There’s No Place Like Home (Depending on Which State You Live In…..)

There’s No Place Like Home (Depending on Which State You Live In…..) 150 150 Kelly Kelleher, MD, MPH

Researchers find wide variation in how federal entitlement and benefit programs are implemented from state to state.

Over the past five decades, the health of America’s children has improved considerably. Unfortunately, those improvements were not evenly distributed. Most American children are healthy and have promising futures. Children in poverty, on the other hand, infrequently move up the social ladder in the United States and are subject to higher rates of hunger, homelessness, violence and other challenges.

In response, the federal government developed a variety of entitlement and benefit programs to directly address the social determinants of health that affect impoverished families and especially their children.  Medicaid provides health insurance and care to low income children. SNAP, formerly known as Food Stamps, provides nutritional support. Supplemental Security Income provides cash assistance to families of poor children with severe disabilities as well as making them eligible for Medicaid. These and other federal programs make up the federal safety net created for poor children through benefit programs.

That safety net has sprouted some significant holes, according to new research on state-to-state variation in the administration of federal programs for children living in poverty. In a recent study derived from a National Academy of Medicine Committee, published in Psychiatric Services in Advance, Supplemental Security Income benefit approval rates varied six-fold across states, and the number of children receiving SSI benefits varied five-fold. In our region, Pennsylvania had roughly 5 percent of children living in poverty receiving SSI while Ohio has roughly 1 percent.

These marked differences are not limited to SSI. The 1996 Child Care Entitlement to States provided federal funds to tribes and states to support child care for low income families (no more than 85 percent of state median income). Because the rules and funds are largely federal, one could expect similar programs across states, but the range of income eligibility across states varies from 30 to 80 percent of state median income. Similarly, the National School Lunch Program serves more than 30 million children each year. It is the second largest nutritional program for children in the United States. Although federal guidelines and support are standard across the country, more than 25 states dropped sliding scale fees in some districts to encourage broader uptake of meals while others chose not to for their children even though administration costs and missed meals go down for those who do.

The patchwork implementation of federal benefits and entitlements to children in poverty across diverse states arises from state, county and local administrative structures, state budget commitments, local paperwork and administrative barriers to enrollment. In addition, it is lacking in awareness and education among low income communities. Overcoming these numerous barriers should not just concern families in poverty. It is also an important issue for clinicians concerned about the outcomes of their care. The best health outcomes include aiding families in obtaining benefits that may lift them out of poverty or ameliorate its effects.

Direct research on the sources and solutions of state-to-state variation in the administration of federal programs is necessary, but aggressive advocacy at the local level is also important. Here at Nationwide Children’s Hospital, we are taking a multilevel approach that is in the process of being implemented.

  • Clinicians can more effectively assess specific poverty challenges among their patients and families. Several local pilots for screening children in medical settings for hunger, housing insecurity and violence are underway, including initiatives from CAP4Kids and Ohio AAP.
  • Clinicians can link their screen positive patients with services and benefit applications. The Health Leads program uses volunteer students to link families directly to social service benefits. Benefit Banks can assist patients and their families with multiple applications and eligibility assessment.
  • Clinicians and health systems can co-locate health care services with social services whenever possible.
  • Health care systems can directly address poverty with housing, employment, safety and advocacy initiatives such as Healthy Neighborhoods Healthy Families here on Columbus’ South Side, our place-based initiative focused on community development in partnership with Church for All People, the United Way of Central Ohio, the Mayor’s Office and others.



Hoagwood KE, Zima BT, Buka SL, Houtrow A, Kelleher KJ. State-to-state variation in SSI enrollment for children with mental disabilities: An administrative and ethical challengePsychiatric Services. 2016 Oct 3. [Epub ahead of print]

About the author

Dr. Kelleher is a pediatrician whose research interests focus on accessibility, effectiveness and quality of health care services for children and their families, especially those affected by mental disorders, substance abuse or violence. He has a longstanding interest in formal outcomes research for mental health and substance abuse services. Dr. Kelleher is director of the Center for Innovation in Pediatric Practice and vice president of Health Services Research at The Research Institute at Nationwide Children’s Hospital. Dr. Kelleher is also professor in the Department of Pediatrics of The Ohio State University College of Medicine.