Who gets what

Rationing Services

Much of what we think of as social service provision is related to principles associated with the English Poor Laws

•Principle of Lesser Eligibility – No one should receive more than they earn.

•The Able-bodied should be encouraged to work.

•The deserving poor should receive more than the able-bodied.

•Those able, but unwilling to work should be considered to be immoral.

•Assistance can be provided by government, but charities should also do their part.

The funding allocation dilemma for government agencies and nonprofit organizations is:•To acquire as many resources for services

for possible.•While using these resources in the most

effective way possible.•And not running out of resources for

people in need.

According to Rein (1983):

in any social service organization, tensions exist between efforts to get clients to adjust to organizational rules and the principle of client self-determination. Client “adjustment” or compliance with organization policies is often used as a mechanism that helps the organization standardize services and keep their cost to a minimum.

An example of using standardization to lower costs:Domino’s Pizza – only a few options for service that will be ready within a short period of time!

Individualization vs. StandardizationOrganizations that try to make services

“fit” client needs or individualize them will encounter the higher costs associated with maximizing benefits. The process of standardization also takes place in situations when social service organizations must verify that services are provided in an equitable manner to all eligible people who apply for them (Smith & Lipsky, 1993).

Standardization in Public BureaucraciesThis push for standardization is particularly the

case with public agencies that are accountable to taxpayers for the manner in which they spend public funds. Such agencies must also make efforts to minimize the costs associated with service delivery while providing services in an equitable manner.

One reason for limiting or rationing services is that given that services to low income people are such a low priority that when the supply of services increase, demand increases. That means that seldom are there enough services for those that need them.

Nonprofit Organizations only need to be accountable to funders, the IRS, and their boards of directors. But they often struggle to limit or ration the services they provide. They often do this by limiting provision to:

•Members of one ethnic group.•Members of one religious group.•People they know or people who have

previously volunteered or given money to the organization (mutual aid societies)

•People who they believe have good moral values.

As with the English Poor Laws, morality is incorporated into the decision of who gets service in both nonprofits and government agencies:•Services may not be given to people who

do not work or who are viewed as immoral.

•People may be required to join a religious group or hear a religious talk in order to receive service.

•People are often required to “prove” they have no income or are otherwise eligible to receive service.

Methods to limit demand for services:• Locating the organization in a place that is

difficult to travel to• Charging user fees• Hours of operation• Requiring a referral from another agency or

case manager• Establishing a wait time for service• Making waiting rooms unwelcoming• Offices that are not accessible to people with

disabilities• Services are only available in English• Work requirements• Income/Means Testing

Proof of eligibility can include:

•Completion of complicated applications•Pay stubs•Receipts for rent and utilities•Social security numbers•Birth certificates for all family members•Bank statements

Another rationing mechanism has to do with the way services are delivered:• Material goods and services (examples: government

commodities such as cheese; public housing).• Cash (Welfare; social security checks)• Expert services provided by professionals (government

reimbursed health/mental health services)• Positive discrimination (Affirmative action)• Consumer subsidies (Universal health care proposals

to help people buy insurance; Section 8 housing assistance)

• Credits/vouchers. Prepayments to providers. Can generally only be used at providers determined by the funder.

• Power over decisions (consumer empowerment; seat on boards; preservation of choice in selection of services benefits).

Benefits provided to low-income individuals differ from other types of benefits:

•Market subsidies –payments made to a third party or monies given to farmers to enhance price of food crops or other goods.

•Government guarantees – government promises to repay loans in event signatory defaults.

•Protective regulation – grants of exclusive or near exclusive rights to a certain market.

•Tax credits for employers; individuals with itemized deductions (biased to high wage earners).

Another way to discourage applicants involves social stigma:•Some social problems such as poverty,

having a child outside marriage, and substance abuse are still viewed as signs of immorality.

•Consequently, people view recipients of some types of programs as immoral. Recipients sometimes view themselves negatively if they apply for these services.

•Sometimes social workers and other social service employees incorporate negative stereotypes into assessment and service delivery decisions.

Stigma and other access barriers:Have been described as the “cost” of free

services (Prottas, 1981). Organizations increase the cost of service by making it more difficult to receive it. This in turn limits the supply of clients.

Questions for Class Discussion

•Does everyone have these documents?•Who is unlikely to have them?•Are these documents easy to obtain?•Are there monetary costs associated with

these documents?•What impact do document and income

verification requirements have on whether a family applies for services?

Social policy discussions have increasingly targeted three demographic groups for reductions in service:• Immigrants – tightening immigration requirements

– refusing services to undocumented people; limiting services to permanent residents who are not citizens.

• Women – requiring work for single mothers on welfare. Limiting benefits to welfare mothers who have more children. Funding programs to promote marriage.

• People with disabilities – Supreme Court decisions have limited the ability of people to sue for reasonable accommodation. Some cuts in Federal and state services for children and adults with disabilities have been made or are proposed.

Other recent developments include:• Privatization – using nonprofit and for-profit

contractors to deliver some services. • Using faith-based organizations to deliver

government services.• De-emphasizing the role of professional service

providers in the delivery of some services.• Requiring that all government funded

organizations use performance based measures in assessing whether private contractors are doing their job. Reimbursement is based on performance– sometimes this leads to the exclusion of people with severe problems from the service system (creaming).

Things that organizations can do to increase access if they have the money:• Serve people who walk in and ask for help.• Have a welcoming waiting room.• Serve people that apply quickly.• Minimize the length of applications and the

number of documents required to establish eligibility.

• Provide services at night or on weekends.• Help clients with day care and transportation.• Advocate to make sure people have access to

services. • Make sure that the organization is wheelchair

accessible and provides appropriate services to other people with disabilities.

• Provide services in more than one language.

Additional Questions:• Should morality be incorporated into service

decisions?• What do you think would happen if there were no

controls on who could receive the service? • Do you ever use moral assumptions when you

make service-related decisions?• How are moral assumptions manifested in

organization documents or decisions?• How do these moral assumptions complement or

conflict with the values and ethics contained in the social work code of ethics?

• What should social workers do to improve access to services for social stigmatized service users?

Who makes eligibility decisions:• Government regulations (Administrative Rules)• Staff (including social workers who interpret

government regulations)• Providers of services who deliver services on

contract may decide whether people are eligible for these services.

• Courts may also interpret legislation and direct how government agencies allocate benefits.

• Eligibility based on past contributions (work or income) – examples – unemployment insurance and social security.

Chambers & Wedel Criteria for Evaluating Eligibility Rules:• Do the eligibility rules make sense in terms of targeting

a specific population group for inclusion in the program.• Is there ideological consistency between how the social

problem is defined and the eligibility rule. (For example, emphasis on individual versus social responsibility).

• Will social stigma affect utilization?• Coverage – can people receive benefits if they are not

members of the target group?• Trade-offs associated with the rule. For example, do we

have to spend more to cover everyone or can we accept that some people will be excluded if we keep costs down.

• Potential for under and over utilization of services.

Basic Principles –Government Budgeting• Programs for the poor (means-tested programs) constitute a

small proportion of the federal budget.• Government entitlement programs constitute a large proportion

of state budgets because of the “matching” requirements in federal legislation (TANF, Medi-Cal). States also spend a large proportion of their budgets on education and prisons.

• President/Governor proposes budget. Legislative branch may change and must approve the budget. President/Governor may veto the budget. Usually detailed negotiations take place.

• Fiscal budget year starts October 1 for the federal government and July 1 for the state.

• Each year in which the federal government fails to raise revenues to off-set expenditures creates a deficit. Money must be borrowed from private sources (some of these sources are in Asia and Europe).

• The accumulated deficit is the national debt. Interest must be paid on the debt – taking federal funds away from other programs.

To analyze government budgets• Look at the percentage of funds allocated by program

type and for whom these services are intended.• Look at whether allocations for specific expenditures

increase or decrease from previous years.• Remember that because inflation affects the value of

a dollar’s purchasing power, no increase or a small increase may actually represent a decrease in funds allocated for a specific program.

• No tax pledges mean that funding must come from exiting revenue sources, an increase in fees for some services, and cuts in some government programs and services. No spending curbs with tax cuts may increase yearly deficits and the national debt.