Welfare Reform: More Coordinated Federal Effort Could Help States
and Localities Move TANF Recipients With Impairments Toward	 
Employment (31-OCT-01, GAO-02-37).				 
								 
The Personal Responsibility and Work Opportunity Reconciliation  
Act of 1996 (PRWORA) significantly changed federal welfare policy
for low-income families with children. PRWORA eliminated eligible
families' legal entitlement to cash assistance and created	 
Temporary Assistance for Needy Families (TANF) block grants to	 
states. TANF emphasizes the importance of work and personal	 
responsibility over dependence on government benefits. Under	 
TANF, states, to avoid financial penalties, must demonstrate,	 
yearly, that an ever-increasing proportion of adults receiving	 
TANF are working or engaged in work-related activities. 	 
Nationwide the U.S. Census Bureau's (Census) Survey of Income and
Program Participation (SIPP) data for 1999 show that a total of  
44 percent of TANF recipients reported having physical or mental 
impairments, a proportion almost three times as high as among	 
adults in the non-TANF population. The percentages of TANF adults
with impairments from 1994 can not be compared to later years	 
because Census broadened its measurements of primarily mental	 
impairments starting with its 1997 SIPP data. Most of the	 
counties that screen for impairments rely predominantly on	 
recipients' self-disclosure, which may not ensure the		 
identification of some impairments that could interfere with	 
employment. Still, for the one-third of counties that reported	 
service data, on average, fewer than half of recipients with	 
impairments were receiving services to move them toward 	 
employment, which may be explained, in part, by the fact that a  
large portion were exempted from program work requirements.	 
Federal agenices, including the Departments of Health and Human  
Services, Labor, and Education, have implemented or are planning 
many research and technical assistance initiatives to facilitate 
state and local efforts to help TANF recipients with impairments 
become employed.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-37						        
    ACCNO:   A02381						        
  TITLE:     Welfare Reform: More Coordinated Federal Effort Could    
Help States and Localities Move TANF Recipients With Impairments 
Toward Employment						 
     DATE:   10/31/2001 
  SUBJECT:   Block grants					 
	     Employment of the disabled 			 
	     Grants to states					 
	     Welfare benefits					 
	     Welfare recipients 				 
	     Supplemental Security Income Program		 
	     Disability Insurance Program			 
	     HHS Temporary Assistance for Needy 		 
	     Families Block Grant				 								 
	     Census Bureau Survey of Income and 		 
	     Program Participation				 								 
	     HHS Aid to Families with Dependent 		 
	     Children Program					 								 
	     HHS Temporary Assistance for Needy 		 
	     Families Program					                                                                 
	     National Survey of America's Families		 

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GAO-02-37
     
Report to Congressional Requesters

United States General Accounting Office

GAO

October 2001 WELFARE REFORM More Coordinated Federal Effort Could Help
States and Localities Move TANF Recipients With Impairments Toward
Employment

GAO- 02- 37

Page i GAO- 02- 37 TANF Recipients With Impairments Letter 1

Results in Brief 3 Background 6 The Percentage of TANF Recipients That
Report Impairments Has

Not Increased as Caseloads Have Declined 9 Counties Are Screening TANF
Recipients for Impairments, but

Recipients May Not Be Receiving Services to Move Them Toward Employment 15
Federal Agencies Provide Assistance to Welfare Programs, but

States and Localities Could Further Benefit If Efforts Were Better
Coordinated 29 Conclusions 33 Recommendation for Executive Action 34 Agency
Comments and Our Evaluation 35

Appendix I Scope and Methodology 37

Appendix II Comments From the Department of Health and Human Services 40

Appendix III GAO Contacts and Staff Acknowledgments 43 GAO Contacts 43 Staff
Acknowledgments 43

Bibliography 44

Related GAO Products 50

Tables

Table 1: TANF One- Parent Families? Participation in Work and Work- Related
Activities 7 Table 2: Examples of Initial and Follow- up Questions About

Impairments in the SIPP 10 Table 3: Key Features of Strategies at Sites
Visited 28 Contents

Page ii GAO- 02- 37 TANF Recipients With Impairments

Table 4: Key Initiatives to Assist States and Localities Serve TANF
Recipients With Impairments 30

Figures

Figure 1: Proportion of TANF Adults Working Full- or Part- time in 1999 11
Figure 2: TANF Recipients With Obstacles to Employment Engaged

in Work or Work- Related Activities 13 Figure 3: Methods Counties Use to
Screen Recipients 17 Figure 4: Points During the Employment Process When
Counties

May Screen Recipients By Any Method 19 Figure 5: Staff Who Conducted
Assessments 20 Figure 6: Primary Agency or Program With Which TANF Agencies

Partnered to Provide Services 24

Abbreviations

ACF Administration for Children and Families ADA Americans With Disabilities
Act of 1990 AFDC Aid to Families With Dependent Children DI Disability
Insurance GPRA Government Performance and Results Act HHS Department of
Health and Human Services NCD National Council on Disability NSAF National
Survey of America?s Families PRWORA Personal Responsibility and Work
Opportunity

Reconciliation Act SIPP Survey of Income and Program Participation SSA
Social Security Administration SSI Supplemental Security Income TANF
Temporary Assistance for Needy Families

Page 1 GAO- 02- 37 TANF Recipients With Impairments

October 31, 2001 The Honorable Benjamin L. Cardin Ranking Minority Member
Subcommittee on Human Resources Committee on Ways and Means House of
Representatives

The Honorable Sander M. Levin The Honorable Robert T. Matsui The Honorable
Fortney Pete Stark House of Representatives

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(PRWORA) significantly changed federal welfare policy for lowincome families
with children. PRWORA eliminated eligible families? legal entitlement to
cash assistance and created Temporary Assistance for Needy Families (TANF)
block grants to states. The Department of Health and Human Services (HHS)
administers the TANF block grant program, which provides states with up to
$16.5 billion each year through fiscal year 2002 and requires them to
maintain a historical level of state spending on welfare- related programs.
Under TANF, states have much greater flexibility and responsibility than
under the prior Aid to Families With Dependent Children (AFDC) program to
design and implement programs that meet state and local needs. At the same
time, TANF emphasizes the importance of work and personal responsibility
over dependence on government benefits. More specifically, to avoid
financial penalties, states must demonstrate, yearly, that an ever-
increasing proportion of adults receiving TANF are working or engaged in
work- related activities. In addition, after 2 years of assistance, or
sooner if the state determines the recipient is ready, TANF adults are
generally required to be engaged in work or work- related activities, and
each state has the prerogative to define ?work? and ?work- related?
activities. These work requirements are more stringent than those of the
previous program. Moreover, states must enforce a lifetime limit of 60
months (or less, at state option) on the length of time adults receive
federal assistance, although up to 20 percent of a state?s adult caseload
may be exempted from this time limit.

Consistent with the thrust of PRWORA, states? TANF programs have generally
taken steps to help adult welfare recipients and applicants find employment
as quickly as possible, called a ?Work- First? approach. TANF
implementation, undertaken in a time of strong economic growth, has

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 02- 37 TANF Recipients With Impairments

been accompanied by a 52- percent decline in the number of families
receiving cash welfare- from 4.4 million in August 1996 to 2.1 million as of
March 2001. With this dramatic decline in the welfare rolls, some
policymakers have expressed concern about those who remain on the rolls who
may have physical or mental impairments and whether they are getting the
assistance needed to become employed. Our previous work, while not focused
solely on physical or mental impairments, found that many who remain on the
welfare rolls have characteristics that may make it difficult for them to
find and maintain jobs, including substance abuse, low educational
attainment, limited work experience, low basic skills, exposure to domestic
violence, and physical or mental impairments. 1

Neither PRWORA nor HHS specifies actions that states must take to assess and
serve individuals with impairments. However, TANF?s increased work focus and
lifetime limits on aid emphasize the expectation that most adults receiving
aid are to take steps toward employment and economic independence and that
states are to encourage and require this transition. The extent to which
that happens, however, is partly dependent on state policies and
implementation at the county level- where TANF program services are actually
provided. While much responsibility for program design has been devolved to
states, HHS retains program oversight responsibilities for TANF funding and,
among other responsibilities, conducting research on the benefits and
effects of the TANF program and disseminating and facilitating the sharing
of information and best practices among states and localities. In addition
to HHS, other federal agencies can play a role in helping TANF recipients
with physical and mental impairments become employed, including the
Department of Labor?s employment and training programs and the Department of
Education?s vocational rehabilitation services.

With TANF?s reauthorization pending in 2002, you asked us to provide
information on how individuals with disabilities or impairments are faring
in the new welfare environment. In response to your request, we are
providing you with information on (1) the percentage of TANF recipients
considered to have physical or mental impairments and how this percentage
has changed over time; (2) how county TANF agencies assess and move
recipients with impairments toward employment; and (3) what

1 See Welfare Reform: Moving Hard- to- Employ Recipients Into the Workforce
(GAO- 01- 368, Mar. 15, 2001).

Page 3 GAO- 02- 37 TANF Recipients With Impairments

key federal efforts are under way to facilitate TANF agencies? efforts to
help this population become employed.

To address the first question, we relied primarily on data from the U. S.
Census Bureau?s Survey of Income and Program Participation (SIPP)- a survey
of households nationwide that asks respondents questions about their TANF
status and functional impairments and uses categories of impairments
generally in keeping with those covered by the Americans With Disabilities
Act of 1990 (ADA). 2 To determine how TANF agencies screen and assess
recipients with impairments and help them move to employment, we sent a
questionnaire to a random, stratified sample of 600 county TANF offices,
representative of county TANF offices nationwide. 3 Our review of the
literature and suggestions by officials at HHS and the Departments of Labor
and Education, experts, key researchers, and service providers, prompted us
to visit four county TANF offices identified as having promising approaches
for identifying and helping TANF recipients with impairments move to
employment: Cumberland County, North Carolina; Sedgwick County, Kansas;
Davidson County, Tennessee; and Leon County, Florida. Finally, to determine
the key efforts of federal agencies to help this population, we interviewed
HHS, Labor, Education, and other federal officials; program advocates; state
and local officials; and reviewed agency documents. We conducted our work
from November 2000 to September 2001 in accordance with generally accepted
government auditing standards.

Nationwide SIPP data for 1999 show that a total of 44 percent of TANF
recipients reported having physical or mental impairments, a proportion
almost three times as high as among adults in the non- TANF population.
Thirty- eight percent of the TANF recipients in 1999 reported an impairment
severe enough that the individual was unable or needed help to perform one
or more activities, such as walking up a flight of stairs or

2 ADA defines persons with disabilities as those who have a physical or
mental impairment that substantially limits one or more major life
activities, such as walking, hearing, etc.; those who have a record of such
impairment; or those who are regarded as having such an impairment.

3 For our questionnaire, we defined an impairment as a physical or mental
health condition, or learning disability, that may interfere with a person?s
ability to work. The questionnaire did not include substance abuse and
domestic violence as impairments. Results in Brief

Page 4 GAO- 02- 37 TANF Recipients With Impairments

keeping track of money and bills. 4 Considering both severe and nonsevere
impairments, 29 percent of TANF adults reported a mental impairment, such as
frequent depression or anxiety or trouble concentrating. While TANF
recipients reporting a physical or mental impairment were less likely to be
working than other TANF recipients, about 20 percent of those with
impairments also reported working full- or part- time. We could not directly
compare the percentages of TANF adults with impairments from 1994 to later
years because Census broadened its measurements of primarily mental
impairments starting with its 1997 SIPP data. However, we did not find any
statistically significant difference after adjusting the 1997 and 1999 data
to be comparable to the 1994 definition of impairments.

Although most counties reported that they are screening TANF recipients for
impairments, many recipients with impairments may not be receiving
assistance to help move them toward employment. Most of the counties that
screen for impairments rely predominantly on recipients? selfdisclosure,
which may not ensure the identification of some impairments that could
interfere with employment. About half of the counties did not provide us
with data on the number of their TANF recipients with impairments despite
their screening efforts. Nearly all of these counties said they did not have
the information. About 27 percent of counties reported exempting those
identified with impairments from requirements to participate in work or
work- related activities, but not from the states? time limits on the
receipt of assistance. Most county TANF officials estimated that fewer than
20 percent of their TANF recipients had impairments that would make work so
difficult that they should be exempt from the federal time limit. Many of
them, however, did not provide us with data on the number of recipients with
impairments to support their estimates. For TANF recipients with impairments
who were receiving services, counties reported providing treatment for
physical or mental impairments, including learning disabilities, and
employment- related services, either through their own agency or a
contractor or by linking with other service providers, including vocational
rehabilitation agencies. Still, for the one- third of counties that reported
service data, on average, fewer than half of recipients with impairments
were receiving services to move them toward employment, which may be
explained, in part, by the

4 The SIPP relies on self- reports of disability and, therefore, may not
accurately reflect the size of the impaired population. Factors other than
health, such as stigmas surrounding certain health conditions, may affect
the reporting of disability.

Page 5 GAO- 02- 37 TANF Recipients With Impairments

fact that a large portion were exempted from program work requirements. The
sites we visited, identified by experts as having promising approaches for
helping recipients with impairments become employed, had implemented
strategies ranging from developing standardized diagnostic screening tools
to forming multidisciplinary teams to identify needed services for
recipients. While the approaches varied, all sites acknowledged that the
strategy had to be tailored to each recipient. These service strategies were
new, however, and had not yet been evaluated.

Federal agencies, including HHS, Labor, and Education, have implemented or
are planning many research and technical assistance initiatives to
facilitate state and local efforts to help TANF recipients with impairments
become employed. In some cases, agencies, and offices within agencies,
collaborated on these efforts. For example, HHS? Administration for Children
and Families (ACF) and Substance Abuse and Mental Health Services
Administration partnered with Labor?s Employment and Training Administration
to hold five conferences for program administrators on promising practices
to move clients with multiple barriers to employment. ACF has also
collaborated with Education and the National Institute for Literacy to
provide technical assistance and training to state and local TANF agencies
on valid screening tools for individuals with learning disabilities. These
initiatives and efforts provide important information to states and
localities involved in the continuing transformation of the nation?s welfare
system. Yet federal officials told us that there is no central focal point
to ensure that research and technical assistance conducted by the federal
agencies is coordinated and disseminated to the states and counties directly
providing services to TANF recipients. In addition, officials at three of
the four counties we visited believed that coordinated federal assistance
was needed to make sure that states and localities have the best information
available to enhance their efforts to help TANF recipients with impairments
take steps toward employment.

To ensure that states and counties get the support they need, we are
recommending in this report that HHS coordinate with other key agencies and
departments, particularly Labor and Education, to make sure that federal
resources, research, and technical assistance related to moving people with
impairments toward employment are disseminated to state and local agencies
that are designing and implementing policies and programs for TANF
recipients. As a means to ensure that this coordination and dissemination of
information occurs, ACF should include its strategies, goals, and measures
regarding this coordination and information dissemination in its annual
performance plan required by the Government Performance and Results Act. In
commenting on the draft

Page 6 GAO- 02- 37 TANF Recipients With Impairments

report, HHS agreed that greater coordination at the federal level would
likely help states and localities move TANF recipients with impairments
toward employment and agreed with our recommendation that it should
coordinate with other key agencies to ensure that research and technical
assistance are disseminated. However, it did not think that strategies to
ensure such coordination should be included in its annual performance plan.
We continue to believe that including coordination strategies, goals, and
measures in its annual performance plan would better ensure that effective
coordination activities take place.

PRWORA built upon and expanded state- level welfare reforms to transform
federal welfare policy for needy families with children. It replaced the
individual entitlement to benefits under the 61- year- old AFDC program with
TANF block grants to the states and emphasized the transitional nature of
assistance and the importance of reducing welfare dependence through
employment, among other goals. PRWORA provides states with the flexibility
to set a wide range of TANF program rules, including the types of programs
and services available and the eligibility criteria for them. In addition,
states may choose to administer TANF directly, devolve responsibility to the
county or local TANF offices, or contract with nonprofit or for- profit
providers to administer TANF. In addition to TANF funds, states may access
other federal funds and programs to provide treatment and employment
services to recipients. For example, states may use Labor?s Welfare- to-
Work grants to operate employment service programs, Medicaid funds to
provide physical or mental health treatment services, and vocational
rehabilitation funds to provide services to recipients. 5

While states have great flexibility to design programs that meet their own
goals and needs, they must also meet several federal requirements designed
to emphasize the importance of work and the temporary nature of TANF aid.
TANF established stronger work requirements for those receiving aid unlike
the AFDC program, which did not require most adult recipients to participate
due to allowable exemptions and minimum participation standards. For
example, parents of children aged 3 and under

5 Welfare- to- Work grants were created by law in 1997 and administered by
Labor to provide states and grantees with nearly $3 billion over 2 years to
help welfare clients considered the hardest to employ find jobs. Background

Work Requirements and Time Limits

Page 7 GAO- 02- 37 TANF Recipients With Impairments

were not required to meet work requirements under AFDC; under TANF parents
may now be required to work, regardless of the ages of their children. 6
Furthermore, to avoid financial penalties, states must ensure that a
steadily rising specified minimum percentage of adult recipients are
participating in work or work- related activities each year. To count toward
the state?s minimum participation rate, adult TANF recipients in families
must participate in a minimum number of hours of work or a work- related
activity a week, including subsidized or unsubsidized employment, work
experience, community service, and job search. These activities are more
employment- focused than the AFDC participation requirements. The required
number of hours of participation and the percentage of a state?s caseload
that must participate to meet mandated rates has steadily increased since
1997, as shown in table 1.

Table 1: TANF One- Parent Families? Participation in Work and Work- Related
Activities

Minimum requirements 1997 1998 1999 2000 2001 2002

Weekly hours 20 20 25 30 30 30 Percentage participation 25 30 35 40 45 50

Note: PRWORA also sets higher minimum hour and participation rates for two-
parent families. The minimum hour requirement is 35 hours, and the minimum
participation rate rises from 75 percent in 1997 to 90 percent in 1999 and
beyond.

If recipients refuse to participate as required, states must impose a
financial sanction on the family by reducing the benefits, or they may opt
to terminate the benefits entirely. States must also enforce a 60- month
limit (or less at state option) on the length of time a family may receive
federal TANF assistance, although the law allows states to provide
assistance beyond 60 months using state funds. 7 A state may exempt up to 20
percent of its average monthly caseload for hardship or having been
subjected to domestic violence.

6 States may choose to exempt parents with children under age 1 from work
requirements, and states may not penalize parents with children under age 6
for not working if childcare is not available.

7 States may count these expenditures toward the maintenance- of- effort
requirement in PRWORA that requires states to spend 80 percent of their
?historic state expenditures? or face a dollar- for- dollar reduction in
their TANF grant. Families with no adult receiving assistance (commonly
referred to as child- only cases) are not subject to the time limit.

Page 8 GAO- 02- 37 TANF Recipients With Impairments

PRWORA devolved significant authority for program results and outcomes to
states and other levels of government. It also reduced HHS? staffing and
restricted it from regulating any area not specified in the law. Despite
these changes, the federal government retains some program oversight
responsibilities. Under the law, HHS is responsible for administering TANF
funding, setting reporting requirements for states, and reviewing state TANF
plans. HHS is also responsible for conducting research on the benefits and
effects of the TANF program and receives funding for welfare reform and
social service research and evaluation studies.

TANF often serves, as did AFDC, as a temporary stopping point for lowincome
individuals with physical or mental impairments considered severe enough to
make them eligible for the federal Supplemental Security Income (SSI)
program. SSI, administered by the Social Security Administration (SSA),
provides cash assistance to low- income individuals who cannot obtain or
retain employment because of a severe long- term impairment and who do not
have sufficient work history to qualify for SSA?s Disability Insurance (DI)
program. 8 To qualify for SSI, an applicant?s impairment must be of such
severity that the person is not only unable to do previous work but is also
unable to do any other kind of substantial work that exists in the national
economy. Prior work experience is not a requirement, and in most states, SSI
eligibility also entitles individuals to Medicaid benefits. As distinct from
TANF, SSI for adults has federallyestablished eligibility requirements and
benefit levels and a nationwide disability determination process. 9 Some
individuals who apply for TANF may have impairments severe enough to make
them eligible to receive SSI. In recent years, even before welfare reform,
states had been actively identifying and referring potential SSI- eligible
welfare recipients to SSI. In these cases, individuals may be on TANF while
they are waiting for their SSI eligibility to be determined. In some cases,
an individual with an impairment severe enough to qualify may not get
referred to the SSI program, but remain on TANF. This puts the individual at
risk of losing aid through a financial sanction or time limit or not
receiving the assistance needed to become employed. Generally, except for
more temporary

8 Cash assistance and services for persons with disabilities who have worked
long enough and recently enough are also available from the DI program.
Other programs, which may be available, include private disability insurance
or pensions and state workers? compensation programs.

9 Some states provide supplemental payments to the federal benefit level.
Federal Program

Responsibilities The Relationship Between TANF and SSI and ADA

Page 9 GAO- 02- 37 TANF Recipients With Impairments

conditions, TANF recipients not eligible for SSI or DI are expected to work,
as their impairments are not severe enough to preclude substantial
employment.

Title I of ADA prohibits discrimination against such persons who have
impairments but who are nonetheless able to perform the essential functions
of the job they seek or hold. Under Title II of the ADA, no qualified
individual with a disability shall be excluded from participation or be
denied the benefits of the services, programs, or activities of a public
entity, or be subject to discrimination by such entity. TANF, as a federal
program, is subject to this requirement 10

National survey data from SIPP show that a total of 44 percent of TANF
recipients aged 18 to 64 self- reported having a physical or mental
impairment in 1999. In contrast, 16 percent of non- TANF adults in the U. S.
population reported having an impairment. Although SIPP data show that TANF
recipients with impairments were much less likely to work than those without
impairments, about 20 percent who reported having impairments also reported
working full- or part- time. As welfare reform has been implemented and
caseloads have plummeted, the proportion of TANF recipients who reported
impairments does not show any notable difference.

SIPP data show that in 1999, a total of 44 percent of TANF adults aged 18 to
64 reported having one or more physical or mental impairments as defined by
Census, and 38 percent reported a severe impairment. Considering both severe
and nonsevere impairments, 29 percent of TANF adults reported having a
mental impairment. These data capture individuals who reported functional or
other activity limitations generally covered by ADA. 11 The proportion of
TANF recipients with impairments is almost three times as high as adults
with impairments in the U. S. nonTANF population. Table 2 provides examples
of questions asked by

10 On January 19, 2001, HHS? Office of Civil Rights issued Summary of Policy
GuidanceProhibition Against Discrimination on the Basis of Disability in the
Administration of TANF to all entities involved in the administration and
operation of TANF programs.

11 ADA was enacted, in part, to remove barriers to employment and receipt of
public services for people with disabilities by prohibiting discrimination.
In the area of employment, the ADA requires employers to make reasonable
accommodations to persons with disabilities (e. g., by providing a magnified
computer screen for a vision- impaired person), unless such accommodations
would impose undue hardship on employers. The Percentage of

TANF Recipients That Report Impairments Has Not Increased as Caseloads Have
Declined

A Large Percentage of TANF Recipients Report Having an Impairment

Page 10 GAO- 02- 37 TANF Recipients With Impairments

Census to identify persons with severe or nonsevere impairments. Appendix I
lists the specific criteria developed by Census that individuals must meet
to be considered impaired as applied in the SIPP.

Table 2: Examples of Initial and Follow- up Questions About Impairments in
the SIPP

Initial impairment question Follow- up impairment question

Do you have difficulty seeing the words and letters in ordinary newspaper
print even when wearing glasses or contact lenses if you usually wear them?

Are you able to see the words and letters in ordinary newspaper print at
all?

Do you have difficulty having your speech understood? In general, are people
able to understand

your speech at all? Do you have any difficulty lifting and carrying
something as heavy as 10 pounds- such as a bag of groceries?

Are you able to lift and carry this much weight at all?

Because of a physical or mental health condition, do you have any difficulty
keeping track of money or bills?

Do you need the help of another person with keeping track of money or bills?

Note: If an individual reports having difficulty performing a specific
activity, a follow- up question usually determines if the level of
difficulty is severe or not. Impairments are generally classified as severe
when an individual is unable to perform or needs help to perform one or more
functional or other activities.

Identifying and measuring impairments or disabilities is a complex
undertaking, and no single survey instrument has been accepted or generally
agreed upon as the preferred method for identifying impairments within a
population. Census believes the extensive set of disability questions
contained in SIPP make it a preferred source to examine most impairment-
related issues. 12 Nevertheless, SIPP data should be interpreted with care.
For instance, SIPP relies on self- reports of impairments and, therefore,
may not accurately reflect the size of the general or TANF population with
impairments. This can result in the overreporting or underreporting of
impairments. For example, although some impairments, such as inability to
walk, missing or impaired limbs, or severely impaired vision, are easy to
identify, many impairments are not. Individuals may not report less obvious
impairments because of certain stigmas surrounding them or because they may
not know of their existence. Some examples of these impairments include
learning disabilities, depression, and mental illness. Other surveys use
different approaches to measure impairments. The National Household Survey
of Drug Abuse and the University of

12 The SIPP data reported do not include impairments related to substance
abuse.

Page 11 GAO- 02- 37 TANF Recipients With Impairments

Michigan?s Women?s Employment Survey, for example, use nonclinical indepth
diagnostic questioning to identify certain psychiatric disorders that may be
overlooked by other survey techniques. 13

Although national survey data show that TANF recipients with impairments are
less likely to be combining welfare and work than those without impairments,
many, in fact, do work. SIPP data show that 20 percent of TANF recipients
with impairments were working full- or parttime in 1999, compared with 44
percent of TANF recipients not reporting impairments. 14 (See fig. 1.) In
addition, SIPP data show virtually no change since 1997 in the percent of
TANF recipients with impairments who work. In 1997, 19 percent of TANF
recipients with impairments (aged 18- 64) were working compared with 20
percent working in 1999.

Figure 1: Proportion of TANF Adults Working Full- or Part- time in 1999

Source: GAO analysis of 1999 SIPP data on disability.

13 Rukmalie Jayakody, Sheldon Danziger, and Harold Pollack, ?Welfare Reform,
Substance Use, and Mental Health,? Journal of Health Politics, Policy and
Law (Aug. 2000). 14 Part- time refers to fewer than 35 hours per week. Many
TANF Recipients

With Impairments Were Able to Combine Welfare and Work

0 10

20 30

40 50

With Impairment Without Impairment

Percentage 20

44

Page 12 GAO- 02- 37 TANF Recipients With Impairments

Whether a TANF recipient with impairments is able to work while receiving
welfare can depend on many complex, interrelated factors, such as other
personal characteristics they may have, and state and local programs and
policies, including benefit levels and policies that encourage or require
work. Regarding personal characteristics, studies have shown that many
factors- including poor health or disability, no high school diploma,
limited work experience, exposure to domestic violence, substance abuse, and
limited English proficiency- make finding and keeping a job more difficult.
Moreover, recipients with impairments may have more than one characteristic
that could interfere with work. Data from a longitudinal University of
Michigan?s Women?s Employment Study show that physical and mental
impairments co- occur with other obstacles to work in almost half of the
sampled cases. More specifically, data from this panel survey of women on
welfare in an urban county in Michigan show that in 1998, two- thirds of
TANF recipients with physical problems and about half of those with mental
health problems also had other obstacles to work. In addition, the Manpower
Demonstration Research Corporation reported that the prevalence of health
problems among women who were receiving welfare suggests that there will be
major challenges to welfare agencies as a growing number of recipients face
time- limit pressures. 15

Nationwide data from another source show that the greater the number of
obstacles a TANF recipient faces, the less likely that recipient is to be
engaged in paid work or work- related activities while receiving welfare. On
the basis of data from its 1999 National Survey of America?s Families
(NSAF), the Urban Institute reported that in 1999, 90 percent of recipients
who had no obstacles were working in paid jobs or engaging in workrelated
activities (in school or training or looking for work), compared with 68
percent of recipients with one obstacle and 54 percent of recipients with
two or more. 16 (See fig. 2.) The Urban Institute has also reported that a
greater proportion of TANF recipients with two or more obstacles to
employment were engaged in work or work- related activities in 1999 compared
with 1997. While many factors could affect this outcome including economic
conditions, welfare agencies increased emphasis on

15 Denise F. Polit, Andrew S. London, and John M. Martinez, The Health of
Poor Urban Women: Findings from the Project on Devolution and Urban Change.(
Manpower Demonstration Research Corporation, May 2001).

16 Sheila R. Zedlewski and Donald Alderson, Before and After Reform: How
Have Families on Welfare Changed? (Washington, D. C.: The Urban Institute,
Apr. 2001).

Page 13 GAO- 02- 37 TANF Recipients With Impairments

requiring and encouraging TANF recipients to take steps toward employment
could be an important one.

Figure 2: TANF Recipients With Obstacles to Employment Engaged in Work or
Work- Related Activities

Source: The Urban Institute 1999 NSAF.

In addition to program policies and practices, research suggests that
successful transitions to work may be more likely for younger people with
impairments and for those who have greater motivation to work and stronger
educational backgrounds. 17 Moreover, some persons with impairments may
benefit from technological and medical advances and social changes, which
have created more opportunities for some individuals with impairments to
work. Nevertheless, some persons with multiple work impediments may need to
learn basic skills and work habits and build self- esteem to successfully
function in the workplace. Some may also face tight labor market conditions,
particularly for low- wage positions, that could constrain employment
opportunities, while others

17 Social Security Disability Insurance: Multiple Factors Affect
Beneficiaries? Ability to Return to Work (GAO/ HEHS- 98- 39, Jan. 12, 1998).

0 10

20 30

40 50

60 70

80 90

100 Zero One Two or More

Percentage 90

68 54

Number of Obstacles

Page 14 GAO- 02- 37 TANF Recipients With Impairments

may need to overcome logistical obstacles, such as transportation
difficulties.

Welfare caseloads dropped 46 percent between 1994 and 1999; however,
national survey data suggest that the proportion of TANF adults reporting
impairments has not changed significantly since welfare reform began.
Because of steps taken by Census beginning with the 1997 SIPP data to
improve and broaden its disability measurement, including measurements of
mental impairments, we adjusted the SIPP data for 1997 and 1999 to be
consistent with the definition used in 1994. The adjusted data showed that
there were no statistically significant differences in the percentage of
TANF recipients reporting impairments since states implemented welfare
reform.

Data from the Urban Institute?s NSAF corroborate SIPP data. They show that
the proportion of adults on TANF who reported a serious physical or mental
health problem was 32 percent in 1997 compared with 36 percent in 1999,
which was not a statistically significant difference. 18

While our analysis shows that the proportion of TANF recipients with
impairments has not increased while caseloads have declined, it is not clear
what this means in so far as outcomes for TANF recipients with impairments.
The proportion of TANF recipients with impairments on the rolls at any given
time and over time is affected by the number and characteristics of
individuals coming onto the rolls and leaving the rolls. Regarding coming
onto the welfare rolls, individuals with impairments maybe less likely to
apply for and receive welfare as welfare agencies implement more stringent
up- front job search requirements or take additional steps to move eligible
individuals onto the SSI rolls. Regarding leaving the welfare rolls, while
we know generally that a majority of former welfare recipients are employed
at some point after leaving welfare, others have left the rolls without
employment, in some cases due to state sanction policies that end welfare
receipt for those who do not meet program or work requirements. 19 Our
previous work showed that

18 Urban Institute data are reported in terms of very poor mental health,
which increased from 22 to 28 percent between 1997 and 1999. The Urban
Institute assesses mental health along four dimensions- anxiety, depression,
loss of emotional control, and psychological well- being- using a five-
point scale to measure the severity of mental health problems. Very poor
mental health indicates those falling in the bottom 10th percentile.

19 For more information on former welfare recipients, see Welfare Reform:
Information on Former Recipients? Status (GAO/ HEHS- 99- 48, Apr. 28, 1999)
and Welfare Reform: Progress in Meeting Work- Focused TANF Goals (GAO- 01-
522T, Mar. 15, 2001). Percentage of TANF

Recipients That Report Impairments Has Not Differed From 1994 to 1999

Page 15 GAO- 02- 37 TANF Recipients With Impairments

recipients who received a sanction often had a higher incidence of
conditions such as health problems and depression than other TANF
recipients. 20 In other cases, former welfare recipients with impairments
may leave TANF to begin receiving SSI. More information would be needed to
determine how individuals with impairments, both potential applicants and
former TANF recipients, have fared as TANF caseloads have declined.

Most counties reported they are screening TANF recipients for impairments
that may interfere with their ability to work, primarily through recipients?
self- disclosure, a method that may not ensure that all impairments,
particularly ?hidden? disabilities, are accurately identified. 21 In
addition, about half of the counties did not know the number of TANF
recipients they had with impairments, with nearly all of these counties
saying they did not have the information. Lack of such data may hinder
counties? abilities to identify and meet the service needs of their TANF
recipients. When serving recipients identified with impairments, counties
often partnered with other federal, state, or local agencies to provide
treatment or employment services. It appears, however, that many TANF
recipients with impairments are not receiving services to move them toward
employment, in part because they are exempted from the work requirements.
Regarding policies for imposing financial sanctions on TANF recipients who
do not comply with program requirements, many counties reported making only
one attempt to notify recipients that they are noncompliant. This could make
recipients with impairments who have trouble complying with program
requirements or understanding sanction notices inappropriately vulnerable to
a sanction. Some selected TANF offices we visited have implemented
strategies targeted at helping recipients with impairments find employment,
but most of these strategies are too new to evaluate.

20 For more information on state sanction policies, see Welfare Reform:
State Sanction Policies and Number of Families Affected (GAO/ HEHS- 00- 44,
Mar. 31, 2000) 21 Hidden disabilities may include learning disabilities;
mental health disorders, such as undiagnosed depression; or physical
impairments, such as hearing problems. Counties Are

Screening TANF Recipients for Impairments, but Recipients May Not Be
Receiving Services to Move Them Toward Employment

Page 16 GAO- 02- 37 TANF Recipients With Impairments

Almost all the counties reported that they screen and assess TANF recipients
for impairments, but many use methods that may not accurately identify all
impairments. 22 In some cases, this may not be a problem because recipients
find and keep jobs, while in other cases, recipients may not be able to
participate in a county?s regular TANF program activities, find a job, or
sustain employment without special assistance. TANF agencies may screen and
assess recipients for impairments for a number of reasons, including
identifying individuals who might be eligible for longterm support under the
SSI or DI programs; should be exempt from work requirements or time limits;
or need treatment or special services, such as job accommodations, to help
them engage more effectively in work or training.

In addition, the extent to which welfare agencies rely on screening and
assessment of impairments and other potential barriers to assess an
individual?s ability to work varies. In our earlier report on hard- to-
employ TANF recipients, we found that some of the states and localities we
visited relied primarily on the job market to identify recipients who have
barriers to employment, such as physical or mental impairments, although
even in these cases an initial minimal screening may be conducted. 23
According to officials in these states, this approach precludes the welfare
agency from prejudging or labeling recipients as hard- to- employ when they
may be able to obtain jobs. At the same time, this approach sends a clear
message that TANF is temporary and that employment is the immediate goal.
Other states and localities we visited for that report relied more heavily
on screening and assessment, believing that by identifying obstacles to
employment early, agencies could more appropriately focus resources and time
on activities and services that hard- to- employ TANF recipients need to
become employed. No one approach has been proven more effective than another
for moving hard- to- employ recipients into jobs.

In our nationwide survey of county TANF agencies, we found that almost all
counties reported that they screen recipients for physical and mental

22 The terms screening and assessment are often loosely applied and can have
different meanings in various treatment and service communities. We defined
screening as ?any

means of gaining information about an individual that can be used to detect
warning signs that suggest that some form of impairment might exist.? If
there is an indication that an impairment may exist, the next step is to
perform an assessment. We defined assessment as

?a comprehensive examination of an individual that is used to identify the
specific impairment( s) he or she has.?

23 See GAO- 01- 368, Mar. 15, 2001. Screening and Assessment

Procedures Are Widely Used, but May Not Identify All Impairments

Page 17 GAO- 02- 37 TANF Recipients With Impairments

health impairments, and three- fourths screen for learning disabilities that
could interfere with recipients? ability to work. Figure 3 shows the methods
that counties reported they relied on to screen recipients.

Figure 3: Methods Counties Use to Screen Recipients

Source: GAO survey of county TANF agencies.

The primary screening method counties used is recipient self- disclosure.
TANF caseworkers ask recipients questions or use intake forms to identify
characteristics that may interfere with a recipient?s ability or the program
requirement to work. Questions on intake forms might ask recipients, ?Do

you currently have any physical or mental conditions?? or ?Has your doctor
placed any limits on your activities?? Relying on this method may not
uncover all impairments- for example, hidden disabilities that may be
unknown to recipients but could still interfere with their ability to work.
Furthermore, sometimes recipients are reluctant to identify impairments
because they are uncertain about potential consequences or do not feel
comfortable in doing so. The willingness of recipients to share information
about impairments can largely depend on the TANF staff?s ability to
establish rapport with recipients. If recipients do not feel comfortable
with TANF staff, they may be reluctant to share information.

Of the 12 percent of counties that rely on a screening exam as their primary
method, most use a screening tool or instrument, which is a more formal,
standardized approach to screening recipients. Some tools are

Recipients? Self- Disclosure 77%

11% 12%

Caseworkers? Observations Screening

Exam

Page 18 GAO- 02- 37 TANF Recipients With Impairments

designed to screen for multiple barriers, including impairments, while
others are designed to screen for a single barrier, such as mental health
problems or learning disabilities. If these tools are improperly
administered, they may not be a reliable predictor of a recipient?s
impairment. For example, some tools must be administered by staff with
specialized training to produce reliable results, while others can be
administered by caseworkers with little or no training. 24 Furthermore, many
tools are validated only for specific populations and may not produce
reliable and valid results for TANF recipients. A study the Urban Institute
conducted for HHS identified a number of tools that TANF agencies use to
screen recipients, but reported that little is known about their ability to
accurately identify barriers or impairments among TANF recipients. 25
Furthermore, it found that few studies or evaluations had been conducted to
assess these tools? effectiveness.

About 11 percent of counties rely on caseworkers? observations to identify

?red flags? (verbal or behavioral cues) that may indicate an impairment. For
example, a caseworker could observe a recipient while he or she is filling
out an application or might observe symptoms of mental illness, such as
anxiety, depression, and behavioral problems. Experts reported that
caseworkers? observations could be a useful part of the screening process
when used in conjunction with other screening methods, especially when
caseworkers are trained to be alert to red flags. However, many caseworkers
are former AFDC eligibility workers who may not have been trained in how to
identify red flags. According to one TANF official we interviewed, learning
disabilities and mental impairments are harder to

24 Kansas Department of Social and Rehabilitation Services contracted with
the University of Kansas to develop a tool to screen recipients for learning
disabilities. Caseworkers with minimal training can administer this tool,
which has an 89- percent reliability rate. Reliability is the consistency of
a person?s score across two points in time. In other words, if a recipient
is screened twice, there is an 89- percent chance that the outcome will be
the same the second time.

25 Terri S. Thompson and Kelly S. Mikelson, Screening and Assessment in
TANF/ Welfareto- Work: Ten Important Questions TANF Agencies and Their
Partners Should Consider.

Report prepared by The Urban Institute for U. S. Department of Health and
Human Services, Office of the Assistant Secretary for Planning and
Evaluation, and Administration for Children and Families (Washington, D. C.:
Mar. 2001).

Page 19 GAO- 02- 37 TANF Recipients With Impairments

identify than physical impairments because of all the subtleties involved in
identifying them. 26

Of the counties that conduct screening, over 90 percent do an initial one at
the intake/ eligibility determination phase, but many counties also screen
recipients during the employment planning process if it appears the
recipient is having problems. Figure 4 shows at which points counties
reported screening recipients.

Figure 4: Points During the Employment Process When Counties May Screen
Recipients By Any Method

Source: GAO survey of county TANF agencies.

If screening suggests an impairment, 76 percent of counties reported that
they assess recipients to determine if they have an impairment. Almost half
of these counties reported that caseworkers perform the largest proportion
of these assessments. (See fig. 5.)

26 For more information on screening for mental impairments see Michelle K.
Derr, Sarah Douglas, and LaDonna Pavetti, Providing Mental Health Services
to TANF Recipients: Program Design Choices and Implementation Challenges in
Four States. Report prepared by Mathematica Policy Research for U. S.
Department of Health and Human Services, Office of the Assistant Secretary
for Planning and Evaluation (Washington, D. C.: Aug. 2001).

0 10

20 30

40 50

60 70

80 90

100

Percentage

Intake/ Initial Eligibility

Employment Planning

Process After Recipient

Has Been Unable to Find Job

After Recipient Has Lost Job

When Recipient Is About to Be

Sanctioned Other

Possible Screening Points 91

77 45

39 44 16

Page 20 GAO- 02- 37 TANF Recipients With Impairments

Figure 5: Staff Who Conducted Assessments

Note: Total may not sum to 100 owing to rounding. Source: GAO survey of
county TANF agencies.

According to some experts, the role of the TANF agency in screening and
assessment should be to identify recipients who might have an impairment and
then refer them to professionals who have the expertise to conduct
assessments. Generally, because some caseworkers are former AFDC eligibility
workers, they may lack the training and expertise to conduct assessments,
which may result in the recipient?s not having his or her impairment
properly identified and evaluated. For example, at the TANF agency we
visited in Davidson County, Tennessee, if caseworkers suspect that a
recipient has a mental health problem or learning disability, they refer the
recipient to a family services counselor, who is a certified social worker
and counselor. The counselor conducts a preliminary assessment and then
refers a recipient with severe symptoms to a psychologist for a
comprehensive assessment and diagnosis.

Almost all counties that conduct assessments reported that they would try to
determine whether a recipient?s impairment affects the recipient?s ability
to work. That determination could be made in various ways, such as using a
physician?s documentation, self- disclosed information, an

Certified Social Worker TANF Caseworker

or Manager, Not a Social Worker

State Vocational Rehabilitation Worker Medical Professional

Other

6% 4% 10% 32%

47%

Page 21 GAO- 02- 37 TANF Recipients With Impairments

assessment of a recipient?s ability to work, and employment history.
Possible outcomes of that review include referrals to vocational
rehabilitation, treatment providers, or SSA for SSI eligibility
determination or development of an individualized plan to move the recipient
toward employment.

About half of all the counties did not provide data on the number of
recipients with impairments that interfere with their ability to work, and
nearly all of these counties reported they did not have these data. Lack of
information on the service needs of TANF recipients, particularly those
nearing a state?s time limit on aid, could hinder an agency?s ability to
provide sufficient services for recipients. In a previous study, only two of
the nine states we reviewed could provide us with statewide data on such
characteristics as recipients with learning disabilities, mental or
psychological conditions, physical impairments, and poor health. 27 Some of
the reasons we cited in that report were the lack of any requirement to
collect such data, the difficulties of identifying such barriers, the lack
of standardized screening and assessment tools, and inadequate computer
systems.

Historically, the AFDC program exempted recipients with impairments from
participation requirements, and many counties reported they continue to
exempt from state work requirements TANF recipients who have impairments,
are caring for a child with an impairment, or are awaiting SSI eligibility
determination because of their impairment. 28

 About 63 percent of counties exempted TANF recipients with impairments
from the work requirements. 29

 About 27 percent of counties exempted TANF recipients with impairments
from the work requirements, but not the state time limit.

 About one- third of counties exempted those caring for a child with an
impairment from the work requirements and the time limit, but an additional
28 percent of counties exempted caregivers from only the work requirements
and not the state time limit.

27 GAO- 01- 368, Mar. 15, 2001. 28 In collecting information from counties,
we asked respondents about what they did regarding exemptions rather than
their exemption policy. 29 These counties include those who exempt
recipients from the work requirements but not the time limits. Half of All
Counties Could

Not Provide Data on Number of TANF Recipients With Impairments

Use of Work Requirement Exemptions for TANF Recipients With Impairments May
Mean They Do Not Receive Assistance That Could Help Them Move Toward
Employment

Page 22 GAO- 02- 37 TANF Recipients With Impairments

 Over half of counties exempted TANF recipients from the work requirements
who were referred to SSA for disability eligibility determination. 30

Counties? apparent reliance on work requirement exemptions for recipients
with impairments raises the issue of whether many such recipients are being
prepared for eventual employment. Some or all of those exempted from work
requirements may move onto the SSI rolls, be included among the 20- percent
exemption from federal time limits, or have only temporary physical or
mental impairments interfering with employment, which may improve over time.
The detailed data needed to make such assessments were not available.
However, it is also possible that many counties have not yet put in place
policies, procedures, and services for addressing the needs of TANF
recipients with physical and mental impairments who may need more or
different types of assistance than others. In those programs where TANF
recipients with impairments are exempted from work requirements, they may
not be getting the help, direction, or encouragement they need to take steps
toward employment. Under these circumstances, recipients with impairments
may not be receiving proper access to TANF services as required by the ADA.
31 When asked what percentage of TANF recipients were receiving services to
move them toward employment, one- third of responding counties who supplied
data reported that, on average, 43 percent of their recipients with
impairments were being served. However, counties that did not exempt
recipients with impairments reported that, on average, 61 percent of their
recipients with impairments were receiving services, almost twice the 34-
percent average in counties that did exempt recipients. 32 Our previous work
and other studies show that some states and localities have moved more
aggressively than others to enforce a work or work- activity requirement for
a larger share of their TANF caseload than others and that

30 In 2000, it took an average of 120 days from the date of SSI application
to receive an initial disability determination. For claims that are denied
and appealed, it may take over a year to reach a final determination. While
awaiting SSI determination, less than one- third of counties suspend
employment services to recipients.

31 HHS Office of Civil Rights guidance states that ?for some public
entities, TANF policies relating to individuals with disabilities consist
only of exemptions from TANF requirements. This practice however, denies
individuals with disabilities access to TANF services and results in
discriminatory exclusion of many individuals with disabilities from the
program.?

32 The number of offices in the 100 counties with the largest populations
reporting the information needed for this analysis was too small to be
included.

Page 23 GAO- 02- 37 TANF Recipients With Impairments

these programs generally have adjusted their program approaches to help
recipients address potential barriers to employment. 33

Work requirement exemption policies could be an issue, particularly with the
more than one- quarter of counties who exempt TANF recipients from the work
requirements but not the state?s time limit. These recipients may be at risk
of reaching their time limit without employment or having received services
to move toward employment, unless they are included in their state?s 20-
percent hardship exemption or the state provides assistance with state
funds. Although there are indications that the 20percent exemption may be
sufficient, it is too early to know how many recipients might be excluded
since many states have not yet defined the criteria for their exemption.

Some TANF officials we interviewed said that their states plan to include
recipients with impairments who are unable to work or who care for a child
with an impairment. About 80 percent of county TANF officials estimated that
fewer than 20 percent of their TANF recipients had impairments that would
make work so difficult that they should be exempt from the federal time
limit. Many of them, however, did not provide us with data on the number of
recipients with impairments that would support their estimates. Recipients
with impairments are only one of many groups that states could include in
their 20- percent exemption. For example, Kansas plans to include recipients
who care for disabled household members, recipients over age 60, victims of
domestic violence or sexual assault, and recipients who are complying with
program rules but remain unemployed or underemployed. It determined that its
exemption would be sufficient to include all recipients who meet these
criteria until 2006. Many states also plan to continue aid beyond the
federal 5- year time limit with state funds. For example, according to TANF
state plans, nine states containing 44 percent of the total 1999 national
caseload intend to provide benefits for all families that reach the time
limit, though often in reduced amounts or noncash form.

33 The welfare reform law also allows each state to reduce its annual
mandated participation rate by an amount equal to the percentage that the
state?s welfare caseload has declined since fiscal year 1995. As a result,
in fiscal year 1999, 23 states had a 0 percent work participation rate. If
the caseload reduction slows or reverses, states may be far less able to
exempt TANF recipients from work participation.

Page 24 GAO- 02- 37 TANF Recipients With Impairments

Most counties that provide treatment and employment services to TANF
recipients with impairments have established linkages with contractors and
other local service providers to provide at least some of these services.
TANF agencies can provide services modified for recipients with impairments
directly or through a contractor, or they can partner with non- TANF
government agencies and other community organizations. These services could
include employment services, such as job readiness training, job training,
education, job search, and community work experience programs, or they could
include referrals to treatment programs for physical impairments, mental
health conditions, or learning disabilities. Figure 6 shows the primary
agency or program with whom TANF agencies partnered to provide modified
services to their recipients with impairments.

Figure 6: Primary Agency or Program With Which TANF Agencies Partnered to
Provide Services

Source: GAO survey of county TANF agencies.

TANF Partners With Multiple Service Agencies When Serving Recipients With
Impairments

Other State or Local

Mental Health Agency Department of LaborFunded Programs State Vocational

Rehabilitation Agency

6% 4% 5% 8%

TANF Agency or Contractor

Department of EducationFunded Programs

36% 41%

Page 25 GAO- 02- 37 TANF Recipients With Impairments

About 60 percent of counties reported they make at least two attempts to
notify recipients that they are noncompliant with TANF requirements, while
about 40 percent reported they make only one attempt. 34 Written
notification is the primary method counties use to inform recipients the
first time they are about to receive a financial sanction. About 60 percent
of counties would make a repeated attempt to contact recipients. In their
second attempt to contact recipients, many counties would also use more
personal methods: 24 percent reported they would schedule an in- person
meeting, and 15 percent would make a home visit. Regardless of the method
used, almost three- quarters of counties with time limits less than the
federal 5- year time limit reported they would assess recipients for
possible impairments if these recipients were nearing the state?s time
limit. About two- thirds of all counties reported they would assess
recipients who failed to comply with the work requirements to determine
whether that recipient had an impairment that could interfere with his or
her ability to work.

In our previous work, we found that recipients who received either a full or
partial sanction often had a higher incidence of conditions such as health
problems and depression than other TANF recipients, and these
characteristics may make it more difficult for them to understand and comply
with program requirements. 35 We reported that states? policies for
notifying recipients varied, but those with a more active conciliation
process often reduced the number of families under sanction and increased
compliance for those families involved in conciliation. 36 For example, many
states require that a written warning notice be sent to recipients, who are
expected to contact the caseworker to resolve their

34 Although federal law requires states to impose a financial sanction on
families who refuse to participate, states generally specify the sanctioning
policies, and many are more stringent than the federal law. States can
decide how and when to inform recipients of sanction policies and sanction
decisions. A sanction can be a full or partial sanction- that is, recipients
can lose all or part of their cash benefits.

35 Welfare Reform: State Sanction Policies and Number of Families Affected

(GAO/ HEHS- 00- 44, Mar. 31, 2000). 36 Conciliation is the process
recipients and agencies use to resolve recipients? noncompliance with TANF
requirements. A Majority of Counties, but

Not All, Take Steps to Ensure That TANF Recipients Do Not Inappropriately
Receive a Sanction

Page 26 GAO- 02- 37 TANF Recipients With Impairments

noncompliance issues within specified time frames. 37 If they fail to do so,
they may lose their opportunity to resolve the noncompliance issues before
they lose all or part of their benefits. Because 40 percent of the counties
in our survey reported making only one attempt to notify recipients before
imposing a sanction, a significant number of recipients with impairments
could be at risk of losing TANF benefits if their impairment hinders their
ability to comply with requirements.

TANF experts identified the four counties we visited as having promising
strategies to move TANF recipients with impairments toward employment. 38
These strategies ranged from developing standardized tools for screening
recipients to establishing multidisciplinary teams to identify needed
services. It is important to note that because these strategies are
relatively new, they have not been evaluated, and little or no data are
available on their long- term impact. Furthermore, some of them have served
only a small number of recipients.

The counties we visited developed various strategies to address the
predicament of recipients who were approaching state or federal time limits
without having found employment. Although their strategies varied widely, a
common element was the counties? realization that these recipients usually
require more intensive case management than other TANF recipients to move
toward employment and an acknowledgment that a ?one- size- fits- all?
approach did not work; thus, their programs and services had to be tailored
to each recipient. All these strategies focused additional efforts on
identifying and serving recipients with impairments.

The four counties we visited differed in how they screened and served
recipients. Two counties conducted limited up- front screening and relied
upon the job market to determine whether the recipient had impairments to
employment, whereas the other two counties conducted more in- depth

37 For more information on states? sanctioning policies, see reports issued
by the HHS Inspector General: Temporary Assistance for Needy Families:
Improving the Effectiveness and Efficiency of Client Sanctions, OEI- 09- 98-
00290 (July 1999); Temporary Assistance to Needy Families: Educating Clients
About Sanctions, OEI- 09- 98- 00291 (Oct. 1999); and Temporary Assistance to
Needy Families: Improving Client Sanction Notices,

OEI- 09- 98- 00292 (Oct. 1999,). 38 Because welfare responsibility has been
devolved, in some cases counties are following their own policies for
screening, assessing, and providing services to TANF recipients with
impairments while in others, they are implementing statewide policies. Some
TANF Offices Have

Implemented Promising Strategies to Address Needs of Recipients With
Impairments, but Programs Are Too New to Evaluate

Page 27 GAO- 02- 37 TANF Recipients With Impairments

screening. The counties also varied as to their reliance on a particular
type of service provider. Sedgwick County, Kansas, and Davidson County,
Tennessee, relied predominantly on nongovernment and community service
providers to conduct assessments and provide services. Cumberland County,
North Carolina, relied on a combination of government agencies, such as
vocational rehabilitation, and nongovernment service providers. Leon County,
Florida, was the only site that required the TANF agency to participate in
its on- site center- referred to as a ?one- stop?- that consolidated a
variety of services, including adult education, employment services, and
counseling services. 39

Two of the sites we visited incorporated employment services as part of
their strategies, and they continue to provide supportive TANF services
after recipients are placed. 40 For example, Leon County developed a program
that provided one- to- one tutoring and employment services, including job
placement and follow- up, to recipients with dyslexia. Sedgwick County
refers recipients with impairments to a contractor for vocational
assessment. If recipients qualify, they can be accepted into a computer or
industrial training program, which also includes job placement and follow-
up services. Recipients with severe or persistent mental health impairments
could also be included in a 6- month training program at a manufacturing
facility. 41 Table 3 summarizes the key features of these strategies.

39 The Workforce Investment Act of 1998 sought to unify the employment and
training system. The act focused mostly on integrating and streamlining
services, requiring most employment and training services to be provided
through a single system, called the OneStop Center System. TANF is not
required to be part of the One- Stop Center System, but localities may
require its participation.

40 For more information on work programs, see Welfare Reform: Work- Site-
Based Activities Can Play an Important Role in TANF Programs (GAO/ HEHS- 00-
122, July 28, 2000) and LaDonna Pavetti, et al., Work- Based Strategies for
Hard- to- Employ TANF Recipients: A Preliminary Assessment of Program Models
and Dimensions, Final Report (Washington, D. C.: Mathematica Policy
Research, May 15, 2001).

41 The manufacturing facility is a nonprofit company, considered a ?social
business enterprise,? and employees receive competitive wages and benefits.
Although 75 percent of its production staff have impairments, the company is
marketed as a regular manufacturing company and competes with commercial
manufacturers. Employees are referred by several sources besides the TANF
agency.

Page 28 GAO- 02- 37 TANF Recipients With Impairments

Table 3: Key Features of Strategies at Sites Visited Site and date
implemented Target population Key feature

Cumberland County, NC; Spring 1999 (statewide)

Recipients who are nearing state or federal time limit Caseworkers offer a
voluntary standardized mental health screening

tool to recipients that was developed for TANF population. As part of the
state?s Success Initiative, the county established a multidisciplinary team
of a social worker, employment service providers, community organizations,
vocational rehabilitation representatives, SSA officials, etc., to identify
what services a recipient needs.

The agency collaborated with the vocational rehabilitation agency, which
accepts all TANF recipients with impairments.

TANF agency acts as a coordinator by bringing together services. Davidson
County, TN; January 2000 (statewide)

Recipients who have not made progress toward retaining employment

All recipients who have a possible or confirmed barrier to employment are
referred to an on- site family services counselor (a certified social
worker) who acts as a ?service hub? for counseling, assessment, referrals,
and intensive case management.

Counselors have access to enhanced services for psychological evaluations
and learning disabilities.

Counselors have small caseloads, and services are confidential. Although
recipients are referred, seeking help from the counselor is voluntary.

Counselors have authority to ?stop the clock? on the state time limit for a
limited period or alter personal responsibility plan as long as they do not
exceed the federal time limit.

State established Customer Service Review units to review the cases of
clients who are noncompliant or are about to have a sanction imposed. Leon
County, FL; March 1999

Recipients with 48 months or more on TANF Dyslexia Research Institute
developed and validated screening and

preassessment tools for TANF caseworkers to use to screen recipients for
dyslexia and learning disabilities.

Recipients with potential learning disabilities are referred to Dyslexia
Research Institute for assessment and services.

Recipients who meet criteria can enroll in the Dyslexia Research Institute
Literacy and Life Skills (DRILLS) program. Services include one- to- one
tutoring, job skills training, and employment placement services and follow-
up.

TANF agency is colocated with agencies providing employment services within
a one- stop center so that employment services are readily available to TANF
recipients.

Page 29 GAO- 02- 37 TANF Recipients With Impairments

Site and date implemented Target population Key feature

Sedgwick County, KS; November 1999 Recipients on TANF longer

than 24 months or who stop progressing through state?s 13- step protocol
designed to move recipient toward employment a

Caseworkers use a validated tool to screen TANF recipients for learning
disabilities.

Selected recipients are referred for assessment and follow- on services to
the Cerebral Palsy Research Foundation (CPRF).

CPRF provides vocational assessment, training, case management, job
placement, and job retention services. It assigns recipients to a ?blue

collar? (manufacturing) or ?white collar? (computer skills, repair, and
maintenance) track. Computer equipment is fully adaptable for recipients
with impairments.

A component of CPRF provides a 6- month training program in a manufacturing
plant for recipients with severe mental impairments. a Kansas did not
require TANF agencies to implement this protocol statewide until May 2001,
but

Sedgwick County started following it in October 2000. Source: GAO
compilation of information from counties visited.

Multiple federal agencies and offices within agencies are involved in the
support of research, technical assistance, and employment services related
to assisting TANF recipients with impairments. However, no focal point or
mechanism currently exists at HHS to ensure that states and localities have
the best information available from the federal level that could enhance
their efforts to help TANF recipients with impairments take steps toward
employment. Within HHS, in addition to ACF?s Office of Family Assistance,
which oversees TANF, ACF?s Administration on Developmental Disabilities and
other offices within HHS, including the Assistant Secretary for Planning and
Evaluation, Office for Civil Rights, and Substance Abuse and Mental Services
Administration all have one or more roles to play in the support of
identifying and serving TANF recipients with impairments. In addition,
Labor?s Office of Disability Employment Policy and the Employment and
Training Administration and Education?s Office of Special Education and
Rehabilitative Services and Office of Vocational and Adult Education also
provide research, services, and technical assistance that could aid TANF
recipients with impairments move toward employment.

In many instances these departments and agencies have taken steps to assist
TANF program administrators in meeting the needs of TANF recipients with
impairments. Table 4 shows some of the key initiatives taken by these
agencies and offices to assist states and localities in assessing and
providing services to TANF recipients. In some cases, these agencies have
collaborated to provide outreach services and technical assistance services.
For example, ACF has partnered with the Substance Federal Agencies

Provide Assistance to Welfare Programs, but States and Localities Could
Further Benefit If Efforts Were Better Coordinated

Page 30 GAO- 02- 37 TANF Recipients With Impairments

Abuse and Mental Health Services Administration and Labor?s Employment and
Training Administration to hold five conferences for program administrators
on promising practices to move clients with multiple barriers to employment.
ACF has also collaborated with Education and the National Institute for
Literacy to provide technical assistance and training to state and local
TANF agencies on valid screening tools for individuals with learning
disabilities. In addition to these and other initiatives, HHS and Labor have
worked together in relation to the administration and research evaluation of
the Welfare- toWork grants, which were geared to the hardest to employ of
TANF recipients.

Table 4: Key Initiatives to Assist States and Localities Serve TANF
Recipients With Impairments Agency Key initiative

Health and Human Services Funded publication of a guide to TANF program
administrators on identifying and addressing mental health problems among
TANF recipients. a

Contracted for a study of existing screening and assessment tools. Funded
publication of a guide on screening and assessing TANF recipients for
employment. b Issued a guide to states and localities on the use of federal
TANF and state maintenance- of- effort funds to address the needs of TANF
recipients. c

Disseminated guidance on steps TANF agencies should take to comply with the
ADA and the Rehabilitation Act. d

Sponsored national and regional conferences to disseminate research and
share promising practices. Labor Drafted a guidebook that includes ways to
identify disabilities common to TANF recipients.

Awarded 191 competitive Welfare- to- Work grants to fund initiatives
focusing on transitioning long- term welfare recipients into jobs, including
those with learning disabilities.

Issued a series of ?Ideas That Work? articles, which discuss different
approaches for delivery of services to people who face multiple challenges,
such as mental illness and physical disabilities. Education Worked with
Washington State to develop a learning disability screening tool.

Jointly funded with HHS and Labor a demonstration project in four states
focusing on learning disabilities among TANF recipients.

a Addressing Mental Health Problems Among TANF Recipients: A Guide for
Program Administrators.

Report prepared by Mathematica Policy Research for HHS Administration for
Children and Families (Washington D. C.: Aug. 2000). b Screening and
Assessment in TANF/ Welfare- to- Work: Ten Important Questions TANF Agencies
and Their Partners Should Consider. Report prepared by the Urban Institute
for HHS Office of the Assistant Secretary for Planning and Evaluation
(Washington, D. C.: Mar. 2001). c Helping Families Achieve Self-
Sufficiency: A Guide on Funding Services for Children and Families

Through the TANF Program, HHS (undated).

Page 31 GAO- 02- 37 TANF Recipients With Impairments

d Summary of Policy Guidance: Prohibition Against Discrimination on the
Basis of Disability in the Administration of TANF, HHS, (Jan. 19, 2001).
Source: GAO compilation of information from agencies.

While individual federal agencies were working on ways to assist states and
counties move TANF recipients with impairments to employment, the
Presidential Task Force on Employment of Adults with Disabilities was
created in March 1998 to develop a coordinated national policy focused on
bringing all adults with disabilities into gainful employment. The task
force brought great visibility to the disability issue, and it has issued
the first three of four required reports to the President. The first two
reports contained a total of 19 high- level recommendations to the
President, all of which have either been initiated or completed. The task
force?s fourth and final report is due July 2002, at which time the
authority for the task force expires. 42

In addition to the task force reports and presidential recommendations, the
task force has produced other benefits as well. The executive order creating
the task force also established a working group on PRWORA. Recognizing the
value of taking a cross- cutting, coordinated approach to this issue, the
working group was composed of representatives from HHS, Labor, Education,
Transportation, Justice, and the National Council on Disability (NCD). 43
The working group submitted a report with recommendations to the
presidential task force in November 1998. The report contained specific
recommendations on such issues as screening and assessment and civil rights
protections; however, they were considered to be the views of the working
group members and did not carry the weight of the task force. Despite
lacking the endorsement of the task force, this coordinated effort to
address TANF recipients with impairments produced some results. For example,
HHS funded the publication of guides on screening TANF recipients for mental
illness and substance abuse and on the prohibition against discrimination on
the basis of disability in the administration of TANF.

42 While authority for the task force is set to expire, the President
announced in February 2001 a ?New Freedom Initiative? designed to more fully
integrate persons with disabilities into the workforce. Among the
initiatives are plans to create a national commission to serve as a
coordinating body for federal agencies that address mental health problems.
The new commission is to study and make recommendations to improve mental
health service delivery and availability.

43 NCD is an independent federal agency that prepares and submits to the
President and Congress progress reports that include recommendations on
national disability policy.

Page 32 GAO- 02- 37 TANF Recipients With Impairments

HHS has recognized the value of external coordination with other federal
agencies and the public and private sector in its strategic plan for fiscal
year 2001- 2006, and ACF?s fiscal year 2002 Government Performance and
Results Act (GPRA) annual performance plan. 44 The strategic plan discusses
the diversity of HHS programs and the variety of ways they can be
coordinated. For example, coordinating mechanisms can be imbedded in service
delivery partnerships, or they can be formal mechanisms, such as
coordinating councils. They can also be ad hoc mechanisms, such as meetings
or workgroups. The ACF?s fiscal year 2002 annual performance plan echoes the
need for both internal and external coordination to administer programs
effectively; however, no specific strategies, goals, or performance measures
were identified to encourage or track linkages among involved agencies.

Despite the recognition of the need for such coordination, officials from
HHS, Labor, and Education told us there is no central focal point to ensure
that research and technical assistance conducted by federal agencies is
coordinated and disseminated to the states and counties directly providing
services to TANF recipients. In addition, some state officials told us that
information or guidance that is jointly issued by ACF- the lead TANF agency-
and other key players is very helpful in encouraging better understanding of
and collaboration among federal programs and services available in the
states to help TANF recipients become employed. For example, ACF and the
Department of Education jointly issued a letter to TANF agencies that
provided information and contacts on vocational rehabilitation agencies in
the states. Our nationwide survey of counties showed that counties often
relied on other agencies to assist TANF recipients with impairments. Other
studies have noted that TANF agencies working with recipients with
impairments often need to build new relationships with programs and service
providers with whom they have not traditionally worked.

Getting information directly to the county level- where many program
decisions are made and services are actually provided- is also important.
Officials in three of the four counties we visited believed that coordinated
assistance from federal agencies was needed. For example, they asked for
technical assistance on the proper use of screening and assessment tools,
guidance on what local offices should be doing to serve TANF recipients with
impairments, and more examples of best practices that could be

44 Strategic Plan FY 2001- 2006, HHS (Sept. 2000).

Page 33 GAO- 02- 37 TANF Recipients With Impairments

replicated locally. They said that current federal technical assistance
efforts, including conferences, are more often available to state- level
officials than the local county TANF officials who are directly serving TANF
recipients.

The National Council on Disability has also noted a lack of systematic
collaboration among federal, state, and local entities on a national scale.
45 The Council believes that these entities need to place greater emphasis
on removing barriers, making linkages, and combining their resources to
better ensure positive employment outcomes for TANF recipients with
impairments.

Welfare reform has led to major changes in state welfare policies and
programs, with greatly increased emphasis on requiring and encouraging most
adult recipients to move toward employment. This represents a significant
departure from previous welfare policy, under which welfare agencies
typically did not expect many recipients, particularly those with physical
or mental impairments, to seek or prepare for employment. While in the years
since welfare reform, states and localities have implemented Work- First
approaches, they are only now beginning to understand how well these more
employment- focused programs are meeting the needs of all TANF recipients,
including those with impairments. As TANF agencies take steps to address the
needs of TANF recipients with physical or mental impairments, much remains
unknown about how well the new welfare system is performing in supporting
this population?s needs and in reducing their dependence on government aid.
About half the counties did not provide data on the number of TANF
recipients with impairments. This suggests that they may not know whether
sufficient service capacity exists to move these recipients toward
employment. In addition, little is known about how best to identify
impairments that may affect TANF recipients? ability to work and what
approaches are effective for helping those with impairments- both long- term
recipients reaching their time limits and new recipients- find and maintain
jobs. Ultimately, many impaired recipients may reach their time limits
without suitable employment skills because their impairments have not been
properly identified and addressed.

Our findings reinforce the importance of having HHS work more closely with
other federal agencies, states, and counties to meet the needs of hard

45 NCD, National Disability Policy: A Progress Report, (June 14, 2001).
Conclusions

Page 34 GAO- 02- 37 TANF Recipients With Impairments

to- employ recipients, particularly as time limits on federal aid approach.
We recommended in our March 2001 report that HHS do more to encourage and
enable states to estimate the number and characteristics of hard- to- employ
TANF recipients, including some with impairments, and identify recipients
who will reach their 60- month limit on aid before they are able to work.
After we made our recommendation, HHS solicited research applications to
award grants to four or five state agencies and large counties to study how
many individuals who are still on TANF are hard to employ or more
disadvantaged, how many are at risk of reaching their time limits, and what
services they need to make the transition to finding and maintaining work.
It is important that research such as this conducted by HHS and other
federal agencies be coordinated to ensure that relevant information is
collected and disseminated nationwide, especially to the welfare agencies
providing services to TANF recipients. As welfare reform evolves, the role
of HHS, in coordination with other key federal players, in supporting and
encouraging research and providing information and technical assistance to
states and county TANF agencies is essential to help them better identify
and move recipients with impairments toward employment. It will also ensure
that states and localities across the nation can learn from each other. Such
efforts should continue as TANF is reauthorized, and HHS, as the lead TANF
agency, should be the focal point for the coordination and dissemination of
information to agencies involved in helping TANF recipients with impairments
toward employment.

As states and localities move forward to determine how best to serve TANF
recipients with impairments, we recommend that HHS, as the lead TANF agency,
serve as the focal point for coordinating and disseminating the research and
technical assistance of federal agencies to ensure that states and counties
have access to the information they need to better identify and move TANF
recipients with impairments toward employment. To help ensure that this
coordination occurs, the Secretary of HHS and the Assistant Secretary for
Children and Families should include strategies, goals, and measures in
ACF?s annual performance plan to ensure that HHS partners with other key
agencies, particularly Labor and Education, to take advantage of federal
resources and knowledge related to helping TANF recipients with impairments
move toward economic independence. Recommendation for

Executive Action

Page 35 GAO- 02- 37 TANF Recipients With Impairments

We provided HHS an opportunity to comment on the report and HHS generally
agreed with our conclusion and recommendation. HHS agreed that greater
coordination at the federal level would likely help states and localities
move TANF recipients with impairments toward employment. It also said that
this conclusion is consistent with the information and feedback they have
been receiving from the states and counties. In addition, as the report
discussed, HHS noted that there is limited federal support for training
opportunities at the local level. It said that it had not been able to
target its conferences or seminars to the very specific implementation needs
of counties, given the great number of localities and its technical
assistance budget. HHS also agreed with our recommendation that it should
coordinate with other key agencies to ensure that research and technical
assistance are disseminated. However, it disagreed that strategies to ensure
such coordination be included in their annual performance plan. HHS stated
that GPRA results should focus on the primary PRWORA goal of engaging
clients in work activities. While we agree that HHS should focus on key
outcomes for the TANF program, we continue to believe that including
coordination strategies, goals, and measures in its annual performance plan
would better ensure that effective coordination activities take place. This
in turn could help states and localities have the research and technical
assistance needed to meet the needs of TANF recipients with impairments. As
HHS stated in its comments, moving welfare recipients with impairments to
work is a relatively new experience for welfare agencies and the very unique
needs of individuals require varied strategies.

HHS? comments appear in appendix I. HHS and two welfare experts also
provided technical comments, which we have incorporated where appropriate.

As agreed with your offices, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days after
its issue date. At that time, we will send copies of this report to the
Secretary of HHS, appropriate congressional committees, and other interested
parties. We will also make copies available to others on request. Agency
Comments

and Our Evaluation

Page 36 GAO- 02- 37 TANF Recipients With Impairments

If you have any questions concerning this report, please contact me or Gale
Harris on (202) 512- 7215. Other staff who made key contributions are listed
in appendix III.

Cynthia M. Fagnoni Managing Director, Education, Workforce,

and Income Security Issues

Appendix I: Scope and Methodology Page 37 GAO- 02- 37 TANF Recipients With
Impairments

To develop estimates of the number of Temporary Assistance for Needy
Families (TANF) recipients with impairments, we analyzed the Census Bureau?s
Survey of Income and Program Participation (SIPP) data for 1994, 1997, and
1999. To determine how county TANF agencies were screening, identifying, and
serving TANF recipients with impairments, we conducted a nationally
representative survey of 600 county TANF administrators from February 13
through June 1, 2001.

SIPP is a national household survey conducted by the U. S. Census Bureau in
which panels of individuals representative of the nation, including those
receiving TANF, are interviewed over a period of 2 years or more. At 4-
month intervals, panel participants are asked a set of ?core? questions
involving such subjects as their labor force activity, welfare program
participation, and demographic characteristics. Periodically, the survey
also asks a detailed set of questions on a variety of topics not covered in
the core section. These questions are called ?topical modules? and are
assigned to particular interviewing cycles or in the survey. For our
purposes, we selected panels starting in 1993 and 1996 and sampled TANF and
non- TANF adults between the ages of 18 and 64. Data from the three
disability topical modules we analyzed were from interviews conducted from
October 1994 to January 1995, August 1997 to November 1997, and August 1999
to November 1999. 1

During these interviews, panel members were asked an extensive set of
questions about their physical or mental impairments, including questions on
a range of functional or other activity limitations. To be identified as
having a disability or impairment in SIPP, individuals must meet specific
disability criteria developed by the U. S. Census Bureau. 2 That is, they
must meet any of the following criteria:

1. Had difficulty performing one or more functional activities, including
seeing, hearing, speaking, lifting, and carrying, using stairs, and walking.

1 We reported on individuals? status at points in time; we did not report on
individuals? change in status over time. 2 Census took steps beginning with
the 1996 panel survey to broaden its measurements of disability. For
example, Census added new questions concerning mental or emotional
conditions that seriously interfere with everyday activities. Appendix I:
Scope and Methodology

Census Bureau?s SIPP Data

Appendix I: Scope and Methodology Page 38 GAO- 02- 37 TANF Recipients With
Impairments

2. Had difficulty with one or more activities of daily living, such as
getting around inside the home, getting in or out of a bed or chair,
bathing, dressing, and eating.

3. Had difficulty with one or more instrumental activities of daily living,
including going outside the home, keeping track of money or bills, preparing
meals, doing light housework, and using the telephone.

4. Had one or more specific conditions, including a learning disability,
mental retardation or another developmental disability, Alzheimer?s disease,
or some other type of mental or emotional condition.

5. Had other mental or emotional condition that seriously interfered with
everyday activities, including frequently depressed or anxious, trouble
getting along with others, trouble concentrating, or trouble coping with
day- to- day stress.

6. Had a condition that limited the ability to work, including around the
house.

7. Had a condition that made it difficult to work at a job or business. 8.
Received federal benefits based on inability to work. 9. Used a wheelchair,
a cane, crutches, or a walker. Persons defined as having a severe impairment
are unable to perform or need help to perform one or more of the activities
or conditions in 1, 2, 3, 6, or 7; had a condition in 5, 8, 9; or had
Alzheimer?s disease, mental retardation, or another developmental
impairment.

Because the estimates we reported from the SIPP were based on samples, they
are subject to sampling error, which varied but did not exceed plus or minus
7 percentage points at the 95- percent confidence interval. Therefore, the
chances are 95 out of 100 that the actual percentages being estimated would
fall within no more than plus or minus 7 percentage points of our estimates.

For the most part, TANF services are provided at the county level, so we
selected a random sample of counties for our survey. We derived a nationwide
listing of counties from Estimates of the Population of Counties by Age and
Sex: 1990- 1999 (U. S. Census Bureau) for 1999 and County Survey Sample

Selection and Response

Appendix I: Scope and Methodology Page 39 GAO- 02- 37 TANF Recipients With
Impairments

selected an overall sample of 600 counties. Before selecting this sample, we
stratified the counties into two groups. The first group consisted of the
100 counties in the United States with the largest populations. The second
group consisted of the remaining counties in the United States. We included
all of the 100 counties with the largest populations in the sample to make
sure that areas likely to have large concentrations of TANF recipients were
represented. From the second group, consisting of all the remaining
counties, we selected a random sample of 500 counties.

After selecting the sample of counties, we used the American Public Human
Services Association?s Public Human Services Directory (20002001) to
determine the name and address of the TANF administrator for each county. In
states with regional TANF programs, we asked the regional director to fill
out a questionnaire for each county in the region. One county reported that
it received only tribal TANF funds, which falls outside the scope of our
study. We removed this county from our initial sample, reducing our sample
to 599 counties. We obtained responses from 540 of 599 counties, for an
overall response rate of about 90 percent. The response rate for the stratum
consisting of the 100 counties with the largest populations was 92 percent.
The response rate for our sample of the remaining U. S. counties was 90
percent. For relevant questionnaire items, we compared the responses of the
administrators completing questionnaires in the 100 most populated counties
to those of administrators in the rest of our sample and found that, for the
most part, offices in both types of counties are similar in the ways that
they identify, assess, and provide services to recipients with impairments.

Because the estimates from our survey are based on a sample of counties,
each is subject to sampling error. The sampling errors for percentage
estimates in the report from our survey varied, but did not exceed plus or
minus 6 percentage points. The sampling error for our estimate of the
average percentage of TANF recipients with impairments that were receiving
services to move them toward employment is plus or minus 7 percentage
points. The sampling error for our estimate of the average percentage of
recipients with impairments that were receiving services in counties that do
not offer any exemptions specifically for those recipients is plus or minus
13 percentage points. The sampling error for our estimate of the average
percentage of recipients with impairments that were receiving services in
counties that offer exemptions specifically for those recipients is plus or
minus 8 percentage points. All of the sampling errors were calculated at the
95- percent confidence interval.

Appendix II: Comments From the Department of Health and Human Services Page
40 GAO- 02- 37 TANF Recipients With Impairments

Appendix II: Comments From the Department of Health and Human Services

Appendix II: Comments From the Department of Health and Human Services Page
41 GAO- 02- 37 TANF Recipients With Impairments

Appendix II: Comments From the Department of Health and Human Services Page
42 GAO- 02- 37 TANF Recipients With Impairments

Appendix III: GAO Contacts and Staff Acknowledgments

Page 43 GAO- 02- 37 TANF Recipients With Impairments

Gale C. Harris, (202) 512- 7235 Kevin M. Kumanga, (202) 512- 4962

In addition to those named above, Carolyn S. Blocker, William E. Hutchinson,
Joel I. Grossman, Grant Mallie, and Elsie Picyk made key contributions to
this report. Appendix III: GAO Contacts and Staff

Acknowledgments GAO Contacts Staff Acknowledgments

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Health Issues that Impact TANF Recipients? Ability to Work,? Issue Notes.

Washington, D. C.: Welfare Information Network, Feb. 2001. Kramer, Frederica
D., ?Seeing TANF from the Inside Out- Reconsidering the Program?s Role in
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Kramer, Frederica D., ?Serving Welfare Recipients with Disabilities,? Issue
Notes. Washington, D. C.: Welfare Information Network, Jan. 1999.

Kramer, Frederica D., ?The Hard- to- Place: Understanding the Population and
Strategies to Serve Them,? Issue Notes. Washington, D. C.: Welfare
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Loprest, Pamela, ?How Are Families That Left Welfare Doing? A Comparison of
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Loprest, Pamela, How Families That Left Welfare Are Doing: A National
Picture. Washington, D. C.: The Urban Institute, Aug. 1999.

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Loprest, Pamela J., and Shelia R. Zedlewski, Current and Former Welfare
Recipients: How Do They Differ? Assessing the New Federalism. Washington, D.
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Personal and Family Challenges: Rationale and Program Strategies.

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Zedlewski, Sheila R., Work- Related Activities and Limitations of Current
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Urban Institute, July 1999.

Zedlewski, Sheila R., and Donald W. Alderson, Before and After Reform: How
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Zedlewski, Shelia R. and Pamela J. Loprest, How Well Does TANF Fit the Needs
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Washington, D. C.: The Urban Institute, Dec. 2000.

Related GAO Products Page 50 GAO- 02- 37 TANF Recipients With Impairments

Welfare Reform: Moving Hard- to- Employ Recipients Into the Workforce

(GAO- 01- 368, Mar. 15, 2001).

Welfare Reform: Work- Site- Based Activities Can Play an Important Role in
TANF Programs (GAO/ HEHS- 00- 122, July 28, 2000).

Welfare Reform: Improving State Automated Systems Requires Coordinated
Federal Effort (GAO/ HEHS- 00- 48, Apr. 27, 2000).

Welfare Reform: State Sanction Policies and Number of Families Affected
(GAO/ HEHS- 00- 44, Mar. 31, 2000).

Welfare Reform: Implementing DOT?s Access to Jobs Program in Its First Year
(RCED- 00- 14, Nov. 26, 1999).

Welfare Reform: Assessing the Effectiveness of Various Welfare- to- Work
Approaches (GAO/ HEHS- 99- 179, Sept. 7, 1999).

Welfare Reform: Information on Former Recipients? Status (GAO/ HEHS99- 48,
Apr. 28, 1999).

Welfare Reform: States? Experiences in Providing Employment Assistance to
TANF Clients (GAO/ HEHS- 99- 22, Feb. 26, 1999).

Welfare Reform: Status of Awards and Selected States? Use of Welfare- toWork
Grants (GAO/ HEHS- 99- 40, Feb. 5, 1999).

Welfare Reform: Child Support an Uncertain Income Supplement for Families
Leaving Welfare (GAO/ HEHS- 98- 168, Aug. 3, 1998). Related GAO Products

(116047)

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