Aligning Systems to Build a Culture of Health: Integrating TANF and Medicaid to Achieve Wealth and Health
Economic security is strongly associated with physical and mental health and
well-being. Programs such as Medicaid which focus on health and Temporary
Assistance for Needy Families (TANF) which aims to improve employment and
financial wellbeing should be better coordinated to provide more effective
services. Programs which integrate physical and mental health services reduce
costs. Findings from
the Building Wealth and Health Network
demonstrate the effectiveness of integrating behavioral health components into
financial programming on improving physical, mental, emotional and financial
Impacts of Trauma and Transfer of Poverty Across Generations
Toxic stress during childhood, defined as prolonged activation of stress
response systems resulting from adversity such as homelessness, hunger, and
neglect, has lifelong effects on a person’s health and well-being. When
toxic stress and a related set of exposures called Adverse Childhood
Experiences (ACEs) - including abuse, neglect, and household instability - are
unaddressed, children are more likely to have physical, mental, and behavioral
health problems that negatively affect their ability to learn in school, gain
employment, and be financially secure later in life. ACEs are also associated
with higher health care use, indicating that health care costs later in life
may be reduced through interventions that prevent and address exposure to
How Adverse Childhood Experiences Influence Health and Well-Being Across the
|Adverse Childhood Experiences
- Domestic Violence
- Household Substance Abuse
|Short-Term Trauma Impacts
- Poor School Performance
- Behavior Problems
- Substance Use
|Health and Economic Outcomes
- Chronic Disease
- Early Death
TANF and Medicaid: Shortcomings and Opportunities
Historically, TANF has focused on steering families toward work without
adequate behavioral and mental health supports. Medicaid, on the other hand,
has been successful in improving access to health care and health outcomes,
but has not traditionally addressed upstream causes of poor health and
well-being. Aligning the two programs may offer opportunities to promote both
health and economic well-being.
Social Determinants of Health
Access to health care and economic security are important and interconnected
social determinants of health.
- Economic Security
- Neighborhood and Environment
- Social Support and Community Context
TANF: Focus on Work Without Addressing Trauma
Temporary Assistance for Needy Families (TANF) is a federal cash assistance
program designed to help low-income families achieve self-sufficiency. Serving
approximately 1.5 million households, TANF reaches less than one in four
families in poverty. Despite high prevalence of trauma exposure among TANF
participants, most state TANF programs do not integrate approaches that
address trauma. Families unable to meet mandated work requirements are more
likely to be sanctioned — having their benefits reduced or cut off
— than offered support. This policy aims to increase compliance with
work requirements, but it only increases families’ barriers to achieving
financial stability. This is highly problematic as sanctioned families are
more likely to have significant health impediments to employment, including
domestic violence, food insecurity, utility shut offs, homelessness, child
hospitalizations, and child development risk. After losing the modest TANF
benefit, families have more difficulty looking for employment, especially
without transportation and childcare supports. The severe penalty of sanctions
often hinders families’ ability to reach self sufficiency and increases
exposure to traumatic events.
Medicaid:Opportunities to Address Social Determinants of Health
Medicaid, a public insurance program providing health coverage to low-income
families and individuals, ensures access to health care for 97 million children,
parents, pregnant women, seniors, and people with disabilities. Medicaid has
improved access to preventive and primary care for millions of Americans,
protecting against and providing care for serious diseases. Recent regulations
focused on managed care have created opportunities for Medicaid to address
social determinants of health, nonmedical concerns that are deeply entwined with
health status, such as access to stable housing and social support networks, or
exposure to environmental toxins or community violence.
Managed care, in which patients are limited to a set of health care providers
in order to reduce costs while improving quality of care, is the predominant
form of Medicaid coverage, accounting for 77% of all Medicaid plans. Updates
to the Medicaid managed care rule in 2016 financially incentivizes health
plans to address social determinants of health through several mechanisms,
including allowing nonclinical supports to be included as covered services and
encouraging states to improve care coordination for their patients. Without
access to medical assistance such as Medicaid, families not only face
significant health consequences, but also an often unbearable economic burden.
Recognizing the important links between health, well-being and economic
security, increasing coordination between systems that address these
components can lead to better outcomes for the families they serve.
Integrating TANF and Medicaid to Improve Health and Economic Well-Being
Nearly 98 percent of TANF participants receive health coverage through
Medicaid, yet the two programs rarely develop coordinated approaches to
address the income and health needs of families. Due to the interconnected
nature between a family’s health and financial well-being, better
coordination between programs such as Medicaid and TANF can provide families
with substantial benefits. Medicaid has been used to fund other supportive
services that promote health, including housing-first programs. For example, a
statute in Pennsylvania’s Medicaid program grants counties the ability
to manage behavioral health services, allowing Philadelphia County’s
Department of Behavioral Health and Intellectual DisAbility Services (DBHIDS)
to take on the role of behavioral health care provider for all Philadelphia
Medicaid enrollees. DBHIDS has been able to reinvest savings from early
intervention and evidence-based practices in system improvements including a
supportive housing program for individuals facing chronic homelessness and
mental illness or substance use disorders. Through this program, participants
have seen substantial improvements in housing stability as well as lower
Although few TANF programs currently incorporate health-promoting activities,
new trauma-informed TANF approaches hold promise for improving both economic
security and mental health. Creating more explicit and effective partnerships
between TANF and Medicaid offers opportunities to more effectively serve
low-income families, improve health and well-being of adults and children, and
lower health costs.
Building Wealth and Health Network
Preliminary outcomes suggest that participating in the Building Wealth and
Health Network has a positive impact on physical and mental health,
employment, and economic security. To assess economic hardship, the Network
measures food, housing, and energy security, as well as self-reported
employment and earnings, over the course of participating in The Network
programming. To assess health, the Network measures depressive symptoms,
self-efficacy and self-reported physical health. At baseline, participants are
also asked about exposure to trauma and violence including ACEs, experiences
of discrimination, and community and intimate partner violence. Compared to
participants in standard TANF programming, participants in the Network’s
Financial SELF empowerment classes showed improved behavioral health outcomes,
including lower depressive symptoms and higher selfefficacy, as well as
improved economic outcomes such as reduced economic hardship and increased
earnings. These findings emphasize the benefit of alignment and coordination
between TANF and Medicaid systems. Because a high proportion of TANF
recipients receive Medicaid health coverage, health-promotion programming in
TANF could lead to reciprocal benefits.
Incorporating behavioral health components into TANF programming could lead to
physical, emotional, and financial health improvements for individual
recipients as well as lowered usage and costs for Medicaid and TANF systems.
Incorporating trauma-informed approaches into TANF and aligning it with
Medicaid could effectively streamline the improvement of health and wealth of
low income families
Selected Results from The Network (October 2015 - May 2018)
||Percentage at Baseline (n=373)
||Percentage at 6-months (n=211)
||Percentage at One Year (n=212)
|Household Food Secure
Caregiver Health (Excellent or Good)
States should be able to utilize Medicaid behavioral health funding to
provide trauma-informed behavioral health support within TANF-funded
education and training programs.
This trauma-informed support aims to improve both health and economic
security. Medicaid funding for behavioral health can promote economic security
if braided into income maintenance programs.
States should be incentivized to integrate behavioral health services into
Health and Human Services should provide trauma-informed care training and
technical assistance to states’ employment training programs made
available to TANF participants.
State should design programs that better align the multiple systems that
families interact with on a regular basis.
States should be encouraged to apply for the Section 1115 Medicaid
demonstration waiver to implement programs that integrate behavioral health
support with employment and training education.
States should be incentivized to implement trauma-informed programs such as
the Building Wealth and Health Network in order to support behavioral health
and economic security initiatives through one program.
Family income support should be viewed as a mechanism that supports
health outcomes along with economic security.
Health insurance and health care programs should be incentivized to include
financial health as an indicator of individual well-being.
States should evaluate programs such as TANF’s success by measuring
health outcomes as well as economic outcomes.
All policies and programs that aim to improve family economic security
and well-being should use trauma-informed language and practice.
States should aim to better understand the connection between social
determinants of health (such as adverse childhood experiences and toxic
stress), economic security and health and wellbeing in order to tailor
programs that produce the most effective outcomes.
Programs aimed at improving economic security and well-being should be
encouraged to track the prevalence of trauma and adversity in order to best
address challenges that families face.