PRWORA built upon and expanded state-level welfare reforms to transform federal welfare policy for needy families with children. It replaced the individual entitlement to benefits under the 61-year-old AFDC program with TANF block grants to the states and emphasized the transitional nature of assistance and the importance of reducing welfare dependence through employment, among other goals. PRWORA provides states with the flexibility to set a wide range of TANF program rules, including the types of programs and services available and the eligibility criteria for them. In addition, states may choose to administer TANF directly, devolve responsibility to the county or local TANF offices, or contract with nonprofit or for-profit providers to administer TANF. In addition to TANF funds, states may access other federal funds and programs to provide treatment and employment services to recipients. For example, states may use Labor’s Welfare-to-Work grants to operate employment service programs, Medicaid funds to provide physical or mental health treatment services, and vocational rehabilitation funds to provide services to recipients. While states have great flexibility to design programs that meet their own goals and needs, they must also meet several federal requirements designed to emphasize the importance of work and the temporary nature of TANF aid. TANF established stronger work requirements for those receiving aid unlike the AFDC program, which did not require most adult recipients to participate due to allowable exemptions and minimum participation standards. For example, parents of children aged 3 and under were not required to meet work requirements under AFDC; under TANF parents may now be required to work, regardless of the ages of their children. Furthermore, to avoid financial penalties, states must ensure that a steadily rising specified minimum percentage of adult recipients are participating in work or work-related activities each year. To count toward the state’s minimum participation rate, adult TANF recipients in families must participate in a minimum number of hours of work or a work-related activity a week, including subsidized or unsubsidized employment, work experience, community service, and job search. These activities are more employment-focused than the AFDC participation requirements. The required number of hours of participation and the percentage of a state’s caseload that must participate to meet mandated rates has steadily increased since 1997, as shown in table 1. If recipients refuse to participate as required, states must impose a financial sanction on the family by reducing the benefits, or they may opt to terminate the benefits entirely. States must also enforce a 60-month limit (or less at state option) on the length of time a family may receive federal TANF assistance, although the law allows states to provide assistance beyond 60 months using state funds. A state may exempt up to 20 percent of its average monthly caseload for hardship or having been subjected to domestic violence. PRWORA devolved significant authority for program results and outcomes to states and other levels of government. It also reduced HHS’ staffing and restricted it from regulating any area not specified in the law. Despite these changes, the federal government retains some program oversight responsibilities. Under the law, HHS is responsible for administering TANF funding, setting reporting requirements for states, and reviewing state TANF plans. HHS is also responsible for conducting research on the benefits and effects of the TANF program and receives funding for welfare reform and social service research and evaluation studies. TANF often serves, as did AFDC, as a temporary stopping point for low- income individuals with physical or mental impairments considered severe enough to make them eligible for the federal Supplemental Security Income (SSI) program. SSI, administered by the Social Security Administration (SSA), provides cash assistance to low-income individuals who cannot obtain or retain employment because of a severe long-term impairment and who do not have sufficient work history to qualify for SSA’s Disability Insurance (DI) program. To qualify for SSI, an applicant’s impairment must be of such severity that the person is not only unable to do previous work but is also unable to do any other kind of substantial work that exists in the national economy. Prior work experience is not a requirement, and in most states, SSI eligibility also entitles individuals to Medicaid benefits. As distinct from TANF, SSI for adults has federally- established eligibility requirements and benefit levels and a nationwide disability determination process. Some individuals who apply for TANF may have impairments severe enough to make them eligible to receive SSI. In recent years, even before welfare reform, states had been actively identifying and referring potential SSI-eligible welfare recipients to SSI. In these cases, individuals may be on TANF while they are waiting for their SSI eligibility to be determined. In some cases, an individual with an impairment severe enough to qualify may not get referred to the SSI program, but remain on TANF. This puts the individual at risk of losing aid through a financial sanction or time limit or not receiving the assistance needed to become employed. Generally, except for more temporary conditions, TANF recipients not eligible for SSI or DI are expected to work, as their impairments are not severe enough to preclude substantial employment. National survey data from SIPP show that a total of 44 percent of TANF recipients aged 18 to 64 self-reported having a physical or mental impairment in 1999. In contrast, 16 percent of non-TANF adults in the U.S. population reported having an impairment. Although SIPP data show that TANF recipients with impairments were much less likely to work than those without impairments, about 20 percent who reported having impairments also reported working full- or part-time. As welfare reform has been implemented and caseloads have plummeted, the proportion of TANF recipients who reported impairments does not show any notable difference. SIPP data show that in 1999, a total of 44 percent of TANF adults aged 18 to 64 reported having one or more physical or mental impairments as defined by Census, and 38 percent reported a severe impairment. Considering both severe and nonsevere impairments, 29 percent of TANF adults reported having a mental impairment. These data capture individuals who reported functional or other activity limitations generally covered by ADA. The proportion of TANF recipients with impairments is almost three times as high as adults with impairments in the U.S. non- TANF population. Table 2 provides examples of questions asked by Census to identify persons with severe or nonsevere impairments. Appendix I lists the specific criteria developed by Census that individuals must meet to be considered impaired as applied in the SIPP. Identifying and measuring impairments or disabilities is a complex undertaking, and no single survey instrument has been accepted or generally agreed upon as the preferred method for identifying impairments within a population. Census believes the extensive set of disability questions contained in SIPP make it a preferred source to examine most impairment-related issues. Nevertheless, SIPP data should be interpreted with care. For instance, SIPP relies on self-reports of impairments and, therefore, may not accurately reflect the size of the general or TANF population with impairments. This can result in the overreporting or underreporting of impairments. For example, although some impairments, such as inability to walk, missing or impaired limbs, or severely impaired vision, are easy to identify, many impairments are not. Individuals may not report less obvious impairments because of certain stigmas surrounding them or because they may not know of their existence. Some examples of these impairments include learning disabilities, depression, and mental illness. Other surveys use different approaches to measure impairments. The National Household Survey of Drug Abuse and the University of Michigan’s Women’s Employment Survey, for example, use nonclinical in- depth diagnostic questioning to identify certain psychiatric disorders that may be overlooked by other survey techniques. Although national survey data show that TANF recipients with impairments are less likely to be combining welfare and work than those without impairments, many, in fact, do work. SIPP data show that 20 percent of TANF recipients with impairments were working full- or part- time in 1999, compared with 44 percent of TANF recipients not reporting impairments. (See fig. 1.) In addition, SIPP data show virtually no change since 1997 in the percent of TANF recipients with impairments who work. In 1997, 19 percent of TANF recipients with impairments (aged 18-64) were working compared with 20 percent working in 1999. Whether a TANF recipient with impairments is able to work while receiving welfare can depend on many complex, interrelated factors, such as other personal characteristics they may have, and state and local programs and policies, including benefit levels and policies that encourage or require work. Regarding personal characteristics, studies have shown that many factors— including poor health or disability, no high school diploma, limited work experience, exposure to domestic violence, substance abuse, and limited English proficiency—make finding and keeping a job more difficult. Moreover, recipients with impairments may have more than one characteristic that could interfere with work. Data from a longitudinal University of Michigan’s Women’s Employment Study show that physical and mental impairments co-occur with other obstacles to work in almost half of the sampled cases. More specifically, data from this panel survey of women on welfare in an urban county in Michigan show that in 1998, two-thirds of TANF recipients with physical problems and about half of those with mental health problems also had other obstacles to work. In addition, the Manpower Demonstration Research Corporation reported that the prevalence of health problems among women who were receiving welfare suggests that there will be major challenges to welfare agencies as a growing number of recipients face time-limit pressures. Nationwide data from another source show that the greater the number of obstacles a TANF recipient faces, the less likely that recipient is to be engaged in paid work or work-related activities while receiving welfare. On the basis of data from its 1999 National Survey of America’s Families (NSAF), the Urban Institute reported that in 1999, 90 percent of recipients who had no obstacles were working in paid jobs or engaging in work- related activities (in school or training or looking for work), compared with 68 percent of recipients with one obstacle and 54 percent of recipients with two or more. (See fig. 2.) The Urban Institute has also reported that a greater proportion of TANF recipients with two or more obstacles to employment were engaged in work or work-related activities in 1999 compared with 1997. While many factors could affect this outcome including economic conditions, welfare agencies increased emphasis on requiring and encouraging TANF recipients to take steps toward employment could be an important one. In addition to program policies and practices, research suggests that successful transitions to work may be more likely for younger people with impairments and for those who have greater motivation to work and stronger educational backgrounds. Moreover, some persons with impairments may benefit from technological and medical advances and social changes, which have created more opportunities for some individuals with impairments to work. Nevertheless, some persons with multiple work impediments may need to learn basic skills and work habits and build self-esteem to successfully function in the workplace. Some may also face tight labor market conditions, particularly for low-wage positions, that could constrain employment opportunities, while others may need to overcome logistical obstacles, such as transportation difficulties. Welfare caseloads dropped 46 percent between 1994 and 1999; however, national survey data suggest that the proportion of TANF adults reporting impairments has not changed significantly since welfare reform began. Because of steps taken by Census beginning with the 1997 SIPP data to improve and broaden its disability measurement, including measurements of mental impairments, we adjusted the SIPP data for 1997 and 1999 to be consistent with the definition used in 1994. The adjusted data showed that there were no statistically significant differences in the percentage of TANF recipients reporting impairments since states implemented welfare reform. Data from the Urban Institute’s NSAF corroborate SIPP data. They show that the proportion of adults on TANF who reported a serious physical or mental health problem was 32 percent in 1997 compared with 36 percent in 1999, which was not a statistically significant difference. While our analysis shows that the proportion of TANF recipients with impairments has not increased while caseloads have declined, it is not clear what this means in so far as outcomes for TANF recipients with impairments. The proportion of TANF recipients with impairments on the rolls at any given time and over time is affected by the number and characteristics of individuals coming onto the rolls and leaving the rolls. Regarding coming onto the welfare rolls, individuals with impairments maybe less likely to apply for and receive welfare as welfare agencies implement more stringent up-front job search requirements or take additional steps to move eligible individuals onto the SSI rolls. Regarding leaving the welfare rolls, while we know generally that a majority of former welfare recipients are employed at some point after leaving welfare, others have left the rolls without employment, in some cases due to state sanction policies that end welfare receipt for those who do not meet program or work requirements. Our previous work showed that recipients who received a sanction often had a higher incidence of conditions such as health problems and depression than other TANF recipients. In other cases, former welfare recipients with impairments may leave TANF to begin receiving SSI. More information would be needed to determine how individuals with impairments, both potential applicants and former TANF recipients, have fared as TANF caseloads have declined. Most counties reported they are screening TANF recipients for impairments that may interfere with their ability to work, primarily through recipients’ self-disclosure, a method that may not ensure that all impairments, particularly “hidden” disabilities, are accurately identified.In addition, about half of the counties did not know the number of TANF recipients they had with impairments, with nearly all of these counties saying they did not have the information. Lack of such data may hinder counties’ abilities to identify and meet the service needs of their TANF recipients. When serving recipients identified with impairments, counties often partnered with other federal, state, or local agencies to provide treatment or employment services. It appears, however, that many TANF recipients with impairments are not receiving services to move them toward employment, in part because they are exempted from the work requirements. Regarding policies for imposing financial sanctions on TANF recipients who do not comply with program requirements, many counties reported making only one attempt to notify recipients that they are noncompliant. This could make recipients with impairments who have trouble complying with program requirements or understanding sanction notices inappropriately vulnerable to a sanction. Some selected TANF offices we visited have implemented strategies targeted at helping recipients with impairments find employment, but most of these strategies are too new to evaluate. Almost all the counties reported that they screen and assess TANF recipients for impairments, but many use methods that may not accurately identify all impairments. In some cases, this may not be a problem because recipients find and keep jobs, while in other cases, recipients may not be able to participate in a county’s regular TANF program activities, find a job, or sustain employment without special assistance. TANF agencies may screen and assess recipients for impairments for a number of reasons, including identifying individuals who might be eligible for long- term support under the SSI or DI programs; should be exempt from work requirements or time limits; or need treatment or special services, such as job accommodations, to help them engage more effectively in work or training. In addition, the extent to which welfare agencies rely on screening and assessment of impairments and other potential barriers to assess an individual’s ability to work varies. In our earlier report on hard-to-employ TANF recipients, we found that some of the states and localities we visited relied primarily on the job market to identify recipients who have barriers to employment, such as physical or mental impairments, although even in these cases an initial minimal screening may be conducted. According to officials in these states, this approach precludes the welfare agency from prejudging or labeling recipients as hard-to-employ when they may be able to obtain jobs. At the same time, this approach sends a clear message that TANF is temporary and that employment is the immediate goal. Other states and localities we visited for that report relied more heavily on screening and assessment, believing that by identifying obstacles to employment early, agencies could more appropriately focus resources and time on activities and services that hard-to-employ TANF recipients need to become employed. No one approach has been proven more effective than another for moving hard-to-employ recipients into jobs. In our nationwide survey of county TANF agencies, we found that almost all counties reported that they screen recipients for physical and mental health impairments, and three-fourths screen for learning disabilities that could interfere with recipients’ ability to work. Figure 3 shows the methods that counties reported they relied on to screen recipients. The primary screening method counties used is recipient self-disclosure. TANF caseworkers ask recipients questions or use intake forms to identify characteristics that may interfere with a recipient’s ability or the program requirement to work. Questions on intake forms might ask recipients, “Do you currently have any physical or mental conditions?” or “Has your doctor placed any limits on your activities?” Relying on this method may not uncover all impairments—for example, hidden disabilities that may be unknown to recipients but could still interfere with their ability to work. Furthermore, sometimes recipients are reluctant to identify impairments because they are uncertain about potential consequences or do not feel comfortable in doing so. The willingness of recipients to share information about impairments can largely depend on the TANF staff’s ability to establish rapport with recipients. If recipients do not feel comfortable with TANF staff, they may be reluctant to share information. Of the 12 percent of counties that rely on a screening exam as their primary method, most use a screening tool or instrument, which is a more formal, standardized approach to screening recipients. Some tools are designed to screen for multiple barriers, including impairments, while others are designed to screen for a single barrier, such as mental health problems or learning disabilities. If these tools are improperly administered, they may not be a reliable predictor of a recipient’s impairment. For example, some tools must be administered by staff with specialized training to produce reliable results, while others can be administered by caseworkers with little or no training. Furthermore, many tools are validated only for specific populations and may not produce reliable and valid results for TANF recipients. A study the Urban Institute conducted for HHS identified a number of tools that TANF agencies use to screen recipients, but reported that little is known about their ability to accurately identify barriers or impairments among TANF recipients. Furthermore, it found that few studies or evaluations had been conducted to assess these tools’ effectiveness. About 11 percent of counties rely on caseworkers’ observations to identify “red flags” (verbal or behavioral cues) that may indicate an impairment. For example, a caseworker could observe a recipient while he or she is filling out an application or might observe symptoms of mental illness, such as anxiety, depression, and behavioral problems. Experts reported that caseworkers’ observations could be a useful part of the screening process when used in conjunction with other screening methods, especially when caseworkers are trained to be alert to red flags. However, many caseworkers are former AFDC eligibility workers who may not have been trained in how to identify red flags. According to one TANF official we interviewed, learning disabilities and mental impairments are harder to identify than physical impairments because of all the subtleties involved in identifying them. Of the counties that conduct screening, over 90 percent do an initial one at the intake/eligibility determination phase, but many counties also screen recipients during the employment planning process if it appears the recipient is having problems. Figure 4 shows at which points counties reported screening recipients. If screening suggests an impairment, 76 percent of counties reported that they assess recipients to determine if they have an impairment. Almost half of these counties reported that caseworkers perform the largest proportion of these assessments. (See fig. 5.) According to some experts, the role of the TANF agency in screening and assessment should be to identify recipients who might have an impairment and then refer them to professionals who have the expertise to conduct assessments. Generally, because some caseworkers are former AFDC eligibility workers, they may lack the training and expertise to conduct assessments, which may result in the recipient’s not having his or her impairment properly identified and evaluated. For example, at the TANF agency we visited in Davidson County, Tennessee, if caseworkers suspect that a recipient has a mental health problem or learning disability, they refer the recipient to a family services counselor, who is a certified social worker and counselor. The counselor conducts a preliminary assessment and then refers a recipient with severe symptoms to a psychologist for a comprehensive assessment and diagnosis. Almost all counties that conduct assessments reported that they would try to determine whether a recipient’s impairment affects the recipient’s ability to work. That determination could be made in various ways, such as using a physician’s documentation, self-disclosed information, an assessment of a recipient’s ability to work, and employment history. Possible outcomes of that review include referrals to vocational rehabilitation, treatment providers, or SSA for SSI eligibility determination or development of an individualized plan to move the recipient toward employment. About half of all the counties did not provide data on the number of recipients with impairments that interfere with their ability to work, and nearly all of these counties reported they did not have these data. Lack of information on the service needs of TANF recipients, particularly those nearing a state’s time limit on aid, could hinder an agency’s ability to provide sufficient services for recipients. In a previous study, only two of the nine states we reviewed could provide us with statewide data on such characteristics as recipients with learning disabilities, mental or psychological conditions, physical impairments, and poor health. Some of the reasons we cited in that report were the lack of any requirement to collect such data, the difficulties of identifying such barriers, the lack of standardized screening and assessment tools, and inadequate computer systems. Historically, the AFDC program exempted recipients with impairments from participation requirements, and many counties reported they continue to exempt from state work requirements TANF recipients who have impairments, are caring for a child with an impairment, or are awaiting SSI eligibility determination because of their impairment. About 63 percent of counties exempted TANF recipients with impairments from the work requirements. About 27 percent of counties exempted TANF recipients with impairments from the work requirements, but not the state time limit. About one-third of counties exempted those caring for a child with an impairment from the work requirements and the time limit, but an additional 28 percent of counties exempted caregivers from only the work requirements and not the state time limit. Over half of counties exempted TANF recipients from the work requirements who were referred to SSA for disability eligibility determination. Counties’ apparent reliance on work requirement exemptions for recipients with impairments raises the issue of whether many such recipients are being prepared for eventual employment. Some or all of those exempted from work requirements may move onto the SSI rolls, be included among the 20-percent exemption from federal time limits, or have only temporary physical or mental impairments interfering with employment, which may improve over time. The detailed data needed to make such assessments were not available. However, it is also possible that many counties have not yet put in place policies, procedures, and services for addressing the needs of TANF recipients with physical and mental impairments who may need more or different types of assistance than others. In those programs where TANF recipients with impairments are exempted from work requirements, they may not be getting the help, direction, or encouragement they need to take steps toward employment. Under these circumstances, recipients with impairments may not be receiving proper access to TANF services as required by the ADA. When asked what percentage of TANF recipients were receiving services to move them toward employment, one-third of responding counties who supplied data reported that, on average, 43 percent of their recipients with impairments were being served. However, counties that did not exempt recipients with impairments reported that, on average, 61 percent of their recipients with impairments were receiving services, almost twice the 34- percent average in counties that did exempt recipients. Our previous work and other studies show that some states and localities have moved more aggressively than others to enforce a work or work-activity requirement for a larger share of their TANF caseload than others and that these programs generally have adjusted their program approaches to help recipients address potential barriers to employment. Work requirement exemption policies could be an issue, particularly with the more than one-quarter of counties who exempt TANF recipients from the work requirements but not the state’s time limit. These recipients may be at risk of reaching their time limit without employment or having received services to move toward employment, unless they are included in their state’s 20-percent hardship exemption or the state provides assistance with state funds. Although there are indications that the 20- percent exemption may be sufficient, it is too early to know how many recipients might be excluded since many states have not yet defined the criteria for their exemption. Some TANF officials we interviewed said that their states plan to include recipients with impairments who are unable to work or who care for a child with an impairment. About 80 percent of county TANF officials estimated that fewer than 20 percent of their TANF recipients had impairments that would make work so difficult that they should be exempt from the federal time limit. Many of them, however, did not provide us with data on the number of recipients with impairments that would support their estimates. Recipients with impairments are only one of many groups that states could include in their 20-percent exemption. For example, Kansas plans to include recipients who care for disabled household members, recipients over age 60, victims of domestic violence or sexual assault, and recipients who are complying with program rules but remain unemployed or underemployed. It determined that its exemption would be sufficient to include all recipients who meet these criteria until 2006. Many states also plan to continue aid beyond the federal 5-year time limit with state funds. For example, according to TANF state plans, nine states containing 44 percent of the total 1999 national caseload intend to provide benefits for all families that reach the time limit, though often in reduced amounts or noncash form. Most counties that provide treatment and employment services to TANF recipients with impairments have established linkages with contractors and other local service providers to provide at least some of these services. TANF agencies can provide services modified for recipients with impairments directly or through a contractor, or they can partner with non-TANF government agencies and other community organizations. These services could include employment services, such as job readiness training, job training, education, job search, and community work experience programs, or they could include referrals to treatment programs for physical impairments, mental health conditions, or learning disabilities. Figure 6 shows the primary agency or program with whom TANF agencies partnered to provide modified services to their recipients with impairments. About 60 percent of counties reported they make at least two attempts to notify recipients that they are noncompliant with TANF requirements, while about 40 percent reported they make only one attempt. Written notification is the primary method counties use to inform recipients the first time they are about to receive a financial sanction. About 60 percent of counties would make a repeated attempt to contact recipients. In their second attempt to contact recipients, many counties would also use more personal methods: 24 percent reported they would schedule an in-person meeting, and 15 percent would make a home visit. Regardless of the method used, almost three-quarters of counties with time limits less than the federal 5-year time limit reported they would assess recipients for possible impairments if these recipients were nearing the state’s time limit. About two-thirds of all counties reported they would assess recipients who failed to comply with the work requirements to determine whether that recipient had an impairment that could interfere with his or her ability to work. In our previous work, we found that recipients who received either a full or partial sanction often had a higher incidence of conditions such as health problems and depression than other TANF recipients, and these characteristics may make it more difficult for them to understand and comply with program requirements. We reported that states’ policies for notifying recipients varied, but those with a more active conciliation process often reduced the number of families under sanction and increased compliance for those families involved in conciliation. For example, many states require that a written warning notice be sent to recipients, who are expected to contact the caseworker to resolve their noncompliance issues within specified time frames. If they fail to do so, they may lose their opportunity to resolve the noncompliance issues before they lose all or part of their benefits. Because 40 percent of the counties in our survey reported making only one attempt to notify recipients before imposing a sanction, a significant number of recipients with impairments could be at risk of losing TANF benefits if their impairment hinders their ability to comply with requirements. TANF experts identified the four counties we visited as having promising strategies to move TANF recipients with impairments toward employment. These strategies ranged from developing standardized tools for screening recipients to establishing multidisciplinary teams to identify needed services. It is important to note that because these strategies are relatively new, they have not been evaluated, and little or no data are available on their long-term impact. Furthermore, some of them have served only a small number of recipients. The counties we visited developed various strategies to address the predicament of recipients who were approaching state or federal time limits without having found employment. Although their strategies varied widely, a common element was the counties’ realization that these recipients usually require more intensive case management than other TANF recipients to move toward employment and an acknowledgment that a “one-size-fits-all” approach did not work; thus, their programs and services had to be tailored to each recipient. All these strategies focused additional efforts on identifying and serving recipients with impairments. The four counties we visited differed in how they screened and served recipients. Two counties conducted limited up-front screening and relied upon the job market to determine whether the recipient had impairments to employment, whereas the other two counties conducted more in-depth screening. The counties also varied as to their reliance on a particular type of service provider. Sedgwick County, Kansas, and Davidson County, Tennessee, relied predominantly on nongovernment and community service providers to conduct assessments and provide services. Cumberland County, North Carolina, relied on a combination of government agencies, such as vocational rehabilitation, and nongovernment service providers. Leon County, Florida, was the only site that required the TANF agency to participate in its on-site center—referred to as a “one-stop”— that consolidated a variety of services, including adult education, employment services, and counseling services. Two of the sites we visited incorporated employment services as part of their strategies, and they continue to provide supportive TANF services after recipients are placed. For example, Leon County developed a program that provided one-to-one tutoring and employment services, including job placement and follow-up, to recipients with dyslexia. Sedgwick County refers recipients with impairments to a contractor for vocational assessment. If recipients qualify, they can be accepted into a computer or industrial training program, which also includes job placement and follow-up services. Recipients with severe or persistent mental health impairments could also be included in a 6-month training program at a manufacturing facility. Table 3 summarizes the key features of these strategies. Multiple federal agencies and offices within agencies are involved in the support of research, technical assistance, and employment services related to assisting TANF recipients with impairments. However, no focal point or mechanism currently exists at HHS to ensure that states and localities have the best information available from the federal level that could enhance their efforts to help TANF recipients with impairments take steps toward employment. Within HHS, in addition to ACF’s Office of Family Assistance, which oversees TANF, ACF’s Administration on Developmental Disabilities and other offices within HHS, including the Assistant Secretary for Planning and Evaluation, Office for Civil Rights, and Substance Abuse and Mental Services Administration all have one or more roles to play in the support of identifying and serving TANF recipients with impairments. In addition, Labor’s Office of Disability Employment Policy and the Employment and Training Administration and Education’s Office of Special Education and Rehabilitative Services and Office of Vocational and Adult Education also provide research, services, and technical assistance that could aid TANF recipients with impairments move toward employment. In many instances these departments and agencies have taken steps to assist TANF program administrators in meeting the needs of TANF recipients with impairments. Table 4 shows some of the key initiatives taken by these agencies and offices to assist states and localities in assessing and providing services to TANF recipients. In some cases, these agencies have collaborated to provide outreach services and technical assistance services. For example, ACF has partnered with the Substance Abuse and Mental Health Services Administration and Labor’s Employment and Training Administration to hold five conferences for program administrators on promising practices to move clients with multiple barriers to employment. ACF has also collaborated with Education and the National Institute for Literacy to provide technical assistance and training to state and local TANF agencies on valid screening tools for individuals with learning disabilities. In addition to these and other initiatives, HHS and Labor have worked together in relation to the administration and research evaluation of the Welfare-to- Work grants, which were geared to the hardest to employ of TANF recipients. While individual federal agencies were working on ways to assist states and counties move TANF recipients with impairments to employment, the Presidential Task Force on Employment of Adults with Disabilities was created in March 1998 to develop a coordinated national policy focused on bringing all adults with disabilities into gainful employment. The task force brought great visibility to the disability issue, and it has issued the first three of four required reports to the President. The first two reports contained a total of 19 high-level recommendations to the President, all of which have either been initiated or completed. The task force’s fourth and final report is due July 2002, at which time the authority for the task force expires. In addition to the task force reports and presidential recommendations, the task force has produced other benefits as well. The executive order creating the task force also established a working group on PRWORA. Recognizing the value of taking a cross-cutting, coordinated approach to this issue, the working group was composed of representatives from HHS, Labor, Education, Transportation, Justice, and the National Council on Disability (NCD). The working group submitted a report with recommendations to the presidential task force in November 1998. The report contained specific recommendations on such issues as screening and assessment and civil rights protections; however, they were considered to be the views of the working group members and did not carry the weight of the task force. Despite lacking the endorsement of the task force, this coordinated effort to address TANF recipients with impairments produced some results. For example, HHS funded the publication of guides on screening TANF recipients for mental illness and substance abuse and on the prohibition against discrimination on the basis of disability in the administration of TANF. HHS has recognized the value of external coordination with other federal agencies and the public and private sector in its strategic plan for fiscal year 2001-2006, and ACF’s fiscal year 2002 Government Performance and Results Act (GPRA) annual performance plan. The strategic plan discusses the diversity of HHS programs and the variety of ways they can be coordinated. For example, coordinating mechanisms can be imbedded in service delivery partnerships, or they can be formal mechanisms, such as coordinating councils. They can also be ad hoc mechanisms, such as meetings or workgroups. The ACF’s fiscal year 2002 annual performance plan echoes the need for both internal and external coordination to administer programs effectively; however, no specific strategies, goals, or performance measures were identified to encourage or track linkages among involved agencies. Despite the recognition of the need for such coordination, officials from HHS, Labor, and Education told us there is no central focal point to ensure that research and technical assistance conducted by federal agencies is coordinated and disseminated to the states and counties directly providing services to TANF recipients. In addition, some state officials told us that information or guidance that is jointly issued by ACF—the lead TANF agency—and other key players is very helpful in encouraging better understanding of and collaboration among federal programs and services available in the states to help TANF recipients become employed. For example, ACF and the Department of Education jointly issued a letter to TANF agencies that provided information and contacts on vocational rehabilitation agencies in the states. Our nationwide survey of counties showed that counties often relied on other agencies to assist TANF recipients with impairments. Other studies have noted that TANF agencies working with recipients with impairments often need to build new relationships with programs and service providers with whom they have not traditionally worked. Getting information directly to the county level—where many program decisions are made and services are actually provided—is also important. Officials in three of the four counties we visited believed that coordinated assistance from federal agencies was needed. For example, they asked for technical assistance on the proper use of screening and assessment tools, guidance on what local offices should be doing to serve TANF recipients with impairments, and more examples of best practices that could be replicated locally. They said that current federal technical assistance efforts, including conferences, are more often available to state-level officials than the local county TANF officials who are directly serving TANF recipients. The National Council on Disability has also noted a lack of systematic collaboration among federal, state, and local entities on a national scale.The Council believes that these entities need to place greater emphasis on removing barriers, making linkages, and combining their resources to better ensure positive employment outcomes for TANF recipients with impairments. Welfare reform has led to major changes in state welfare policies and programs, with greatly increased emphasis on requiring and encouraging most adult recipients to move toward employment. This represents a significant departure from previous welfare policy, under which welfare agencies typically did not expect many recipients, particularly those with physical or mental impairments, to seek or prepare for employment. While in the years since welfare reform, states and localities have implemented Work-First approaches, they are only now beginning to understand how well these more employment-focused programs are meeting the needs of all TANF recipients, including those with impairments. As TANF agencies take steps to address the needs of TANF recipients with physical or mental impairments, much remains unknown about how well the new welfare system is performing in supporting this population’s needs and in reducing their dependence on government aid. About half the counties did not provide data on the number of TANF recipients with impairments. This suggests that they may not know whether sufficient service capacity exists to move these recipients toward employment. In addition, little is known about how best to identify impairments that may affect TANF recipients’ ability to work and what approaches are effective for helping those with impairments—both long-term recipients reaching their time limits and new recipients—find and maintain jobs. Ultimately, many impaired recipients may reach their time limits without suitable employment skills because their impairments have not been properly identified and addressed. Our findings reinforce the importance of having HHS work more closely with other federal agencies, states, and counties to meet the needs of hard- to-employ recipients, particularly as time limits on federal aid approach. We recommended in our March 2001 report that HHS do more to encourage and enable states to estimate the number and characteristics of hard-to-employ TANF recipients, including some with impairments, and identify recipients who will reach their 60-month limit on aid before they are able to work. After we made our recommendation, HHS solicited research applications to award grants to four or five state agencies and large counties to study how many individuals who are still on TANF are hard to employ or more disadvantaged, how many are at risk of reaching their time limits, and what services they need to make the transition to finding and maintaining work. It is important that research such as this conducted by HHS and other federal agencies be coordinated to ensure that relevant information is collected and disseminated nationwide, especially to the welfare agencies providing services to TANF recipients. As welfare reform evolves, the role of HHS, in coordination with other key federal players, in supporting and encouraging research and providing information and technical assistance to states and county TANF agencies is essential to help them better identify and move recipients with impairments toward employment. It will also ensure that states and localities across the nation can learn from each other. Such efforts should continue as TANF is reauthorized, and HHS, as the lead TANF agency, should be the focal point for the coordination and dissemination of information to agencies involved in helping TANF recipients with impairments toward employment. As states and localities move forward to determine how best to serve TANF recipients with impairments, we recommend that HHS, as the lead TANF agency, serve as the focal point for coordinating and disseminating the research and technical assistance of federal agencies to ensure that states and counties have access to the information they need to better identify and move TANF recipients with impairments toward employment. To help ensure that this coordination occurs, the Secretary of HHS and the Assistant Secretary for Children and Families should include strategies, goals, and measures in ACF’s annual performance plan to ensure that HHS partners with other key agencies, particularly Labor and Education, to take advantage of federal resources and knowledge related to helping TANF recipients with impairments move toward economic independence. We provided HHS an opportunity to comment on the report and HHS generally agreed with our conclusion and recommendation. HHS agreed that greater coordination at the federal level would likely help states and localities move TANF recipients with impairments toward employment. It also said that this conclusion is consistent with the information and feedback they have been receiving from the states and counties. In addition, as the report discussed, HHS noted that there is limited federal support for training opportunities at the local level. It said that it had not been able to target its conferences or seminars to the very specific implementation needs of counties, given the great number of localities and its technical assistance budget. HHS also agreed with our recommendation that it should coordinate with other key agencies to ensure that research and technical assistance are disseminated. However, it disagreed that strategies to ensure such coordination be included in their annual performance plan. HHS stated that GPRA results should focus on the primary PRWORA goal of engaging clients in work activities. While we agree that HHS should focus on key outcomes for the TANF program, we continue to believe that including coordination strategies, goals, and measures in its annual performance plan would better ensure that effective coordination activities take place. This in turn could help states and localities have the research and technical assistance needed to meet the needs of TANF recipients with impairments. As HHS stated in its comments, moving welfare recipients with impairments to work is a relatively new experience for welfare agencies and the very unique needs of individuals require varied strategies. HHS’ comments appear in appendix I. HHS and two welfare experts also provided technical comments, which we have incorporated where appropriate. As agreed with your offices, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its issue date. At that time, we will send copies of this report to the Secretary of HHS, appropriate congressional committees, and other interested parties. We will also make copies available to others on request. If you have any questions concerning this report, please contact me or Gale Harris on (202) 512-7215. Other staff who made key contributions are listed in appendix III. To develop estimates of the number of Temporary Assistance for Needy Families (TANF) recipients with impairments, we analyzed the Census Bureau’s Survey of Income and Program Participation (SIPP) data for 1994, 1997, and 1999. To determine how county TANF agencies were screening, identifying, and serving TANF recipients with impairments, we conducted a nationally representative survey of 600 county TANF administrators from February 13 through June 1, 2001. SIPP is a national household survey conducted by the U.S. Census Bureau in which panels of individuals representative of the nation, including those receiving TANF, are interviewed over a period of 2 years or more. At 4- month intervals, panel participants are asked a set of “core” questions involving such subjects as their labor force activity, welfare program participation, and demographic characteristics. Periodically, the survey also asks a detailed set of questions on a variety of topics not covered in the core section. These questions are called “topical modules” and are assigned to particular interviewing cycles or in the survey. For our purposes, we selected panels starting in 1993 and 1996 and sampled TANF and non-TANF adults between the ages of 18 and 64. Data from the three disability topical modules we analyzed were from interviews conducted from October 1994 to January 1995, August 1997 to November 1997, and August 1999 to November 1999. During these interviews, panel members were asked an extensive set of questions about their physical or mental impairments, including questions on a range of functional or other activity limitations. To be identified as having a disability or impairment in SIPP, individuals must meet specific disability criteria developed by the U.S. Census Bureau. That is, they must meet any of the following criteria: 1. Had difficulty performing one or more functional activities, including seeing, hearing, speaking, lifting, and carrying, using stairs, and walking. 2. Had difficulty with one or more activities of daily living, such as getting around inside the home, getting in or out of a bed or chair, bathing, dressing, and eating. 3. Had difficulty with one or more instrumental activities of daily living, including going outside the home, keeping track of money or bills, preparing meals, doing light housework, and using the telephone. 4. Had one or more specific conditions, including a learning disability, mental retardation or another developmental disability, Alzheimer’s disease, or some other type of mental or emotional condition. 5. Had other mental or emotional condition that seriously interfered with everyday activities, including frequently depressed or anxious, trouble getting along with others, trouble concentrating, or trouble coping with day-to-day stress. 6. Had a condition that limited the ability to work, including around the house. 7. Had a condition that made it difficult to work at a job or business. 8. Received federal benefits based on inability to work. 9. Used a wheelchair, a cane, crutches, or a walker. Persons defined as having a severe impairment are unable to perform or need help to perform one or more of the activities or conditions in 1, 2, 3, 6, or 7; had a condition in 5, 8, 9; or had Alzheimer’s disease, mental retardation, or another developmental impairment. Because the estimates we reported from the SIPP were based on samples, they are subject to sampling error, which varied but did not exceed plus or minus 7 percentage points at the 95-percent confidence interval. Therefore, the chances are 95 out of 100 that the actual percentages being estimated would fall within no more than plus or minus 7 percentage points of our estimates. For the most part, TANF services are provided at the county level, so we selected a random sample of counties for our survey. We derived a nationwide listing of counties from Estimates of the Population of Counties by Age and Sex: 1990-1999 (U.S. Census Bureau) for 1999 and selected an overall sample of 600 counties. Before selecting this sample, we stratified the counties into two groups. The first group consisted of the 100 counties in the United States with the largest populations. The second group consisted of the remaining counties in the United States. We included all of the 100 counties with the largest populations in the sample to make sure that areas likely to have large concentrations of TANF recipients were represented. From the second group, consisting of all the remaining counties, we selected a random sample of 500 counties. After selecting the sample of counties, we used the American Public Human Services Association’s Public Human Services Directory (2000- 2001) to determine the name and address of the TANF administrator for each county. In states with regional TANF programs, we asked the regional director to fill out a questionnaire for each county in the region. One county reported that it received only tribal TANF funds, which falls outside the scope of our study. We removed this county from our initial sample, reducing our sample to 599 counties. We obtained responses from 540 of 599 counties, for an overall response rate of about 90 percent. The response rate for the stratum consisting of the 100 counties with the largest populations was 92 percent. The response rate for our sample of the remaining U.S. counties was 90 percent. For relevant questionnaire items, we compared the responses of the administrators completing questionnaires in the 100 most populated counties to those of administrators in the rest of our sample and found that, for the most part, offices in both types of counties are similar in the ways that they identify, assess, and provide services to recipients with impairments. Because the estimates from our survey are based on a sample of counties, each is subject to sampling error. The sampling errors for percentage estimates in the report from our survey varied, but did not exceed plus or minus 6 percentage points. The sampling error for our estimate of the average percentage of TANF recipients with impairments that were receiving services to move them toward employment is plus or minus 7 percentage points. The sampling error for our estimate of the average percentage of recipients with impairments that were receiving services in counties that do not offer any exemptions specifically for those recipients is plus or minus 13 percentage points. The sampling error for our estimate of the average percentage of recipients with impairments that were receiving services in counties that offer exemptions specifically for those recipients is plus or minus 8 percentage points. All of the sampling errors were calculated at the 95-percent confidence interval. 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Jayakody, Rukmalie, Sheldon Danziger, and Harold Pollack, “Welfare Reform, Substance Use and Mental Health.” Journal of Health Policies and Law, Aug. 2000. Johnson, Amy and Alicia Meckstroth, Ancillary Services to Support Welfare to Work. Washington, D.C.: Mathematica Policy Research, Inc., June 22, 1998. Kalil, Ariel, et al., Getting Jobs, Keeping Jobs, and Earning a Living Wage: Can Welfare Reform Work? Ann Arbor, Mich.: Program on Poverty and Social Welfare Policy, University of Michigan, Aug. 1998. Kramer, Frederica D., “Screening and Assessing for Physical and Mental Health Issues that Impact TANF Recipients’ Ability to Work,” Issue Notes. Washington, D.C.: Welfare Information Network, Feb. 2001. Kramer, Frederica D., “Seeing TANF from the Inside Out—Reconsidering the Program’s Role in the Wake of Welfare Reform.” The Forum, Vol. 3, No. 2. New York, N.Y.: National Center for Children in Poverty, Columbia University, July 2000. 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Summary: The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 significantly changed federal welfare policy for low-income families with children. The act eliminated eligible families' legal entitlement to cash assistance and created Temporary Assistance for Needy Families (TANF) block grants to states. TANF emphasizes the importance of work and personal responsibility rather than dependence on government benefits. To avoid financial penalties, states must demonstrate yearly that an ever-increasing proportion of adults receiving TANF are working or engaged in work-related activities. The U.S. Census Bureau's Survey of Income and Program Participation (SIPP) for 1999 show that 44 percent of TANF recipients nationwide had physical or mental impairments, a proportion almost three times as high as among adults in the non-TANF population. The percentages of TANF adults with impairments from 1994 can not be compared to later years because Census broadened its measurements of mental impairments starting with its 1997 SIPP data. Most of the counties that screen for impairments rely on recipients' self-disclosure, which may not ensure the identification of some impairments that could interfere with employment. Still, for the one-third of counties that reported service data, fewer than half of recipients with impairments were receiving services to move them toward employment. This situation may be explained by the fact that many recipients were exempted from program work requirements. Federal agencies, including the Departments of Health and Human Services, Labor, and Education, have many research and technical assistance initiatives underway to facilitate state and local efforts to help TANF recipients with impairments become employed.