Policy & Practice | Summer 2024

The Magazine of the American Public Human Services Association Summer 2024

Advancing Social and Economic Mobility for Equitable, Long-Term Success

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contents

Vol. 82, No. 2 Summer 2024

features

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16

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Paid Family Medical Leave that Works Effective Program Design and Implementation

Healthy Opportunities, Healthy Outcomes

Going Fast & Far Partnering to Support the Summer EBT Program

Leveraging the Power of Communities to Improve Health Outcomes for Equitable, Long-Term Success

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30

t Error Rates: ing What They Are Support SNAP Reducing Them

First-Person Perspective The Power of Research and People with Lived Experience in Systemic Change in Kentucky

Payment Error Rates Understanding What They Are and How to Support SNAP Agencies in Reducing Them

departments

4 APHSA Insights

10 Technology Speaks

36 Staff Spotlight

Lessons Learned: Engaging People with Lived Experience utrition Assistance Program (SNAP) is the most effective tool that Americans have to combat cent years, the response to the COVID-19 pandemic has displayed the strength of SNAP in y adapting to needs across the country and has been a success story in the resiliency of f support in the face of economic crisis. However, the significant and necessary changes in perations in order to make this happen have strained the resources and workforce of state and administer the program and have often come into conflict with the pre-existing rules governing gencies are expected to meet. rror Rate (PER) measures the assumed accuracy of SNAP benefit calculations using Quality m a national sample. The national PERs for Fiscal Years 2022 (11.54%) and 2023 (11.68%) marked from the FY 2019 rate of 7.36%. Since QC reviews were suspended by Congress during FYs 2020 he first post-COVID-19 error rates, reflecting the impact of the pandemic on program operations. 6 From Our Partners Social Work Today: How a Community-Led Approach to Social Care Can Change Lives 8 Research Corner Using Behavioral Science to Normalize SNAP Among Older Adults Shaping Policy Action: Customer Insights on EBT Theft 35 Staff Spotlight Dominic Hollis, Registration Specialist Staff Spotlight Jenny Duggan, Marketing & Communications Specialist

Carmelle Coby, People Engagement Associate

Staff Spotlight Julia Mueller, Community Engagement Specialist

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Summer 2024 Policy & Practice

Strategic Industry Partners DIAMOND

APHSA Executive Governing Board

Chair Grace Hou, Secretary, Illinois Department of Human Services Vice Chair Rodney Adams, Principal/CEO, R Adams & Associates Treasurer Kathy Park, CEO, Evident Change CEO Reggie Bicha, President & CEO, APHSA Leadership Council Chair Kelly Garcia, Director, Iowa Department of Health and Human Services Local Council Chair Dan Makelky, Director, Douglas County (CO) Department of Human Services Elected Director Derrik Anderson, Executive Director, Race Matters for Juvenile Justice

Elected Director Vannessa Dorantes, Managing Director, Casey Family Programs Elected Director Sherron Rogers , Vice President & CFO, Johns Hopkins All Children’s Hospital Elected Director Terry Stigdon , CEO, American Red Cross Elected Director Jennifer Sullivan , Enterprise Senior Vice President, Strategic Operations, Atrium Health Immediate Past Chair Dannette Smith, Commissioner, Behavioral Health Administration

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Policy & Practice Summer 2024

Policy & Practice™ (ISSN 1942-6828) is published four times a year by the American Public Human Services Association, 1300 N. 17th Street, Suite 340, Arlington, VA 22209. For subscription information, contact APHSA at (202) 682-0100 or visit the website at www.aphsa.org. Copyright © 2024. All rights reserved. This magazine may not be reproduced in whole or in part without written permission from the publisher. The viewpoints expressed in contributors’ materials are the authors’ own and do not necessarily reflect the policies or views of APHSA. Postmaster: Send address changes to Policy & Practice 1300 N. 17th Street, Suite 340, Arlington, VA 22209

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Emerging Technology and Process Innovation: Modernizing for the Future of Human Services

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APHSA’s blog, The Catalyst , encourages the exchange of creative ideas and promising initiatives to strengthen the human services sector and accelerate our collective impact. Featuring content from members, partners, and staff, our blog posts focus on what it takes to build well-being from the ground up. Organized around areas of impact as well as a variety of special series, our goal is to spark new ideas and accelerate the spread of promising approaches that help realize our shared vision for thriving communities built on human potential.

Read the Latest Post, Visit APHSA.org/APHSABlog/default.aspx

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Summer 2024 Policy & Practice

aphsa insights By Paige Clay, Morgan McKinney, Julia Mueller, Adrian Geraldo Saldaña, and Zahava “Zee” Zaidoff

Lessons Learned: Engaging People with Lived Experience

T he American Public Human Services Association (APHSA) believes the expertise and insight of people with lived experience in human services systems can and should drive system transformation and modernization. To that end, we conducted a Lived Experience National Scan (LENS) in January 2024. LENS collected information from human services leaders who identified successful and emerging practices that engage people with lived experience, as well as people with lived experience who had been engaged by their agencies. Specifically, we asked how they tapped into people’s lived experi ence with human services systems, and how that lived experience was leveraged to shape organizational decision-making and strategy development. The survey and interview data col lected represented 100 initiatives from 54 agencies located across 30 U.S. states. Based on these findings, we have identified six areas of best practice for engaging people with lived experience in the effort to make human services systems more people centered, user-friendly, and equitable. Purpose and Goals Develop meaningful and impactful roles for people with lived experience to occupy in your agency’s moderniza tion and strategy development. n People with lived experience can serve in many roles and project types. Their expertise can be tapped in the areas of educating

policymakers, planning, supporting service participants, consulting and advising, reimagining programs and services, material redesign, and training delivery and technical assistance.

Compensation Pay your initiative participants as you would pay other consultants. n Provide participants with options to choose how to be compensated. If your agency has administra tive barriers to compensating participants, partner with a com munity-based organization that can administer timely compensation with minimal administrative burden on the participants.

Recruitment and Representation

Use multiple channels to recruit people with lived experience that represent the diversity of your communities served. n Initiative participants are excellent recruiters of other people with lived experience. n Tap into other local and regional councils of people lived experience, especially when seeking representa tion from across the state.

Accessibility and Resources to Support Participation

Make thoughtful accommodations to maximize access and provide resources

Illustration by Chris Campbell

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Policy & Practice Summer 2024

of accomplishments and achieve ments fueled by their commitment to change systems for the better. You can access the full report at https://bit.ly/ LENS-2024 . The Lived Experience National Scan is part of APHSA's Advancing Family Economic Mobility (AFEM) project, in partnership with the W.K. Kellogg Foundation and Doris Duke Foundation. For more information, visit www.familyeconomicmobility.com.

that build capacity across your initia tive participants. n Continuously check in with par ticipants about how to maximize accessibility, as barriers can present in various ways and at various times. n Participants should be offered support around Strategic Sharing, to share their lived experiences authen tically, safely, and on their own terms. n Staff should receive training on trauma, strengths-based engage ment, and equity, diversity, inclusion, and belonging to minimize the potential for judgmental language and implicit bias. More seasoned participants can mentor new partici pants, and alumni should connect with current participants. n Provide participants with prep time before public speaking engagements, meeting facilitation, training, or testifying. Evaluation Develop feedback loops to continuously listen to your initiative participants and inform them about how their contribu tions have led to concrete changes.

n Continuously assess for participant feedback at every step in the process. n Close the feedback loop with people with lived experience to ensure that they know exactly how their participation and expertise has affected positive change within the agency. Agency Integration, Systems Change, and Impact Continuously message the value and expertise of people with lived experi ence and your agency’s culture will shift to integrate them across all programs and operations. Conclusion LENS offers a wider perspective on what’s possible around sharing power and modernizing systems, and proved to be an apt acronym for the project. The full LENS report articulates the wide range of practices that can engage and elevate the expertise of people with lived experience, while also highlighting a small selection

Paige Clay is a Lived Experience Consultant.

Morgan McKinney is a Process Innovation Associate for Community Collaboration at APHSA.

Julia Mueller is a Community Engagement Specialist at APHSA.

Adrian Geraldo Saldaña is an Organizational Effectiveness Consultant at APHSA.

Zahava “Zee” Zaidoff is a Community Advocate.

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Summer 2024 Policy & Practice

from our partners

By Héctor Upegui

Social Work Today: How a Community-Led Approach to Social Care Can Change Lives

S ocial workers help to improve people’s lives by empowering them with the tools they need to function better in their environments, improve their relationships with others, and solve personal and family problems through individual, social, and psy chological support. 1 Social workers contribute such vital work in our com munities and have a critical role in ensuring everyone receives the support they need to live full and healthy lives. But in today’s world of increasing inequality, 2 aging populations, 3 and increasing needs of citizens, govern ment and organizations in the private sector are facing higher demand for services with scarcer resources. Now, more than ever, an innovative, commu nity-led approach to service delivery is needed, to better support social workers in doing their best work. Engaging the community can help reduce stigma attached to benefits application, by activating individuals and their families to meaningfully participate in their own care, and equipping them with strategies to impact their own outcomes. It can also help relieve the workload of social workers, allowing them to focus on their critical work. Community engagement is a crucial part of social work and vital to fostering an eco social world based on inclusion, respect, and mutual understanding. External Drivers of Change More than two-thirds of the world’s population lives in countries where inequality has grown, 2 posing

the pandemic, economists expected a shortage of 195,000 social workers in the United States by 2030. 4 With struggling resources and a higher demand for social protection services, it’s no longer sustainable to embed social workers within families to share critical life skills. By acti vating communities, social workers can support targeted groups in a more coordinated and efficient way, employing person-centered and dig ital-first services to drive engagement from those in need of support. A Community Approach Communities are diverse, and can encompass everything from geog raphy, to people who share the same

additional challenges to social welfare, including unemployment, financial hardship, homelessness, and other threats to well-being. Additionally, the number of people aged 65 and older is expected to double over the next three decades to reach 1.6 billion in 2050. 3 These trends create an increasing demand for services from these growing groups in the community. These external forces are exacer bated by challenges that social workers themselves are facing. Balancing an increased workload can lead to high stress levels for most professions, but for social workers, an extended global pandemic and its effects on mental health have had a knock-on effect on their burnout. Even prior to

Illustration by Chris Campbell

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Policy & Practice Summer 2024

whom multiple in-person appointments had previously posed a barrier, as well as households with additional informal caring responsibilities, that were too time-stretched to visit in person. With New York’s extremely diverse population, the team was diligent in addressing the needs of visually impaired communities, and house holds with limited English proficiency by ensuring the platform supported multiple languages and by providing special services to support those who are sight impaired, such as the Job Access With Speech (JAWS) interface. Consideration was also given to communities who may not have access to technology, and the depart ment added computers to 15 of the city’s SNAP centers (office locations for the Supplemental Nutrition Assistance Program) to support access for these groups. Community Outreach Taking it one step further, the government department works with state and local agencies, advocates, employers, and community- and faith-based organizations to reach people who are not currently receiving support from supplemental food assistance but may be eligible. 6 This community-led approach prioritizes older adults, people with disabilities, and immigrant and mixed status households, to help inform them about the availability of benefits assistance. It also helps them to understand and navigate eligibility and the application process. In some cases, applications for benefits can be returned to the commu nity organizations themselves, instead of directly to the SNAP centers. Benefits for All This community-led approach has improved experiences for those in need of support, reducing barriers around access and helping to build trust and reduce stigma and misperceptions about eligibility. The result is increased access to services, and more take-up of essen tial support for individuals, children, and families. Increasing awareness and access to social programs like this one is vital in working toward a more

equitable society. What’s more, when access to services begins sooner, this earlier intervention can create poten tial cost savings for the state. With digital services and community organizations supporting adminis trative processes around program awareness and application, social workers have more time to spend on the complexities of creating tailored outcomes plans for individuals, and on empowering them to take a more active role in their own care coordination. Social workers deserve recognition for the incredible work they do every day. Let’s empower them to focus on the important work, so they feel supported and engaged to make a dif ference where it matters most. Learn more about the New York City HRA and its approach to food assistance benefit application at https://www.merative.com/documents/ case-study/new-york-case-study. Reference Notes 1. The National Association of Social Workers. (1956). American Journal of Public Health and the Nations Health, 46 (1), 90–91. https://doi.org/10.2105/ AJPH.46.1.90 2. United Nations Department of Economic and Social Affairs. (2020). World social report 2020: Inequality in a Rapidly Changing World. https://www.un.org/en/ desa/world-social-report-2020 3. United Nations Department of Economic and Social Affairs. (2023). World social report 2023: Leaving no one behind in an ageing world. https://www.un.org/ development/desa/pd/sites/www.un.org. development.desa.pd/files/undesa_ pd_2023_wsr-fullreport.pdf 4. Lin, V. W., Lin, J., & Zhang, X. (2016). U.S. social worker workforce report card: Forecasting nationwide shortages. Social Work, 61 (1):7–15 https://doi.org/10.1093/ sw/swv047 5. Merative. New York City Human Resources Administration Case Study: Improving the process of applying for Supplemental Food Assistance. https://www.merative.com/documents/ case-study/new-york-case-study . 6. U.S. Department of Agriculture Food and Nutrition Service. (2024). SNAP outreach. https://www.fns.usda.gov/snap/outreach

values, customs, religion, gender, race, interests, and skills. Members of a community often feel a sense of trust within their group, and can positively influence each other in their environ ments. Social workers help people of every background and age, but they are especially equipped to advocate for communities that are underserved. Empowering people in their own community environment, with an understanding of the issues they face and a respect for their particular needs and requirements within that commu nity, can help reduce anxieties around using services, particularly fears around discrimination, and better engage people to be active participants in their own care. Overcoming Barriers Sustainable change in any sector needs structural support. Innovative community-led approaches practiced by social workers at the ground level need policy support at the govern ment level for long-term success. Skills-building for effective coordi nation between social workers and community groups and leaders can support progress and create new ways of working. Technology that stream lines the process of delivering services to communities can give time back to caseworkers to focus on people-centric care. It can also empower individuals to work toward improving their lives. Better Experiences The largest social services agency in the United States, the New York City Human Resources Administration (NYC HRA), was looking to improve the experience of applying for supple mental food assistance. 5 A key focus was putting citizens’ needs first and opening up new ways to apply for assis tance. The solution they implemented is a good example of a community-led approach to social care, leading to better experiences for the individuals in need of services. The NYC HRA improved service access by enabling citizens to apply for benefits using mobile and online technology and by upgrading its existing Cúram platform. This supported the needs of communities with reduced mobility, for

Héctor Upegui is a Worldwide Market Development Executive at Cúram at Merative.

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Summer 2024 Policy & Practice

research corner

By Jackie Budilov and Anam Bhatti

Using Behavioral Science to Normalize SNAP Among Older Adults

F ood security steadily improved among older adults for a decade, but this progress reversed course in 2022. 1 That year, 11.8 million seniors were food insecure—a 25 percent increase from the previous year. Among older adults of color, the situation was worse, with food insecurity among American Indian and Alaska Native, Hispanic, Black, Native Hawaiian and Pacific Islanders surging nearly 40 percent. The Supplemental Nutrition Assistance Program (SNAP) plays a crucial role in alleviating food inse curity and reducing health care costs among older adults. SNAP participa tion leads to fewer hospital visits, emergency room visits, and long-term care admissions. 2 Despite its benefits, only 37 percent of eligible adults aged 50 and older are enrolled in SNAP. 3 Given low enrollment rates, the AARP Foundation conducted research to better understand barriers to applying for SNAP and identify effective marketing messages that motivate people to apply. In an online survey of nearly 1,500 older adults likely to be eligible for SNAP in Texas and Georgia, three out of four respondents were not participating in the program. Commonly cited reasons for low SNAP enrollment include lack of program awareness, stigma asso ciated with it, and confusion about eligibility requirements. 4 This survey found awareness was not a significant issue: 85 percent of respondents not enrolled were familiar with SNAP, but stigma and confusion about eligi bility requirements were found to be important barriers.

themselves using SNAP) and 127 percent more likely to have moderate to-high community stigma (negative feelings about others using SNAP), compared to those who were enrolled in the program. The survey also tested marketing messages that sought to counter stigma, developed using behav ioral science research to emphasize factors that motivate human behavior change. Survey participants were asked to evaluate the messages,

Many older adults fear judgment and hold negative perceptions about receiving government assistance. This stigma, combined with ingrained social norms valuing self-reliance and independence, can discourage eligible older adults from seeking help. Using a self-reported stigma question naire, the AARP Foundation survey found that older adults who were not enrolled in SNAP were 44 percent more likely to have moderate-to-high self-stigma (negative feelings about

Illustration by Chris Campbell

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Policy & Practice Summer 2024

Food costs are rising in Texas. SNAP can help.

Get extra money for groceries

including how relevant they were to them, whether they made them feel more positive about SNAP, and whether they made them more likely to apply. The message that was least effective was an audio ad featuring a grandmother describing how SNAP helps her provide healthy food for her grandchildren. The “Grandkids” message intended to motivate older adults living in intergenerational households, but it inadvertently reinforced a misconception that SNAP eligibility requires living with children at home—a belief reported by 37 percent of survey respondents who were eligible for SNAP but not enrolled. This finding emphasizes the importance of choosing messages that clarify common eligibility questions: Importantly, 85 percent of those not enrolled said they would apply if they knew they were eligible. The most motivating ads, particu larly for people with high self-stigma and community stigma, were those that normalized SNAP participa tion. The messages “Food costs are rising” and “Get help with your gro ceries” offered a social justification, or permission, for an uncomfortable behavior. They highlighted that many older adults need help making ends meet or are already using SNAP. One of the ads also described a “friendly and convenient” process, tapping into a common desire to avoid friction. About 85 percent of all survey respon dents found the ads to be personally relevant, and a majority of those with high self-stigma or community stigma said the ads made them think more positively about SNAP. These ads were deployed in a mar keting campaign online, in grocery stores and senior centers, and through direct mail to test their effective ness at motivating people to apply for SNAP. Based on a post-campaign online survey of 538 older adults, of those who recalled the ads, people with more exposure to the messages had lower self-stigma and were more likely to report that their opinion of SNAP improved and that they were likely to apply.

Your SNAP card works just like a debit card. Use it at grocery stores, farmers markets, and other approved locations. It’s easier than ever to sign up. SNAP specialists are ready to help every step of the way. Find out if you qualify and then apply online or by phone. Se habla español. VISIT aarpfoundation.org/TXSNAP CALL 866-935-1003

When food costs are on the rise, a trip to the grocery store can take a bite out of your monthly income. Let SNAP boost your grocery budget.

VISIT aarpfoundation.org/SNAPTexas CALL 866-913-5121 TEXT Get SNAP 2 to 74544 Find out if you qualify for an average of $133 a month .

(Above) This SNAP ad, tested in AARP Foundation’s market ing campaign, normalizes the challenge of affording food amid rising costs and gives social permission to get help.

(Right) Highlighting the easy application process appeals to a common desire for reduced friction.

To learn more about the AARP Foundation and our work on SNAP, visit aarpfoundation.org/aphsa. Reference Notes 1. Dean, O., & Figueiredo, C. A. (2024). Food insecurity increased to 1 in 10 adults ages 50 and older in 2022. Washington, DC: AARP Public Policy Institute. https://doi.org/10.26419/ppi.00162.003 2. Berkowitz, S. A., Palakshappa, D., Rigdon, J., Seligman, H.K., & Basu, S. (2021). Supplemental Nutrition Assistance Program participation and health care use in older adults: A cohort study. Annals of Internal Medicine, 174 (12), 1674–1682. https://doi.org/10.7326/M21-1588 3. Dean, O., Gothro, A., Bleiweiss-Sande, R., Navarro, S., & Reynolds, M. (2022). Older adult Supplemental Nutrition Assistance Program (SNAP) participation series. Washington, DC: AARP Public Policy Institute. https://doi.org/10.26419/ ppi.00166.000 4. Levin, M., Paprocki, A., Mack, M., & Grey, C. Older adult SNAP access. https:// www.aarp.org/content/dam/aarp/aarp_ foundation/pdf/2021/spr-older-adult snap-access-report-full-report.pdf Jackie Budilov is a Senior Program Manager of Health Essentials programs at the AARP Foundation. Anam Bhatti is a Program Research Manager of Impact Analytics at the AARP Foundation.

AARP Foundation is encouraged that the findings from this pilot campaign can inform outreach strat egies for other organizations and motivate older adults to apply for SNAP. Here are some ways other orga nizations can use this research: 1. Shift social norms to reduce stigma. Craft messages that emphasize the commonality and acceptability of SNAP participation among older adults. Highlighting how many seniors benefit from SNAP and addressing the rise in food costs can normalize the program and reduce self-stigma and community stigma. 2.Tailor messages to address mis conceptions about eligibility requirements. Avoid messages that might inadvertently reinforce false beliefs, such as the necessity of having children to qualify for SNAP. Instead, ensure that communica tions clarify eligibility requirements and dismantle common misconcep tions that prevent eligible seniors from applying. programs. These messages, and others designed with insights from behavioral science, can be used to increase participation rates for Medicaid, unemployment insur ance, or other programs. 3.Leverage behavior change research for other benefits

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Summer 2024 Policy & Practice

technology speaks

By Julianna Lai, Justin King, and Toral Patel

Shaping Policy Action: Customer Insights on EBT Theft

T he theft of electronic benefits tremendous harm to Americans with low-income and caused sig nificant financial losses for taxpayers. In California alone, losses have amounted to $181 million, while the federal government has spent $61.5 million on replacement benefits. These staggering figures only reflect reported losses. Stakeholders across human services have been working tirelessly to implement new processes and security measures for (EBT), but theft continues to affect American families at an unprecedented rate. Propel, the team behind the Providers app, surveyed 10,690 EBT customers in April 2024 to understand their awareness of EBT theft and the challenges they face. This survey included 1,770 theft victims. The following insights can help inform ongoing efforts to strengthen the EBT system, a crucial lifeline for millions of households. EBTTheft Exacerbates Food and Financial Insecurity Among surveyed theft victims, 81 percent reported theft of their Supplemental Nutrition Assistance Program (SNAP) benefits with an average loss of $925. A smaller share lost cash benefits, with a higher average loss of $1,482. Around 12 percent of surveyed theft victims had both SNAP and cash benefits stolen; one third were victimized multiple times. These losses have staggering impacts on the financial, physical, transfer (EBT) cards has inflicted

“It’s devastating to have your benefits stolen or threatened, espe cially when you’re counting on every penny and trying to change your life for the better,” wrote Megan from Washington. Customers Lack Critical Information About EBTTheft A quarter of all survey respondents had never heard about EBT theft, and more than 51 percent have limited to

and mental health of SNAP house holds that already grapple with food insecurity. As a result of EBT theft, 44 percent of surveyed theft victims borrowed money or went into debt, and 40 percent struggled to pay essential expenses such as rent and utilities. Fifty-three percent of theft victims skipped meals or ate less, and 54 percent relied on food banks or other charitable organizations after losing their benefits. Nearly 60 percent reported increased stress or anxiety.

Illustration by Chris Campbell

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Policy & Practice Summer 2024

no understanding of how skimming or phishing works. One respondent said, “I didn’t know that [criminals] can scan our cards or steal from them like that. I thought it was not possible with our EBT cards. Like they were pro tected somehow.” Even among those who had experienced theft in the past year, 41 percent were unaware of how the crimes work. Moreover, consumer access to essential account data varies by state, making it hard to detect and report theft. About half of state EBT customer portals provide the time and date of transactions, but not key details like retailer name and address. Unsurprisingly, 50 percent of surveyed theft victims did not know whether their benefits were stolen at an ATM, store, online, or via phishing. And 14 percent of theft victims could not decipher if their benefits had been drained in-state or out-of-state. ManyTheft Victims Did Not File a Reimbursement Claim More than a third of surveyed theft victims reported that they did not file a claim. The most common reasons were not knowing they could (50%) and believing it wouldn’t be worth the effort (24%). More than 40 percent of surveyed theft victims reported the process of filing for reimbursement to be somewhat or very difficult. “I had to do the investigation, and it’s still not resolved,” one respondent wrote. Twenty-two percent reported spending a “significant” amount of time filing their claim. “It’s too hard to get your stuff replaced,” said Lea, a respondent from Oregon. “[It’s] just as much stress as losing the assistance.” Nearly 90 percent of all survey respondents have taken action to protect their EBT cards. This includes frequently changing PIN (20%), avoiding online shopping (20%), and reporting suspicious outreach (17%). In states where available, this also includes card locking (11%) and trans action blocking (9%). EBT Customers Need Systemic Protection

While a growing number of states and vendors are making card locking available through online customer portals and mobile apps, only a handful offer the feature through the call center. Call center functionality expands the tool’s accessibility and provides a critical back-up option for customers when the portal is down. However, our survey respondents recognize these tools fall short of true systemic protection. “The state defi nitely needs to upgrade their systems to make it very difficult, if not impos sible, for theft to occur,” wrote Nikki from Texas. Urgent Need for Policy Action Systemic reforms are essential to close the security gap between main stream financial services and EBT, to ease outsized burdens on customers who may be at risk, and uphold the integrity of essential support programs. Policymakers have a clear path forward: n Extend the reimbursement

n Simplify claims processes. States and the U.S. Department of Agriculture should take steps to raise awareness about reimbursement and streamline claims processes to ensure victims can access support seamlessly. n Bolster EBT card security. Congress should require the rapid adoption of chip cards and card locking technology across states and deliver federal funding to ensure consumers and taxpayer dollars are protected. It should also mandate a specific term for periodic review and updates of EBT card security measures. n Ensure EBT customer access to data. Congress should unambigu ously ensure EBT customers have the same basic rights and consumer pro tections as others, including reliable electronic access to their balance and detailed transaction data.

Julianna Lai is the Policy and Community Content Specialist at Propel.

authority. Congress should extend the existing reimbursement authority and remove the two-incidence cap. With only two states in sight of adopting systemic protections via chip cards this year, households with low income remain at risk to theft.

Justin King is the Policy Director at Propel.

Toral Patel is the Senior Manager of Policy and Partnerships at Propel.

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Summer 2024 Policy & Practice

Paid Family Medical Leave that Works Effective Program Design and Implementation

ome home events and situations are particularly disruptive to people’s lives, forcing them to make impossible choices when they are most vulnerable. An individual may need time to recover from a serious illness, care for a new child, or tend to a sick family member—and have to weigh whether they can afford to risk their paycheck and job security. Paid family and medical leave (PFML) programs aim to help people get through such life events by providing employees with job-protected, paid time off. Research suggests that paid family leave can improve the well-being of workers and their families, create family and employ ment stability, and boost gender and racial equity, all without marked disruption for employers. 1,2 Thirteen By Arjun Gupte, Tiffany Dovey Fishman, Scott Malm, and Sagar Pandit S

states and the District of Columbia have enacted mandatory PFML programs; others offer voluntary programs through private insurance. 3 As more states consider enacting PFML or evaluate models for similar job-protected benefits, policymakers can look to recent program launches around the country for lessons learned.

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Summer 2024 Policy & Practice

Program Delivery and Stakeholder Needs

Program priorities, rules, and opera tions will evolve over the course of time; and it helps to work in an envi ronment that embraces change, along with IT systems that can adapt quickly. Key Lessons Learned Several factors help determine program outcomes in the early years, and rulemaking, systems design, and operational constraints all drive these factors: 1. Design for equity and access. Ensuring equitable access to PFML benefits remains a signifi cant challenge. Workers with low wages, part-time employees, and gig workers often face barriers to accessing programs, highlighting the need for policies that address these disparities. Human-centered design offers the processes and tools to understand varied stakeholders’ needs and to fashion programs with those needs in mind. 2.Defining goals and measuring success. Clear and unambiguous program goals support efficient rulemaking, operational design, and IT delivery. This includes metrics across all aspects of the program, including equitable access, customer experience measurement, automa tion targets, claim processing/first payment targets, and operational costs and expense ratio. 3.Implementation approaches. Flexibility and adaptability are key to successful delivery, given the complexity of launching a new program. Managers should deploy supporting systems in an iterative and agile manner, pre senting opportunities to offer—and receive—feedback. Early launches, pilots, and beta releases offer the means to iterate and improve while managing go-live risks. 4.Design for program integrity. Benefit program abuse spiked during the COVID-19 pandemic, and bad actors continue to target these programs. 5 Program direc tors should keep integrity central during rulemaking, systems design, and operations. Certain core com ponents—employer verification, employee ID verification, health care provider verification—are

To implement PFML programs, many states utilize a social insurance policy model that funds benefits through pooled payroll taxes—premiums—on employees and/or employers. Only one state has gone its own way in utilizing a mandatory private insur ance system that requires employers to provide coverage through a state approved plan. 4 Many states with PFML programs exempt employers that already offer paid leave through private plans, as long as the coverage meets or exceeds that of the state. No matter the system parameters, or the state, the program’s stakeholder group is large and varied. Specifically, PFML programs offer wage replacement and job protection to support employees who need to take leave, aiming to maintain their finan cial security and employment status. And naturally, these programs have an impact on other stakeholders— employers, of course, but also health care providers and state programs such as unemployment insurance and workers’ compensation. Many state PFML programs offer special dispen sation to smaller employers in order to limit their financial burden, while larger employers tend to look for scale and efficiencies with similar payroll taxes enforced by unemployment insurance programs. Similarly, health care providers, with patient interests taking precedence, seek a seamless and automated process to certify medical claims for leave applicants. Human-centered design (HCD) offers the processes and tools to understand these varied stakeholders and to design programs with their needs in mind (see Figure 1). Recent successful launches of PFML programs have all included enactment of PFML to program launch is about two years—not long to design and build a management organization, develop rules and policy, procure and implement IT systems, and stand-up customer support structures. State program directors have had success by embracing a startup mentality and utilizing agile processes across these varying and concurrent threads. HCD in their implementation. For many states, the time from

Arjun Gupte is a managing director with

Deloitte Consulting LLP’s Government & Public Services practice.

Tiffany Dovey Fishman is a senior manager with Deloitte’s Center for Government Insights.

Scott Malm is a principal in Deloitte’s

Government and Public Services practice.

Sagar Pandit is a managing director with Deloitte Consulting LLP and leads Deloitte’s Paid Family and Medical Leave services.

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Figure 1. Human-centered design puts people at the center of the design and delivery of public programs

Traditional problem solving approach

Human-centered design approach

Identify operational goals

Understand stakeholders

Create concepts

Create concepts

Fit concepts to stakeholders

Build operational systems

Source: Deloitte Development LLC

non-negotiable aspects of PFML program delivery. 5. Outreach and marketing. Awareness of a new PFML program, among both workers and employers, is central to successful adoption. Setting targets for outreach and driving an intentional marketing effort can help. Many states with programs have aimed to build awareness through social media campaigns, roadshows, webinars, and traditional advertising. Looking Ahead For any state, implementing a paid family and medical leave program is a complex and multifaceted endeavor that requires careful planning, collabo ration, and foresight. By understanding the need for PFML, embracing key components of effective programs, learning from existing models, and addressing challenges and concerns, statescan develop effective, secure PFML programs that promote work force well-being, economic stability, and social equity. About Deloitte Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited, a UK private company limited by guarantee (“DTTL”), its network of member firms, and their related entities. DTTL and each of its member firms are legally separate and independent entities. DTTL (also referred to as “Deloitte Global”) does not provide services to clients. In the United States, Deloitte refers to one or more of the US member firms of DTTL, their related entities that operate using the “Deloitte”

name in the United States and their respective affiliates. Certain services may not be available to attest clients under the rules and regulations of public accounting. Please see www.deloitte.com/about to learn more about our global network of member firms. This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte shall not be responsible for any loss sustained by any person who relies on this publication. Reference Notes 1. Better Life Lab. (2021). To have and have not: What it means to live in a country that does not guarantee paid family and medical leave. New America. https://www.newamerica.org/ better-life-lab/reports/to-have-and-have-not 2. Larner, S., & Applebaum, E. (2014). Business as usual: New Jersey employers’ experiences with Family Leave Insurance. Center for Economic and Policy Research. https://cepr.net/ documents/nj-fli-2014-06.pdf 3. Bipartisan Policy Center. (2024). State paid family leave laws across the U.S. https://bipartisanpolicy.org/explainer/ state-paid-family-leave-laws-across the-u-s/ Copyright © 2024 Deloitte Development LLC. All rights reserved.

4. See Reference Note#3 5. U.S. Department of Justice. (2024).

COVID-19 fraud enforcement task force releases 2024 report. https://www.justice .gov/opa/pr/covid-19-fraud-enforcement task-force-releases-2024-report

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Opportunities, outcomes Healthy Healthy

Leveraging the Power of Communities to Improve Health Outcomes for Equitable, Long-Term Success

ver the years, I’ve seen, again and again, how nonmedical factors—known as social determinants of health (SDOH)—have an outsized impact on health outcomes. These include education, working conditions, food and housing insecurity, and access to affordable, quality health care. Addressing social determinants is the key to improving health and reducing long-term health inequities. It’s also the mission of our life-changing Healthy Opportunities Pilots (HOP) in the state of North Carolina. By Jay Ludlam o

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Often, health care focuses on the body. You cut your finger, you get a bandage. Whole-person care is different because it also takes social determinants into account.

Whole-Person Care Often, health care focuses on the body. You cut your finger, you get a bandage. To prevent illness, you get a vaccine. Whole-person care is dif ferent because it also takes social determinants into account. When I served as Deputy Division Director in the Department for Social Services for MO Health Net in Missouri, whole-person care was already well established. Our director strove for the inclusion of behavioral and physical health care into our Medicaid contracts with our managed care organizations, which delivered a better, more streamlined care experience and reduced costs. Most important, this approach enabled our Medicaid members to respond to their issues and needs—on their own. The Launch of HOP My experience in Missouri proved we could apply our efforts to address social needs for Medicaid recipients in North Carolina. Dr. Mandy K. Cohen, then North Carolina’s Secretary of Health and Human Services, and now the Director for the Centers for Disease Control and Prevention, was all in on whole-person care. She sup ported us fully on integrating social determinants into HOP, which we launched in 2022. HOP is the first program of its kind to test and evaluate the impact of providing select evidence-based,

“

Carolina through October 2024. HOP is part of North Carolina’s 1115 waiver, where the Center for Medicaid and CHIP Services has approved the use of Medicaid dollars to deliver social services.

nonmedical interventions to Medicaid members with high needs. The federal government autho rized up to $650 million in federal and state Medicaid funding for HOP to operate in three regions of North

HOP pulled together the right resources to provide the support needed at both the community and human services level. At its core, HOP is a new delivery system for whole-person care that legitimizes addressing social determinants by bringing them under the umbrella of Medicaid. n 288,000 services delivered n Significant reduction in ER visits n $85 reduction in medical costs per member, per month hop by the numbers

Jay Ludlam is the Deputy Secretary for North Carolina Medicaid at the state’s Department of Health and Human Services.

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Learning from the Pandemic: Contact Tracing We were in the HOP planning stage and able to learn from approaches we used in our pandemic work, demon strating how we could address social risks to improve health. This experience facilitated a philos ophy focused on trying something and making investments in our community, then using data to inform whether or not the interventions we proposed were working. If outcomes didn’t improve, we adjusted. If they did, we increased interventions, thereby creating a virtuous cycle to strengthen the program. This data validation was necessary to meet the requirements of the 1115 waiver when we received an infusion of federal funds during the pandemic and because we were using Medicaid dollars. North Carolinians have a strong sense of community, and we made sure to engage our community partners in our pandemic work in a way that was meaningful to them. We included their voices on policy formation and program aspects, and we got their feedback. We proved that investing in people in North Carolina was worth while. HOP is the natural evolution of our pandemic work. The Impact of HOP We were able to do more with HOP because we focused on social deter minants, giving citizens a more robust system of support. Take one example: Local hospitals identified children in Charlotte who were adversely affected by asthma. They were missing school, and their parents were missing work to care for them. Understanding the connec tion between social risks and health enabled hospital workers to go into the community and investigate the environments in which these asthmatic kids were living. When they found health concerns like mold, they helped these families get new carpeting, air purifiers, and filters. The quality of

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The quality of life for these families improved.

life for these families improved. The kids could go back to school and keep learning—the parents could go back to work and keep earning. HOP doesn’t just affect individuals and communities. North Carolina also benefits because healthier people and communities mean a reduc tion in costs for the state. Focusing on social determinants allows us to be successful, and the framework we’re using feels scalable from an administrative, infrastructure, and community standpoint. Focusing on People Delivers Extraordinary Results We are seeing results of HOP quickly. We’re able to demonstrate in a statistically significant way that improvements are happening. Our primary finding: The longer a member is in HOP, the fewer their social needs and the better their health. We’re making people healthier

and we’re creating relationships within the community to help their efforts become sustainable after the upfront investment.

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What’s Next for HOP? With HOP, we have created a

legacy for communities that can be built around supporting people with Medicaid. Over the next few years, we plan to: n Extend HOP statewide, so we can cover more populations (like foster children and previously incarcerated individuals) n Strengthen our community-based organizations and help them become sustainable n Add new services My team and I are looking forward to continuing the work to expand HOP’s services throughout the entire state of North Carolina. We can’t stop now. When we invest in our people, we win.

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