The WIC program was created in 1972 in response to growing evidence of poor nutrition and related health problems among low-income infants, children, and pregnant women. It is intended to serve as an adjunct to good health care during critical times of growth and development. In addition, WIC was designed to supplement the Food Stamp Program and other programs that distribute foods to needy families. Several population groups are eligible for the supplemental foods and nutrition services offered by WIC. Eligible groups include lower-income pregnant women, nonbreastfeeding women up to 6 months postpartum, breastfeeding women up to 1 year postpartum, infants, and children up to age 5 who are at nutritional risk. WIC provides cash grants to support program operations at 88 state-level WIC agencies, including those in all 50 states, American Samoa, the District of Columbia, Guam, Puerto Rico, the U.S. Virgin Islands, and 33 Indian tribal organizations. Food and NSA grants are allocated to the state agencies through a formula based on caseload, inflation, and poverty indices. Small amounts are also set aside and distributed, at USDA’s discretion, to fund updates to infrastructure—like the development of electronic benefit transfers—and to fund evaluations performed by state agencies. Some state-level agencies that operate the program at both the state and local levels retain all of their WIC grants. The remaining state-level agencies retain a portion (the national average is about one-quarter) of the funds for their state-level operations and distribute the remaining funds to nearly 1,800 local WIC agencies. In 1998, state and local WIC agencies relied primarily on their federal NSA grant funds to support their NSA operations. Although no state-matching requirement exists for federal WIC funding, some state WIC agencies have received supplemental funds from their state governments for NSA. Some state and local WIC agencies also receive in-kind contributions, such as office space, from nonfederal sources such as local governments and private nonprofit agencies. NSA grants cover the costs of providing various nutrition services— participant services, nutrition education, and breastfeeding promotion. Participant services include numerous activities such as determining eligibility, food benefit distribution, screening for up-to-date immunizations, and referrals to other health or social services. Each of these activities includes many processes. For instance, we reported in September 2000 that certification involves identifying income, participation in a qualifying program such as Medicaid, pregnancy or postpartum status, and medical or nutritional risks. The length of time that a person is certified to participate in the program typically ranges from 6 months to 1 year, depending on such factors as whether the participant is a woman, a child, or an infant. Nutrition education consists of individual or group education sessions and the provision of information and educational materials to WIC participants. Regulations require that the nutrition education bear a practical relationship to participant nutritional needs, household situations, and cultural preferences. Nutrition education is offered to all adult participants and to parents and guardians of infant or child participants, as well as child participants, whenever possible. It may be provided through the local agencies directly or through arrangements made with other agencies. Individual participants are not required to attend or participate in nutrition education activities to receive food benefits. Breastfeeding promotion activities focus on encouraging women to breastfeed and supporting those women who choose to breastfeed. Each local agency is required to designate a breastfeeding coordinator, and new staff members are required to receive training on breastfeeding promotion and support. WIC endorses breastfeeding as the preferred method of infant feeding. Although state agencies must operate within the bounds of federal guidelines, they have the flexibility to adjust program services to meet local needs. States can add program requirements. For example, in 1999, Montana required its local agencies to formally document referrals made to WIC participants, though this is not required by program regulation. States that utilize local agencies to provide nutrition services also provide these local agencies with some discretion in implementing the local program. This means that the specifics of the WIC program can vary from state to state and locality to locality. In 2001, USDA and the National Association of WIC Directors (NAWD) distributed revised Nutrition Service Standards that provide WIC agencies with guidelines on providing high-quality nutrition services. The WIC program faces the following challenges in delivering high-quality nutrition services: (1) coordinating its nutrition services with health and welfare programs undergoing considerable change; (2) responding to health and demographic changes in the low-income population that it serves; (3) recruiting and keeping a skilled staff; (4) improving the use of information technology to enhance service delivery and program management; (5) assessing the effect of nutrition services; and (6) meeting the increased program requirements without a corresponding increase in funding. Over the past decade, major changes in the nation’s health and welfare delivery systems have presented WIC agencies with the challenge of identifying and enrolling eligible participants and coordinating with other service providers in a new environment. More specifically, state Medicaid agencies’ increased reliance on private managed care organizations has reduced the service delivery role of local public health agencies, the entities with which WIC agencies have had a long-established relationship. As a result, WIC’s link to the health care system has been weakened, making it more difficult for WIC agencies to identify eligible individuals and coordinate services with their participants’ health care providers. Additionally, changes brought about by welfare reform—which include the elimination of Temporary Assistance for Needy Families (TANF), Food Stamp, and Medicaid benefits for many individuals including noncitizens— have decreased WIC’s ability to reach eligible individuals through these programs. Two recent and related changes in the health care system are presenting new challenges to WIC agencies in carrying out their referral, outreach, and coordination efforts. The first change is the rapid growth since 1991 in the percentage of Medicaid beneficiaries who are enrolled in managed care (see fig. 1). This increase in the percentage of Medicaid beneficiaries receiving health services from managed care providers contributed, in part, to the second change: the reduction or elimination of direct health care services by many local public health departments. According to a national survey of local health departments offering comprehensive primary care services in urban areas in 1995, about 20 percent stopped providing such services to women and children by 1999. Similarly, about 9.4 percent of those offering comprehensive primary care services to women in nonurban areas in 1995 stopped providing such services by 1999, and 15.5 percent of nonurban agencies stopped providing such services to children. With the reduction in the number of public health departments serving women and children, public health officials have increasingly turned to WIC to help address the health needs of low-income children. According to CDC, WIC has become the single largest point of access to health- related services for low-income preschool children. Consequently, the CDC has turned to WIC to provide services traditionally performed by local health departments, such as identifying children who are not fully immunized. These changes have several implications for WIC. Historically, many WIC participants have been able to receive health services, such as pediatric care, at the WIC sites. This proximity could facilitate the required link between WIC services and health care; health care providers could easily refer Medicaid and uninsured patients to the WIC program, and WIC staff could easily refer WIC participants to appropriate health care services. This arrangement also made it more convenient for participants to schedule appointments for both WIC and health services. However, as Medicaid managed care providers have increasingly replaced local public health clinics as providers of maternal and child health care, this link between WIC services and health care has weakened. The convenience for many WIC staff and participants of having WIC and health care services co-located has been lost. As a result, many WIC agencies must extend their outreach efforts to contact people, especially uninsured individuals not connected with the health care system, who are eligible for WIC. Given these changes, it will be a challenge for WIC to effectively coordinate its services with other health providers. Evidence already suggests that WIC agencies are struggling with this coordination. For example, a national survey conducted by the Women’s and Children’s Center at Emory University’s Rollins School of Public Health found that only 26 percent of state WIC agencies had made specific arrangements, such as developing formal guidance, for the collaboration of services between WIC and managed care providers in 2000. The Center published a resource guide to assist in the collaboration between WIC and managed health care. The guide identified several barriers to the coordination between WIC and managed care providers and provided descriptions of strategies that state and local WIC agencies can use to overcome such barriers, though it suggests that employing suggested strategies will increase staff responsibility and program costs. The barriers include the following: Lack of understanding. WIC staff do not understand the managed care system and managed care providers do not understand WIC. Lack of specific requirements. State Medicaid agencies may not have instituted specific contractual requirements for managed care organizations or providers to make referrals or supply needed information to WIC agencies. Communication difficulties. Managed care providers’ change in ownership has been accompanied by communication difficulties. The termination of Medicaid contracts with managed care providers and the location of some managed care provider headquarters in another state can also make communication difficult. Welfare reform, which made major changes to the nation’s social safety net, has also placed new demands on WIC’s client services and outreach. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), which replaced the Aid to Families with Dependent Children with TANF, established a lifetime, 5-year time limit on the receipt of TANF benefits and required states to place work or work-related requirements on a percentage of households receiving TANF. The act also made several categories of noncitizens ineligible for TANF, food stamps, and Medicaid. Welfare reform has contributed to the decline in the participation in public assistance programs.