When free money isn’t enough: notes on perilous program design.
Twenty percent of those who are eligible for the federal Earned Income Tax Credit (EITC) don’t use it. One in five of those who qualify neglect a combined 17 billion dollars in benefits each year. Despite this, the EITC has allowed more than five million people to rise above the poverty line. It’s one of the largest anti-poverty tools in the US. Why are so many missing out?
I'll cover a few big reasons shortly, but first it's important to note just how many state agencies and nonprofits are suffering the same fate. The programs are there, but they are persistently underutilized. It can be demoralizing for executive directors. I’ve heard so many of them share the same story: “I did all I could, but it was exhausting. We had the best team and a great program, but the problem was bigger than us. Burnout was inevitable.”
If your work feels like an uphill battle, remember this — big problems don’t have simple solutions. And the societal issues most of us are working to address are complex. But that doesn’t mean they are insurmountable. Program design is key. So, let’s first examine two flawed models. Then, I’ll compare them with a program design that reduced unwanted pregnancies by 44 percent.
What not to do.
Let’s start by taking a closer look at the EITC, the third largest social welfare program after Medicaid and Supplemental Nutrition Assistance Program (SNAP). The EITC provides working parents with a tax refund based on the amount of money they make and the number of children they are working to support. So why is it underused?
Accessing the EITC is just too difficult for many eligible beneficiaries. It’s part of the tax code. A tax code so confusing that 59 percent of Americans pay a professional to file their taxes. The EITC beneficiary can’t do that. They don’t have the money. They also likely don’t know what the EITC is or if they qualify.
Qualification is where it really gets bad. This year, the EITC was expanded again as part of the American Rescue Plan. Specifically:
It’s a one-time tax break this year only.
Low-wage workers without children can receive up to $1,500.
Age and income limits have been expanded.
Care for children under 13 years old, an elderly parent or a child with a disability can be reimbursed up to $8,000.
Eligible recipients must have worked, looked for work or been a full-time student.
Here are three reasons the latest EITC expansion won’t help many of the people the American Rescue Plan is trying to aid:
The EITC is associated with dependent children. People without children aren’t going to be aware of it.
Awareness of the program’s expansion is relying on news outlets that do not reach a low-income audience.
Increasing participation would require a massive public education campaign that isn’t in place.
Fair enough.
If you’re saying the tax code is an easy target, I’ll give you that. Unfortunately, the EITC is only a place to get started. In a recent interview with the New York Times, author and sociologist Matthew Desmond noted that an estimated 140 billion dollars in government assistance goes unspent each year. Programs like government health insurance, unemployment insurance and supplemental security income are all programs that contribute to that staggering total.
Since many of us work to address issues faced by senior citizens, let’s examine the Supplemental Nutrition Assistance Program (SNAP). According to the AARP Foundations’ Food Research and Actions Center, only 42 percent of eligible senior citizens access SNAP compared to 83 percent of all eligible people. I don’t believe that people over 65 are unaware of food assistance programs.
Understanding eligibility requirements is certainly a factor in some cases, but for now, we’ll assume that problem was solved. In a good faith effort to make the program as accessible as possible, the government provides access to SNAP online — once you establish a username and password on the Department of Social Services’ (DSS’) web portal. The process is cumbersome, especially for those unfamiliar with technology. The work around is to apply in person, standing in line, at a county DSS office — hardly a friendly solution for older individuals with mobility issues.
Programs over people.
I do realize SNAP is a well-intentioned program that helps a great number of people. Nevertheless, like many forms of public assistance, it has been designed with the program in mind, not the people intended to access it. This isn’t malicious, it’s by default for most systems from the highway department to the health department. In contrast are the program designs of for-profit entities competing for consumer demand. Anyone who has experienced the efficiency of Chick-fil-A’s drive-thru has seen capitalism at work. Chick-fil-A had to reengineer the drive-thru experience during the COVID-19 pandemic, and it continued to prosper as a result. It’s time to take a step back and examine your program’s design through the eyes of the people you’re hoping to serve.
How to tell if you have a problem.
Under-resourced individuals face many obstacles to accessing the services available to them. What are you asking of the people who need your organization’s help? If you can answer yes to more than three of these questions, it’s time to reassess your program design.
Are you asking them to schedule an appointment?
Is your website the only efficient entry point?
Are you counting on clients to use their cellular data plan to search and find your service?
Is it complicated for your audience to determine their eligibility?
Do you depend solely on word-of-mouth messaging to reach new consumers?
Do you require program participants to complete extensive paperwork?
Do you offer your service only during standard business hours?
Do you fail to tell people beforehand what they can expect when accessing your program?
Does your program lack a well-funded public education campaign?
Are your clients unable to access your service remotely?
Researching program design.
Reassessing program design needs to begin with research. Yet research almost always gets skipped. You likely haven’t invested time or resources in it because you believe that you know your audience. You’ve studied them. You are in front of them everyday. But not doing proper research is where your problem begins, and it only gets worse from there.
The longer you’ve been running your program, the blinder you could be to your clients’ barriers to access.
You need to do both qualitative and quantitative research, and in that order. I like to use individual interviews or conversations among small groups to determine broader qualitative hypotheses that can be vetted using a quantitative survey.
It’s important to include not only current consumers, but also lapsed clients and non-clients. Commissioning primary (original) research is best, but if you have access to a study fielded by a peer program in another state or region, you can start by reviewing their findings. Either way, I recommend pairing your findings with less formal input by community stakeholders. A thorough research process should uncover not only what barriers are in place but how they need to be addressed.
Reducing unwanted pregnancies by 44 percent.
I followed the same research trifecta in 2017, when my colleagues and I were asked to develop a public education campaign for a statewide contraception access program in South Carolina. The goal was to reduce unintended pregnancy by increasing access to contraceptive care for low-income women 18-44 years old. Achieving this would allow for greater educational attainment and improved socioeconomic mobility; however, the research showed that the barriers were daunting.
Time/Transportation
The existing program required an appointment. Requiring a patient to make an appointment is standard, but it wasn’t realistic for our clients. Ever wonder why so many access primary healthcare through the emergency room? Many hourly employees, particularly those in food service or retail, can’t predict what shifts they are given. Last minute changes and substitutions are the norm. In addition to uncertain schedules, access to reliable transportation can be difficult. In rural areas of South Carolina, public transportation is nonexistent. Add child care to the equation and the idea of an appointment becomes insurmountable.
Stigma
We didn’t need research to tell us that there is stigma surrounding access to birth control. It did however reveal some nuances that informed the program’s later evolution. My colleagues and I interviewed several nurses who counseled patients whose prescriptions were refused by pharmacists. “You’re not married. I’m not filling this.” We heard about clinics with receptionists who gossiped about who was visiting the clinic. I even met one provider in a small town who said that patients feared having their cars seen in the parking lot.
Coercion
Research also revealed that patients regularly felt that providers preferred prescribing a particular method of birth control. Many patients had experienced blatant coercion. A significant portion just didn’t feel heard when attempting to discuss previous experiences or side effects. While our program practices Shared Decision Making, our providers were going to have to overcome a judgmental stereotype. We wouldn’t have seen this coming without qualitative interviews, and we backed up the stories with qualitative questions that proved they weren’t outliers.
Newer Products/Myths
The program provided access to eight methods of birth control, including the most effective methods, implants and intrauterine devices (IUDs). While women in South Carolina had been able to access contraceptive counseling at the state’s system of county health departments for decades, availability of implants and IUDs was new. There was some awareness of implants and IUDs, but unfortunately, there were myths and misperceptions to overcome. One example being that IUDs were only for women who already had children. Another issue was word-of-mouth discussions about individual side effects that made them seem universal.
Unclear Pricing
While the program was largely free, there were exceptions. Some methods had modest costs for uninsured patients. Other methods weren’t always covered by insurance. Only Medicaid patients had access to all eight methods for free. Insured patients would be asked for a copayment. As a result, we couldn’t market the service as free. We were required to caveat free by using the phrase “free or low-cost,” a near tragic liability when communicating with a population who is the frequent target of bait and switch marketing tactics.
Inconsistent Network of Partners
Clinical partners were decentralized. Different locations had different hours. There were more than 20 sets of policies about filing for Medicaid, parental consent and determining billing policies. This undermined efforts to build a user-friendly, patient-centric program to an audience skeptical about access to medical care in general, and especially reproductive health.
Given the quantity and severity of the barriers facing our audience, I was skeptical about our ability to succeed. Then I was forwarded an article that really made me worry.
Spreadable Program Design
The article, “Selling Social Change,” was in Stanford Social Innovation Review. It introduced me to the principles of the Diffusion of Innovation Theory, outlining the following five attributes for successful program design:
Better than what exists (both costs and benefits)
Compatible with beneficiaries’ values, past experiences and needs
Simple to use (or do) and understand
Testable without having to commit to it
Observable such that others can see the benefit of adopting it
At first, the five metrics read like a checklist of things our initiative failed to deliver. In retrospect, it was a list of goals for the program we needed to design. And we were going to have to make changes to the program design while the initiative was in progress, not before it started. Every large initiative has that moment of panic. The not-so-sudden realization that the mountain is just too high. Then you just have to begin walking up it anyway.
An early step was deciding to name the program No Drama. The idea was to make No Drama the antidote to all the drama that came with accessing birth control before our program. Finding birth control is drama. Paying for it is drama. Dealing with shame and stigma is drama.
The name pushed us to face the same barriers the patients did, and working to overcome what we could was paramount to the program’s success. Here's what’s key. It’s never going to be perfect. And it certainly didn’t start without its share of pitfalls. Here are the measures we took to try and achieve as many principals of the Diffusion of Innovation Theory as possible.
1) Better than what exists (both costs and benefits)
Title X grants have funded family planning services in county health departments since the 1970s. Some smaller and more rural counties offered care only one or two days per week. Meanwhile, several counties in South Carolina had no OBGYN practices at all. So, expanding access to care was a game changer. Our grant maker enabled more than 20 federally qualified health centers (FQHCs) to begin offering contraceptive care for the first time. Access grew from 48 health departments to more than 120 clinic locations. This ensured a clinic was within 30 miles of every resident in the state. That increase in access was certainly better than what previously existed, but communicating it was key. A clinic finder on the No Drama website allowed users to enter their zip code and see a list of the five clinics closest to them.
No Drama was launched using a toll-free mobile number **nodrama. It was easy, it was free and it was memorable. It also didn’t work. We were living proof that young people don’t want to talk on the phone.
A simple form solved this. We added it to the website and increased appointment requests fourfold. The form did nothing more than prompt an outbound call from No Drama to the patient, but it put the patient in control, and that was better than what previously existed. This was an early win. It not only gave the initiative solid footing and positive reviews, it also taught us that we needed to be in the business of continual refinements to program design.
This healthy perspective became critical in 2020, when our partners struggled to address the pandemic. With COVID-19 spreading rapidly, the last place anyone wanted to be was in a medical office.
Thankfully, one of our clinical partners was a university health center. The lack of students congregating in class or for social events and abbreviated class schedule resulted in excess capacity. This enabled us to work with them to launch a telemedicine program. Accessing care from anywhere eliminated transportation barriers, stigma and provider inconsistencies. We even worked with a pharmacy to fill prescriptions by mail.
Appointment requests went from 298 in April 2020 to 1,154 in July 2020.
2) Compatible with beneficiaries’ values, past experiences, and needs
Our beneficiaries’ past experiences weren’t consistent. In some cases, previous contraceptive care visits had been their only access to healthcare. Other cases involved judgement by nurses or receptionists who didn’t respect patients’ confidentiality. In our case, it was important to be mindful of negative past experiences in our communications with prospective patients.
To that end, participating providers benefited from in-depth training to ensure best practices surrounding the avoidance of stigma. Without this, we wouldn’t have been able to promise a patient experience free from it. A statewide billboard campaign made the following promise to prospective patients: “Birth control questions? Get answers, not attitude.”
Just as with the EITC and SNAP programs, navigating the healthcare system, and Medicaid in particular, can be overwhelming. Layer on top of that the fact that many patients are teenagers accessing the healthcare system for the first time. Intimidating practices are also in place, like patients with lower literacy levels being handed a clipboard full of intake forms to complete.
To combat this, we added a chat feature to the website where patients could access a full-time patient advocate. While unable to offer medical advice, the patient advocate knows the idiosyncrasies of every clinical partner as well as the intricacies of the Medicaid system. She’s also familiar with common side effects associated with each method of birth control. This not only improved patients’ access and experiences, but also created advocates for the program. Word of this level of assistance has certainly spread. The patient advocate offered 1,976 interventions in 2021 and 2,999 in 2022.
3) Simple to use (or do) and understand
Anything unknown before a virtual or office visit is a potential barrier. So, our approach has been to do everything we can to take away uncertainty about the service using a section of the No Drama website titled “How It Works.” In it are details about who qualifies (everyone) and specific cost variables according to insurance status. There’s a section on the website titled: “How much will it cost?” where prospective patients select from a drop-down menu labeled “Select Your Situation.” Choices include: no insurance, on Medicaid, have insurance and not sure. Methods that are free and methods that are low-cost are sorted according to one’s selection. Having no variables would be better, but any barriers brought about by questions about cost have been mitigated. Lastly, we included 15 frequently asked questions.
4) Testable without having to commit to it
Obviously, there’s no way we can accomplish this one. But again, we made the best attempt by developing a method finder. The method finder is a survey that starts with a series of medical questions covering topics such as hypertension, blood clots, tobacco use and migraines. Visitors are queried about any experiences they might have had with the eight methods offered. The third and final criteria asks visitors to select what’s most important to them. Priorities include convenience, privacy, avoiding side effects, etc. Based on the answers patients provide, the method finder presents options that can be compared by level of effectiveness, functionality, pros and cons and possible side effects. The method finder was added three years after the program’s launch and immediately became the third most frequented page on the website.
5) Observable such that others can see the benefit of adopting it
Again, not possible, but showing women helped by the program was. We already used patient experience evaluation surveys to look for ways to improve the program. So, we added a question about willingness to share one’s story. Nine patients were willing to be interviewed on camera. Our goal was to ensure visitors to No Drama could find someone with whom they could relate. We were fortunate enough to have a gifted interviewer that put our respondents at ease, allowing them to describe what drew them to the program and explain how they had benefited.
The videos also provided content for social media. All of this occurred in the program’s sixth year. The goal of showing actual patients was to demonstrate a new social norm. Through nine women, we were able to offer prospective patients a sense of belonging to a larger group of like-minded people. Reactions were positive and swift, further increasing appointment requests.
Your terms can prevent the very change you’re working to achieve.
Change doesn’t happen on anyone’s terms other than the people you are trying to benefit. My colleagues and I did what we could to align our program with the principals of Diffusion Innovation Theory. Seeing it from the patient’s point of view, we just made it easier for people to access our program and understand what to expect.
Something to feel good about.
Before launching a statewide public education campaign, we feared a possible backlash. I imagined an irate parent on the phone telling me that their eight-year-old was asking about birth control after seeing one of our billboards. Or an angry social media post saying we were promoting promiscuity. We prepared a playbook anticipating every undesirable scenario we could imagine. Thankfully, we didn’t have to use it.
We also expected our message might become partisan. In fact, it was anything but. We have and continue to enjoy support from both sides of the political spectrum. Politically conservative lawmakers appreciated that our program has saved South Carolina taxpayers over $240,000,000. More ideologically liberal policy makers appreciated that their constituents had greater access to women’s healthcare. The No Drama program benefits not only patients and their families, it’s also a win for policy makers of every political leaning.
The outcomes have been promising. Over six years, one in three women in South Carolina of childbearing age has benefited from the program. That’s more than 400,000 people. Unwanted births have decreased by 44 percent and intended pregnancies have increased by 16 percent.
There are so many good people working hard to deliver services to those in need. There are more than 1.5 million nonprofits in the US. But the number of programs doesn’t seem to be advancing against the persistence of the problems they are trying to solve. I believe that the more complex the problem, the greater the obligation to make the interventions easy to access. That means aligning program design with beneficiaries’ needs.
If you’re overwhelmed by the struggle to achieve behavioral change, you are among thousands of public service professionals. If you step up and address program design, you are among a handful who will be helping thousands more people as a result.
Take care,
Kevin
