July 2018

Economic security is strongly associated with physical and mental health and well-being. Programs such as Medicaid which focus on health and Temporary Assistance for Needy Families (TANF) which aims to improve employment and financial wellbeing should be better coordinated to provide more effective services. Programs which integrate physical and mental health services reduce costs. Findings from the Building Wealth and Health Network demonstrate the effectiveness of integrating behavioral health components into financial programming on improving physical, mental, emotional and financial outcomes.

Impacts of Trauma and Transfer of Poverty Across Generations

Toxic stress during childhood, defined as prolonged activation of stress response systems resulting from adversity such as homelessness, hunger, and neglect, has lifelong effects on a person’s health and well-being. When toxic stress and a related set of exposures called Adverse Childhood Experiences (ACEs) - including abuse, neglect, and household instability - are unaddressed, children are more likely to have physical, mental, and behavioral health problems that negatively affect their ability to learn in school, gain employment, and be financially secure later in life. ACEs are also associated with higher health care use, indicating that health care costs later in life may be reduced through interventions that prevent and address exposure to trauma.

How Adverse Childhood Experiences Influence Health and Well-Being Across the Lifespan

TANF and Medicaid: Shortcomings and Opportunities

Historically, TANF has focused on steering families toward work without adequate behavioral and mental health supports. Medicaid, on the other hand, has been successful in improving access to health care and health outcomes, but has not traditionally addressed upstream causes of poor health and well-being. Aligning the two programs may offer opportunities to promote both health and economic well-being.

Social Determinants of Health

• Economic Security
• Education
• Food
• Healthcare
• Neighborhood and Environment
• Social Support and Community Context

TANF: Focus on Work Without Addressing Trauma

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Medicaid:Opportunities to Address Social Determinants of Health

Managed care, in which patients are limited to a set of health care providers in order to reduce costs while improving quality of care, is the predominant form of Medicaid coverage, accounting for 77% of all Medicaid plans. Updates to the Medicaid managed care rule in 2016 financially incentivizes health plans to address social determinants of health through several mechanisms, including allowing nonclinical supports to be included as covered services and encouraging states to improve care coordination for their patients. Without access to medical assistance such as Medicaid, families not only face significant health consequences, but also an often unbearable economic burden. Recognizing the important links between health, well-being and economic security, increasing coordination between systems that address these components can lead to better outcomes for the families they serve.

Integrating TANF and Medicaid to Improve Health and Economic Well-Being

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Building Wealth and Health Network

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Selected Results from The Network (October 2015 - May 2018)

Policy Recommendations

States should be able to utilize Medicaid behavioral health funding to provide trauma-informed behavioral health support within TANF-funded education and training programs.

This trauma-informed support aims to improve both health and economic security. Medicaid funding for behavioral health can promote economic security if braided into income maintenance programs.

• States should be incentivized to integrate behavioral health services into employment programs.
• Health and Human Services should provide trauma-informed care training and technical assistance to states’ employment training programs made available to TANF participants.

State should design programs that better align the multiple systems that families interact with on a regular basis.

• States should be encouraged to apply for the Section 1115 Medicaid demonstration waiver to implement programs that integrate behavioral health support with employment and training education.
• States should be incentivized to implement trauma-informed programs such as the Building Wealth and Health Network in order to support behavioral health and economic security initiatives through one program.

Family income support should be viewed as a mechanism that supports health outcomes along with economic security.

• Health insurance and health care programs should be incentivized to include financial health as an indicator of individual well-being.
• States should evaluate programs such as TANF’s success by measuring health outcomes as well as economic outcomes.

All policies and programs that aim to improve family economic security and well-being should use trauma-informed language and practice.

• States should aim to better understand the connection between social determinants of health (such as adverse childhood experiences and toxic stress), economic security and health and wellbeing in order to tailor programs that produce the most effective outcomes.
• Programs aimed at improving economic security and well-being should be encouraged to track the prevalence of trauma and adversity in order to best address challenges that families face.