SAFETY NET PROGRAM INTEGRATION
The COVID-19 pandemic triggered a surge in demand for government services as Americans navigated illness, job losses, work from home and school closures. As need increased, so did pressure on officials to make it easier for lower-income people to apply for government benefits that were suddenly being sought more than ever.
The crisis forced states to find new ways to be efficient and accurate as they addressed the tsunami of applicants and beneficiaries. With the pandemic’s intensity easing, at least for now, states are focusing on how they can build on lessons learned, including addressing a longtime goal of using technology to streamline eligibility and enrollment processes for people who need low-income benefits.
These programs saw millions of new enrollees from the start of the pandemic, from the Supplemental Nutrition Assistance Program (SNAP), once known as food stamps; to Temporary Assistance for Needy Families, or TANF; to unemployment insurance and Medicaid health coverage for lower-earning people.
The Trump administration declared a federal public health emergency in January 2020 due to the pandemic. That declaration included a waiver of interviews for SNAP and jobless benefit applicants, and temporarily paused the need for Medicaid enrollees to reapply for their benefits. This helped states by temporarily reducing their administrative burden.
While the public health emergency has been extended through early 2023, the Omnibus spending bill passed by Congress in December 2022 allows states to restart Medicaid redeterminations on April 1, 2023. This development is prompting states to confront how they’ll handle remaining backlogs of beneficiary renewals and resume normal operations without burdening beneficiaries and agency staff. It also gives states an incentive to administer benefits from multiple programs more efficiently.
States that have already tried consolidating the administration of various benefit programs have had mixed results. But they can use the pressure of the eventual end of the public health emergency as a forcing mechanism for action. Together with billions of dollars in pandemic relief that the federal government has made available to states, they have an opportunity to invest in the technical talent and approaches needed to streamline application and delivery of benefit programs.
SUMMARY OF OPPORTUNITIES
This memo lays out meaningful actions states can take in the first 200 days of 2023 to improve access to benefits, make sure tax dollars are appropriately spent and ease staff workload:
Engage technical leaders who prioritize the customer experience
Engage technical leaders who prioritize making the public’s experience with social safety net programs simpler. People have become used to digital transactions that are fast and understandable, and governments must give Americans the user-friendly experience they expect.
Leverage the pressure of the sunsetting public health emergency
Use the impending expiration of the federal public health emergency, and federal pandemic aid, as incentives for action. Minimizing churn — when recipients lose coverage, often to quickly re-enroll — running programs efficiently and giving the public the service it deserves will be challenging as states face their own workforce shortages. However the sunsetting public health emergency is a strategic window of opportunity.
Improve data sharing across programs
Improve data collection and its sharing across different programs. Many states store benefit program data on outdated technology, making the sharing of information difficult. With the right expertise, states can improve accuracy, reduce redundant information collection and enhance how beneficiaries are served.
The COVID-19 pandemic triggered a surge in demand for government services across the country as millions of Americans coped with illness, job losses, working from home and school closures. At the same time, states were adjusting how their own employees would work during the pandemic. They were also deciding how to enroll large numbers of people for assistance remotely for the first time.
This increased pressure on state programs to become more efficient and reduce barriers for people seeking benefits, including for programs that help lower-income earners. These programs include the Supplemental Nutrition Assistance Program (SNAP); Temporary Assistance for Needy Families (TANF); unemployment insurance; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Medicaid health coverage and the Children’s Health Insurance Program (CHIP). All of these programs saw large increases in enrollment from the start of the pandemic, including 5.8 million additional enrollees in SNAP and 19.3 million enrollees in Medicaid and CHIP., 
As the pandemic began in January 2020, the Trump administration declared a federal public health emergency, a declaration that temporarily reduced the administrative burden for states. This order waived interviews for SNAP and jobless benefit applicants, and paused renewals for Medicaid enrollees. It also increased federal payments to states for Medicaid coverage and financial support for health care providers.
The Trump and Biden administrations both extended the public health emergency several times and it remains unclear exactly when it will end. While the administration extended it again through early 2023, the omnibus spending bill passed by Congress in December 2022 allows states to restart Medicaid redeterminations as soon as April 1, 2023 regardless of when the PHE ends.
The emergency’s end will force states to confront how they will handle the extra administrative requirements that will return after the declaration expires. This means they will also have to assess how they’ll handle remaining case backlogs and resume normal operations without burdening beneficiaries and agency staff. Because the pandemic forced states to handle benefit programs for vast numbers of lower-income people, the crisis has served as a lab for studying weak spots in their programs.
Best in class states strive to administer benefits from multiple programs more efficiently, and there are plenty of incentives for states to do that. Having separate applications for benefit programs, for example, requires people to complete duplicative forms and contact multiple call centers, providing the same information to different agencies. This is cumbersome for the public, inefficient for states and increases opportunity for fraud, waste and abuse.
States have seen the costs of inefficient and burdensome approaches before. When Tennessee required 319,000 Medicaid recipients to use paper forms to renew coverage in 2019, 63% of these forms were never returned, leading to 10% of children on Medicaid losing coverage.,  The paper process has since been replaced by a digital one, significantly easing the burden on both families and staff.
The use or absence of user-friendly technology has an outsized impact on whether benefit programs help the people they were designed to serve.
Many states have experienced the same technical challenges with streamlining benefit programs that they did with the health insurance exchanges in 2014, when online health care marketplaces created by the Affordable Care Act had problematic rollouts. Risky, outdated approaches to technology projects continue to make it harder for states to deliver on ambitious priorities in human services programs.
Even so, states can use the pressure of the eventual end of the public health emergency as a forcing mechanism for action. Together with billions of dollars in pandemic relief for states from the federal government, states have an opportunity to invest in the technical talent and approaches needed to streamline application and delivery of benefit programs and turn a difficult moment into an opportunity.
FEDERAL DOLLARS CREATE A TIMELY OPPORTUNITY FOR SUCCESS OR FAILURE
Financial help for these investments can come from aid packages enacted during the pandemic. These include:
KEY TECHNOLOGY OPPORTUNITIES FOR THE FIRST 200 DAYS OF 2023
Below are meaningful steps that state leaders can take at the beginning of 2023 to streamline benefit program delivery and improve the beneficiary experience. In the first 200 days:
- Empower technical leaders who prioritize customer experience;
- Use the end of the public health emergency to spur action;
- Improve data sharing across programs, and data collection.
EMPOWER TECHNICAL LEADERS WHO PRIORITIZE CUSTOMER EXPERIENCE
Americans expect speed and ease in digital transactions, from shopping for groceries to applying for jobs and finding places to live. Government has lagged behind the private sector in providing a 21st-century customer experience. This contributes to constituent frustration and growing distrust in the government’s ability to deliver at the moment of need.
Some of the gap between how the private and public sectors serve their users can be explained by technical capability. But even more is due to the government’s lack of focus on improving customer experience. Private sector companies focus on their customers by working to improve things like:
To deliver significant improvements that staff and constituents will recognize in their day-to-day interactions with government, states can find and empower agency leaders who prioritize customer experience and allocate resources needed to improve it. Doing this early in an administration can build momentum and set the tone for prioritizing customer experience as agencies set policy, build technology and develop their operations.
Engage the state’s technology leadership in policy and implementation planning
Governments that successfully build resilient, human-centered programs include technical leaders in policy and implementation discussions from the start. Modern technical leaders have a clear track record of delivering software and personal experience with approaches like:
Hire and empower a chief customer experience officer (CXO)
A CXO is an executive leader who focuses on enhancing customer experience and improving programs and services for users at all stages.
Many families seeking Medicaid, SNAP or TANF benefits expect the process to be slow and confusing. Government’s lack of customer focus can come at a cost to staff as well, with hours wasted each year tracking down paperwork and collecting the same information multiple times. This creates an unnecessary administrative burden and increases opportunities for errors and fraud. A great CXO, partnered with the right program and technology leaders, can help build an integrated benefits program strategy anchored in the customer experience, and create small wins and measurable progress to move toward efficient, human-centered services.
An effective CXO has the authority to convene resources across agencies, experiment with new initiatives and hold officials accountable for improving how services are delivered. While they do not need to be a technology professional, they should be familiar with modern technical principles and practices, and know how to engage technology teams to improve the public’s experience. They must be leaders who earn trust, are empathetic and can persuade staff from different agencies to move goals and ideas forward. They must also have access to operational and technical officials who can test and implement new ideas.
In the private sector, CXOs typically oversee developers, designers and researchers who deliver software that improves customer experience. In state government, the CXO’s responsibilities could include:
Notable best practice: Issuing a customer experience executive order
A governor’s executive order can be a powerful way to establish priorities and allocate resources. Clearly articulated priorities, combined with resources and empowered leaders, can accelerate transformative change.
Virginia and Pennsylvania have issued customer experience executive orders in recent years, laying out “citizen-focused” technology priorities and goals for “customer service transformation.” The orders set measurable goals for improving beneficiaries’ experience, providing a single entry point for multiple benefit programs and collecting and publishing feedback from people using the system.
At the federal level, a recent customer service executive order directs agencies to:
USE THE END OF THE PUBLIC HEALTH EMERGENCY TO SPUR ACTION
With the sunset of the federal public health emergency on the horizon, states are developing plans to address the backlog of cases on food stamps (SNAP), unemployment insurance and Medicaid that has accrued over the past two years.
However, the approaching expiration of the emergency, along with large amounts of available federal pandemic aid, are key incentives to improve safety net programs and deliver better outcomes for constituents and staff.
Processing backlogs, minimizing the churn of beneficiaries, ensuring well-run programs and providing the public with high-quality service will be a challenge, especially as states still face their own workforce shortages. This means that capitalizing on available resources and acting decisively to implement crucial reforms in the first 200 days of 2023 will have a big impact on how much progress states can make. In addition to the opportunities outlined below, states can find additional information here in Center on Budget and Policy Priorities’ Opportunities to Streamline Enrollment Across Public Benefit Programs.
Rethink timing and technology to reduce administrative burden in Medicaid
While the public health emergency gives states administrative flexibility across several programs, only Medicaid has let states pause their eligibility evaluations for current enrollees. This has allowed millions of beneficiaries continuous coverage for over two years. While beneficiaries are still expected to report income and household changes, they did not have to go through the usual annual recertification process to maintain their benefits.
Once the public health emergency designation ends, states will have 12 months to complete Medicaid eligibility evaluations. The scope of this task is huge. During the pandemic, the number of recipients on Medicaid increased 20% from 71 million to 86 million. An estimated 17.4% of enrollees — about 15 million individuals — will leave the program. Another 9.5% of enrollees — about 8.2 million individuals — will lose coverage because they are no longer income eligible. However, most of these enrollees will likely be eligible for significant subsidies in the form of advanced premium tax credits, which help people afford coverage on their state’s health insurance exchange. Importantly, around 5.3 million children are expected to lose coverage under Medicaid or the federal Children’s Health Insurance Program.
To minimize disruptions and confusion, states can consider several steps.
Spread the Medicaid redetermination backlog over 12 months to make the administrative burden more manageable
The federal Centers for Medicare and Medicaid Services is encouraging states to do this. The private Kaiser Family Foundation Data found in early 2022 that 41 states plan to spread their redeterminations over nine to 12 months. States that have not done this yet could reconsider in early 2023.
Maximize automated renewals
According to Medicaid rules, if a state can validate that a household still meets income requirements during the annual reexamination process, the family can be automatically renewed without requiring any additional information. This process, also known as ex parte renewal, can significantly lower the burden on staff and reduce gaps in coverage that occur when paperwork is not processed on time. By validating eligibility using electronic data sources and simplifying program administration, a state can also reduce errors and strengthen program integrity.
A state’s ex parte renewal process is an important indicator of its ability to deliver digital services to the public. While most states have a version of this renewal process, the percentage of enrollees they can verify electronically varies widely.
States can prioritize developing technology to strengthen their ex parte processes and perform automated renewals now. Electronic data sources that can help states verify income include:
The non-profit Center on Budget and Policy Priorities (CPBB) offers one important and detailed resource on Medicaid redetermination that states can use as they lay out priorities for 2023 and beyond. CBPP also offers guidance to improve the ex parte renewal process.
Use text messaging to communicate with Medicaid and SNAP enrollees
Eighty-one percent of Americans text regularly, sending 6 billion texts every day. Yet few states use automated text messaging to communicate with program beneficiaries. Texting gives states an opportunity to increase effectiveness and reduce enrollment churn. A Louisiana pilot project that texted Medicaid and SNAP enrollees to remind them to submit renewal information improved their renewal rate by as much as 20%.
Previous rules made it difficult to communicate with beneficiaries by text. However, in 2021 the Federal Communications Commission (FCC) allowed states to text with beneficiaries for eligibility and enrollment reasons. States can use that to update contact information in a beneficiary’s Medicaid and SNAP case.
Up to 14.2 million Medicaid beneficiaries could lose health coverage when redetermination processes resume, some for administrative reasons. For example, they may not receive and return required paperwork on time due to an address change. These families may only realize the problem at a visit to the doctor, resulting in a potentially destabilizing lapse in benefits. This problem can occur with SNAP and unemployment insurance recipients as well.
To assist states, CMS has put together a toolkit on enrollee communication. Benefits Data Trust and the Beeck Center for Social Impact + Innovation at Georgetown University have also produced a toolkit to support standing up a text messaging program to reduce SNAP churn.
IMPROVE DATA SHARING ACROSS PROGRAMS, AND DATA COLLECTION
Data is the foundation of a state’s integrated benefits efforts. States that streamline beneficiaries’ experience across programs use data to reduce redundancy and improve the accuracy of eligibility determinations. But because many states’ SNAP, TANF and Medicaid data is kept in isolated and outdated systems, sharing it across programs is a challenge.
It’s not an insurmountable hurdle. To combine data and improve the public’s and staff’s experiences, states need modern technical talent and approaches. Even small steps can improve state systems.
Hire or appoint an integrated benefits data leader
Whether a state’s goal is “no wrong door” or “one-stop shop,” it cannot meaningfully improve people’s experience or eliminate redundancies across programs without good data. When data is accurate and accessible, states can determine eligibility for multiple programs at once and reduce the times they ask applicants to share the same information.
To progress toward integrating benefit programs, a state can hire and empower a data leader who can develop a data strategy, identify opportunities for data sharing and work with program and technical teams to get tools that provide value. Integrated benefits data leaders will have hands-on experience delivering data tools and software products and a track record of building teams that can deliver results.
Convene a sprint team to identify high-priority data-sharing opportunities
State agency data systems are often isolated from each other, which can increase staffs’ administrative burdens and frustrate beneficiaries by making them provide the same information multiple times to different agencies. A top integrated benefits goal and best practice is for applicants to share their information only once across benefit programs.
A sprint team is a targeted team brought together temporarily to rapidly solve a challenge. When given appropriate resources and authority, it can deliver tangible progress quickly. A team could identify three data-sharing opportunities that would reduce administrative burden for beneficiaries and staff and can be implemented in six to nine months. An effective team is empowered to deliver the process changes and technology needed to share the data.
While the composition of a sprint team may vary, it should include:
States that do not have a digital services team may not have product managers and software engineers on staff. To fill this gap, they could contact organizations like Code for America and U.S. Digital Response, or use existing private contracting to bring in expertise.
When tackling data-sharing projects across programs, it’s critical that states engage legal counsel early. Counsel will have to determine how data sharing can happen safely while following regulations. When legal teams take an overly cautious interpretation of federal guidance, useful data sharing can stall.
An example of a data sharing opportunity with real world impact occurs in the Free and Reduced Price School Meals Program, where states can get permission from the Food and Nutrition Service to automatically qualify children in families who are income eligible for Medicaid. Today, 26 states do this. This data sharing ranges from spreadsheets to full-scale, automated data integration across systems.
Focus on small wins to gain momentum
Many states set ambitious integrated benefits goals. While a clear vision is critical for uniting staff and vendors on a common goal, the technology to support it is most effective when it’s delivered incrementally and prioritized based on user needs.
This can help a state reduce risk and deliver small but meaningful wins that staff and customers can quickly appreciate. Small wins are important for projects like streamlining the redetermination process, finding new data-sharing opportunities across programs or exploring new ways to communicate with beneficiaries.
Vermont developed a digital uploader to let applicants submit documents for health care or economic services programs. The digital tool replaced mail and in-person submissions and reduced processing times by 40%.
When the Vermont uploader was developed, the state first tested the tool with 50 users in one office. While the uploader was being gradually expanded to the entire state — which took a year — Vermont used the time to also prioritize other investments in integrating technology.
Collect and publish performance data to identify priorities
A state cannot understand how its benefit programs are serving residents without data on performance and accessibility for Medicaid, SNAP, WIC and TANF.
Data that states provide to the federal government on these programs often focuses on compliance. Some states like California and Washington have taken a broader approach and collect information that includes publicly available data on recipient churn and advanced call center metrics. This has helped identify problems serving residents. States achieve the best outcomes when this data also advances their efforts to integrate programs.
An important first step toward improving customer experience is collecting baseline customer service data. In 2021, Code for America released the Safety Net Scorecard, which states can use to evaluate how effectively they are delivering digital benefits. The scorecard focuses on data in three categories: equitable access, effective delivery and compassionate integrity — meaning recipients receive the benefits they need fully and forthrightly. States could start by selecting one or two items from the scorecard to develop performance measurements like average days to process an application, percent of applications that are denied for procedural reasons, and level of churn among beneficiaries.
States can use this information to set clear performance goals and define the ideal customer experience. Gold standard examples include ensuring that applicants:
Once performance goals are set, agency leaders can work with technical leaders to:
Map beneficiaries’ movement through the renewal process to find bottlenecks
A journey map is a powerful tool for an agency to understand the redetermination and renewal process as the recipient experiences it, and how to improve it. A map documents each step an individual takes, including what they do, whom they interact with, time involved and where they get stuck. Journey maps, frequently used in the private sector, remain rare in government. An example of a journey map created by U.S. Digital Response to better understand the experience of families applying for child care benefits can be found here.
This simple exercise can help identify problems, including common points of confusion, process bottlenecks and unnecessary duplication.
States with digital services teams, like Georgia and New Jersey, can charge them with journey mapping. States without digital services teams can contact groups like Code for America and U.S. Digital Response for help. There are also web-based tutorials like NYC Service Design Studio’s guide to use journey mapping.
A journey map can help states set priorities to improve the redetermination process. The team can develop performance goals and a technology and business process roadmap to make the public’s experience better. By starting with things that can be accomplished quickly, the state can demonstrate meaningful improvement to staff and beneficiaries early on. It can then use the momentum to focus on improvements that take more work.
Colorado did this successfully in 2019, when they worked with Code for America to map how it redetermined Medicaid recipients, letting them simplify the process whereby enrollees report changes to their household information. The result was a simple website that let beneficiaries provide updated information without having to visit an office or submit paperwork. The first version laid the groundwork for more complex technology and data integration with Colorado’s Medicaid record system.
The Preparing for Human-Centered Redesign toolkit from Civilla and the Beeck Center for Social Impact + Innovation at Georgetown University offers a helpful starting point.
BEYOND THE FIRST 200 DAYS
While the first 200 days of a new or returning administration are critical for building momentum needed for delivering policy priorities, some longer-term strategies can also help deliver better services for residents.
LEVERAGE FEDERAL FUNDS TO BUILD MODERN TECHNICAL TEAMS AND APPROACHES
States can submit proposals to CMS and FNS for money to plan and implement technology modernization. These are known as advanced planning documents, or APDs. States can use technology to help integrate benefit programs by applying for funds that will help:
Many states take multiyear approaches to technical planning. States could use APD funds to hire consultants to develop a roadmap for incremental but important progress. This could produce outcomes including:
BUILD DIGITAL SERVICES CAPACITY
Using technology to integrate benefit programs in a way that reduces administrative burden and improves the enrollee experience requires specialized expertise like:
More information on how to build a digital services capacity can be found in the Talent memo.
BUILD PROCEDURES TO SUPPORT PROCUREMENT OF MODERN TECHNOLOGY
States often lack the in-house talent and procurement procedures to make sure the technology they buy provides a worthwhile benefit. With many pandemic-era contracts due for rebidding, states have a chance to hold contractors accountable.
Contracts that favor user-centered, incremental ways to obtain technology have a better chance of success. This often requires state officials to explore new approaches. Beyond the first 200 days, states could pull together a small team of procurement, program and technical experts who can:
For more information regarding state procurement, see the procurement memo.