27-05-2025
Here's why delivery of social services is so complicated
Photo illustration by Getty Images.
A few months ago, I was having coffee with a friend who was helping a relative apply for Medical Assistance.
He looked at me, astonished, and maybe a little outraged, and said, 'You have to mail a piece of paper to change an address.'
I nodded, looking down at my coffee.
Anyone who has worked in human services braces themselves for these stories. They range from headache-inducing bureaucratic annoyances all the way to horror stories of people so caught up in red tape nightmares that they can't access life-saving care or treatment.
Why is this? Why are human services so complicated?
The answer starts with us — the attitudes of the American people — and is reinforced through all other levels of the policy process, from budgeting to service delivery.
America's attitude toward poverty is shaped by 16th century English Poor Laws, particularly the idea of 'deserving' and 'undeserving' poor.
This manifests itself in our nation's reliance on means-tested programs. Means-testing means only low-income people qualify for a service. Other rich democracies rely more on services that are available to everyone.
Means-tested programs rely on complex eligibility processes — both for initial application and to prove continued eligibility. Sometimes, people must report various information on a monthly basis to remain eligible for benefits or services.
It's a continuous requirement to prove that you really need help.
While some process is necessary, the number of rules and the degree of complexity to follow them reflects the public ambivalence toward these services.
These values can get muddled in the largest U.S. means-tested program, Medicaid (called Medical Assistance in Minnesota).
Medicaid is largely thought of as a health care program for low-income families. It is means-tested. At times over the past two decades, Republicans have referred to Medicaid as 'welfare health care' to justify budget cuts.
At the same time, Medicaid provides health care and long-term care for low-income seniors and people with disabilities. Health care for seniors and people with disabilities has broad public support, and many believe this basic dignity is a right, not a privilege.
Yet the process of getting grandma into the nursing home or helping a person with disabilities live and work in the community is complicated by the fact that these services are paid for by Medicaid, a means-tested program. As a result, families trying to help a grandparent or another relative often find themselves caught in a morass of rules and red tape.
All because the best our nation could do for vulnerable people needing long-term care was to cobble some services onto Medicaid.
This ambivalence about helping poor people also plays into another facet of the policy process: budget cutting.
Human services are some of the largest and fastest growing programs: Medicaid and SNAP are two of the larger programs in the federal budget, and Medicaid is the largest program in many states' budgets.
Whether reductions are made for political reasons or to address budget deficits doesn't matter: Human services programs will be at the center, because that's where the money is.
But few politicians really want to cut low-income people off benefits, especially not health care for people in their districts, and especially not elderly people in nursing homes or people with disabilities.
So, instead of simple changes that would reduce benefits or coverage, the budget cutting solutions are often more complex policy changes wrapped in messaging about 'work' or 'fraud and abuse.'
We see this happening right now at the federal level with Medicaid and SNAP. A skittish Congress has backed off from direct cuts to Medicaid, opting instead for work requirements and other eligibility changes — under the guise of weeding out the people who don't deserve health care.
In other words, Congress is intentionally creating complex hoops designed to cause people to lose health care, all in order to cut the budget to pay for tax cuts.
Once these policies are passed by Congress, federal agencies create regulations to further detail how policies must be implemented by states. At the state level, additional legislation may be required to sort out any areas of state discretion under the new federal laws. And then state agencies develop rules or guidance for counties, tribes or private entities that deliver the services.
Each step adds more specificity — and more complexity.
And the constant changes in policy from year to year compounds the problem.
It all lands on people trying to get necessities like health care and groceries — and the frontline workers who are just trying to help their clients obtain these simple human needs.
I've focused on eligibility policies, but this complexity has infected other policies as well. The decisions regarding who gets into a nursing home or what services a person with disabilities can get in the community had, in the past, relied partly on discretion by a local social worker. Now these decision factors are fixed in law and supported by structured, mandatory assessment tools.
This ensures consistency, but when people are denied services, it can feel like the decision was made in a black box.
I'm not sure it is possible to undo this cycle. There are never enough resources to meet all the needs. Combine that with our ambivalence about who deserves help, and it's a self-perpetuating mess.
The best hope for fixing this problem — to make it simpler for people to get the services they need — is at the point of service delivery.
Of course, as I wrote here in 2023, that requires us to overcome another challenge: We focus a lot on public policy and not enough on the the operational mechanics of programs and how they work (or don't) for the person who needs it.
Yet I have some optimism for this solution for two reasons: It is in the control of state and local officials who care about human services, and digital tools offer real opportunities for simplifying the consumer experience.
But we need the will to do it — to put the needed focus on efforts to improve service delivery, while still managing the unstoppable policy machine.
SUPPORT: YOU MAKE OUR WORK POSSIBLE
