CENTER ON LABOR, HUMAN SERVICES, AND POPULATION RE S E AR C H RE P O R T What Are Human Services, and How Do State Governments Structure Them? Heather Hahn Eleanor Pratt DaQuan Lawrence Laudan Y. Aron with Kassandra Martinchek, Aaron R. Williams, and Paige Sonoda December 2022 AB O U T T HE U R BA N I NS T I T U TE The Urban Institute is a nonprofit research organization that provides data and evidence to help advance upward mobility and equity. We are a trusted source for changemakers who seek to strengthen decisionmaking, create inclusive economic growth, and improve the well-being of families and communities. For more than 50 years, Urban has delivered facts that inspire solutions-and this remains our charge today. Copyright © December 2022. Urban Institute. Permission is granted for reproduction of this file, with attribution to the Urban Institute. Cover image by Bradley Laird/Shutterstock. Contents Acknowledgments iv What Are Human Services, and How Do State Governments Structure Them? 1 What Are Human Services? 1 How Do States Structure Their Human Services Systems? 1 State Agency Structures 1 Changes in State Agency Structures 5 Roles of Counties in Program Administration 6 Use of Contracting in State Human Services 7 Executive and Legislative Structure and Authority 9 How Do Human Services Align or Coordinate with One Another and with Health Care? 11 Formal Organizational Agency Structures 11 Other Formal Structures 12 Integrated Technology 12 Integrated Budget Processes 13 What Factors Facilitate or Impede Alignment and Coordination? 13 Factors Facilitating Alignment and Coordination 14 Factors Impeding Alignment and Coordination 15 How Do Governance Structures Affect Funding, Innovation, and Customer Experience? 17 Effect of Governance Structures on Funding 17 Effect of Governance Structures on Innovation 20 Effects of Governance Structures on Customer Experiences 21 Conclusion 23 Appendix A. How Are Programs and Services Distributed across State Human Service Agencies? 24 Appendix B. Are There Key Types of State Human Services Governance Structures? 41 Notes 47 References 49 About the Authors 50 Statement of Independence 52 Acknowledgments This project has been made possible in part by grant number 77756 from the Robert Wood Johnson Foundation (RWJF), through Northeastern University. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. Any opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the prime sponsor, nor the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. Our study was one component of the RWJF-funded Northeastern University project on Advancing Alignment through State Government Practices: studying public-sector administrative, regulatory, and procurement practices to help achieve successful alignment of health care and human services. Our work was informed by collaboration and iteration with the other project component leaders at Northeastern University: Lori Gardinier, Amy Helburn, Emily Mann, and especially Jean Flatley McGuire. We also benefited from feedback and guidance from the project's advisory group members: Mary Lou Breslin, Ana Lòpez-De Fede, David Hansell, Jody Levison-Johnson, and Judith Warren. Learn more about the Human Services State Government Alignment project here: https://bouve.northeastern.edu/rwjf-human-services-state-government-alignment-project. We are grateful to the experts on human services and state governance who shared their time and knowledge: Mark Greenberg, Jordan Hynes, Rosalynd Mosser, Don Moynihan, Phil Rocco, Jennifer Wagner, and Susan Yackee. We also are indebted to Ann Flagg, Matt Lyons, Mary Nelson, and Tracy Wareing of the American Public Human Services Association. Not only did they provide guidance and feedback, but they were also instrumental in reaching out to human services agencies in every state to confirm or correct the information on their agency structures. Finally, we thank the leaders and staff of the state agencies included in our case studies: the Colorado Department of Human Services, Kentucky Cabinet for Health and Family Services, Massachusetts Executive Office of Health and Human Services, New Jersey Department of Children and Families, New Jersey Department of Human Services, North Carolina Department of Health and Human Services, Oklahoma Department of Human Services, Oregon Department of Human Services, Wisconsin Department of Children and Families, and Wisconsin Department of Health Services. iv ACKNOWLEDGMENTS ACKNOWLEDGMENTS v What Are Human Services, and How Do State Governments Structure Them? What Are Human Services? Human services-a sector critical to helping individuals, families, and communities thrive and optimizing health, well-being, and equity for the country as a whole-are often underappreciated and misunderstood. 1 Recent reports have documented the urgent need to strengthen the human services sector in the United States (Kresge Foundation 2014; Oliver Wyman 2017), including the need to invest in leadership and develop talent; address infrastructure needs and increase the sector's capacity; promote effective practice, advance collaborations, and weaken silos; and influence public opinion and policy though messaging, advocacy, and civic engagement. It is also increasingly clear that the health care system can benefit from far greater alignment with and support from human services and social care (Committee on Integrating Social Needs Care 2019; McGuire and Shellenberger 2019). States, along with cities and counties, play a central role in the organization, management, and delivery of human services. This project describes the range of approaches state governments take in structuring their human services systems and explores the implications (if any) of these structures for alignment and coordination among various human services and with the health care sector. The importance of how human services are organized and structured at the state level remains unclear. Not surprisingly, states have taken different approaches to how they structure their human services, and some periodically reorganize these structures. Agency structure alone is unlikely to account for how well human services are supported or delivered but may facilitate or complicate aspects of how such a comprehensive and complex set of services operates. The study examines state human services structures and examines ways these structures might affect how the system functions. This study drew on various data sources and methods to examine state approaches to structuring human services. We conducted interviews with national experts in human services and state governance; a scan of the research literature on this topic; a (quantitative) cluster analysis of state human services governance structures based on available data; and, finally, (qualitative) in-depth interviews with human services agency leaders in eight states: Colorado, Kentucky, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, and Wisconsin. 2 Key staff of the American Public Human Services Association (APHSA) served an advisory role on the project, providing input and feedback to the research team. This work was conducted from January 2021 through September 2022, and because the study period coincided with the global COVID-19 pandemic, all interviews were conducted virtually. Although the term itself is familiar to most people, human services, or social services as they are sometimes called, are difficult to define or describe succinctly. Descriptions often involve listing various target populations (such as vulnerable children and families or disabled, homeless, or refugee populations) or types of services (such as child protection, supportive housing, employment, and training). In general, human services  span a wide range of cash and in-kind benefits and individual, family, and community support services;  span the life course, from the earliest to the latest ages and stages of life;  are provided in various places and settings, including community-based and institutional settings, residential and nonresidential settings, public and private settings, and individual and group settings;  are designed, financed, administered, and delivered through a complex array of public (government) and private nonprofit entities, including multiagency partnerships;  can intersect with, but are distinct from, other service systems such as education, health care, and legal services; human services are also distinct in that governments are responsible for paying for most services and benefits; and  seek to optimize lifelong human development over time and place and advance population health, well-being, and equity. No single agreed-upon set of programs and services encompass human services. Even people working within this large ecosystem might describe its boundaries differently depending on what part of the system they occupy. Following a deliberative consultative process that considered how states organize human services in practice, the scope of human services generally recognized in the literature, 3 and the scope identified by the experts we interviewed, this study focused on the following human services (figure 1):  disability and independent living services  child, family, and community services 2 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM?  cash and in-kind benefits  aging and senior services  workforce development and financial well-being services Various other services were mentioned during our informant interviews and case studies. Most of the agency heads defined "human services" as those housed within their own agencies. But they also mentioned other services that tended to be located outside their agencies; these included housing, juvenile justice, and domestic violence services, and behavioral health and substance use programs. Some human services are delivered at the community level, but our primary interest here is in services (and alignment of services) delivered to individual people or families. Collectively, human services as a sector interfaces with a complex array of organizations and other sectors. These include (1) other publicly funded agencies and organizations, such as those working in education, employment, and justice; (2) community-based organizations delivering a wide array of services and supports in community settings; (3) philanthropic organizations, which operate locally, regionally, or nationally; (4) academic and vocational institutions; (5) private sector organizations, including businesses; and (6) public health and human services agencies (Oliver Wyman 2017). WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 3 FIGURE 1 Classification of Human Services Programs and Functions Source: Urban Institute. How Do States Structure Their Human Services Systems? State governance of human services can be multifaceted and complex. A basic way to view variation in state human services governance structures is to assess which programs and services are administered by which state agencies, and the roles of county governments and contractors in administering or implementing human services programs. Human service governance structures also differ with respect to the roles played by the state's executive and legislative branches. In this section, we describe the range of state approaches along these dimensions. Throughout this report, we use the term "agency" to refer generically to state government entities that may be named, for example, agencies, departments, commissions, or offices, depending on the state. State Agency Structures State agency structures-which programs and services are administered by which agencies-often reflect a state's attempt to balance tension between specializing in a particular policy area and collaborating across policy areas. Generally, state agency structures range from those with a few agencies that broadly encompass a wide range of human services programs and functions, possibly even health care and public health programs and functions, to those that have multiple, narrowly focused agencies. Several states have consolidated services vital to children and families (sometimes including health care) by creating a Department of Children and Families or a similarly named agency separate from or within another human services agency. Specific state agency names and structures vary widely, with 18 different names for main human services agencies used among the 50 states. The most common name, "Human Services" department or agency, is used in 16 states, followed by "Health and Human Services" departments, commissions, or executive offices in 12 states, as shown in figure 2. Four states have a "Department of Social Services." The remaining 18 states use 15 other name variations. In general, the names do little to clarify which programs and services the agencies include. (See appendix A.) For example, about half of the departments of "Human Services" administer Medicaid, a major source of funding of state human services, despite not having the word "health" in their name. FIGURE 2 Names of States' Main Human Services Agencies Source: Authors' review of state websites; 36 states verified the accuracy of the information. Note: "Main human services agency" is defined as the state agency that administers the largest number of human services programs. For this study, we define the "main human services agency" as the agency with the most human services programs within it. To determine which agencies were responsible for which programs, we searched each state's website for the programs included in our conceptual definition of human services, as illustrated in figure 1. In some cases, states' public-facing websites do not clearly indicate which agencies administer which programs. Inquiries to the APHSA and the National Association of Medicaid Directors revealed that these organizations do not maintain comprehensive information on state agency structures, perhaps in part because state structures and names evolve over time. Administrators in our case study states confirmed that most of the information we had collected from their websites was accurate. With assistance from APHSA, we also sought confirmation from a state human services administrator in each state and received confirmation or corrections from 36 states. Nonetheless, these data include a degree of uncertainty and will likely change over time. On average, states' main human services agencies administer about half of the human services programs we examined, with a range of 2 to 11 state agencies administering the remaining programs. Looking specifically at each state's main human services agency, we found the following distribution of programs and services (also shown in figure 3). 2 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM?  Nearly all states' main human services agencies administer Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) (49 states) and Temporary Assistance for Needy Families (TANF) cash assistance (48 states).  Most states' main human services agencies administer adult protective services and elder justice (41 states), child support enforcement (40 states), and child care assistance (39 states) .  Greater variation occurs across states in whether their main human services agency administers the following programs and services: » immigrant and refugee assistance: 38 states » child protective services, foster care, adoption, and independent living services: 36 states » disability-related services and supports: 36 states » community-based behavioral health: 33 states » Medicaid eligibility determination: 32 states » vocational rehabilitation and work supports for veterans, dislocated workers, and people with disabilities: 17 states » housing assistance: 12 states  Least likely to be administered by the state's main human services agency are reentry programs (8 states), financial education and asset building programs (5 states), apprenticeship programs (3 states), and unemployment insurance programs (2 states). See appendix A for more details on the distribution of programs and services across state human services agencies. WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 3 FIGURE 3 Number of States in Which Main Human Services Agency Administers Selected Programs and Services SNAP 49 TANF cash assistance 48 Adult protective services and elder justice 41 Child support enforcement 40 Child care assistance 39 Immigrant and refugee assistance 38 Child protective services, foster care, etc. 36 Disability-related services and supports 36 Community-based behavioral health 33 Medicaid 32 WIC 22 Vocational rehabiliation 17 Housing assistance 12 Reentry programs 8 Financial education 5 Apprenticeship programs 3 Unemployment insurance 2 Source: Authors' review of public state websites; 36 states verified the accuracy of the information. Notes: "Main human services agency" is defined as the state agency that administers the largest number of human services programs. SNAP = Supplemental Nutrition Assistance Program; TANF = Temporary Assistance for Needy Families; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. Given the importance of Medicaid in human services funding, the agency controlling it greatly influences state policy, as we discuss later in the report. Federal law requires states to designate a single agency to administer or oversee administration of Medicaid. Figure 4 identifies the 32 states in which the main human services agency is also the agency with primary responsibility for administering or overseeing Medicaid. Though states must designate a single state agency, many states involve additional agencies in various aspects of Medicaid. For example, in Oklahoma, the Department of Human Services operates the community side of long-term care for Medicaid, which is sizable. In addition, in some states a different agency handles at least some Medicaid eligibility determinations. 4 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? FIGURE 4 States Where the Main Human Services Agency Is Also the Designated Single State Agency for Medicaid Source: Authors' review of public state websites; 36 states verified the accuracy of the information. Note: "Main human services agency" is defined as the state agency that administers the largest number of human services programs. Changes in State Agency Structures Agency structures vary over time-not only across, but also within states. National data from 2008 indicate that 32 states had recently reformed their human services agency structures. 4 Most of our case study states experienced structural reform at some point in the past 20 years, almost always with the intent to increase attention and resources on state priorities. Some states consolidated health agencies with human services agencies. Others split them or reorganized the structure among human services divisions. Kentucky and Massachusetts created combined health and human services agencies long enough ago that leaders in both states believed they could judge the comprehensive agency structure a more effective model for coordination and alignment. For example, bringing MassHealth into the Massachusetts Executive Office of Health and Human Services signaled that the state was focused on making better use of Medicaid funding. In WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 5 contrast, Oregon separated its health care functions from the Department of Human Services effective 2011. New Jersey, North Carolina, and Wisconsin each created new entities focused on certain issues related to children and families to bring increased attention and resources to this specific population and their well-being. In New Jersey, the Department of Children and Families is the state's first cabinet- level agency devoted exclusively to serving and supporting at-risk children and families, as well as those with intellectual or developmental disabilities and behavioral health or substance use challenges. The New Jersey Department of Human Services continues to administer supports and services related to health insurance, income support, food assistance, and catastrophic medical expenses for children and families. In North Carolina, the new division was created through a reorganization of divisions within the Department of Health and Human Services. Wisconsin's reform was a combination of these approaches. In Colorado, child care recently separated from the rest of human services into the new Department of Early Childhood, directly under the governor. The Department of Early Childhood will also increase local control to work more closely with local stakeholders and decisionmakers and be more responsive to local needs. Similarly, the division overseeing Oregon's subsidized child care program will be moved to the newly created Department of Early Learning and Care on July 1, 2023. Roles of Counties in Program Administration Though this report focuses on human services governance at the state level-not services entirely within the purview of counties, localities, or community-based organizations-sometimes program roles that are typically held at the state level are delegated to counties. States vary considerably in how extensively they delegate formal roles to counties in administering or implementing human services programs, and the roles often vary by program within a state. In this context, county roles in administering human services can include anything from county-funded employees implementing state- established policies and practices to county governments making their own policy choices about program services. For example, 10 states share SNAP program administration with county governments 5 but differ in the degree of state-county administrative cost sharing and whether the counties can implement federally allowable policy options (Cahill, Tracy, and Cheyne 2018). Similarly, 11 states identify as having county or local administration of TANF, 6 but these states vary in the degree of county financial contributions and policy discretion over benefits and services (HHS 2018; Hahn, Kassabian, et al. 2015). 6 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? County administration is not all-or-nothing within a state; the number of county-administered programs in a state varies across the nation. Considering seven major programs or functions typically administered by state human services agencies, we find three states (Colorado, North Carolina, and Ohio) have delegated some aspects of administration to its counties for all seven programs or functions. In 35 states, none of these are county administered. On average, states use county administration for 1.3 of the 7 programs or functions, typically child welfare or child support enforcement. 7 Our case study states varied in their use of county administration. In some states, such as Colorado, many programs are county administered. In others, only a few programs are county administered, and three of our case study states had no county-administered programs. Table 1 shows county administration of the seven human services programs and functions we reviewed. States may also have special circumstances in which they administer programs in a particular county. In Wisconsin, SNAP and TANF are state supervised and county administered, except in Milwaukee County, where the state administers the programs. TABLE 1 County Administration of Human Services Programs or Functions in Case Study States Program or function CO KY MA NJ NC OK OR WI Child Care and Development Fund x x x x Child support enforcement x x x Child welfare x x x xb Medicaid eligibility determinations x x xa xb SNAP x x x x Social Services Block Grantb x x x TANF cash assistance x x x x Source: Authors' interviews with state agency leaders. SNAP = Supplemental Nutrition Assistance Program; TANF = Temporary Assistance for Needy Families. a Hybrid program administration. b The Social Services Block Grant, administered by the US Department of Health and Human Services, Administration for Children and Families, provides flexible funding to support social services addressing a wide range of population needs. In states marked with an "x" the state passes the block grant funding to the counties. Use of Contracting in State Human Services Government-funded human services activities may be carried out by government employees or contracted to nongovernmental providers, either for profit or nonprofit. The extent to which services are contracted may reflect a combination of federal program rules, unionization of government WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 7 employees, or state choice (either codified in legislation or regulations, or open to the discretion of state leaders). According to our interviews with human services and state administration experts, contractors are characteristically hired for specific services, rather than comprehensive program administration, and delivery of services to the public are among the tasks typically contracted. Nationwide, most state human services agencies use contracts to outsource the delivery of services to the public. Though dated, the most recent survey in 2008, 8 found that only 4 responding states (Maine, Maryland, New Hampshire, and Washington) reported not using service delivery contracts. 9 Though the remaining states varied widely in the extent of using service delivery contracts, states most commonly (17 states) reported that roughly 21 to 40 percent of their human services agency's budget was allocated to contracting for delivery of services to the public. That share is likely to be heavily influenced by the programs included in the human services agency budget, which we know vary across states. Among our case study states, all use contractors to some extent in at least the delivery of human services, but a few states stand out for their extensive use of contracts. In Massachusetts, about 70 percent of the human services budget flows through contracts and public procurements. In Wisconsin, Department of Children and Families budget dollars flow to other entities largely through competitively procured contracts or to counties for administration. In Oregon, almost 90 percent of the Department of Human Services budget is spent on direct services. Though state employees provide some of those direct services, roughly two-thirds of those funds go to communities and community-based organizations (box 1). BOX 1 Role of Community Advocates and Nonprofit Organizations Nonprofit community-based organizations (CBOs) account for a critical portion of the human services ecosystem. Alongside government agencies, CBOs build capacity within communities and deliver services directly to individuals and families through contracts with various government agencies and additional funding from private foundations and other sources. A recent study found that across the nation more than 210,000 human services CBOs deliver about $200 billion in services to individuals, families, and communities each year.a Further, "these CBOs are more than just service providers. Human Services CBOs contribute to the development of policies to improve the human capital of our nation. They create innovative approaches to produce better outcomes, and they produce significant economic return in their local economies as employers and purchasers of goods and services."b Despite the important role CBOs play, collectively they face a wide range of financial and operational challenges, including constraints imposed by their funders, regulatory and legal constraints, 8 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? and underdeveloped financial risk management capabilities. One state agency leader we interviewed noted that community advocates for human services customers don't have the strength in advocacy or lobbying presence of hospital associations. In some states, community advocates and nonprofit organizations have formal relationships with the state government, not only as contractors but also as advisors. For example, the Illinois Social Services Advisory Council meets regularly with the Department of Human Services. According to an expert interview, this information sharing mitigates hostile interactions and lawsuits and encourages integration throughout human services programs. Having a mandated role for community advocates ensures their engagement and continuity across governors' administrations. Further, the advisory council offers social accountability, which can improve performance by increasing citizen engagement and government responsiveness.c Nearly all states reported in a 2008 survey that their human services agencies were engaged in some kind of collaborative project with nonprofit organizations.d a Oliver Wyman, A National Imperative: Joining Forces to Strengthen Human Services in America (Washington, DC: Alliance for Strong Families and Communities, 2017). b Oliver Wyman, National Imperative, p. 19. c Jonathan Fox, "Social Accountability: What Does the Evidence Really Say?" World Development 72 (2015): 346–61, http://dx.doi.org/10.1016/j.worlddev.2015.03.011. d La Follette School of Public Affairs, American State Administrators Project (ASAP) survey, University of Wisconsin–Madison, 2008, https://asap.wisc.edu. Executive and Legislative Structure and Authority Governors and state legislatures have important roles in determining state human services budgets, policies, structures, leaders, and service delivery. The specific roles, authorities, and relationships of the executive and legislative branches vary by state and may be defined in state constitutions. Further, decisions made by a governor in one state may be made by the head of a human services agency in another state. Differences may exist even across programs in a single state. The roles and relationships between governors and legislators and their implications are their own field of study beyond the scope of this project. Nonetheless, we describe what we learned from our interviews with state agency leaders and other experts and from secondary survey data 10 about how roles for state executives and legislatures differ across states in human services budgets, policies, and structure decisions. In any state, the executive branch must work with the legislature to allocate funds, but the executive and legislative branches have varying roles in budget decisions across states. For example, in Oklahoma, the governor's office cannot develop a budget and can only negotiate on the budget it receives from the state legislature; the governor can veto line items in the budget, but the line items can WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 9 also be overridden by the state legislature. In all other case study states, the governor proposes a budget to the state legislature through different mechanisms, some more formal than others, usually with input from the human services agency. Even where the governor proposes the budget, states vary in how much their legislature changes the budget and the extent to which they use the budget to make policy. For example, in New Jersey, the governor's budget message is the single most important policy statement that the governor makes on how the legislature should allocate the state's resources for programs and services. The legislature, through hearings conducted by its appropriations committees, reviews the governor's budget and makes changes. According to our interviews in New Jersey, the legislature occasionally adds funds but does not often remove the budget items the Department of Human Services proposes, despite having the authority to do so. In some states the legislature passes federal block grants to the relevant agencies. In others, such as North Carolina, the legislature sometimes includes language on specific uses of federal appropriations through the TANF and Child Care Development Fund block grants. Wisconsin is notable for the governor's broad ability to line-item veto, but the legislature also exerts considerable influence over the budget. The relative power of the executive and legislative branches over policy and structural decisions, beyond those made through budget actions, can also vary considerably across states. In Kentucky, as in other states, the governor's cabinet typically has discretion over policy. However, both the governor and the legislature can exert power if they have a particular interest in a program or policy. For example, the Kentucky General Assembly can not only include budget language that specifies how funds are spent but also introduce bills that dictate aspects of policy or program implementation. In Massachusetts, the governor has considerable authority in running and structuring the executive branch, but many programs and major structures are set in statute, preventing the governor from making structural changes without legislative endorsement. In Wisconsin, too, the governor is afforded oversight and policymaking power but would need approval from the state legislature to restructure state human services. All Wisconsin state agencies are defined by state statute, which mandates that states must request rulemaking authority or new statutory provisions to create a new program. States also vary in their rules about how human services agency leaders are selected, which can have important implications for the leadership of the agency. In some states, it is up to the governor alone. In others, the state legislature has input on such decisions, for example, confirming the governor's selection. In Kentucky, the governor has the authority to appoint cabinet members without approval from the legislature. In Oklahoma, a 2012 change to the state constitution shifted power to the legislature by requiring that the Oklahoma senate confirm the governor's appointee for Director of 10 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? Human Services (previously, a state commission had the authority to hire and fire the agency director). Where both the executive and legislative branches are involved, the relevance of each role can vary depending on whether the governor is of the same party as the majority of state legislators. How Do Human Services Align or Coordinate with One Another and with Health Care? What are the implications of state human services structures for alignment and coordination among human services and with the health care sector? The short answer is that agency structure can affect alignment and coordination but does not determine it. For a more nuanced answer, we first consider where and how alignment and coordination occur. The human services and health care sectors can align and coordinate through formal agency organizational structures, such as a comprehensive Department of Health and Human Services. When a single agency administers a wide swath of health and human services programs and functions, a single agency secretary, director, or commissioner can have a holistic view, and all programs and services can be unified through a single strategic plan. However, a single, comprehensive agency with thousands of employees can also have siloed divisions, each with their own turf and interests. Alignment and coordination can occur through other formal structures, including cabinets, councils, or cohorts of leaders, even when human services programs are spread across multiple agencies. Alignment and coordination can also occur through integrated technology and budget processes. In states with county-administered human services, counties may create systems with more or less coordination and alignment than the state system. In this section, we describe how the case study states align and coordinate their human services functions through formal agency structures, other formal structures, technology, and budget processes. Formal Organizational Agency Structures A single agency director or commissioner who oversees a comprehensive set of human services programs can facilitate alignment and coordination. For example, several states that have a single director told us that concentrating programs in one department affords the director a holistic view to identify areas of common interest and overlap. Alignment may also occur when every agency reports to the same commissioner. Likewise, we heard that programs may lack alignment when they are separated from each other across departments. WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 11 Strategic plans can also provide alignment and coordination. Case study states reported using department-level and agencywide strategic plans. In several states with large agencies housing both health and human services, shared priorities and goals fostered alignment across divisions. County administration of human services may influence alignment and coordination across human services. For example, county human services governance structures may mirror the integration or silos that exist at the state level, or counties may have their own structures that include more integration or more silos than at the state level. We heard from case study states that even within a single state, counties may differ in the level of coordination between their departments and services. Others felt that state control (rather than county administration) helped promote consistent alignment throughout the state. Other Formal Structures Cabinet structures may also support alignment and coordination. In our case study states, cabinets meet regularly. In one state, a cabinet with more than 30 related agencies and commissions met every other week for two hours. In other states, interagency and leadership councils meet around specific goals. For example, a leadership council may focus on a specific population, such as young children. These cabinets and councils provide opportunities for alignment and relationships that promote coordination. Some states also align by function, with cohorts of general counsels, technology officers, and legislative liaisons that meet regularly across departments. Finally, some states have specific projects or grants, such as preschool development grants, that create opportunities for departments to work together. Integrated Technology In some cases, technology also allows for alignment and coordination. For example, states with an integrated eligibility system for Medicaid, SNAP, TANF, and child care assistance can more easily offer customers a single online application for multiple programs. Further, integrated systems facilitate data sharing and coordination across programs. Single online applications for Medicaid, SNAP, and TANF are available in 26 states, but only half of that number include LIHEAP, the Low-Income Home Energy Assistance Program. 11 In one case study state that uses technology to track program outcomes, regular updates and program data review facilitate coordination. 12 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? Integrated Budget Processes In several case study states the budget process represents an opportunity for alignment. For example, in one state with a large health and human services agency, programs and divisions collaborate to create the budget. In another state, the budget office of the human services agency works closely with that of the health agency. As with a strategic planning process, the budget development process can help departments and agencies align around their overall priorities, rather than by program or division. Of course, legislative control over the budget also matters, with legislatures in some states having more power over the actual budget. What Factors Facilitate or Impede Alignment and Coordination? Having described that alignment and coordination across human services and with the health care sector can occur through state agency organization and other formal structures, as well as through budget processes and technology, we describe the more nuanced factors that can facilitate or impede that alignment and coordination. First, it is important to understand that though an agency's organizational structure can create the conditions for alignment and coordination, organizational structure does not guarantee it. A leader we interviewed in a state where human services programs are separated from the lead health agency described how the lack of formal structures means human services, public health, and Medicaid only align because of staff interest and priorities. Another noted that in her state, where human services programs are spread across multiple agencies, the programs are "running their own little fiefdoms" and one agency was metaphorically "nipping at the heels" of another agency that had more power and access to funding. In contrast, the leader of a large consolidated health and human services agency described how having health and human services combined in a single agency facilitated their ability to respond quickly and collectively during the COVID-19 pandemic. Nonetheless, the leader of another state with large, consolidated health and human services agencies described how the divisions within his agency remained siloed and "focused on their own turf and interests." The people we interviewed agreed that factors beyond agency structure can influence coordination and alignment among human services and with the health care sector. WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 13 Factors Facilitating Alignment and Coordination Several factors can facilitate alignment and coordination, according to the agency leaders in our case study states: a commitment from the governor and leaders at all levels of state government to a unified vision and a culture of alignment, personal relationships across agencies, and regular meetings among human services leaders and those in other departments. Circumstances related to the pandemic- namely, virtual meetings and abundant federal funding-also facilitated coordination across human services and/or health agencies. This section discusses what we learned about each of these factors. Leadership is a top factor influencing alignment and coordination-specifically, the priorities, vision, personality, and commitment of state human services leaders (Hahn, Gearing, et al. 2015). Agency leaders we interviewed gave examples of both active leadership and lack of leadership and their impact on coordination. Several state agency leaders described how agencies can be motivated to coordinate by a unifying vision of improving outcomes for people in need. In contrast, where vision and leadership for integration were lacking, silos remained within an otherwise consolidated health and human services agency. Leadership is important not only from governors and agency heads, but also from middle-tier and frontline staff, according to multiple people we interviewed. Several described their governors' direction and expectations that people work together, both as a matter of course and on special projects or priorities, as facilitating coordination. Governors themselves, as well as a first lady or policy advisors in the governor's office, can bring together commissioners and agency secretaries to work under cross-departmental policy initiatives. Likewise, they described how cabinet secretaries signal their intention for alignment and coordination and actively encourage personnel at all levels to lead coordination efforts. Though coordination requires engagement at all levels, it is commitment from top leaders to creating a culture of alignment, innovation, and collaboration that galvanizes agencies to participate. Full coordination, our experts noted, requires agreement from leaders at all levels, especially career leaders such as bureau directors. Because the election of new governors and appointment of agency officials periodically disrupt agency operations, career leaders can have an important role in continuing or impeding coordination and alignment. Relationships are another key to coordination and alignment at all levels of state government. The people we interviewed explained that when agency leaders have relationships with each other, they are better positioned to recognize opportunities for overlap, alignment, and coordination. Sometimes leaders build these relationships as they work with different agencies throughout their careers; they 14 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? bring their experiences, perspectives, and relationships with them. Interagency committees, councils, and other meetings that include personnel at multiple levels across multiple departments also create opportunities to build relationships and coordinate. One person we interviewed commented that long- time career staff who have relationship history with other agencies can either facilitate or impede coordination. Meetings can facilitate coordination and alignment, as suggested in our discussion of relationship building. The people we interviewed described, for example, weekly meetings among leaders within the same department, monthly breakfasts among leaders of separate departments, and daily instant messaging conversations between key leaders on ongoing topics. In addition to meetings among small groups of leaders, they noted, coordination and alignment can be facilitated through meetings among all cabinet leaders, as well as one-on-one meetings between the secretary and each department head or other such individual executive management meetings. The COVID-19 pandemic and the state and federal responses to it have facilitated further integration. First, the unprecedented nature of the crisis required innovation and cooperation. Second, additional funding from federal COVID-19 relief funds and increased state tax revenue have contributed to an abundance of funding that lessens the competition for resources and facilitates innovation and coordination. 12 As one person we interviewed explained, "Agencies aren't super territorial because we are not in a famine as we often find ourselves." Third, the "technology-first" approach during the pandemic made cross-agency meetings logistically easier, and these virtual meetings in turn facilitated the relationship building and cross-agency or cross-department discussions that facilitate coordination and alignment. Factors Impeding Alignment and Coordination Factors impeding alignment and coordination within human services and with the health care sector, besides agency silos, include competition for limited funding; federal or state legislative requirements about program spending; agency staff who lack the interest, skills, or cross-systems knowledge necessary for collaboration; and the demands of meeting day-to-day program obligations and handling crises. Competition for limited funding can impede coordination in the same way that abundant funding can facilitate it. Access to funding, however, is not merely a matter of the total amount of funding but also the process for obtaining it. Legislative control over the budget was mentioned by several people we interviewed as a potential impediment to both coordination and innovation. One state human WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 15 services leader noted that legislative control of the budget, combined with legislative turnover, can discourage long-term coordinated investments, such as investments in technology that could facilitate alignment. Another state's human services leader noted that legislative control of the budget can allow the legislature to create policy with the budget, including specifying how the agency can spend federal block grants. Yet another state's human services leader noted that legislative control of the budget can limit the ability of agencies to act quickly, nimbly, or creatively. Federal requirements about program spending can also impede alignment and coordination. For example, federal law requires states to designate a single agency to administer or oversee administration of Medicaid. 13 State agency leaders discussed how this federal requirement can complicate coordination and alignment, as well as contribute to competition for Medicaid funding, in states where human services functions are split across multiple agencies. Both the federal and state legislative funding requirements can at times require coordination or alignment. Yet, from the perspectives of the state agency leaders we interviewed, these requirements limit and complicate their own power to decide how to innovate or align programs across agencies. Agency staff who lack the interest, skill, or cross-systems knowledge necessary for collaboration can impede alignment and coordination that depends on proactive decisions and concerted actions. Agency leaders in several of our case study states highlighted this point. They noted that "the ship of state is designed to turn slowly," and the security and stability that characterize government careers can attract people averse to taking risks and making changes quickly. This inertia among some career staff can impede alignment, coordination, and innovation in human services. Even when people are theoretically interested in collaborating, they sometimes lack the skills and resources to understand multiple systems and how they could work together. Further, the relationships among long-time career staff and their relational history with other agencies can either facilitate or impede coordination. Finally, the demands of meeting day-to-day program obligations and inevitable crises can impede the proactive decisions and concerted actions required for innovative cross-program coordination. One agency leader noted that in contrast with the private sector, where considerable attention is focused on innovating for the future, state government offices are focused "90 percent on keeping the trains running" and handling crises and "at most 10 percent" looking to the future and innovating. 16 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? How Do Governance Structures Affect Funding, Innovation, and Customer Experience? Several aspects of state human services governance structures influence the flow of funding, the pace of innovation, and the satisfaction of customers. Effect of Governance Structures on Funding The governance of state human services affects the flow of funding, including mechanisms for drawing down federal funds to the state and spending funds within the state (box 2). Consolidated human services agencies and combined health and human services create opportunities for strategic braiding of multiple funding sources, including Medicaid, but funding streams can still be siloed within consolidated agencies. Likewise, having separate agencies can create competition for funding, but leaders across separate agencies can work cooperatively on funding decisions. States with both combined and separate health and human services agency structures told us they attempt to maximize the appropriate use of Medicaid and other federal funding for human services. Also affecting a state's flow of funding are the authorities of the executive and legislative branches, and whether human services are administered by counties. And, of course, it is easier to share funds when more funds are available. State human services having a single cabinet or agency head can facilitate strategic budgeting decisions across functions and funding streams, including using Medicaid dollars for human services. Federal requirements limit how funding can be used, but having a single agency overseeing multiple human services programs and health care makes it easier to braid multiple funding streams for related purposes. For example, Kentucky's single Cabinet for Health and Family Services helps the commonwealth makes it easier to use Medicaid funding appropriately for human services, according to our interviews. Because Medicaid funding is abundant relative to all other human services funding, its strategic use can benefit state human services goals. Although $10 million in funding is a small amount to Medicaid, that funding is considered extraordinary to human services agencies. For example, North Carolina's combined Department of Health and Human Services can take a strategic approach to budgeting that prioritizes the outcomes of the people they serve and helps the state offer several alternative services in behavioral health, such as a nurse family home visiting program. WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 17 TANF funding is small relative to Medicaid or SNAP but governed by federal rules that allow considerable flexibility within federal requirements. States with broad human services agencies may be well positioned to identify opportunities for using TANF funds. Nevertheless, having a single cabinet or secretary does not ensure that Medicaid and other dollars are shared throughout the agency. Though a comprehensive structure creates the opportunity for states to use Medicaid dollars more effectively, it can still be challenging for a large agency to operationalize. For example, in North Carolina, despite its combined Department of Health and Human Services and strategic approach to budgeting, according to our interviews, funding still flows largely through compartmentalized divisions. Having separate agencies can create competition between agencies for funding. In states with separate agencies, multiple agencies communicate with each other but also must compete every year for funding, including Medicaid funding. For example, in Wisconsin, where Medicaid is administered by the Department of Health Services and child welfare by the Department of Children and Families, complex cross-agency discussions are required to address instances when the administration of Medicaid impacts the child welfare system. Because far fewer families are served by the child welfare system than by Medicaid, challenges related to child welfare can be more difficult to get the attention they need, and child welfare is less likely to access funding that could be transformative. Having separate agencies focused on similar populations can create opportunities to leverage funding in ways that reach a broader group. For example, in New Jersey, the Department of Human Services can use funding for maternal and infant health analyses, initiatives, and outreach in coordination with the Department of Health for individuals and providers such as community doulas, beyond Human Services's traditional focus on Medicaid. More generally, this awareness promotes equity across departments because commissioners and department policy staff are attuned to the effects of program changes on sister agencies, as well as to programs that need to stay aligned. States with combined health and human services agency structures and states with separate structures both attempt to maximize the appropriate use of Medicaid and other federal funding. Kentucky, which has a combined Cabinet for Health and Family Services, attempts to maximize appropriate use of Medicaid, including support of all health-related services aligned with human services. Colorado, Oregon, and Oklahoma, which do not administer Medicaid through their primary human services agencies, also actively consider how Medicaid funding can support human services. Though Colorado's Department of Human Services is separate from its Department of Health Care Policy and Financing, the state expects to use more Medicaid funding for human services soon, 18 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? especially for behavioral health and homelessness services. Oregon, like other states, already attempts to maximize the use of federal Medicaid dollars for services for people with developmental disabilities and for behavioral health. In Oklahoma, multiple agencies meet regularly to determine the best use and match strategy for Medicaid and focus on getting the best match rate to draw down federal funds. The authorities of the executive and legislative branches can also affect human services funding. As discussed, in some of our case study states, the state legislature may be essentially a rubber stamp for the governor's budget. Others make only minor changes and automatically pass through block grants to the relevant agencies. In other situations-whether through the constitutional structure or party politics-the legislature can dictate how agencies spend federal block grants and essentially create policy with the budget. Further, the relationship between the executive and legislative branches can affect how quickly decisions are made. For example, in Wisconsin funding spends months in "legislative limbo," as the state legislature has unique statutes that require legislative control, and the executive branch is prevented from acting quickly or nimbly. We also heard in our interviews that legislative control of the budget, combined with legislative turnover, can impede long-term vision, such as investment in technology that can facilitate coordination and alignment or improve human services delivery. County administration of human services can also affect the flow of funding. In some states, administration of human services programs can involve counties contributing their own funding toward service delivery and program administration, states distributing state or federal funding to counties, or any combination of these. In Colorado, where counties have unusually extensive responsibility for administering and delivering (and for some programs, funding) human services, the funding available in small counties can be too low to provide adequate services. 14 More than one-third of Colorado's counties have fewer than 10,000 residents and three counties have fewer than 1,000 residents. 15 Some of these small, rural counties with limited funding may face trade-offs, for example, between child protective services and adult protective services. These counties may have enough funding for only one staff member, perhaps with limited education and salary, who single-handedly serves as the human services department for the county. The availability of funding also affects the level of competition or cooperation across agencies. As discussed, we heard from several state agency leaders that federal COVID-19 relief funds and increased state tax revenue have facilitated cooperation across agencies. Some noted that their long- standing experiences of working collaboratively across human services allowed them to better seize opportunities that expanded funding created. One leader noted that the state's child protective WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 19 services programs received additional funding following a lawsuit, which allowed the agencies to work cooperatively to address underlying problems. BOX 2 Human Services Funding and Spending Most state and local spending on human services is financed by federal transfers. In 2017, federal funding through intergovernmental transfers to state and local governments, totaling $438 billion, accounted for 65 percent of state and local "public welfare" spending. "Public welfare" here includes cash assistance through Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), and other payments made directly to individuals as well as payments to physicians and other service providers under programs like Medicaid. State and local governments spent $673 billion, or 22 percent of direct general spending, on public welfare, including federal transfers. Further, this spending was found to be the largest source of direct general spending at the state and local levels in that year, when including federal transfers. (Excluding federal transfers, spending on elementary and secondary education become the largest share of state and local spending.) Almost all-96 percent-of this public welfare spending covered operational costs, including payments to Medicaid providers and to nonprofits or other private providers of public services for low- income beneficiaries, and program administration (the largest share was vendor payments for medical care, which totaled $544 billion dollars in 2017, or 81 percent of all state and local public welfare spending). Of the remaining 4 percent, most spending was devoted toward direct cash assistance to beneficiaries of programs such as TANF, SSI, and LIHEAP, the federal Low-Income Home Energy Assistance Program. Source: "State and Local Backgrounders," Urban Institute, accessed November 17, 2022, https://www.urban.org/policy- centers/cross-center-initiatives/state-and-local-finance-initiative/state-and-local-backgrounders/public-welfare-expenditures. Effect of Governance Structures on Innovation Though having separate agencies for health and human services can impede innovation-and a combined agency can facilitate innovation-state officials provided numerous examples of innovative cross-agency problem solving. Issues other than alignment, they noted, can have at least as great an effect on agency innovation. Having multiple human services agencies or separate health and human services agencies can impede innovation, according to our interviews. When people in one department have great ideas, 20 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? they sometimes can implement those ideas only in collaboration with other departments that control access to funding or administer related programs. For example, for the New Jersey Department of Children and Families to implement their universal home visiting program they needed a Medicaid waiver that only another agency could request. In contrast, leaders in the comprehensive Massachusetts Executive Office of Health and Human Services have grown accustomed to looking at issues broadly, which has facilitated innovation. Nonetheless, our interviews also revealed numerous examples of innovative cross-agency problem solving. For example, despite Colorado having separate agencies for human services and health, their leaders' unified people-centric approach and regular meetings have facilitated innovative solutions to cross-agency problems, such as addressing the health care needs of people leaving prison, young people aging out of foster care, and people experiencing homelessness. In Oklahoma, both the Department of Human Services and the Department of Health have chief innovations officers who meet regularly to share and implement ideas. During a recent Innovation Week, the departments sponsored a "hackathon" to explore ways to improve government policies across six state agencies. Officials in New Jersey made the case that multiple agencies enable great ideas to spread further. Each department brings a different perspective and is often working with a slightly different group of individuals. For example, implementation of a universal postpartum home visiting program by the New Jersey Department of Children and Families requires participation by the state's Medicaid program, which is administered by the Department of Human Services. Pooling both departments' experience with various payers, as well as knowledge of efforts by federal partners and other state Medicaid approaches, contributed to a program design with achievable goals and operational parameters. A few leaders noted that issues other than agency structure or alignment had a greater influence on innovation. For example, the electoral cycle creates disruption in state government administration and service delivery: every few years new governors and agency leaders want to make changes but have limited time to implement and scale their ideas. In addition, the day-to-day demands of running agencies and programs leaves little time for innovating. One leader contrasted this reality of state government with the private sector, where considerable attention is focused on innovating for the future. Effects of Governance Structures on Customer Experiences Regardless of their human services structures, our case study states believe that unified access to multiple state services will best serve their customers and are working toward that goal. Though most leaders noted they have not yet achieved their vision, some states shared early examples of coordinated WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 21 service delivery. Human service structures may be more or less aligned at the county than at the state level. Nearly all of our case study states strive for a unified, person-centered approach to human services but have not yet achieved this goal, which means people are not served as well as they could be. A couple of state officials noted that outdated technology and the siloed nature of funding are challenges for achieving a unified, person-centered approach to human services. For example, one leader explained that much of the state's technology is 30 to 50 years old and the systems do not allow for sufficient communication across human services programs to create a unified experience for customers. Another leader explained that siloed funding duplicates resources and confuses customers. For example, the state has multiple hotlines funded for specific targeted demographics. Nonetheless, our case study states shared examples of coordinated service delivery. In addition to a new integrated online application for multiple programs, the Oregon Department of Human Services has launched a new initiative, Building Well-Being Together, focused on the whole well-being of people, families, and communities, especially those left behind because of race, age, disability, identity, and place. The initiative is a call to action for other government agencies, Tribes, providers, and communities to work together to ensure that everyone has the services and supports they need. A demonstration project is under way in a rural Oregon community affected by wildfire where the state will provide integrated, holistic services. They hope this will be a model they can expand elsewhere in the state. New Jersey has established 57 Family Success Centers that provide coordinated services. Likewise, Oklahoma used federal COVID-19 funding to create 52 Hope Centers during the pandemic to meet family needs created by school closures. This model evolved into the Workforce Hope Center model: in a single location on a bus line with onsite child care, customers can meet with all relevant government agencies to access resources related to work readiness, GEDs, English as a second-language education, career coaching, career education, mental health, immunizations, well-child checkups, food pantries, professional clothing closets, and more. Oklahoma has already opened at least one Workforce Hope Center and has plans for 20 to 25 more. In states with county-administered human services programs, customers' experiences depend on the county. State officials in all case study states with county administration of human services noted that county services may be more or less aligned than at the state level or in other counties. 22 WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? Conclusion Human services encompass a wide and varying range of programs and services fundamental to protecting and optimizing lifelong human development. Though there is no consensus around exactly which programs and services should be considered human services, there is growing awareness of the need to strengthen this sector. As the health care system increasingly recognizes the role of human services in addressing the social determinants of health, it is important for the health care system to better understand, support, and coordinate with the human services landscape. This report focuses on describing the human services landscape within state governments, including how state governments structure their human services agencies, the ways in which state agencies and programs align and coordinate, the factors that affect their alignment, and how state human services governance structures affect funding, innovation, and customer experiences. Drawing on interviews with leaders in human services agencies in eight states, as well as national data and interviews with national experts in human services, we found that state human services governance structures vary along multiple dimensions. The complexity of state structures and approaches to human services administration, funding, and service delivery cannot be boiled down to a few simple models. (See appendix B for an attempt to do so quantitatively.) Nor is it clear that any specific model or approach is best for supporting coordinated program administration and service delivery and providing a person-centered approach or the integrated experience for customers that many state leaders seek. Interviews with agency leaders in our case study states revealed both challenges and successes across agency structures. Factors in addition to state human services governance structures have implications for alignment, coordination, innovation, funding, and outcomes. Politics, relationships, the priorities of the governor and legislature, and state history and culture can all shape a state's approach to human services and specific policy choices. Future research could build on this description of state human services governance to investigate the combined effects of state governance structures and state policy choices on key outcomes, and how a strengthened human services sector can optimize population health, well-being, and equity while reducing costly demands on the nation's health care systems. WHAT ARE HUMAN SERVICES, AND HOW DO STATE GOVERNMENTS STRUCTURE THEM? 23 Appendix A. How Are Programs and Services Distributed across State Human Service Agencies? As summarized in the body of this report, states vary in their agency structures, including how many and which agencies administer the wide range of human services programs, services, and functions. For this study, we define the "main human services agency" as the agency overseeing the largest number of programs included in our conceptual definition of human services, as illustrated in figure 1. To identify which programs were in which agencies, we searched each state's website. Some states' public-facing websites do not clearly indicate which agencies administer which programs. To improve the accuracy of our information, we worked with the APHSA to seek confirmation or correction from a state human services administrator in every state. We received confirmation or corrections from 36 states. Nonetheless, these data include a degree of uncertainty and will likely change over time. In tables A.1–A.7, organized roughly by category of human services, we identify for each state whether each program is administered primarily by the main human services agency (indicated by an "x") or by another agency (indicated by the initials of that agency). 24 APPENDIX A TABLE A.1 State Agencies Administering Nutrition and Cash Assistance Programs Other cash assistance (general Cash assistance assistance, other Main human services agency SNAP WIC (TANF) state cash) Alabama Department of Human Resources x APH x - Alaska Department of Health x x x x Arizona Department of Economic Security x DOH x x Arkansas Department of Human Services x DOH x - California Health and Human Services Agency x x x x Colorado Department of Human Services x DPHE x x Connecticut Department of Social Services x DPH x x Delaware Department of Health and Social Services x x x x Florida Department of Children and Families x Florida Health x - Georgia Department of Human Services x DPH x x Hawaii Department of Human Services x DOH x x Idaho Department of Health and Welfare x x x - Illinois Department of Human Services x x x x Indiana Family and Social Services Administration x DOH x - Iowa Department of Health and Human Services x x x x Kansas Department for Children and Families x DHE x x Kentucky Cabinet for Health and Family Services x x x - Louisiana Department of Children and Family Services x DOH x x Maine Department of Health and Human Services x x x x Maryland Department of Human Services x DOH x x Massachusetts Executive Office of Health and Human Services x x x x Michigan Department of Health and Human Services x x x - Minnesota Department of Human Services x DOH x x Mississippi Department of Human Services x SDH x - Missouri Department of Social Services x DHSS x - Montana Department of Public Health and Human Services x x x - Nebraska Department of Health and Human Services x x x x Nevada Department of Health and Human Services x x x - New Hampshire Department of Health and Human Services x x x x New Jersey Department of Human Services x DOH x x New Mexico Human Services Department x DOH x x New York Office of Temporary and Disability Assistance x DOH x x North Carolina Department of Health and Human Services x x x x North Dakota Department of Human Services x x x x APPENDIX A 25 Other cash assistance (general Cash assistance assistance, other Main human services agency SNAP WIC (TANF) state cash) Ohio Department of Job and Family Services x DOH x - Oklahoma Human Services Department x DOH x - Oregon Department of Human Services x OHA x x Pennsylvania Department of Human Services x DOH x x Rhode Island Executive Office of Health and Human Services x x x x South Carolina Department of Social Services x DHEC x - South Dakota Department of Social Services x DOH x - Tennessee Department of Human Services x DOH x - Texas Health and Human Services Commission x x x - Utah Health and Human Services Department DWS x DWS DWS Vermont Agency of Human Services x DOH x x Virginia Office of the Secretary of Health and Human x x x x Resources Washington Department of Social and Health Services x DOH x x West Virginia Department of Health and Human Resources x x x x Wisconsin Department of Health Services x x DCF - Wyoming Department of Family Services x DOH x x Source: Urban Institute review of state websites. Information verified by 36 states. Notes: "Main human services agency" is defined as the agency with the most human services programs within. Programs and services administered by the main human services agency are marked with an "x." Programs and services administered by other agencies are marked with the agency initials. Table cells for programs without state administration are marked "-." APH = Alabama Public Health; DCF = Department of Children and Families; DHE = Department of Health and the Environment; DHEC = Department of Health and Environmental Control; DHS = Department of Health Services; DHSS Department of Health and Senior Services; DOH = Department of Health; DPH = Department of Public Health; DPHE = Department of Public Health and the Environment; DWS = Department of Workforce Services; n/a = not applicable; OHA = Oregon Health Authority; SDH = State Department of Health; SNAP = Supplemental Nutrition Assistance Program; TANF = Temporary Assistance for Needy Families; WIC = Special Supplemental Nutrition Program for Women, Infants and Children. 26 APPENDIX A TABLE A.2 State Agencies Administering Child Care, Housing, Transportation, Utility Assistance Programs, and Unemployment Insurance Utility assistance Child care Transpor- (LIHEAP, assistance Housing tation Lifeline, Unemployment Main human services agency (CCDF) programs assistance other) insurance Alabama Department of Human Resources x AHFA x DECA DOL Alaska Department of Health x AHFC - x DLWD Arizona Department of Economic Security x x - x x Arkansas Department of Human Services x x - DEE DOC California Health and Human Services Agency x BCSHA x x LWDA Colorado Department of Human Services DEC DLA DOT x DLE Connecticut Department of Social Services x DOH - x DOL Delaware Department of Health and Social Services x SHA - x DOL Florida Department of Children and Families x x - DEO DEO Georgia Department of Human Services x DCA - x DOL Hawaii Department of Human Services x - - x DLIR Idaho Department of Health and Welfare x IHFA x x DOL Illinois Department of Human Services x x x DCEO DES Indiana Family and Social Services Administration x HCDA x HCDA DWD Iowa Department of Health and Human Services x IFA - DHR WD Kansas Department for Children and Families x KHRC - x DOL Kentucky Cabinet for Health and Family Services x - - x EWDC Louisiana Department of Children and Family Services DOE HC - HC WC Maine Department of Health and Human Services x x x SHA DOL Maryland Department of Human Services - - - x DOL Massachusetts Executive Office of Health and Human Services DEEC DHCD - DHCD DUA Michigan Department of Health and Human Services x x - x DLEO Minnesota Department of Human Services x x - CD DEED Mississippi Department of Human Services x - - x DES Missouri Department of Social Services x - - x DLIR Montana Department of Public Health and Human Services x - - x DLI Nebraska Department of Health and Human Services x - - x DOL Nevada Department of Health and Human Services x - x x DETR New Hampshire Department of Health and Human Services x x x DOE DES New Jersey Department of Human Services x DCA - DCA DLWD New Mexico Human Services Department ECECD HAMFA x x DWS2 New York Office of Temporary and Disability Assistance OCFS x - x DOL North Carolina Department of Health and Human Services x x - x DOC North Dakota Department of Human Services x x - x Job Service APPENDIX A 27 Utility assistance Child care Transpor- (LIHEAP, assistance Housing tation Lifeline, Unemployment Main human services agency (CCDF) programs assistance other) insurance Ohio Department of Job and Family Services x - - DOD x Oklahoma Human Services Department x - - x ESC Oregon Department of Human Services DEL HCS x HCS ED Pennsylvania Department of Human Services x x - x DLI Rhode Island Executive Office of Health and Human Services x RIHousing x x DLT South Carolina Department of Social Services x SHFDA DHHS DOA DEW South Dakota Department of Social Services x HA x x DLR Tennessee Department of Human Services x - - HDA DLWD Texas Health and Human Services Commission WC - - DHCA WC Utah Health and Human Services Department DWS1 DWS1 - DWS1 DWS1 Vermont Agency of Human Services x HA - x DOL Virginia Office of the Secretary of Health and Human Resources x - - x EC Washington Department of Social and Health Services DCYF - - DOC ESD West Virginia Department of Health and Human Resources x - - x DOC Wisconsin Department of Health Services DCF DOA - DEHCR DWD Wyoming Department of Family Services x x - x DWS1 Source: Urban Institute review of state websites. Information verified by 36 states. Notes: "Main human services agency" is defined as the agency with the most human services programs within it. Programs and services administered by the main human services agency are marked with an "x." Programs and services administered by other agencies are marked with the agency initials. Table cells for programs without state administration are marked "-." AHFA = Alabama Housing Finance Authority; AHFC = Alaska Housing Finance Corporation; BCSHA = Business, Consumer Services and Housing Agency; CCDF = Child Care Development Fund; CD = Commerce Department; DCA = Department of Community Affairs; DCEO = Department of Commerce and Economic Opportunity; DCF = Department of Children and Families; DCYF = Department of Children, Youth, and Families; DEC = Department of Early Childhood; DECA = Department of Economic and Community Affairs; DEE = Department of Energy and the Environment; DEEC = Department of Early Education and Care; DEED = Department of Employment and Economic Development; DEHCR = Division of Energy, Housing, and Community Resources; DEL = Department of Early Learning and Care (as of 7/1/2023); DEO = Department of Economic Opportunity; DES = Department of Employment Security; DETR = Department of Employment, Training, and Rehabilitation; DEW = Department of Employment and Workforce; DHCA = Department of Housing and Community Affairs; DHCD = Department of Housing and Community Development; DHHS = Department of Health and Human Services; DHR = Department of Human Rights; DLA = Department of Local Affairs; DLE = Department of Labor and Employment; DLEO = Department of Labor and Economic Opportunity; DLI = Department of Labor and Industry; DLIR = Department of Labor and Industrial Relations; DLR = Department of Labor and Regulation; DLT = Department of Labor and Training; DLWD = Department of Labor and Workforce Development; DOA = Department of Administration; DOC = Department of Commerce; DOD = Department of Development; DOE = Department of Energy; DOH = Department of Housing; DOL = Department of Labor; DOT = Department of Transportation; DUA = Department of Unemployment Assistance; DWD = Department of Workforce Development; DWS1 = Department of Workforce Services; DWS2 = Department of Workforce Solutions; EC = Employment Commission; ECECD = Early Childhood Education and Care Department; ED = Employment Department; ESC = Employment Security Commission; ESD = Employment Security Department; EWDC = Education and Workforce Development Cabinet; HA = Housing Authority; HAD = Housing Development Agency; HAMFA = Housing Authority and Mortgage Finance Authority; HC = Housing Corporation; HCDA = Housing and Community Development Authority; HCS = Housing and Community Services; HDA = Housing Development Agency; IHFA = Idaho Housing and Finance Association; KHRC = Kansas Housing Resources 28 APPENDIX A Corporation; LIHEAP = Low-Income Home Energy Assistance Program; LWDA = Labor and Workforce Development Agency; OCFS = Office of Child and Family Services; SHA = State Housing Authority; SHFDA = State Housing, Finance, and Development Authority plus county-run programs; WC = Workforce Commission; WD = Workforce Development. TABLE A.3 State Agencies Administering Child, Family, and Community Services Child protective Youth Child support Family and services, foster development, enforcement intimate Immigrant care, adoption, prevention, and partner and Main human independent and diversion fatherhood violence Reentry Homeless refugee service agency living services services programs services programs services assistance Alabama Department of Human x DOYS x x DOC - x Resources Alaska Department of Health DFCS x DOR/DFCS x DOC HFC CSS Arizona Department of Economic DCS3 - x x x x x Security Arkansas Department of Human x x DFA - DOC - x Services California Health and Human x x x - x x x Services Agency Colorado Department of Human x x x x DOC DLA x Services Connecticut Department of Social DCF - x DCF DOC DOH x Services Delaware Department of Health and DSCYTF DSCYTF x - - x x Social Services Florida Department of Children x DJJ DOR x DOC x x and Families Georgia Department of Human x - x - DOC DCA x Services Hawaii Department of Human x x AG - - x DLIR Services Idaho Department of Health and x DJC x ICDV DOC x x Welfare Illinois Department of Human DCFS x DHFS x DES x x Services Indiana Family and Social Services DCS4 PDC DCS4 - DOC HCDA x Administration Iowa Department of Health and x DHR x - DOC IFA x Human Services APPENDIX A 29 Child protective Youth Child support Family and services, foster development, enforcement intimate Immigrant care, adoption, prevention, and partner and Main human independent and diversion fatherhood violence Reentry Homeless refugee service agency living services services programs services programs services assistance Kansas Department for Children x x x x DOC KHRC x and Families Kentucky Cabinet for Health and x DJJ x - - - - Family Services Louisiana Department of Children x x x x DOC HC GOHSEP and Family Services Maine Department of Health and x - x - DOC x - Human Services Maryland Department of Human x - x - - x x Services Massachusetts Executive Office of Health x x DOR x MPB DHCD x and Human Services Michigan Department of Health and x x x x DOC x x Human Services Minnesota Department of Human x - x - DOC x x Services Mississippi Department of Human DCPS x x - DOC - - Services Missouri Department of Social x x x - DOC x - Services Montana Department of Public x - x - DOC x - Health and Human Services Nebraska Department of Health and x - x - DCS1 x x Human Services Nevada Department of Health and x x x x x - x Human Services New Hampshire Department of Health and x x x x DOC x x Human Services New Jersey Department of Human DCF DCF x DCF x x x Services New Mexico Human Services CYFD CYFD x CYFD CD x x Department New York Office of Temporary and OCFS OCFS x OCFS DCCS x x Disability Assistance 30 APPENDIX A Child protective Youth Child support Family and services, foster development, enforcement intimate Immigrant care, adoption, prevention, and partner and Main human independent and diversion fatherhood violence Reentry Homeless refugee service agency living services services programs services programs services assistance North Carolina Department of Health and x - x DPH DPS x x Human Services North Dakota Department of Human x x x x x x x Services Ohio Department of Job and x - x - DRC - x Family Services Oklahoma Human Services x - x - - - x Department Oregon Department of Human x x DOJ x DOC/OYA x x Services Pennsylvania Department of Human x - x x DOC x x Services Rhode Island Executive Office of Health x x x Treasury x OHCD x and Human Services South Carolina Department of Social x DJJ x x DOC/DPP - x Services P South Dakota Department of Social x x x OPS-CVS DOC HA x Services Tennessee Department of Human DCS2 DCS2 x - DOC - - Services Texas Health and Human DFPS - AG - DCJ x - Services Commission Utah Health and Human x x x - - DWS DWS Services Department Vermont Agency of Human Services x x x - x x x Virginia Health and Human x DJJ x x - DHCD x Resources Washington Department of Social and DCYF DCYF x x DOC DC x Health Services West Virginia Department of Health and x - x - - - x Human Resources Wisconsin Department of Health DCF DCF DCF DCF x - x Services Wyoming Department of Family x x x AG DOC x - Services Source = Urban Institute review of state websites. Information verified by 36 states. APPENDIX A 31 Notes = "Main human services agency" is defined as the agency with the most human services programs within it. Programs and services administered by the main human services agency are marked with an "x.". Programs and services administered by other agencies are marked with the agency initials. Table cells for programs without state administration are marked "-."AG = Attorney General; CD = Corrections Department; CSS = Catholic Social Services; CYFD = Children, Youth, and Families Department; DC = Department of Commerce; DCA = Department of Community Affairs; DCCS = Department of Corrections and Community Supervision; DCF = Department of Children and Families; DCFS = Department of Children and Family Services; DCJ = Department of Criminal Justice; DCPS = Department of Child Protection Services; DCS1 = Department of Correctional Services; DCS2 = Department of Children's Services; DCS3 = Department of Child Safety; DCS4 = Department of Child Services; DCYF = Department of Children, Youth, and Families; DES = Department of Employment Security; DFA = Department of Finance and Administration; DFCS = Department of Family and Community Services; DFPS = Department of Family and Protective Services; DHCD = Department of Housing and Community Development; DHFS = Department of Healthcare and Family Services; DHR = Department of Human Rights; DJC = Department of Juvenile Corrections; DJJ = Department of Juvenile Justice; DLA = Department of Local Affairs; DLIR = Department of Labor and Industrial Relations; DOC = Department of Corrections; DOJ = Department of Justice; DOR = Department of Revenue; DOYS = Department of Youth Services; DPH = Department of Public Health; DPPP = Department of Probation, Parole, and Pardon Services; DPS = Department of Public Safety; DRC = Department of Rehabilitation and Correction; DSCYTF = Department of Services for Children, Youth, and Their Families; DWS = Department of Workforce Services; FPS = Department of Family and Protective Services; HA = Housing Authority; HC = Housing Corporation; HCDA = Housing and Community Development Authority; HCS = Housing and Community Services; HFC = Housing Finance Corporation; ICDV = Idaho Council on Domestic Violence; IFA = Iowa Finance Authority; GOHSEP = Governor's Office of Homeland Security and Emergency Preparedness; KHRC = Kansas Housing Resources Corporation; MPB = Massachusetts Parole Board; OCFS = Office of Child and Family Services; OHCD = Office of Housing and Community Development; OPS-CVS = Office of Public Safety–Crime Victims Services; OYA = Oregon Youth Authority; PDC = Public Defender Council; Treasury = Crime Victims Compensation Program. TABLE A.4 State Agencies Administering Disability and Independent Living Services Early identification Disability-related Community-based Main human services agency and intervention services and supports behavioral health Alabama Department of Human Resources DRS x x Alaska Department of Health x x x Arizona Department of Economic Security x x - Arkansas Department of Human Services x x x California Health and Human Services Agency x x x Colorado Department of Human Services DEC x x Connecticut Department of Social Services - DDS x Delaware Department of Social Services x x x Florida Department of Health and Social Services DOH APD x Georgia Department of Children and Families - DBHDD x Hawaii Department of Human Services x x - Idaho Department of Human Services x x x Illinois Department of Health and Welfare x x x Indiana Department of Human Services x x x Iowa Family and Social Services Administration x x x Kansas Department of Health and Human Services - DADS DADS Kentucky Department for Children and Families x x x Louisiana Cabinet for Health and Family Services DOH DOH DOH Maine Department of Children and Family Services x x x 32 APPENDIX A Early identification Disability-related Community-based Main human services agency and intervention services and supports behavioral health Maryland Department of Health and Human Services - DOD - Massachusetts Department of Human Services x x x Michigan Executive Office of Health and Human Services x x x Minnesota Department of Health and Human Services x x x Mississippi Department of Human Services x DRS DMH Missouri Department of Human Services DESE - DMH Montana Department of Social Services - x - Nebraska Department of Health and Human Services x x x Nevada Department of Health and Human Services x x x New Hampshire Department of Health and Human Services x x x New Jersey Department of Human Services x x x New Mexico Human Services Department DOH x x New York Office of Temporary and Disability Assistance DOH OPDD OMH North Carolina Department of Health and Human Services x x x North Dakota Department of Human Services x x x Ohio Department of Job and Family Services DDD DDD DMHAS Oklahoma Human Services Department DOH x DMHSAS Oregon Department of Human Services - x HA Pennsylvania Department of Human Services x x - Rhode Island Executive Office of Health and Human Services x x x South Carolina Department of Social Services BabyNet DDSN DMH South Dakota Department of Social Services - DHS x Tennessee Department of Human Services - x DMHSAS Texas Health and Human Services Commission x x x Utah Health and Human Services Department - x x Vermont Agency of Human Services - x x Virginia Office of the Secretary of Health and Human Resources x x x Washington Department of Social and Health Services DCYF x HCA West Virginia Department of Health and Human Resources x - x Wisconsin Department of Health Services x x x Wyoming Department of Family Services DOH DOH DOH Source: Urban Institute review of state websites. Information verified by 36 states. Notes: "Main human services agency" is defined as the agency with the most human services programs within it. Programs and services administered by the main human services agency are marked with an "x." Programs and services administered by other agencies are marked with the agency initials. Table cells for programs without state administration are marked "- ."APD = Agency for Persons with Disabilities; DADS = Department for Aging and Disability Services; DBHDD = Department of Behavioral Health and Developmental Disabilities; DCYF = Department of Children, Youth, and Families; DDD = Department of Developmental Disabilities; DDS = Department of Developmental Services; DDSN = Department of Disabilities and Special Needs; DEC = Department of Early Childhood; DESE = Department of Elementary and Secondary Education; DHS = Department of Human Services; DMH = Department of Mental Health; DMHAS = Department of Mental Health and Addiction Services; DMHSAS = Department of Mental Health and Substance Abuse Services; DOD = Department of Disabilities; DOH APPENDIX A 33 = Department of Health; DRS = Department of Rehabilitation Services; DSS = Department of Senior Services; HA = Health Authority; HCA = Health Care Authority; OMH = Office of Mental Health; OPDD = Office for People with Developmental Disabilities. TABLE A.5 State Agencies Administering Aging and Senior Services Adult Home-delivered Aging protective Housing and meals/community services services and home-based Main human services agency dining centers elder justice supports Transportation Alabama Department of Human Resources DSS DSS x x x Alaska Department of Health x x x x x Arizona Department of Economic Security x x x x - Arkansas Department of Human Services x x x x x California Health and Human Services Agency x x x x x Colorado Department of Human Services x x x x x Connecticut Department of Social Services DADS DADS x x DDS Delaware Department of Health and Social Services x x x x x Florida Department of Children and Families DEA DEA DEA DEA DEA Georgia Department of Human Services x x x x - Hawaii Department of Human Services DOH DOH x DOH x Idaho Department of Health and Welfare CA CA CA CA CA Illinois Department of Human Services DA DA DA DA DA Indiana Family and Social Services Administration x x x x - Iowa Department of Health and Human Services DA DA x DA DA Kansas Department for Children and Families x DADS x DADS - Kentucky Cabinet for Health and Family Services x x x x - Louisiana Department of Children and Family Services DOH DOH DOH DOH - Maine Department of Health and Human Services x x x x - Maryland Department of Human Services DA DA x x - Massachusetts Executive Office of Health and Human x x x x - Services Michigan Department of Health and Human Services x x x x x Minnesota Department of Human Services x x x x - Mississippi Department of Human Services x x x x x Missouri Department of Social Services DHSS DHSS DHSS DHSS - Montana Department of Public Health and Human x x x x x Services Nebraska Department of Health and Human Services - x x - - Nevada Department of Health and Human Services x x x x - New Hampshire Department of Health and Human Services x x x x x 34 APPENDIX A Adult Home-delivered Aging protective Housing and meals/community services services and home-based Main human services agency dining centers elder justice supports Transportation New Jersey Department of Human Services x x x x x New Mexico Human Services Department ALSD ALSD ALSD ALSD ALSD New York Office of Temporary and Disability OA OA OCFS/OA OA OA Assistance North Carolina Department of Health and Human Services x x x x x North Dakota Department of Human Services x x x x x Ohio Department of Job and Family Services DA DA x DA - Oklahoma Human Services Department x x x x - Oregon Department of Human Services x x x x x Pennsylvania Department of Human Services x DA DA x/DA - Rhode Island Executive Office of Health and Human x x x x x Services South Carolina Department of Social Services DA DA x DA - South Dakota Department of Social Services DHS DHS DHS DHS DHS Tennessee Department of Human Services CAD CAD x CAD CAD Texas Health and Human Services Commission x x x x - Utah Health and Human Services Department x - x x - Vermont Agency of Human Services x x x x - Virginia Office of the Secretary of Health and x - x x - Human Resources Washington Department of Social and Health Services x x x x - West Virginia Department of Health and Human - BSS x BSS - Resources Wisconsin Department of Health Services x x x x - Wyoming Department of Family Services DOH DOH x DOH DOH Source: Urban Institute review of state websites. Information verified by 36 states. Notes: "Main human services agency" is defined as the agency with the most human services programs within it. Programs and services administered by the main human services agency are marked with an "x." Programs and services administered by other agencies are marked with the agency initials. Table cells for programs without state administration are marked "-." ADSS = Department of Senior Services; ALSD = Aging and Long-Term Services Department; BSS = Bureau of Senior Services; CA = Commission on Aging; CAD = Commission on Aging and Disability; DA = Department on Aging; DADS = Department of Aging and Disability Services; DDS = Department of Developmental Services; DEA = Department of Elder Affairs; DHS = Department of Human Services; DHSS = Department of Health and Senior Services; DOH = Department of Health; DSS = Department of Senior Services; OA = Office for the Aging; OCFS = Office of Child and Family Services. APPENDIX A 35 TABLE A.6 State Agencies Administering Workforce Development and Financial Well-Being Services Employment Vocational Financial related services rehabilitation and education, for people work support for asset receiving cash Summer veterans, dislocated building, and in-kind youth Apprenticeship workers, and people other Main human services agency benefits employment programs with disabilities financial Alabama Department of Human Resources x x DOC DRS x Alaska Department of Health x DLWD DLWD DLWD - Arizona Department of Economic Security x - x x - Arkansas Department of Human Services DOC - DOC DOC - California Health and Human Services Agency x LWDA LWDA x BCSHA Colorado Department of Human Services x DLE DLE DLE - Connecticut Department of Social Services x DOL DOL DADS - Delaware Department of Health and Social x - DOL DOL - Services Florida Department of Children and Families DEO - DEO DOE DFS Georgia Department of Human Services x x DOE VRA - Hawaii Department of Human Services x - DLIR x - Idaho Department of Health and Welfare x DOL DOL x - Illinois Department of Human Services x x DES x - Indiana Family and Social Services x - DWD x - Administration Iowa Department of Health and Human x - DWD DOE - Services Kansas Department for Children and Families x - DOC x - Kentucky Cabinet for Health and Family Services x EWDC EWDC EWDC - Louisiana Department of Children and Family x - WC WC - Services Maine Department of Health and Human x DOL DOL DOL - Services Maryland Department of Human Services x DOL DOL DOE - Massachusetts Executive Office of Health and Human x multiple EOLWD x - Services Michigan Department of Health and Human x - DLEO DLEO - Services Minnesota Department of Human Services x DEED DLI DEED - Mississippi Department of Human Services x - DES DRS - Missouri Department of Social Services x DHEWD DHEWD DESE - 36 APPENDIX A Employment Vocational Financial related services rehabilitation and education, for people work support for asset receiving cash Summer veterans, dislocated building, and in-kind youth Apprenticeship workers, and people other Main human services agency benefits employment programs with disabilities financial Montana Department of Public Health and x - DLI x - Human Services Nebraska Department of Health and Human - - DOL DOE - Services Nevada Department of Health and Human x - DBI DBI - Services New Department of Health and Human x DOE DOL x x Hampshire Services New Jersey Department of Human Services x DLWD DLWD DLWD - New Mexico Human Services Department x DWS DWS DVR DWS New York Office of Temporary and Disability x x DOL ED - Assistance North Carolina Department of Health and Human x - - x x Services North Dakota Department of Human Services x - DOC x DOC Ohio Department of Job and Family x x x OOD - Services Oklahoma Human Services Department x - OWD DRS - Oregon Department of Human Services x - BLI x x Pennsylvania Department of Human Services x - DLI DLI - Rhode Island Executive Office of Health and Human x DOE DLT x Treasurer Services South Carolina Department of Social Services x - TCS VRD Treasurer South Dakota Department of Social Services DLR DLR DLR DHS - Tennessee Department of Human Services DLWD DLWD DLWD x - Texas Health and Human Services WC - WC WC - Commission Utah Health and Human Services DWS DWS DWS DWS - Department Vermont Agency of Human Services x - DOL x x Virginia Health and Human Resources x - DLI x - Washington Department of Social and Health x - DLI x DOC Services West Virginia Department of Health and Human x GIP DED DRS STO Resources APPENDIX A 37 Employment Vocational Financial related services rehabilitation and education, for people work support for asset receiving cash Summer veterans, dislocated building, and in-kind youth Apprenticeship workers, and people other Main human services agency benefits employment programs with disabilities financial Wisconsin Department of Health Services x - DWD DWD - Wyoming Department of Family Services DWS - DWS DWS - Source: Urban Institute review of state websites. Information verified by 36 states. Notes: "Main human services agency" is defined as the agency with the most human services programs within it. Programs and services administered by the main human services agency are marked with an "x." Programs and services administered by other agencies are marked with the agency initials. Table cells for programs without state administration are marked "-." BCSHA = Business, Consumer Services, and Housing Agency; BLI = Bureau of Labor and Industries; CEO = ; DBI = Department of Business and Industry; DCF = Department of Children and Families; DED = Department of Economic Development; DEED = Department of Employment and Economic Development; DEO = Department of Economic Opportunity; DES = Department of Employment Security; DESE = Department of Elementary and Secondary Education; DFS = Department of Financial Services; DHEWD = Department of Higher Education and Workforce Development; DHS = Department of Human Services; DLE = Department of Labor and Employment; DLEO = Department of Labor and Economic Opportunity; DLI = Department of Labor and Industry; DLIR = Department of Labor and Industrial Relations; DLR = Department of Labor and Regulation; DLT = Department of Labor and Training; DLWD = Department of Labor and Workforce Development; DOC = Department of Commerce; DOE = Department of Education; DOL = Department of Labor; DRS = Division of Rehabilitation Services; DSS = Department of Social Services; DVR = Division of Vocational Rehabilitation; DWD = Department of Workforce Development; DWS = Department of Workforce Services; DWSS = Division of Welfare and Supportive Services; ED = Education Department; ES = Employment Security; EmD = Employment Department; EOLWD = Executive Office of Labor and Workforce Development; EWDC = Education and Workforce Development Cabinet; GIP = Governor's Internship Program; LWDA = Labor and Workforce Development Agency; OOD = Opportunities for Ohioans with Disabilities; OWD = Office for Workforce Development; TCS = Technical College System (Apprenticeship Carolina); VRA = Vocational Rehabilitation Agency; VRD = Vocational Rehabilitation Department; WC = Workforce Commission. 38 APPENDIX A TABLE A.7 State Agencies Administering Medicaid and Public Health Designated Medicaid Main human services agency Medicaid eligibility single state agency Public health Alabama Department of Human Resources x AL Medicaid DPH Alaska Department of Health x x x Arizona Department of Economic Security HCCCS HCCCS - Arkansas Department of Human Services x x DOH California Health and Human Services Agency x x x Colorado Department of Human Services DHCPF DHCPF DHCPF Connecticut Department of Social Services x x DPH Delaware Department of Health and Social Services x x x Florida Department of Children and Families x x - Georgia Department of Human Services x DCH DPH Hawaii Department of Human Services x x - Idaho Department of Health and Welfare x x x Illinois Department of Human Services x DHFS DPH Indiana Family and Social Services Administration x x DOH Iowa Department of Health and Human Services x x x Kansas Department for Children and Families DHE DHE/DADS DHE Kentucky Cabinet for Health and Family Services x x x Louisiana Department of Children and Family Services DOH DOH DOH Maine Department of Health and Human Services x x x Maryland Department of Human Services DOH DOH - Massachusetts Executive Office of Health and Human Services - x x Michigan Department of Health and Human Services x x x Minnesota Department of Human Services x x - Mississippi Department of Human Services DOM DOM - Missouri Department of Social Services x x DHSS Montana Department of Public Health and Human Services x x x Nebraska Department of Health and Human Services x x x Nevada Department of Health and Human Services x x x New Hampshire Department of Health and Human Services x x x New Jersey Department of Human Services - x DOH New Mexico Human Services Department x x DOH New York Office of Temporary and Disability Assistance - DOH - North Carolina Department of Health and Human Services - x x North Dakota Department of Human Services x x x Ohio Department of Job and Family Services DOM DOM DOH Oklahoma Human Services Department HCA HCA - Oregon Department of Human Services DHS HA HA APPENDIX A 39 Designated Medicaid Main human services agency Medicaid eligibility single state agency Public health Pennsylvania Department of Human Services x x - Rhode Island Executive Office of Health and Human Services x x x South Carolina Department of Social Services DHHS DHHS DHEC South Dakota Department of Social Services x x DOH Tennessee Department of Human Services - TennCare - Texas Health and Human Services Commission x x - Utah Health and Human Services Department DOH DOH - Vermont Agency of Human Services x x DOH Virginia Health and Human Resources x x - Washington Department of Social and Health Services - HCA DOH West Virginia Department of Health and Human Resources x x x Wisconsin Department of Health Services x x x Wyoming Department of Family Services DOH DOH DOH Source: Urban Institute review of state websites. Information verified by 36 states. Notes: "Main human services agency" is defined as the agency with the most human services programs within it. Programs and services administered by the main human services agency are marked with an "x". Programs and services administered by other agencies are marked with the agency initials. Table cells for programs without state administration are marked "- ."AHCA = Agency for Health Care Administration; DADS = Department for Aging and Disability Services; DCH = Department of Community Health; DHCPF = Department of Health Care Policy and Financing; DHE = Department of Health and Environment; DHEC = Department of Health and Environmental Control; DHFS = Department of Healthcare and Family Services; DHHS = Department of Health and Human Services; DHS = Department of Human Services; DHSS = Department of Health and Senior Services; DOH = Department of Health; DOM = Department of Medicaid; DPH = Department of Public Health; HA = Health Authority; HCA = Health Care Authority; HCCCS = Health Care Cost Containment System. 40 APPENDIX A Appendix B. Are There Key Types of State Human Services Governance Structures? The variations in state human services governance structures lead to the question of whether states tend to follow a limited number of approaches to human services governance. Although qualitative analysis of our case studies led us to conclude that the complexity of state human services governance structures cannot be summarized in a few simple models, we examined this question statistically by conducting a formal cluster analysis to see how states fell into groups on the basis of the characteristics of their human services governance structures. The cluster analysis focused specifically on state governance structure: we included a wide range of elements of structure and excluded any characteristics of state policy, outcomes, and context. We found that the empirical groupings of states emerging from the cluster analysis did not resonate with people's experiences and are not especially useful on a practical basis. This finding is perhaps not surprising, given that people familiar with state human services typically, and sensibly, consider not only governance structures but also aspects of policy, outcomes, and state context deliberately excluded from our cluster analysis. More interesting, this finding suggests that governance structures have limited influence on policy and outcomes and are not determined by state contextual characteristics. Nonetheless, this statistical examination of the data may contribute to future work. Methods Cluster analysis is an unsupervised machine learning technique that uses algorithms to examine state-by- state data on a large number of variables. The algorithms create groups of states whose characteristics are quantitatively most similar to other states in their group and most different from the states in other groups. Our analysis plan was to (1) select variables on the basis of subject matter expertise and gather available state-by-state data on those variables, (2) standardize continuous variables by dummy encoding and reweighting categorical variables and rescaling ordinal variables, (3) perform principal component analysis to decorrelate variables and focus on the variables that contribute the most variation to the data, (4) use k- means clustering with many values of k, (5) pick the best model, (6) validate and test for robustness, and (7) summarize the clusters using variables included in the typology and contextual variables. APPENDIX B 41 We selected variables to include in the analysis using a literature scan and interviews with experts in human services and human services governance. This background research suggested which conceptual dimensions of difference across state approaches to human services governance we would include. We aimed to include variables and data that represented the broad range of human services programs and functions included in figure 1. Nonetheless, the variables and data skew somewhat toward cash and in- kind benefits, especially TANF and SNAP. As discussed earlier in this report, nearly all states include these programs in their main human services agencies. A smaller number of states include the other categories of programs and functions, such as aging and senior services or workforce development services. For each concept identified as an important dimension of state differences in approaches to human services governance, we identified not only specific variables representing those concepts but also state-by- state data quantifying those variables. The data used in the cluster analysis come from a wide variety of sources. The data have several limitations. A fundamental limitation is that data cannot capture the nuance of reality, especially for an enterprise as complex and nuanced as governance. For example, the Association of State Administrators Project survey includes extensive data on details of governance. Yet, its results rely on state administrators reducing the complexity of their legislatures' influence on human services policy changes to a categorical response of slight, moderate, or high. In addition, because several variables contain missing values and most clustering algorithms are not robust to missing data, we filled missing values by pulling information from other years for nonresponse, with mean imputation, and with nearest neighbor imputation. After identifying and gathering the state-by-state data, we processed variables to standardize continuous variables, convert categorical variables into numeric variables, reweight the variables to account for correlations between variables, and then add weights to variables based on theory and subject-matter expertise. We then performed principal component analysis to decorrelate variables and focus on the variables that contributed the most variation to the data. Finally, we applied the cluster analysis methods to small, medium, and large sets of variables and tried a range of methods of preprocessing and algorithms. K-means clustering with principal components analysis performed the best. This process resulted in five clusters we summarize qualitatively and quantitatively. Results In this section, we present the results of the cluster analysis, including which states fall into each of the five clusters and descriptions of the clusters. These descriptions capture the typical characteristics of the cluster 42 APPENDIX B and may not be applicable to every state within the cluster. Each of the 50 states is assigned to one cluster using data that characterize the structure of its human services. The data relate directly to human services and do not characterize the structure of other policy areas within states. States were clustered on the following bases:  their alignment of human services programs  the authority of the executive versus legislative branches over human services' budgets and policies  their use of combined applications for human services programs  the degree of county authority in budgeting, policy, and program administration for human services  the extent of contracting  their average salaries for human services personnel relative to salaries of all state employees  recent reforms to human services  the role of community advocates and the nonprofit sector in human services  their investment in human services Figure B.1 shows how each state fits into each of the five clusters. Table B.1 details the characteristics of clusters according to key dimensions of human services structures. FIGURE B. 1 Map of States by Cluster Assignment Source: Urban Institute analysis. APPENDIX B 43 TABLE B.1 Cluster Descriptions Based on Dimensions of Human Services Structures Salaries for human services State Authority of executive versus personnel investment Color legislature over budget and Combined County relative to all Recent in public on map policy applications administration Contracting state employees reform welfare Blue High levels of governor budget Average number of High county Slightly Relatively high Recent Much higher proposing, high ability of human services administration of higher use of ratio of public reform to public governor to reorganize agency agencies and more SNAP, TANF, CSE, service welfare salaries human welfare services, greater likelihood that than half of states Medicaid delivery relative to all state services spending agency head approves social use multiple contribution and contracts employees agencies relative to services appointee, agency head applications or eligibility compared more total or cabinet approves welfare portals with other clusters likely expenditures appointee, average legislative and average county oversight of human services administration for CCDF, SSBG, and AAA Yellow Average levels of governor Only one human Average county Average use Average ratio of Recent Average budget control, greater services agency and administration for of service public welfare reform to spending on likelihood that governor 1 in 3 states use SNAP, TANF, CSE, delivery salaries relative to human public approves welfare or social multiple applications CCDF, SSBG, AAA, contracts all state services welfare services appointee (but may be or portals Medicaid employees agencies relative to appointed by agency head or contribution and more other cabinet), greater legislative eligibility compared likely expenditures oversight of human services or with other clusters joint governor-legislative oversight Black Lower levels of governor budget Only one human Average county Slightly Average ratio of Less likely Average control; average ability of services agency and administration for higher use of public welfare to have spending on governor to reorganize agency more than half of SNAP, TANF, service salaries relative to recent public services; greater likelihood that states use multiple CCDF, SSBG delivery all state reform to welfare cabinet approves social services applications or compared with contracts employees human relative to appointee; agency head, cabinet, portals other clusters and services other or civil service approves welfare low county agencies expenditures appointee; high levels of administration for legislative oversight of human CSE and AAA, and services Medicaid contribution, no 44 APPENDIX B Salaries for human services State Authority of executive versus personnel investment Color legislature over budget and Combined County relative to all Recent in public on map policy applications administration Contracting state employees reform welfare county administration of Medicaid eligibility Grey High levels of governor budget Slightly higher Average county Average use Relatively low Average Average proposing, average ability of number of human administration for of service ratio of public likelihood spending on governor to reorganize agency services agencies SNAP, TANF, delivery welfare salaries of recent public services, greater likelihood that and relatively few CCDF, SSBG, AAA; contracts relative to all state human welfare governor or agency head states use multiple high county employees services relative to approves social services and applications or administration of reform other welfare appointees, no shared portals CSE and Medicaid expenditures oversight of human services contribution, no (only done by legislature) county administration of Medicaid eligibility Pink High levels of governor budget Highest number of No county Average use Relatively low Average Average control; average ability of human services administration of of service ratio of public likelihood spending on governor to reorganize agency agencies and most SNAP, TANF, CSE, delivery welfare salaries of recent public services; no shared oversight of states (3 in 4) use CCDF, SSBG, and contracts relative to all state human welfare human services (only oversight multiple applications Medicaid eligibility; employees services relative to by legislature); equally likely or portals high levels of reform other governor, agency head, or county AAA, low expenditures cabinet approves welfare county Medicaid appointee; governor approves contribution social service appointee Source: Urban Institute analysis. AAA = area agency on aging; CCDF =Child Care Development Fund; CSE = child support enforcement; SNAP = Supplemental Nutrition Assistance Program; SSBG = Social Services Block Grant; TANF = Temporary Assistance for Needy Families. APPENDIX B 45 To rule out the possibility that one or two variables drive the results we observe, we use a predictive model to determine variable importance for the five clusters. 16 We find that all variables contribute and the top 10 variables are relatively balanced. The typology focuses on variables that describe the structure of state-level human services. Variables related to state demographics and specific human services programs may be useful to provide a broader picture of the characteristics of each cluster. While these variables are not used to develop the typology, they are intimately tied with human services programs and administration at the state level. Limitations Cluster analysis is summarization. Data summarization removes some information in exchange for clarity and understanding. For example, means are useful but they remove information about the shape and spread of a variable. Cluster analysis is useful, but it hides the unique dimensions of observations. Cluster analysis simultaneously considers all dimensions instead of one or two dimensions at a time. The structure of state human services is complicated. This typology adds clarity through summary, but states within a given cluster can differ dramatically on one or two variables at a time. Discussion This typology describes observed structure in the data. The typology does not describe why states have their structure of state human services. The structures of state human services are the products of policy decisions over decades that reflect demographics, economics, structural racism, and politics. The typology also does not describe how structures affect outcomes in states. It is impossible to model the effects of state human services structure on outcomes without first understanding state human services structure. We hope this typology can contribute to future work. 46 APPENDIX Notes 1 "Building a New Narrative on Human Services," FrameWorks Institute, https://www.frameworksinstitute.org/toolkit/human-services/. 2 Colorado, Kentucky, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, and Wisconsin were chosen to reflect diversity along several dimensions of interest, including number of state human services agencies, Medicaid expansion status, number of county-administered programs, the governor's budget-making and oversight power, region, population density, and party distribution among state legislators. Selection also considered suggestions from experts and whether the states were included in related projects. 3 We also consulted the National Taxonomy of Exempt Entities (NTEE) system used by the IRS and others to classify nonprofit organizations. The NTEE classifies the following topics within its broad "human services" category: criminal and legal related; employment; food, agriculture, and nutrition; housing and shelter; public safety, disaster preparedness and relief; recreation and sports; youth development; and human services. For more information on NTEE codes, see Deondre Jones, "National Taxonomy of Exempt Entities (NTCC) Codes," Urban Institute National Center for Charitable Statistics, 2019, https://nccs.urban.org/project/national- taxonomy-exempt-entities-ntee-codes. 4 La Follette School of Public Affairs, American State Administrators Project (ASAP) survey, University of Wisconsin–Madison, 2008, https://asap.wisc.edu. 5 The 10 states that share SNAP program administration with county governments are California, Colorado, Minnesota, New Jersey, New York, North Carolina, North Dakota, Ohio, Virginia, and Wisconsin. 6 The 11 states that administer TANF by county or locality are California, Colorado, Maryland, Minnesota, New Jersey, New York, North Carolina, North Dakota, Ohio, Virginia, and Wisconsin. 7 The seven programs and functions counted are SNAP, TANF, child welfare, child support enforcement, the Child Care Development Fund, the Social Services Block Grant, and Medicaid eligibility determinations. To identify and measure the degree of county administration in a state, we relied on data from various sources: SNAP (NACo 2019); TANF (NACo 2018); child welfare (Child Welfare Information Gateway 2018); child support enforcement (Fishman and Dybdal 1999); Child Care Development Fund (NACo 2020); Social Services Block Grant (Mackey 2022); and Medicaid eligibility determinations (unpublished compilation from various sources). 8 To identify and measure state human service agencies' use of contracting, we relied on state human services agency administrators' responses to the 2008 American State Administrators Project survey. We used two American State Administrators Project survey questions: (1) a yes/no question, "In recent years, some state agencies have used contracts (or contracting out) to outsource the delivery services to the public. Does your agency use such contracts?" Respondents who answered "yes" to the first question were then asked, (2) "Currently, about what percentage of your agency's budget is allocated to contracting for delivery of services to the public?" Administrators were offered a choice from six categorical responses: 5 percent or less, 6–10 percent, 11–20 percent, 21–30 percent, 31–40 percent, and more than 40 percent. 9 California, Oregon, Texas, and Vermont provided no information about their use of service delivery contracts in the American State Administrators Project Survey. 10 La Follette School of Public Affairs, American State Administrators Project (ASAP) survey, University of Wisconsin–Madison, 2008, https://asap.wisc.edu. 11 Code for America, "Bringing Social Safety Net Benefits Online: Examining Online Platforms for All 50 States," 2019, accessed October 22, 2022, https://www.codeforamerica.org/features/bringing-social-safety-net- benefits-online/. NOTES 47 12 "How the COVID-19 Pandemic Is Transforming State Budgets," Urban Institute, April 16, 2021, https://www.urban.org/policy-centers/cross-center-initiatives/state-and-local-financeinitiative/projects/state- fiscal-pages-covid-edition. 13 Medicaid and CHIP Payment and Access Commission (MACPAC), "Medicaid 101/Administration," accessed October 22, 2022, https://www.macpac.gov/medicaid-101/administration/. 14 See Hahn, Gearing, and others (2015) for details on the roles of counties in Colorado and other states in TANF administration, funding, and service delivery. 15 Cubit, "Colorado Counties by Population," accessed November 7, 2022 https://www.colorado- demographics.com/counties_by_population. 16 We use a random forests model with cluster ID as the outcome variable. This is necessary because we reduce dimensions with principle component analysis before applying the k-means algorithm. 48 NOTES References Cahill, Rachel Meeks, Jennifer Tracy, and Andrew Cheyne. 2018. "Ten Degrees of Decentralization: Overview of SNAP Operations in County-Administered States." Washington, DC: CLASP. Child Welfare Information Gateway. 2018. "State vs. County Administration of Child Welfare Services." Washington, DC: Children's Bureau. Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation's Health. 2019. Integrating Social Care into the Delivery of Health Care Moving Upstream to Improve the Nation's Health. Washington, DC: National Academies of Sciences, Engineering, and Medicine. Fishman, Michael E., and Kristin Dybdal. 1999. State Financing of Child Support Enforcement Programs. Report prepared for Assistant Secretary for Planning and Evaluation and Office of Child Support Enforcement. Washington, DC: US Department of Health and Human Services. Hahn, Heather, Maeve E. Gearing, Michael Katz, and Ria Amin. 2015. Observations of Leaders Driving Changes in State Government: Leadership Tools and Lessons from Two Work Support Strategies States. Washington, DC: Urban Institute. Hahn, Heather, David Kassabian, Lina Breslav, and Yvette Lamb. 2015. A Descriptive Study of County- versus State- Administered Temporary Assistance for Needy Families Programs. Washington, DC: Urban Institute. HHS (US Department of Health and Human Services, Administration for Children and Families, Office of Family Assistance). 2018. Temporary Assistance for Needy Families: 12th Report to Congress, Fiscal Years 2014 and 2015. Washington, DC: US Department of Health and Human Services. Kresge Foundation. 2014. A Call for Action: Strengthening the Human Services Sector. Troy, MI: Kresge Foundation. Mackey, Rachel. 2022. "Support the Social Services Block Grant (SSBG)." Washington, DC: National Association of Counties. McGuire, Jean, and Kim Shellenberger. 2019. A Review of Healthcare and Human Services Engagement. Boston: Northeastern University. NACo (National Association of Counties). 2018. "Counties and the Temporary Assistance for Needy Families Program." Washington, DC: NACo. ---. 2019. "Understanding the County Role in the Supplemental Nutrition Assistance Program." Washington, DC: NACo. ---. 2020. "Proposals to Address the COVID-19 Child Care Crisis." Washington, DC: NACo. Oliver Wyman. 2017. A National Imperative: Joining Forces to Strengthen Human Services in America. Washington, DC: Alliance for Strong Families and Communities. REFERENCES 49 About the Authors Heather McCallum Hahn is associate vice president for the Center on Labor, Human Services, and Population at the Urban Institute. She is a national expert on Temporary Assistance for Needy Families (TANF) with more than two decades of experience conducting research on policies affecting the well- being of children and families, including TANF, the Supplemental Nutrition Assistance Program, child care subsidies, child support, and other supports for families with low incomes. She coleads Urban's From Safety Net to Solid Ground initiative, providing timely and rigorous analyses of state and federal policy changes and the Kids' Share project, examining federal spending and tax expenditures on children. Before joining Urban, Hahn was an assistant director for education, workforce, and income security issues at the US Government Accountability Office. She holds a BA in philosophy and certificate in women's studies from Brandeis University, an MPP from Duke University, and a PhD in political science from Stanford University. Eleanor Pratt is a research associate in the Center on Labor, Human Services, and Population. Her work focuses on racial equity, the social safety net, and policies related to poverty and family well-being. Before rejoining Urban, Pratt translated research to policy at the Institute for Research on Poverty, wrote and managed grants with Heartland Alliance, and worked in the Office of the Mayor of the City of Chicago. She started her career as a research assistant at the Urban Institute. She holds a BA in sociology and anthropology from Swarthmore College and an MPA from the University of Wisconsin– Madison. DaQuan Lawrence is a research analyst in the Health Policy Center at the Urban Institute. His research focuses on vaccine access in communities with low incomes, health equity in Medicaid, and state human services structures. He has previous experience researching rights and international public policy and working in the Dominican Republic, Haiti, Indonesia, Liberia, and South Africa. Outside Urban, Lawrence is cofounder and chairman of Strong Men Overcoming Obstacles Through Hard-work (SMOOTH) Inc., a nonprofit that aims to educate, develop, empower, and organize young Black men to improve their graduation and retention rates during their public school or college matriculation. Lawrence holds a bachelor's degree in sociology with a minor in philosophy and criminal justice from Morgan State University and received his master's degree in international public policy from the Johns Hopkins University School of Advanced International Studies. He is pursuing a doctoral degree in African Studies with a focus on public policy at Howard University. 50 ABOUT THE AUTHORS Laudan Y. Aron is a senior fellow in the Health Policy Center. Since joining Urban in 1992, she has spent more than 25 years conducting research and policy analysis on a wide range of social welfare issues, including health and disability, education, employment and training, homelessness, and family violence. She directed and coedited the groundbreaking 2013 study for the National Research Council and Institute of Medicine US Health in International Perspective: Shorter Lives, Poorer Health, which found a large and growing US "health disadvantage" relative to other high-income countries. Her work focuses on how social and economic conditions shape health and well-being, and how social welfare programs (broadly defined) can best support healthy human development across the life course and over time and place. Aron holds a BS in mathematics from McGill University and an MA in demography from the University of Pennsylvania. Kassandra Martinchek is a research associate in the Center on Labor, Human Services, and Population and an expert on food security, food access, and financial well-being. She leverages qualitative analysis, econometrics, and big data to understand disparities in families' financial health and access to food, structural barriers to financial and food security, and policies that can reduce these gaps. She holds an MPA from the University of Wisconsin–Madison and is pursuing her PhD in public policy and administration from George Washington University. Aaron R. Williams is a senior data scientist in the Income and Benefits Policy Center and Program on Retirement Policy at the Urban Institute, where he works on retirement policy, microsimulation models, data privacy, and data imputation methods. He holds a BS in economics from Virginia Commonwealth University, a BA in music from Virginia Commonwealth University, and an MS in mathematics and statistics from Georgetown University. Paige Sonoda is a research assistant in the Center on Labor, Human Services, and Population, where she contributes to qualitative research on the social safety net. She holds a BA in psychology and sociology from Bates College. ABOUT THE AUTHORS 51 STATEMENT OF INDEPENDENCE The Urban Institute strives to meet the highest standards of integrity and quality in its research and analyses and in the evidence-based policy recommendations offered by its researchers and experts. We believe that operating consistent with the values of independence, rigor, and transparency is essential to maintaining those standards. As an organization, the Urban Institute does not take positions on issues, but it does empower and support its experts in sharing their own evidence-based views and policy recommendations that have been shaped by scholarship. Funders do not determine our research findings or the insights and recommendations of our experts. 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