    TANF and SSI: Opportunities Exist to Help People with Impairments
    Become More Self-Sufficient (15-SEP-04, GAO-04-878).

    The nation's social welfare system has been transformed into a
    system emphasizing work and personal responsibility, primarily
    through the creation of the Temporary Assistance for Needy
    Families (TANF) block grant. The Supplemental Security Income
    (SSI) program has expanded policies to help recipients improve
    self-sufficiency. Given that SSA data indicate an overlap in the
    populations served by TANF and SSI, and the changes in both
    programs, this report examines (1) the extent that TANF
    recipients with impairments are encouraged to apply for SSI and
    what is known about how SSI caseload growth has been affected by
    such TANF cases, (2) the extent that work requirements are
    imposed on TANF recipients applying for SSI, and the range of
    services provided to such recipients, and (3) the extent that
    interactions exist between the SSI and TANF programs to assist
    individuals capable of working to obtain employment.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-04-878
        ACCNO:   A12411
      TITLE:     TANF and SSI: Opportunities Exist to Help People with
    Impairments Become More Self-Sufficient
         DATE:   09/15/2004
      SUBJECT:   Aid for the disabled
    	     Aid for the elderly
    	     Block grants
    	     Interagency relations
    	     Social security benefits
    	     Surveys
    	     Welfare benefits
    	     Welfare recipients
    	     Workfare
    	     HHS Temporary Assistance for Needy
    	     Families Block Grant

    	     SSA Supplemental Security Income
    	     Program

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    GAO-04-878

    United States Government Accountability Office

     GAO	Report to the Chairman, Subcommittee on Human Resources, Committee on Ways
                          and Means, House of Representatives

    September 2004

    TANF AND SSI

    Opportunities Exist to Help People with Impairments Become More Self-Sufficient

    GAO-04-878

    [IMG]

    September 2004

    TANF AND SSI

    Opportunities Exist to Help People with Impairments Become More Self-Sufficient

      What GAO Found

    In our nationwide survey of county TANF offices, we found that nearly all
    offices reported that they refer recipients with impairments to SSI, but
    the level of encouragement to apply for SSI varies. While almost all of
    the county TANF offices stated that they advise such recipients with
    impairments to apply for SSI, 74 percent also follow up to ensure the
    application process is complete, and 61 percent assist recipients in
    completing the application. Because TANF offices are referring individuals
    with impairments to SSI, these referrals will have some effect on the SSI
    caseload. However, due to data limitations, the magnitude of the effect
    these referrals have on SSI caseload growth is uncertain. While SSA can
    identify whether SSI recipients have income from other sources, it cannot
    easily determine whether this income comes from TANF or some other
    assistance based on need. In addition, past research has not found
    conclusive evidence regarding the impact that TANF referrals have on SSI
    caseload growth.

    Estimates from our survey found that although some TANF offices impose
    work requirements on individuals with impairments, about 86 percent of all
    offices reported that they either sometimes or always exempt adult TANF
    recipients awaiting SSI determinations from the work requirements. One key
    reason for not imposing work requirements on these recipients is the
    existence of state and county TANF policies and practices that allow such
    exemptions. Nevertheless, county TANF offices, for the most part, are
    willing to offer noncash services, such as transportation and job
    training, to adult recipients with impairments who have applied for SSI.
    However, many recipients do not use these services. This low utilization
    may be related to exempting individuals from the work requirement, but it
    may also be due to the recipients' fear of jeopardizing their SSI
    applications. Another reason for the low utilization of services is that
    many services are not necessarily available; budgetary constraints have
    limited the services that some TANF offices are able to offer recipients
    with impairments.

    Many county TANF offices' interactions with SSA include either having a
    contact at SSA to discuss cases or following up with SSA regarding
    applications for SSI. Interactions that help individuals with impairments
    increase their self-sufficiency are even more limited. In all the states
    we visited, we found that such interactions generally existed between TANF
    agencies and other agencies (such as the Departments of Labor or
    Education). In addition, 95 percent of county TANF offices reported that
    their interactions with SSA could be improved. State and county TANF
    officials feel they have to take the lead in developing and maintaining
    the interaction with SSA. One SSA headquarters official stated that SSA
    has no formal policy regarding outreach to TANF offices but would consider
    a partnership provided there is some benefit for SSA. Still, about 27
    percent of county TANF offices reported that they were discouraged in
    their attempts to establish a relationship with SSA because staff at the
    local SSA field office told them that they did not have the time or the
    interest.

    United States Government Accountability Office

    Contents

      Letter

    Results in Brief
    Background
    TANF Recipients with Impairments Are Encouraged to Apply to

    SSI; Impact on SSI Caseload Growth Is Inconclusive

    TANF Offices Differ in Their Exemptions from Work Requirements, but
    Utilization of Noncash Services Is Generally Low

    Some Interaction Between County TANF Offices and SSA Exists,

    but Opportunities Exist for Improvement Conclusions Recommendations Agency
    Comments and Our Response

                                           1

                                          3 5

    10

    13

    16 19 20 21

    Appendix I Scope and Methods

    Appendix II	Comments from the Department of Health and Human Services

    Appendix III Comments from the Social Security Administration

      Appendix IV GAO Contacts and Staff Acknowledgments 31

    GAO Contacts 31 Staff Acknowledgments 31

      Tables

    Table 1: County TANF Office Policies for Referring Adult Cash Recipients
    to SSI 10 Table 2: Information Used by County TANF Offices to Determine
    whether to Refer Adult Recipients to SSI 11 Table 3: Agencies or Programs
    That Support TANF Offices by

    Providing Services to At Least Some Adult TANF Cash

    Recipients Awaiting SSI Eligibility Determinations 19

    Abbreviations

    AFDC Aid to Families with Dependent Children
    ALJ Administrative Law Judge
    DDS Disability Determination Service
    DI Disability Insurance
    HHS Department of Health and Human Services
    PRWORA Personal Responsibility and Work Opportunity

    Reconciliation Act of 1996 SSA Social Security Administration SSI
    Supplemental Security Income TANF Temporary Assistance for Needy Families

    This is a work of the U.S. government and is not subject to copyright
    protection in the United States. It may be reproduced and distributed in
    its entirety without further permission from GAO. However, because this
    work may contain copyrighted images or other material, permission from the
    copyright holder may be necessary if you wish to reproduce this material
    separately.

    United States Government Accountability Office Washington, DC 20548

    September 15, 2004

    The Honorable Wally Herger
    Chairman, Subcommittee on Human Resources
    Committee on Ways and Means
    House of Representatives

    Dear Mr. Chairman:

    Over the past several years, the nation's social welfare system has been
    transformed from a system emphasizing income support to one
    emphasizing work and personal responsibility. Central to this
    transformation was the creation of the Temporary Assistance for Needy
    Families (TANF) block grant in 1996. Administered by the Department of
    Health and Human Services (HHS), TANF provides states with
    $16.5 billion each year. The Social Security Administration's (SSA)
    disability programs, including the Supplemental Security Income (SSI)
    program, have also recently expanded policies and initiated demonstration
    projects aimed at helping recipients enter the workforce and achieve self
    sufficiency. SSI, which serves adults with low income and assets, paid
    about $18.6 billion in benefits in 2002 to about 3.8 million working age
    (18-64) recipients with blindness or other disabilities.1

    SSA's disability determination process can be lengthy, extending over
    2 years when all administrative appeals are included. Concerns exist
    whether TANF recipients with impairments who are applying for SSI
    receive employment-related services while waiting for an eligibility
    determination. The disability management literature has emphasized that
    the longer an individual with an impairment remains out of the workforce
    the less likely the individual is to ever return to work. Providing such
    services in a timely manner also has implications for TANF recipients
    running up against the TANF program's 5-year time limit because in
    2000, nearly 59 percent of all working age applicants for SSI were denied

    2

    benefits.

    1SSI also provides income assistance to children with disabilities and the
    aged who have low income and assets.

    2This includes individuals who may have been denied benefits and abandoned
    their claims before exhausting all appeals.

    While TANF caseloads have decreased since the program's inception, in
    1996, not all recipients leave TANF to go to work. Some recipients with
    impairments severe enough to qualify them for SSI leave TANF once they are
    determined eligible for SSI. SSA administrative data have shown an overlap
    in the populations served by TANF and SSI: Up to 25 percent of the SSI
    caseload age 18 to 64 received income assistance based on need (including
    TANF) prior to becoming eligible for SSI, and this figure has remained
    fairly stable over the past few years.3

    Given the new environment in which both programs have placed increased
    emphasis on encouraging recipients to find employment, and the overlap in
    both populations, this report examines (1) the extent to which TANF
    recipients with impairments are encouraged to apply for SSI and what is
    known about how SSI caseload growth has been affected by such TANF cases;
    (2) the extent to which work requirements are imposed by TANF agencies on
    their recipients who are applying for SSI, and the range of services TANF
    agencies provide to such recipients with impairments; and (3) the extent
    to which interactions exist between the SSI and TANF programs to assist
    individuals capable of working obtain employment.

    To do this work, we conducted a mail survey of a stratified random sample
    of 600 county TANF offices,4 representative of county TANF offices
    nationwide. The survey gathered data on the extent that TANF recipients
    with impairments are encouraged to apply for SSI, whether work
    requirements are imposed and the type of services provided during the
    period of SSI eligibility determination, and the extent that interactions
    exist between the SSI and TANF programs. Our survey achieved an 88 percent
    response rate, and we weighted the results to generalize our findings to
    all county TANF offices nationwide.5 To determine what is known about how
    SSI caseload growth has been affected by TANF referrals for SSI, we
    identified and reviewed reports studying this issue and assessed each
    study's findings. We also visited five states (Arizona,

    3A field in SSA's database does indicate whether an applicant receives
    assistance based on need, but this includes TANF as well as other forms of
    income assistance based on need. While this does not give an accurate
    estimate of the portion of SSI recipients who were TANF recipients, it
    does provide an upper bound.

    4The surveys were mailed to either the director of the county TANF office
    or the regional director, depending on the structure of the TANF program
    in each state. The surveys were completed by the director or his/her
    designee.

    5Sampling errors for estimates presented in this report did not exceed 5
    percentage points. See appendix I for a more detailed discussion of
    sampling errors.

      Results in Brief

    Colorado, Iowa, Oregon, and Vermont) known for providing employmentrelated
    services to TANF recipients with impairments, to gain an understanding of
    the types of interactions that exist between the SSI and TANF programs and
    to assess whether there are opportunities for improving these agencies'
    efforts at assisting their recipients with impairments into employment. In
    each of these states, we interviewed state and county TANF officials, and
    SSA field office staff, as well as SSA headquarters officials. We
    conducted our work between June 2003 and May 2004 in accordance with
    generally accepted government auditing standards. See appendix I for a
    more detailed discussion of our methods.

    Estimates from our nationwide survey of county TANF offices indicated that
    almost all offices reported that they encourage at least some TANF
    recipients with impairments to apply for SSI, but the effect these TANF
    referrals have had on SSI caseload growth is inconclusive. In order to
    better serve individuals with impairments, nearly all TANF offices rely on
    one or more methods to identify impairments. Although nearly all county
    TANF offices reported that they refer recipients with impairments to SSI,
    the level of encouragement that these individuals receive to apply for SSI
    appears to vary. While almost all county TANF offices stated that they
    advise such recipients with impairments to apply for SSI, about 74 percent
    also follow up to ensure the application process is complete, and about 61
    percent assist recipients in completing the application. Because TANF
    offices are referring individuals with impairments to SSI, these referrals
    will have some effect on the SSI caseload. However, due to data
    limitations, the magnitude of the effect these referrals have on SSI
    caseload growth is uncertain. While SSA can identify whether SSI
    applicants have income from other sources, it cannot easily determine
    whether this income comes from TANF or some other assistance based on
    need. Furthermore, SSA does not collect any data indicating whether an
    applicant is referred from another program. In addition, past research has
    not found conclusive evidence regarding the impact that TANF referrals
    have on SSI caseload growth.

    Although some TANF offices impose work requirements on individuals with
    impairments, about 86 percent of all offices reported that they either
    sometimes or always exempt adult TANF recipients with impairments awaiting
    SSI eligibility determinations from the work requirement. One key reason,
    cited by some county TANF officials we interviewed, for not imposing work
    requirements on adult TANF recipients with impairments awaiting SSI is the
    existence of state or county TANF policies and practices that exempt
    recipients from the work requirements.

    Nevertheless, county TANF offices, for the most part, are willing to offer
    noncash services, such as transportation and job training, to adult
    recipients with impairments who have applied for SSI. However, our survey
    and interviews with state and county TANF officials indicate that many
    recipients do not use these services. This low utilization may be related
    to exempting individuals from the work requirement, but there are other
    reasons. Some TANF officials we interviewed in the states we visited said
    that one of the reasons recipients with impairments do not use these
    services is because of the recipient's fear of jeopardizing their SSI
    applications. Another reason for the low utilization of services is that
    many services are not necessarily available. Forty percent of county TANF
    offices noted that one of the reasons adult TANF recipients with
    impairments were not participating in work activities was an insufficient
    number of job training or related services. Some state and county TANF
    officials we interviewed indicated that budgetary constraints have also
    limited the services that they are able to offer recipients with
    impairments.

    Interactions between TANF offices and SSA are limited. Our survey showed
    that some TANF offices have stated an interest in developing a
    relationship with SSA. However, estimates from our survey showed that 53
    percent of counties reported that their interactions included having a
    contact with SSA, and 64 percent reported that their interactions included
    following up with SSA regarding a recipient's application for SSI.
    According to our survey results and interviews with TANF officials in the
    states we visited, interactions that help individuals with impairments
    increase their self-sufficiency are limited. In the states we visited, we
    found that such interactions generally existed between TANF agencies and
    other agencies (such as the Department of Labor or Department of
    Education). Nevertheless, county TANF offices would like to improve their
    interactions with SSA, with 95 percent of county TANF offices reporting
    that their interactions could be improved. For example, about 57 percent
    of counties reported that receipt of training on the SSI application
    process and eligibility requirements is a useful interaction. However,
    only 6 percent of counties reported that they would like to improve
    interactions with SSA specifically related to providing SSA with
    information on employment-related services, such as vocational
    rehabilitation, that recipients received prior to applying for SSI. Some
    state and county TANF officials that we interviewed also said that they
    felt they had to take the lead in developing and maintaining interactions
    with SSA. One SSA headquarters official indicated that SSA has no formal
    policy regarding outreach to TANF offices but would consider such a
    partnership provided there is some benefit for SSA. The official also
    added that they will always respond to TANF training or information
    requests.

    However, about 27 percent of county TANF offices reported that they were
    discouraged in their attempts to establish a relationship with SSA because
    the local SSA field office told them that they did not have the time or
    the interest.

    In order to help individuals with impairments increase self-sufficiency
    and to address the gap in continuous work services between TANF and SSI,
    we are recommending that SSA, as part of a new demonstration project, work
    with TANF agencies to identify those low-income individuals with
    impairments who while potentially eligible for SSI may also have the
    capacity to work, and coordinate services to increase the likelihood that
    such individuals can obtain employment and become more self-sufficient. In
    order to facilitate and encourage a sharing of information among TANF
    offices to increase self-sufficiency of recipients with impairments, we
    are recommending that HHS provide space on its Web site to serve as a
    clearinghouse for information regarding best practices and opportunities
    for TANF agencies to interact with SSA. HHS should be able to minimize its
    work and expense by using its Web site to share this information. Both SSA
    and HHS generally agreed with our recommendations and indicated that they
    look forward to working together to help low-income individuals with
    impairments become more self-sufficient.

    The Personal Responsibility and Work Opportunity Reconciliation Act of
    1996 (PRWORA) replaced the individual entitlement to benefits under the
    61-year-old Aid to Families with Dependent Children (AFDC) program with
    TANF block grants to states and emphasized the transitional nature of
    assistance and the importance of reducing welfare dependence through
    employment. Administered by HHS, TANF provides states with $16.5 billion
    each year,6 and in fiscal 2002, the total TANF caseload consisted of 5
    million recipients. 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. 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. Some states have also adopted "work first" programs,
    in which recipients typically are provided orientation and

    6In addition to federal funds, states must also provide funding for TANF.
    However, states are not required to spend all of their block grant in the
    year the money is received; instead they can accumulate unused funds to be
    used at a later time. Therefore, total TANF expenditures in 2002,
    including federal, state, and accumulated funds, totaled $28.4 billion.

      Background

    assistance in searching for a job; they may also receive some readiness
    training. Only those unable to find a job after several weeks of job
    search are then assessed for placement in other activities, such as
    remedial education or vocational training.

    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.
    For example, TANF established stronger work requirements for those
    receiving cash benefits than existed under AFDC. 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, job search, providing child care for other TANF
    recipients, and (under certain circumstances) education and training. If
    recipients refuse to participate in work activities 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,7 although the law allows
    states to provide assistance beyond 60 months using state funds.8

    The TANF caseload includes, as did AFDC, low-income individuals with
    physical or mental impairments considered severe enough to make them
    eligible for the federal SSI program. Administered by SSA, SSI is a
    meanstested income assistance program that provides essentially permanent
    cash benefits9 for individuals with a medically determinable physical or
    mental impairment that has lasted or is expected to last at least 1 year
    or to result in death and prevents the individual from engaging in
    substantial

    7A state may exempt up to 20 percent of its average monthly caseload for
    hardship or having been subjected to domestic violence.

    8Estimates from our survey show that only 2 percent of counties always,
    and 16 percent sometimes, move TANF recipients with impairments awaiting
    SSI determinations to state only funded cash assistance.

    9While the SSI regulations do not guarantee permanent benefit status, only
    0.4 percent of SSI disability recipients leave SSI because of work, and
    only 6.8 percent are no longer eligible because of medical improvement.
    Excess income or resources can also end a person's SSI benefits.

    gainful activity. 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 gainful work that
    exists in the national economy. Work is generally considered substantial
    and gainful if the individual's earnings exceed a particular level
    established by statute and regulations.10 SSA also administers the
    Disability Insurance program (DI), which uses the same definition of
    disability, but is not means-tested and requires an individual to have a
    sufficient work history.

    For both DI and SSI, SSA uses the Disability Determination Service (DDS)
    offices to make the initial eligibility determinations.11 If the
    individual is not satisfied with this determination, he or she may request
    a reconsideration of the decision with the same DDS.12 Another DDS team
    will review the documentation in the case file, as well as any new
    evidence, and determine whether the individual meets SSA's definition of
    disability. If the individual is not satisfied with the reconsideration,
    he or she may request a hearing before an Administrative Law Judge (ALJ).
    The ALJ conducts a new review and may hear testimony from the individual,
    medical experts, and vocational experts. If the individual is not
    satisfied with the ALJ decision, he or she may request a review by SSA's
    Appeals Council, which is the final administrative appeal within SSA.13
    Despite recent improvements to the process, going through the entire
    process, including all administrative appeals, can average over 2 years.

    In most states, SSI eligibility also entitles individuals to Medicaid
    benefits. TANF recipients may apply for Medicaid benefits and are likely
    to qualify, but receipt of TANF benefits does not automatically qualify a
    recipient for Medicaid.

    10In 2004 the substantial and gainful activities level for nonblind
    individuals is $810 per month, and for blind individuals is $1,350 per
    month, of countable earnings. Both levels are indexed to the average wage
    index.

    11There are 54 primarily state-operated DDS offices; their staff consists
    generally of a variety of positions such as disability examiners, medical
    consultants, vocational specialists, and quality assurance personnel.

    12In September 2003, the Commissioner testified before the House Committee
    on Ways and Means, saying that she intended to revise the disability
    determination process. For example, she proposed eliminating the
    reconsideration and the Appeals Council stages of the current process.

    13If the individual is not satisfied with the Appeals Council action, the
    individual may appeal to a federal district court. The individual can
    continue legal appeals to the U.S. Circuit Court of Appeals and ultimately
    to the Supreme Court of the United States.

    While SSA has recently expanded policies and initiated demonstration
    projects aimed at helping DI and SSI beneficiaries enter or return to the
    workforce and achieve or at least increase self-sufficiency, its
    disability programs remain grounded in an approach that equates impairment
    with inability to work. This approach exists despite medical advances and
    economic and social changes that have redefined the relationship between
    impairment and the ability to work. The disconnect between SSA's program
    design and the current state of science, medicine, technology, and labor
    market conditions, along with similar challenges in other programs, led
    GAO in 2003 to designate modernizing federal disability programs,
    including DI and SSI, as a high-risk area urgently needing

    14

    attention and transformation.

    The Ticket to Work and Work Incentives Improvement Act of 1999 amended the
    Social Security Act to create the Ticket to Work and Self-Sufficiency
    Program (Ticket Program). This program provides most DI and SSI
    beneficiaries with a voucher, or "ticket," which they can use to obtain
    vocational rehabilitation, employment, or other return-to-work services
    from an approved provider of their choice. The program, while voluntary,
    is only available to beneficiaries after the lengthy eligibility
    determination process. Once an individual receives the ticket, he or she
    is free to choose whether or not to use it, as well as when to use it.
    Generally, disability beneficiaries age 18 through 64 are eligible to
    receive tickets. The Ticket Program has been implemented in phases and is
    to be fully implemented in 2004.

    The Social Security Advisory Board15 (Advisory Board) has questioned
    whether Social Security's definition of disability is appropriately
    aligned with national disability policy. The definition of disability
    requires that individuals with impairments be unable to work, but then
    once found eligible for benefits, individuals receive positive incentives
    to work.16 Yet

    14GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.: Jan. 1,
    2003).

    15The Social Security Advisory Board is an independent, bipartisan board
    created by the Congress and appointed by the President and the Congress to
    advise the President, the Congress, and the Commissioner of Social
    Security on programs and matters related to SSA.

    16In addition to the Ticket Program, SSA also offers other work incentives
    to disability beneficiaries aimed at encouraging work. For SSI recipients,
    these work incentives include such things as earned income exclusions
    (which are intended to make work more enticing since some earned income is
    excluded from countable income), a deduction for impairment-related work
    expenses, and continuation of SSI, which allows beneficiaries to work and
    continue receiving benefits until their countable income exceeds the SSI
    limit.

    the disability management literature has emphasized that the longer an
    individual with an impairment remains out of the workforce the more likely
    the individual is to develop a mindset of not being able to work and the
    less likely the individual is to ever return to work.17 Having to wait for
    return-to-work services until determined eligible for benefits may be
    inconsistent with the desire of some individuals with impairments who want
    to work but still need financial and medical assistance. The Advisory
    Board, in recognizing that these inconsistencies need to be addressed, has
    suggested some alternative approaches. One option they discussed in a
    recent report is to develop a temporary program, which would be available
    while individuals with impairments were waiting for eligibility
    determinations for the current program. This temporary program might have
    easier eligibility rules and different cash benefit levels but stronger
    and more individualized medical and other services needed to support a
    return to work.18

    SSA has also realized that one approach may not work for all
    beneficiaries, and in recent years it has begun to develop different
    approaches for providing assistance to individuals with disabilities. One
    example of these efforts is the proposed Temporary Allowance
    Demonstration, which would provide immediate cash and medical benefits for
    a specified period to individuals who meet SSA's definition of disability
    and who are highly likely to benefit from aggressive medical care. SSA is
    also in the process of developing the Early Intervention Demonstration.
    This demonstration project will test alternative ways to provide
    employment-related services to disability applicants. Although both of
    these demonstration projects only cover the DI program, SSA also has the
    authority to conduct other demonstration projects with SSI applicants and
    recipients.

    17GAO, SSA Disability: Return-to-Work Strategies From Other Systems May
    Improve Federal Programs, GAO/HEHS-96-133 (Washington, D.C.: July 11,
    1996).

    18Social Security Advisory Board, The Social Security Definition of
    Disability, (Washington, D.C.: Oct. 2003).

      TANF Recipients with Impairments Are Encouraged to Apply to SSI; Impact on SSI
      Caseload Growth Is Inconclusive

    Estimates from our nationwide survey of county TANF offices indicated that
    almost all offices reported that they refer at least some recipients with
    impairments to apply for SSI. But the level of encouragement these
    individuals receive from their local TANF office to apply for SSI varies,
    with many offices telling the individual to apply for SSI and some offices
    helping the recipient complete the application. Because TANF offices are
    referring individuals to SSI, these referrals will have some effect on the
    SSI caseload. However, findings regarding the impact that these SSI
    referrals from TANF have on SSI caseload growth are inconclusive, due to
    data limitations.

        Nearly All County TANF Offices Refer Recipients with Impairments to Apply
        for SSI, but the Level of Encouragement Varies

    Based on estimates from our survey, 97 percent of all counties refer at
    least some of their adult TANF recipients with impairments to SSA to apply
    for SSI. As table 1 shows, 33 percent of county TANF offices said that it
    is their policy to refer to SSI only those adults whose impairments are
    identified as limiting or preventing their ability to work. However,
    another 32 percent of county TANF offices said that it is their policy to
    refer all TANF recipients identified with impairments to SSI for
    eligibility determinations.

    Table 1: County TANF Office Policies for Referring Adult Cash Recipients
    to SSI

                                     Policy Percent

    Refer all recipients with impairments

    Refer based on criteria from SSI eligibility determination process

    Refer only those who are work limited

    No policy

    Source: Percentages are estimated from GAO survey of county TANF offices.

    Note: Respondents were also given the option of indicating that their
    policy was something other than those listed above, and 2 percent of
    respondents indicated other.

    TANF offices reported that they rely on several methods to identify an
    individual's impairment and assess whether the individual could work or
    should be referred to SSI. Estimates from our survey indicated that all
    county offices rely on the applicant to disclose his or her impairment. In
    addition, 96 percent of all counties rely on caseworker observation, about
    57 percent use a screening tool, and about 60 percent use an intensive
    assessment.

    Once recipients are identified as having impairments, TANF offices need to
    decide which individuals to refer to SSI. As table 2 shows, many

    counties rely on multiple forms of documentation or other information to
    make this decision, rather than referring all individuals with
    impairments. Specifically, 94 percent of all counties reported that they
    use documentation from a recipient's physician, and 95 percent reported
    that they use self-reported information from the recipient.

    Table 2: Information Used by County TANF Offices to Determine Whether to
    Refer Adult Recipients to SSI

                                  Information Percent

    Documentation from recipient's physician

    Documentation from medical professional other than a physician

        Evaluation by an on-site or vendor medical professional 31 Evaluation of
        recipient's ability to work by state vocational rehabilitation worker 70

    Informal evaluation by caseworker or social worker

    Documented evaluation by caseworker

    Behavior observed by caseworker

    Self-reported information from recipient

    Source: Percentages are estimated from GAO survey of county TANF offices.

    While nearly all county TANF offices reported that they refer at least
    some individuals with impairments to SSI, the level of encouragement such
    individuals receive from their local TANF office appears to vary. About 98
    percent of county TANF offices reported that they tell these recipients to
    call or go to SSA to apply for SSI. About 61 percent reported that they
    will also assist a recipient in completing the SSI application, and about
    74 percent reported that they follow up to ensure the application process
    is complete. Some of the variation in the level of encouragement may be
    explained by the fact that some states are work first states. Officials we
    interviewed in four states acknowledged that they try to get all TANF
    recipients to work, including recipients with impairments. Therefore,
    while they make referrals to SSI, officials in these work first states
    told us that they try to encourage work more than the SSI application
    process.19 However, officials in all five of the states we visited stated
    that if they feel an individual has a severe impairment, they would have
    the individual apply for SSI.

    19The labor market may also be a contributing factor in deciding to refer
    an individual with an impairment to SSI.

        Findings About How SSI Caseload Growth Has Been Affected by Referred TANF
        Recipients with Impairments Are Inconclusive due to Data Limitations

    Since county TANF offices refer individuals with impairments to SSI, these
    referrals will have some effect on the SSI caseload. To determine the
    magnitude of the effect that these TANF referrals have had on SSI caseload
    growth, SSA would need to know who among their applicants are TANF
    recipients. However, SSA headquarters officials told us that the agency
    does not know who is referred or how people are referred because it does
    not collect those data. Although the SSI application specifically asks
    whether the applicant is receiving TANF, this information is combined with
    other income assistance based on need in SSA's database. Therefore, while
    the working age (18-64) SSI caseload has increased 33 percent over the
    last decade, SSA does not have an easy way to accurately determine the
    magnitude of the effect that the TANF referrals have had on the growth of
    the SSI rolls. 21

    Also, in a study funded by SSA and conducted by The Lewin Group,
    researchers found little, if any, evidence that TANF had increased
    referrals to SSI. 22 Only one of the five states the researchers visited
    remarked of a perceptible increase in transitions to SSI. The authors
    noted that the likely reason for not finding a significant increase in
    referrals due to welfare reform is the fact that referrals to SSI had
    already been occurring under AFDC, and that the full impact of the welfare
    reform changes would not be known until the time limit for benefit receipt
    had elapsed.23 However, to date there have not been any studies that
    looked at this issue.

    In addition to SSA not knowing the magnitude of the effect that TANF
    referrals have had on SSI caseload growth, TANF officials we interviewed
    stated that they generally do not have historical data on SSI referrals,
    approvals, and denials. But officials in most states that we visited said
    they are in the process of improving their data collection in this
    respect,

    20In order for SSA to obtain this information, special processing runs are
    required. Based upon recent work, SSA determined that 95 percent of the
    reported income based on need was from TANF.

    21Over the last few years, the percentage of the SSI caseload age 18 to 64
    that received income assistance based on need prior to becoming eligible
    for SSI has remained fairly stable at 25 percent. While this does not give
    an accurate estimate of the portion of SSI recipients who were TANF
    recipients, it does provide an upper bound.

    22Cornell University and The Lewin Group, Policy Brief: Transitions from
    AFDC to SSI Prior to Welfare Reform, (Ithaca, NY: Feb. 1, 2000).

    23HHS pointed out that recipients in all states have reached the 5-year
    national time limit. However, all states are under the 20 percent limit on
    extensions, so there is no reason to expect a sharp increase in referrals
    to SSI.

      TANF Offices Differ in Their Exemptions from Work Requirements, but
      Utilization of Noncash Services Is Generally Low

    including tracking methods to determine the status of an SSI application,
    which should provide them with better data in the future.

    TANF offices vary in whether they make work requirements mandatory for
    their adult recipients with impairments awaiting SSI eligibility
    determinations. Even though estimates from our survey showed that 83
    percent of county TANF offices reported offering noncash services to TANF
    recipients with impairments who are awaiting SSI eligibility
    determinations, these services may not be available or are not fully
    utilized. Reasons for this low service utilization may include exemptions
    from the work requirements and an insufficient number of job training or
    related services.

        Work Requirements Are Not Always Mandatory for Those TANF Recipients with
        Impairments Awaiting SSI Eligibility Determinations

    Estimates from our survey showed that about 86 percent of county TANF
    offices have policies that always or sometimes exempt from the work
    requirements adult TANF recipients with impairments who are referred to
    SSI for eligibility determinations. Also, about 31 percent of county TANF
    offices consider the number of times a recipient is denied and appeals an
    SSI decision as a factor when deciding to exempt recipients from the work
    requirements.

    Our survey further found that 82 percent of counties reported exempting
    recipients, in part, on the basis of the degree to which the impairment
    limits the recipient's ability to work. In addition, about 69 percent of
    county TANF offices reported that the severity of the impairment was a
    major factor in their decisions to exempt people with impairments who are
    awaiting SSI determinations from work requirements. One TANF official we
    interviewed told us that the recipients' impairments were too great to
    participate in work activities.

    However, some of the state and county TANF officials we interviewed
    explained that they have developed alternative practices to help
    recipients with impairments participate in work activities. TANF officials
    from two of the states we visited told us that they have developed a
    modified work requirement for adult TANF recipients with impairments.24 A
    TANF official

    24A modified work policy, for example, allows TANF recipients with
    impairments to work fewer hours than the federal work requirement without
    being sanctioned. Modified work policies are defined by the state and are
    not federally approved.

    from one of these states said that the modified work requirements
    encourage individuals with impairments to work, but they do not expect
    that these individuals will be able to work in a full-time capacity. One
    county TANF official we interviewed explained that the work requirements
    and services provided for their recipients with impairments are very
    individualized, based on recommendations of the doctors who meet with the
    recipients. However, in all of the states and counties we visited, TANF
    officials said that individualized services can be costly. One state
    official said that his state's program does not have the funds to pay for
    the training needed by people with learning disabilities. The official
    added that when people with impairments need substantial help, there were
    limits as to what could be funded in a work first state.

        A Broad Range of Services Are Offered to Recipients Awaiting SSI
        Determinations, but Utilization Is Low

    Even though about 51 percent of county TANF offices do not require adult
    TANF recipients awaiting SSI determinations to participate in any type of
    job services, education services, work experience programs, or other
    employment services, 83 percent of county TANF offices reported that they
    are still willing to provide work-related or support services to this
    population. One state official we interviewed reported that the services
    provided are the same for persons with or without impairments. Officials
    in this state explained that these services include transportation, child
    care, medical assistance, tuition assistance, vocational rehabilitation,
    and assistance with obtaining SSI benefits.

    Even though county TANF offices may be willing to offer noncash services
    to their recipients, among those counties that could provide us with
    information on service utilization, utilization of these services tended
    to be low. While the low utilization of services may be due to exemptions
    from the work requirements, service availability may also be an issue.
    Estimates from our survey showed that 40 percent of county TANF offices
    reported one of the reasons adult TANF recipients with impairments, who
    are awaiting SSI eligibility determinations, are not participating in work
    activities is that there are an insufficient number of job training or
    related services available for them to use. In addition, some TANF
    officials that we interviewed cited not only limited funding, but also
    their offices' own TANF policies as factors that might explain why
    services may not be available to recipients with impairments. For example,
    a state TANF official we interviewed said that state budget cuts have
    resulted in trimming of support services made available to recipients.
    Another state official explained that adult recipients with impairments
    who are placed in an exempted status are allowed access to medical
    services but not workrelated support services, such as transportation,
    clothing, or vehicle

    repairs. The official further explained that those services are limited to
    those individuals who are in work activities.

    In addition, estimates from our survey showed that 50 percent of county
    TANF offices reported recipients' motivation to apply for SSI was one of
    the conditions that might challenge or hinder their offices in providing
    employment services. Some state and county TANF officials we interviewed
    also believe that one of the main reasons why there is low utilization of
    services is recipients' fear of jeopardizing their SSI applications. While
    participation in a work activity does not necessarily preclude an
    individual from obtaining disability benefits from SSA, estimates from our
    survey showed that 41 percent of county TANF offices reported that their
    recipients with impairments, awaiting SSI eligibility determinations, are
    unsure whether or not the demonstration of any work ability would hinder
    or disqualify their chances for SSI eligibility. State and county TANF
    officials we interviewed explained that recipients applying for SSI or
    awaiting an SSI decision fear participating in work activities. Some of
    the county TANF officials we interviewed explained that this population
    does not want to participate in work-related services for fear of
    jeopardizing their applications. These officials noted that compounding
    recipients' fears are attorneys who may be attempting to protect their
    clients' interests by sending TANF offices notices saying that any work
    activity could jeopardize their clients' SSI applications. These fears
    have led to TANF workers having some difficulty in getting their
    recipients with impairments to explore work options during the time they
    are applying for SSI. One state TANF official we interviewed pointed out
    that conversations with their recipients about work activities have
    generally occurred because the recipients want to volunteer for such
    activities. A county TANF official explained that there is a challenge in
    providing work services to this population, as the recipients are so
    focused on getting on SSI that it is difficult to get them to focus on
    anything else.

    Yet another reason for the low use of noncash service is that some of the
    county TANF officials we interviewed expressed some uncertainty as to how
    to best serve their adult TANF recipients with impairments, explaining
    that they are sending mixed signals when it comes to encouraging work. One
    county TANF official we interviewed said that on one hand, recipients are
    being told about using TANF services to obtain employment, and then, on
    the other hand, recipients are being told to apply for SSI benefits, which
    require an applicant to focus on his or her inability to work. Some TANF
    offices also allow TANF recipients with impairments to count applying for
    SSI as a work activity. Estimates from our survey showed that about 30
    percent of county TANF offices reported

      Some Interaction Between County TANF Offices and SSA Exists, but Opportunities
      Exist for Improvement

    that they consider the SSI application process an activity that satisfies
    the work requirement. Also, another county official we interviewed stated
    that if a client goes into an exempted status, the client must participate
    in at least one activity a week, but not necessarily a work activity. It
    can be any service the TANF office has to offer, including physical
    therapy or assistance in completing the SSI application.

    Some county TANF offices have developed interactions with SSA offices, but
    such interactions have been of a limited nature and have focused on the
    SSI application process. Estimates from our survey indicated that some
    TANF offices have some form of interaction with SSA. Estimates from our
    survey also showed that two frequently reported forms of interaction
    between county TANF offices and SSA include having a contact at SSA with
    whom to discuss cases and following up with SSA regarding applications for
    SSI.

    In describing his office's interactions with SSA, one state TANF official
    we interviewed said that his office, SSA, and DDS have a good working
    relationship, which includes cross training between the agencies and
    discussions concerning the SSI application process. However, estimates
    from our survey showed about 95 percent of county TANF offices reported
    that they would like to develop a relationship, or improve their
    relationship, with their local SSA field office with regard to adult TANF
    recipients applying for SSI. One state TANF official that we interviewed
    said that his office does not have much of a relationship with SSA. He
    noted that he had no contacts within SSA but would like to develop a
    formal relationship with DDS so that they could make faster determinations
    for the deferred TANF caseload. A county TANF official we interviewed said
    that her office's communication with SSA is largely one-sided. This TANF
    official explained that even though her office sends documentation that
    supports a recipient's SSI application, SSA does not inform them of any
    eligibility decisions it makes with TANF applicants. As a result, TANF
    staff must rely on their recipients telling them about decisions or on a
    computer system that indicates if an individual is receiving benefits.
    Finally, in all of the states we visited, TANF officials told us that they
    interact with SSA to assist their TANF recipients with impairments get
    onto SSI. Estimates from our survey also showed that 64 percent of
    counties reported that their interactions were TANF officials following up
    with SSA regarding a recipient's SSI application, and 53 percent reported
    having a contact at SSA to discuss cases.

    TANF offices identified a number of ways they would like to improve
    interactions with SSA, but most of these focused on making the SSI
    application process more efficient and not on working together to assist
    TANF recipients with impairments toward employment and selfsufficiency.
    Estimates from our survey showed about 57 percent of the county TANF
    offices said that they would like to receive training from SSA regarding
    the SSI application process and eligibility requirements, 50 percent said
    they would like to have a contact at SSA with whom to discuss cases, and
    41 percent said they would like to have regular meetings or working groups
    with SSA regarding interactions and other issues related to serving
    low-income individuals with impairments. In addition, one TANF official we
    interviewed would like interactions with SSA to be improved and thinks
    they could be if he knew what DDS was looking for in the application
    process, such as what it requires for evidence. In contrast, only 6
    percent of county TANF offices reported that they would like to improve
    interactions with SSA specifically related to providing SSA with
    information on employment-related services received while on TANF.

    Although TANF offices reported an interest in developing a close working
    relationship with SSA, based on their interactions with SSA, some state
    and county TANF officials believed that they had to take the lead in
    developing these relationships. For example, one TANF official we
    interviewed explained that he had attempted to make contact with SSA to
    discuss a potential partnership and address some of the county's issues
    with the SSI application process but received no response. The county
    official then wrote a letter to a top SSA regional official asking about
    partnering opportunities. In response, the regional official instructed
    the SSA area director, along with the local SSA and state DDS office, to
    meet with county officials.

    One SSA headquarters official we interviewed told us there is no SSA
    policy that directs or encourages their field offices to interact with
    TANF offices. The official also told us that SSA would consider such a
    partnership with TANF offices but would want assurances of what the
    benefits would be for SSA. In addition, the official said that the agency
    does not want to start up a partnership that would overly tax its already
    high workloads. The official further said that if it were to develop a
    relationship with TANF offices, SSA would then have to develop a training
    program and then administer it to all operations personnel. The official
    noted that developing and administering such a training program would not
    be a small task. SSA officials did state that if a TANF office makes a
    request for training sessions, SSA would be willing to provide training on

    the application process. However, about 27 percent of county TANF offices
    reported that they were discouraged in their attempts to establish a
    relationship with SSA because the local SSA field office told the TANF
    office that SSA did not have the time or the interest.

    While officials at SSA headquarters stated that they are largely unaware
    of any partnerships or interactions between TANF offices and local SSA
    field offices, some local SSA officials have found such relationships
    beneficial. In particular, one SSA official has found his office's
    relationship with the local TANF office to be a form of outreach for SSA
    by helping his office identify people who would qualify for SSI. He
    explained that his local SSA office does not always have the time or staff
    to conduct outreach. He further explained that TANF case managers can
    explain the benefits and provide assistance to the TANF recipient applying
    for SSI. Thus, when a letter comes from the DDS that initially denies the
    claim, the individual is less likely to throw it away, as he or she is
    more aware of the process. This could save SSA time and money as the
    applicant knows that he or she must appeal within a certain amount of
    time, thereby reducing the need to start over because of missed deadlines.

    While 34 percent of those county TANF offices that provide services to
    recipients awaiting SSI eligibility determinations reported interacting
    with SSA in some manner to serve adult TANF recipients with impairments, a
    much higher proportion reported receiving assistance from other agencies
    or programs. For example, as table 3 shows, 91 percent of county TANF
    offices reported that at least some of their recipients awaiting SSI
    determinations received assistance from the state vocational
    rehabilitation agencies, and 86 percent of all offices reported that at
    least some of their recipients received assistance from the state or local
    mental health agency. Further, in all of the states we visited, TANF
    offices reported working with other agencies, such as the Department of
    Education and the Department of Labor, to help TANF recipients with
    impairments find work.

    Table 3: Agencies or Programs That Support TANF Offices by Providing Services to
    At Least Some Adult TANF Cash Recipients Awaiting SSI Eligibility Determinations

                                    Agencies Percent

                            State Vocational Rehabilitation

    Other U.S. Department of Education Programs

    Social Security Administration

    U.S. Department of Labor

    State or Local Mental Health Agency

    Community Programs

    Other

    None

    Conclusions

    Source: Percentages are estimated from GAO survey of county TANF offices.

    With the new emphasis on work and self-sufficiency taken by TANF and SSI,
    and the overlap in the populations served by both programs, opportunities
    exist to improve the way these two programs interact in order to help
    individuals with impairments become more self-sufficient. While some
    interactions between TANF offices and SSA do exist, they are often limited
    to how best to assist a TANF recipient with impairments become eligible
    for essentially permanent cash benefits under SSI. Moreover, the practice
    by most TANF offices of exempting individuals from work requirements while
    awaiting SSI eligibility determination, as well as SSA's policy of
    offering return-to-work services and incentives only after a lengthy
    eligibility process, undermines both programs' stated goals of promoting
    self-sufficiency. In addition, this practice runs counter to the
    disability management literature that has emphasized that the longer an
    individual with an impairment remains out of the workforce the less likely
    the individual is to ever return to work. In recognition of this, SSA is
    planning demonstration projects that will test alternative ways to provide
    benefits and employment supports to DI applicants. However, TANF
    recipients with impairments, because of their low income and assets, are
    more likely to apply and qualify for SSI. Moreover, TANF recipients with
    impairments often receive assessments of their conditions and capacity to
    work while on TANF. Since SSA cannot easily identify who among its
    applicants are TANF recipients, SSA is also unable to systematically
    identify the types of services that the SSI applicant may have received
    through TANF or know whether the SSI applicant has been assessed as having
    the capacity to work or not. Being able to identify the receipt of TANF
    benefits, as well as the noncash services received through TANF, may help
    SSA accomplish its mission of promoting the employment of

    beneficiaries with impairments. By sharing information and establishing
    better working relationships with TANF agencies, SSA could identify, among
    its applicants who are or were TANF recipients, those individuals capable
    of working and could then target them for employment-related services and
    help them achieve self-sufficiency or at least reduce their dependency on
    cash benefits. Although the disconnect in work requirements between TANF
    and SSA's disability programs and the timing of when employment-related
    services are provided to SSI recipients could be barriers to establishing
    a continuity of services, the earlier provision of employment-related
    services, as part of a demonstration project, could mitigate these
    potential barriers.

    While some county TANF officials we interviewed have developed working
    relationships with their local SSA office, other counties have not or may
    be unaware of the possibilities for interactions with SSA and how to go
    about establishing these relationships. Sharing best practices about how
    TANF agencies can distinguish, among the recipients they have referred to
    SSI, those individuals without the capacity to work from those with the
    capacity to work and who could benefit from employment-related services
    could help ensure that those individuals with work capacity be given the
    assistance they need to help them obtain employment. Moreover, sharing
    best practices for establishing useful interactions with SSA could help
    ensure that employment-related services could continue after the person
    becomes eligible for SSI.

    To help individuals with impairments become more self-sufficient and to
    address the gap in continuous work services between the TANF and SSI
    programs, we are recommending that SSA, as part of a new demonstration
    project, work with TANF offices to develop screening tools, assessments,
    or other data that would identify those TANF recipients with impairments
    who while potentially eligible for SSI may also be capable of working.
    Once these recipients have been identified, the TANF offices and SSA could
    work together to coordinate aggressive medical care and employment-related
    services that would help the individual obtain employment and achieve or
    at least increase self-sufficiency.

    In order to facilitate and encourage a sharing of information among TANF
    offices regarding the development of interactions with SSA that might
    increase self-sufficiency of recipients with impairments, we are
    recommending that HHS provide space on its Web site to serve as a
    clearinghouse for information regarding best practices and opportunities
    for TANF agencies to interact with SSA. This would allow state and county

      Recommendations

      Agency Comments
      and Our Response

    TANF officials to share information on what they are doing, what works,
    and how to go about establishing relationships with SSA. It would also
    provide states and counties with access to the research of federal
    agencies, state and county offices, and other researchers that they may
    need in order to develop a strong functional relationship with SSA and
    help TANF recipients with impairments move toward economic independence.
    HHS should be able to minimize its work and expense by using its Web site
    to share this information.

    We provided a draft of this report to HHS and SSA for comment. Both
    agencies generally agreed with our recommendations and indicated that they
    look forward to working together to help low-income individuals with
    impairments become more self-sufficient. Specifically, SSA stated that it
    would be pleased to work with HHS on the planning and design of a
    demonstration project. Likewise, HHS stated that it would be pleased to
    have its staff work with SSA to develop a process or criteria for
    identifying individuals who could benefit from employment services.

    In addition, in response to the findings of our report, SSA said it would
    take immediate measures to ensure that it responds to all requests from
    TANF offices for training on SSA's programs.

    Also in its comments, SSA suggested that we include in our report the fact
    that states may exempt up to 20 percent of their caseload from the time
    limits and that many states waive work requirements for persons applying
    for SSI. In both the draft we sent to SSA and the final version, we
    included a footnote explaining the time limit exemptions, and in the body
    of the report we discussed the issue of work requirement exemptions for
    persons applying for SSI.

    HHS' comments appear in appendix II and SSA's comments appear in appendix
    III. In addition, both HHS and SSA provided technical comments, which we
    have incorporated as appropriate.

    As agreed with your office, unless you publicly announce its contents
    earlier, we plan no further distribution until 30 days after the date of
    this letter. At that time, we will send copies to the Secretary of HHS,
    the Commissioner of Social Security, appropriate congressional committees,
    and other interested parties. The report is also available at no charge on

    GAO's Web site at http://www.gao.gov. If you have any questions about this
    report, please contact me or Carol Dawn Petersen on (202) 512-7215. Other
    staff who made key contributions are listed in appendix IV.

    Cynthia M. Fagnoni Managing Director, Education, Workforce, and Income
    Security Issues

                             Appendix I: Scope and Methods

    To determine the extent that Temporary Assistance for Needy Families
    (TANF) recipients with impairments are encouraged to apply for
    Supplemental Security Income (SSI), whether work requirements are imposed,
    the range of services provided during the period of SSI eligibility
    determination, and the extent that interactions exist between the SSI and
    TANF programs, we conducted a nationally representative survey of 600
    county TANF administrators from October 14, 2003, through February 20,
    2004.

    For the most part, TANF services are provided at the county level, so we
    selected a random probability sample of counties for our survey. We
    derived a nationwide listing of counties from the U.S. Bureau of the
    Census's county-level file with 2000 census data and yearly population
    estimates for 2001 and 2002. We selected a total sample of 600 counties
    out of 3,141 counties. To select 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, using the 2002 estimates. The
    second group consisted of the remaining counties in the United States. We
    included all of the 100 counties with the largest populations in our
    sample to ensure 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 (2002-2003) 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. We obtained
    responses from 527 of 600 counties, for an overall response rate of about
    88 percent.1 The responses are weighted to generalize our findings to all
    county TANF offices nationwide. Sample weights reflect the sample
    procedure, as well as adjusting for nonresponse.

    Because we followed a probability procedure based on random selections,
    our sample is only one of a large number of samples that we might have
    drawn. Since each sample could have provided different estimates, we
    express our confidence in the precision of our particular sample's results

    1The 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 87 percent.

    Appendix I: Scope and Methods

    at a 95 percent confidence level at an interval of plus or minus 5
    percentage points. This is the interval that would contain the actual
    population value for 95 percent of the samples we could have drawn. In
    other words, we are 95 percent confident the confidence interval will
    include the true value of the study population.

    In addition to the reported sampling errors, the practical difficulties of
    conducting any survey may introduce other types of errors, commonly
    referred to as nonsampling errors. For example, differences in how a
    particular question is interpreted, the sources of information available
    to respondents, or the types of people who do not respond can introduce
    unwanted variability into the survey results. We included steps in both
    the data collection and data analysis stages for the purpose of mitigating
    such nonsampling errors.

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

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

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

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

    Appendix III: Comments from the Social Security Administration

    Appendix III: Comments from the Social Security Administration

    Appendix IV: GAO Contacts and Staff Acknowledgments

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    Staff 	In addition to those named above, David J. Forgosh, Cady Summers,
    Megan Matselboba, Christopher Moriarity, and Luann Moy made key

      Acknowledgments contributions to this report.

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