during the transition period, which hampered their ability to produce summary reports for the caseload as a whole.
The WSS initiative was grounded in research suggesting that working families who get and keep core work support programs (Medicaid/CHIP and nutrition and child care assistance) are then better able to stabilize their lives, advance their careers, and raise their children (Mills, Compton, and Golden 2011). Yet the research also showed that many eligible families did not receive help, partly because of barriers in cumbersome state systems. The initiative represented a direct commitment of substantial philanthropic resources to states—not a typical target of foundation funding—to see if they could and would reform their systems to help families and reduce burden on state workers.
The evaluation found that financial and technical assistance from the WSS initiative helped states make progress toward streamlining access to work support programs and strengthening families. States redesigned access by setting new and higher goals for timeliness, revamping technology, changing policies, and changing how local offices operate. Their experiences highlighted the considerable challenges involved in making lasting and meaningful large-scale change. They also showed that meaningful changes in service delivery and state bureaucracies are possible.
The evaluation also demonstrated measurable improvements in the ability of states to deliver benefits in a timely manner—sometimes on the same day a family applies—and the number of families participating in the full package of programs they are eligible for. Given the many concurrent changes during this period, we cannot attribute these improvements solely to WSS. But they demonstrate that large-scale change is possible in these critical work support systems.
Going forward, substantial opportunities exist for states to reach all families and individuals eligible for core work support systems, especially as states adopt Medicaid expansion and potentially reach many additional families. The experiences of the WSS states offer specific ideas about how to diagnose and fix the barriers that prevent families from participating and burden state workers and administrative systems. Resources available through WSS and the willingness of states to serve as models and advisors can push this agenda forward.2 In addition, a current effort by WSS national partners the Center for Law and Social Policy and the Center on Budget and Policy Priorities seeks to spread these ideas through state advocates and policymakers.3 At the national level, the initiative underlines the value of statutory provisions and executive actions, such as rules related to federal funding for technology improvements, that have facilitated integrated and streamlined enrollment. It also offers insight into where federal rules create duplicative work for families and how to provide guidance to states on streamlining and integrating delivery of work supports. At a time of considerable controversy over these programs, WSS demonstrated that states with different political, geographic, and budgetary contexts could all commit to ensuring that all eligible families receive and keep these core work support programs.
- WSS evaluation publications and resources are available at http://urbn.is/1YEpX5r.↩
- “WSS Resources,” Center for Law and Social Policy, accessed June 17, 2016, http://www.clasp.org/issues/work-support-strategies/resources.↩
- “Advancing Strategies to Align Programs,” Center for Law and Social Policy, accessed June 17, 2016, http://www.clasp.org/issues/work-supports/pages/asap.↩
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Hahn, Heather, Maeve E. Gearing, Michael Katz, and Ria Amin. 2015. Observations of Leaders Driving Changes in State Government: Leadership Tools and Lessons from Two Work Support Strategies States. Washington, DC: Urban Institute.
Hahn, Heather, Ria Amin, David Kassabian, Maeve E. Gearing. 2016. Improving Business Processes for Delivering Work Supports for Low-Income Families: Findings from the WSS Evaluation. Washington, DC: Urban Institute.
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Loprest, Pamela, Victoria Lynch, and Laura Wheaton. 2016. “Changes in Joint Medicaid/CHIP and SNAP Participation Rates, 2011 to 2013.” Washington, DC: Urban Institute.
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Rohacek, Monica, and Lindsay Giesen. 2013. arly Lessons from the Work Support Strategies Initiative: Kentucky. Washington, DC: Urban Institute.
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About the Authors
Heather Hahn is a senior fellow in the Center for Labor, Human Services, and Population at the Urban Institute. Throughout her career, Hahn has conducted nonpartisan research on the wide range of issues related to the well-being of children and families, including cash assistance, nutrition assistance, and other supports for low-income families as well as education, labor, and other policy issues. Hahn has extensive experience designing and conducting case studies related to the implementation of supports for low-income families. At Urban, she has also collaborated on several reports examining federal spending and tax expenditures on children; she is currently colead of the evaluation of the Work Support Strategies initiative.
The Ford Foundation provided generous lead funding for the Work Support Strategies initiative, including its evaluation, by committing $21 million over five years. The Open Society Foundations, Annie E. Casey Foundation, Kresge Foundation, and JPMorgan Chase also gave crucial support. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission.
The views expressed are those of the author and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at www.urban.org/support.
The author would like to acknowledge the other members of the Work Support Strategies evaluation team who helped collect and analyze the data on which this report is based, including Pamela Loprest, Julia B. Isaacs, Monica Rohacek, Ria Amin, Maeve Gearing, David Kassabian, and Michael Katz. Thanks also to Olivia Golden and Elizabeth Lower-Basch for reviews of earlier drafts and their helpful insights. And we would like to thank the many state and local staff members in Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina who participated in the site visit interviews and responded to requests for administrative data.