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Challenges and Solutions to Public Assistance System Alignment: How Trauma-informed Programming Unveiled Barriers to Aligning TANF and Medicaid


Cross-sector collaboration and systems alignment can address social determinants of health, improve family well-being, and create a more equitable society. In attempts to align Temporary Assistance for Needy Families (TANF) and Medicaid to promote health through its trauma-informed program, The Building Wealth and Health Network (The Network) encountered three major challenges to meeting those goals including TANF’s culture of compliance, societal and systems-level forces of racism and discrimination, and misaligned partnerships. Utilizing intentional efforts to address these challenges, such as incentives for innovation and partnerships and the promotion of racial equity initiatives, can address these challenges and improve the effectiveness of these programs while promoting health equity.

Key Terms and Definitions

  • Social Determinants of Health

    Social determinants of health are environmental conditions in which people are born, live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

  • Earned Income Disregard

    Earned Income Disregard allows qualified individuals and families receiving TANF assistance to keep more of their earned income for a period of up to two years following an increase in employment income.

  • Trauma-informed Care

    Trauma-informed care is an approach in the human service field that recognizes trauma symptoms and acknowledges the role trauma may play in an individual’s life.


Both Medicaid and TANF are crucial supports for low-income families. However, both programs in their current iterations have significant limitations.

The goal of TANF is to: “help needy families achieve self-sufficiency;” however, the measure of the program’s success and funding are based on the number of participants entering and staying in the workforce and overall reduction in welfare participants. These policies, widely known as “Work First,” do not consider participants’ health and wellness, despite knowledge that major barriers to work include physical, emotional, and mental conditions and other major social and behavioral adversities. Research has shown that many caregivers return to TANF or become “disconnected” from public assistance due to poor health or lack of success in the workforce. Additionally, most states have disinvested in TANF cash assistance over time (see policy brief: Pennsylvania Cash Assistance Behind the Times, 2020) and rely heavily on a culture of compliance.

Medicaid has improved access to preventive and primary care for millions of Americans, protecting against and providing care for serious diseases, but it has not traditionally addressed the root causes of poor health and well-being.


Due to the interconnected nature of health and financial well-being, better coordination between programs such as Medicaid and TANF offers significant opportunities to address both family health and economic security. Nearly all TANF participants receive Medicaid health coverage, an overlap that presents great opportunities for integrated approaches to address these needs. However, the two programs rarely coordinate. To be effective, it is necessary for siloed systems and programs in which families participate to be more aligned.

Building Wealth and Health Network

The Network is a trauma-informed, healing-centered, financial empowerment program integrated into TANF programming in Pennsylvania. It uses a peer-group format aimed to build the wealth and health of caregivers with low incomes. The program consists of 16 curriculum-based group sessions and one-year savings program that includes opening savings accounts and deposit matching incentives. The Network addresses mental and emotional health along with financial health and employment. The Network offers an opportunity to align systems as it has successfully integrated trauma-informed financial empowerment into traditional TANF programming. Program results demonstrate that a workforce training and curriculum that combine trauma-informed peer support with financial empowerment education improves depressive symptoms, coping strategies, employment, income, and overall economic security, including food security. It also reduces TANF participation over time.

Challenges to System Alignment and Proposed Solutions

Despite the promising success The Network has shown in improving social determinants of health, there are several significant challenges that inhibit successful system alignment, including:

  • TANF’s culture of surveillance and compliance
  • Intersectional forms of institutional racism and gender discrimination
  • Misaligned partnerships that lead to lack of opportunity for partners to make innovations

TANF’s Culture of Surveillance and Compliance


‘Work-First’ policies create a punitive environment that does not attend to health and well-being, despite evidence that poor health and well-being are barriers to work. This makes alignment between systems such as Medicaid and TANF on the basis of health promotion and addressing upstream health factors extremely challenging.

Proposed Solutions

  1. Incentivize state programming (ex: through waivers) to integrate evidence based, trauma-informed programming
  2. Shift focus from punitive, isolating ‘work-focused’ policies to ones that truly put health, well-being and dignity at the forefront
  3. Implement necessary policy priorities, including:
    • Increase cash allotment to reflect inflation rate since its last increase or to reach at least 50% of Federal Poverty Line
    • Develop a Cost of Living Adjustment that increases the cash grant each year with inflation rate
    • Raise the Earned Income Disregard
    • Raise or eliminate the TANF asset limit to allow families to build economic security without losing benefits, ensuring future financial stability and improved health and well-being

Racism and Discrimination


Institutionalized racism is a major barrier to public assistance reform. Racism and discrimination in public assistance programs and policies perpetuate stigma towards participants, create barriers to participation, and restrict the state’s ability to innovate

Proposed Solutions

  1. Acknowledge and address systematic oppression and discrimination as a form of trauma
  2. Use trauma-informed language and practices in policies and programs that aim to improve family economic security and well-being should
  3. Seek out opportunities for programs and organizations to support community coalitions, racial equity initiatives, and direct-action organizations run by Black, Indigenous and non-Black people of color
  4. Create incentives at all levels of government to deliberate on and commit to a reparations process

Misaligned Partnerships


Reliance on grant funding through academic institutions leads to issues of time-sensitivity and ongoing funding. High turnover in academic settings because of grant cycles and staff turnover at the state level limit innovation. Large social services organizations are constricted and unable to innovate but should be at the center of this work.

Proposed Solutions

  1. Align funding sources for all partners to ensure continuity of programs
  2. Reduce stagnation from staff turnover by placing health promotion and system alignment as a top priority
  3. Incentivize innovation for social service programming

For more information about this work, please see the following article: Weida EB, Egan V, Chilton M (2020). How trauma-informed programming to treat social determinants unveils challenges to systems alignment. Journal of Health Care for the Poor and Underserved. In press.