“It’s Like Night and Day”: How Bureaucratic Encounters Vary across WIC, SNAP, and Medicaid
Abstract
Research characterizes public assistance programs as stigmatizing and stressful (e.g., psychological costs) but obscures differences across programs or the features of policy design that contribute to varied bureaucratic encounters. Using 83 interviews with Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Medicaid beneficiaries, and 60 interviews with staff from those programs, we examine how people differentiate their experiences across programs. We find that WIC staff members describe the program as facilitating, rather than constraining, personal interactions with clients. In contrast, SNAP and Medicaid workers report pressure to process clients expeditiously and accurately, leading several caseworkers to express frustration and suspicion of the information provided by recipients. WIC participants in all three programs described positive, supportive interactions with WIC staff and viewed the program as a source of social support. In contrast, participants reported stigmatizing encounters with SNAP and Medicaid staff and inaccessible caseworkers.
The quality of citizens’ interactions with the government shapes whether they claim benefits, how they perceive the government, and whether they participate in politics (Barnes and Henly 2018; Barnes 2020; Heinrich et al. 2022; Michener 2018; Moynihan, Herd, and Harvey 2015).1 Most studies describe interactions with government employees as negative for low-income citizens (Herd and Moynihan 2019). Indeed, many studies attribute the stigma and stress of claiming means-tested benefits to negative and contentious interactions between welfare bureaucrats and clients (Barnes and Henly 2018; Hays 2003; Soss 1999b; Watkins-Hayes 2009, 2011).2 These negative experiences deter program use, diminish confidence in public institutions, and undermine policy goals (Heinrich 2015; Barnes and Hope 2017; Baekgaard and Tankink 2021).
While offering valuable insights into the barriers to accessing government assistance, these studies focus on programs that process cases or classify client eligibility to distribute benefits (Hasenfeld 1972, 2010). In these contexts, scholars usually attribute costly encounters with bureaucrats to policy parameters that encourage bureaucrats to limit beneficiaries’ access to programs and prevent workers from providing high-quality tailored services (Soss 1999a; Soss, Fording, and Schram 2011; Tummers and Bekkers 2014; Tummers et al. 2015). Others credit positive experiences to exemplar bureaucrats who wield discretion to reduce the costs of encounters (Watkins-Hayes 2009; Lavee 2021).
We argue that these outcomes do not apply uniformly to all government programs. Belying the widely accepted perspective of Wilbur Cohen—Lyndon Johnson’s secretary of health, education, and welfare (the precursor to the Department of Health and Human Services)—we provide evidence countervailing the assertion that “a program that deals only with the poor will end up being a poor program.” Instead, this research underscores low-income citizens’ reliance on a range of social services that vary in design and implementation. Some programs encourage and incentivize workers to go beyond processing and even to retain cases. Yet, we know very little about how clients experience these kinds of programs. How do bureaucrats and citizens interact in programs that are designed to retain and engage rather than process clients?
Building on studies of street-level bureaucracy and administrative burden, we examine how differences in policy design—policy objectives and incentives—shape clients’ experiences with bureaucrats (Burden et al. 2012). We depart from examining the costs of claiming in means-tested programs to shed light on the potential benefits of doing so. We argue that program experiences improve when policies are designed to structure rather than constrain long-term personal interactions between bureaucrats and clients.
To make this case, we compare bureaucrat-client interactions in three social programs that are often used concurrently by low-income families: WIC, Medicaid, and SNAP. Although a tradition of historical and feminist literature describes WIC as paternalistic, controlling, and constraining low-income women’s choices (Mink 1995; Gordon 1988; MacKay 2019), we argue that features of WIC’s policy design can cultivate supportive, rather than controlling, citizen-state interactions. The program reflects a venue for long-term interpersonal interactions between WIC participants and staff members through quarterly appointments and nutritional education. Moreover, WIC incentivizes participant retention through discretionary funding mechanisms that reward client retention, caseload expansion, and customer service.
In contrast, SNAP and Medicaid policies create pressure to process cases quickly and accurately, undermining the quality of bureaucratic encounters in ways that increase the psychological costs of benefits. To examine differences in client-staff interactions across these policy contexts, we analyze qualitative interview data from 9 WIC staff members, 35 SNAP and Medicaid workers, and 83 recipients of WIC and either SNAP or Medicaid. The evidence reveals sharp contrasts in how WIC, SNAP, and Medicaid workers interact with their clients. Unlike traditional welfare bureaucrats, who face trade-offs between processing cases and developing personal relationships with clients, WIC staff engage in personal conversations with participants on topics beyond determining eligibility. WIC staff attribute these personal interactions to WIC’s long-term interactions with clients and policy incentives that encourage staff to retain clients. Quarterly appointments over several years create opportunities for mutual sharing between participants and WIC staff members, and staff work to build rapport with WIC participants to maintain caseloads and to bring about the program’s behavior-change objectives.
In contrast, SNAP and Medicaid workers emphasize processing applications and renewals accurately and within state and federal policy deadlines. Workers repeatedly mentioned the threat of state-enforced penalties if their units failed to meet deadlines or processed cases with high error rates. As a result, SNAP and Medicaid workers interacted with clients to gather information about eligibility and often viewed clients as hurdles to fulfilling their professional responsibilities.
From the clients’ perspectives, WIC participants rarely reported stigmatizing interactions with WIC staff—instead of describing neutral, positive, personal, or tailored experiences. In many instances, participants interpreted program experiences as forms of social support and viewed WIC staff members as offering emotional encouragement, advice, and access to resources. In contrast, WIC participants reported negative experiences with SNAP and Medicaid staff and difficulty with contacting workers. In this sense, SNAP and Medicaid experiences mirrored the insights of previous social policy studies that find negative interactions with bureaucrats (Soss 1999a; Watkins-Hayes 2011; Barnes and Henly 2018; Michener 2018).
This research contributes to the study of social policy administration by showing how variation in policy features shapes citizens’ interactions with bureaucrats. Our findings complement the administrative burden literature by highlighting the elements of policy design that benefit, rather than burden, clients. We begin by discussing psychological costs in means-tested programs. We then discuss how differences in policy features may yield different kinds of citizen-state interactions by turning to our cases: WIC, SNAP, and Medicaid. We conclude with a call for a deeper understanding of how policy objectives and incentives inform both implementation and citizen-state interactions.
Street-Level Bureaucracy and Contentious Bureaucratic Encounters
Most social policy research examines citizen-state interactions in programs that process clients—wherein bureaucrats classify client eligibility for assistance and distribute benefits (Hasenfeld 1972, 2010). A rich literature documents the psychological costs—the stress and stigma—clients experience in means-tested programs and points to bureaucrats as an important source of these costs (Brodkin 2015; Soss et al. 2011; Barnes and Henly 2018; Nisar 2018). For example, research finds that most Aid to Families with Dependent Children (AFDC) clients viewed their experiences as degrading and expected poor treatment from workers (Soss 1999a, 93). Other qualitative studies suggest that even when bureaucrats share racial and gender identities with clients, they engage in a “constrained, arm’s length approach” that clients interpret as “aloofness and disconnection” (Watkins-Hayes 2011, i243–i246). Although some research suggests that the challenging conditions of street-level work can lead bureaucrats to move toward clients, thereby providing informal resources (Tummers et al. 2015; Jilke and Tummers 2018; Lavee 2021), social policy research, especially in the US context, tends to focus on how ambiguous policy goals, performance pressures, high caseloads, and few resources undermine the quality of citizen-state interactions.
Post–welfare reform policies have only further inhibited staff’s ability to offer quality, tailored, personal service experiences. Emphasis on “workfare” and performance standards in Temporary Assistance to Needy Families (TANF) have made encounters with welfare programs increasingly burdensome and punitive (Brodkin 2015; Brodkin and Marston 2013; Soss et al. 2011). Policy incentives to push welfare clients into work, coupled with limited resources, encourage bureaucrats to shift the burden of accessing benefits to claimants (Brodkin, Fuqua, and Waxman 2005; Brodkin and Majmundar 2010). Performance standards incentivize bureaucrats to sanction or threaten to sanction clients.
Although shedding light on the factors that shape the way bureaucrats interact with clients in means-tested programs, research has not yet examined how beneficiaries experience programs that incentivize bureaucrats to recruit and retain clients. We propose that if policies that emphasize efficiency and disposal of clients hinder supportive relationships between bureaucrats and clients, then programs that extend personal interactions between bureaucrats and clients and incentivize caseload retention may yield positive beneficial interactions. We now turn our attention to our cases of study—WIC, SNAP, and Medicaid.
WIC Policy Design
WIC is the third-largest food assistance program in the United States, serving 6.2 million families in 2020 and half of all infants (Toossi, Jones, and Hodges 2022). The program provides nutrition assistance to low-income pregnant women and children who face nutritional risks. Women who are pregnant, nonbreastfeeding up to 6 months postpartum, or breastfeeding up to a year postpartum are eligible for the program. Children from infancy to age 5 are also eligible.
Families receiving TANF, Medicaid, or SNAP can become automatically eligible for WIC programs. Applicants who are ineligible for SNAP, Medicaid, and TANF, but who have a household income of less than 185 percent of the federal poverty line are also eligible for WIC. Participants are also eligible for WIC if they experience nutritional risks like anemia, low maternal weight gain, and inadequate growth in children.3 Although the WIC eligibility period is a year, participants must meet quarterly appointments to maintain eligibility. These appointments include an in-person recertification appointment every 6 months, where nutritional risk is reassessed, and three other appointments that focus on nutritional education and distributing benefits (Kline et al. 2020).
WIC aims to ensure positive health outcomes among nutritionally at-risk mothers and children under five. WIC food vouchers, nutritional education, and breastfeeding support are meant to promote positive eating behaviors and reduce nutritional risks. Nutritional education sessions occur quarterly. Through these sessions, nutritionists advise participants on the optimal use of WIC supplemental foods and teach participants about the relationships between nutrition, physical activity, and good health.4
WIC staff members typically fall into two categories: processing clerks and nutritionists.5 WIC processing clerks—the equivalent of eligibility workers—conduct initial intake processes that include collecting income eligibility documents, guiding applicants through a set of intake questions, and collecting anthropometric measures from applicants.6 Nutritionists use the information collected by processing clerks to conduct nutritional education, which includes asking participants about their eating habits, food preferences, and health concerns, along with developing a food package that is tailored to participants’ needs. Once nutritional education concludes, WIC processing clerks issue benefits to participants.
WIC participants can experience these services over a long period. Participants who remain eligible have up to four appointments annually from pregnancy to the fifth birthday of the eligible child (up to 22 appointments). Although most child participants enter the program within the first 3 months of life and exit after their first birthdays, studies suggest that between 25 and 30 percent of all WIC children remain in the program from infancy to their fifth birthdays (Gundersen 2005). Furthermore, national estimates that point to short spell lengths do not account for women with multiple children under five who may have several short spells of program use with each new pregnancy. In short, WIC participants may not have five continuous years of program use, but they may intermittently use the program over time.
Policy Incentives: Outreach, Retention, and Customer Service
In addition to policy features that prescribe long-term personal interactions, WIC policy incentivizes caseload retention through block grant funding that rewards caseload maintenance, as well as policy guidelines that promote outreach and customer service. The Federal Nutrition Service (FNS) allocates block grants to WIC state agencies that contract out service delivery to 2,000 local WIC sponsoring agencies (e.g., county health departments, nonprofit health clinics, nonprofit agencies). The FNS determines state funding levels by “projected program enrollment”—the average number of participants served each month from the previous year. State WIC agencies then assign “base caseloads” to local WIC agencies and adjust funding levels when caseloads fluctuate (USDA 2008). Federal policy requires WIC state agencies to maintain 95 percent of caseloads.7 Agencies lose administrative funds when they do not maintain caseloads.
Decades of research highlights WIC’s benefits, including higher birth-weight outcomes, lower infant mortality, improved diets for young children, and greater use of health-care services (Bitler and Currie 2005; Siega-Riz et al. 2004; Buescher et al. 2003). Scholars have also observed recent declines in program participation,8 which have resulted in WIC policies that stress the importance of outreach, retention, and customer service. For example, national- and state-level WIC policy guidelines encourage WIC directors to partner with community organizations and agencies to recruit clients (Boe, Riley, and Parsons 2009). The North Carolina WIC manual recommends that WIC directors establish satellite sites, provide flexible clinic hours and walk-in appointments, and allow proxies to pick up benefits on behalf of participants. WIC policy likewise emphasizes good customer service skills across all staff members. North Carolina’s WIC manual describes good customer service as “essential to the WIC Program’s success” and recommends WIC directors “take care to ensure all the staff are practicing good customer service” and attend customer service training (North Carolina Division of Public Health 2022). These trainings instruct staff on how to acknowledge participants, listen and respond to participants’ feelings, and incorporate participants’ suggestions and feedback (North Carolina Division of Public Health 2022; Connecticut WIC Program 2003).
WIC policy design reflects a unique departure from the design of means-tested programs that constrain interactions between bureaucrats and clients. While providing food benefits, the program structures personal interactions with clients through long-term nutritional counseling on dietary habits. Furthermore, block grants that reward caseload retention, coupled with federal guidelines that encourage outreach, flexible appointments, and customer service, incentivize WIC staff to provide tailored service delivery.
Medicaid and SNAP: Basic Structure
Medicaid was created in 1965 to provide health coverage for low-income Americans. As of 2022, over 87 million people were enrolled (Corallo and Moreno 2022). Both federal and state governments contribute funding to Medicaid. Each year, the secretary of health and human services calculates the percentage of Medicaid expenses the federal government will cover for each state; states take responsibility for the remaining costs (HHS 2018).
The federal government mandates that states cover a minimum set of services to “mandatory eligibility groups” (Centers for Medicare and Medicaid Services 2018a). Beyond these federal requirements, states exercise discretion in deciding whether to include additional eligibility groups and whether to cover additional services (Centers for Medicare and Medicaid Services 2018b, 2018c). Therefore, Medicaid eligibility, benefits, and costs can vary substantially across the states (Michener 2018).
SNAP has been the nation’s largest anti-hunger program for over five decades (USDA 2012). SNAP provides monthly assistance to low-income families to support food purchases. In 2021, over 41 million beneficiaries received average benefits of $121 per month (Center on Budget and Policy Priorities 2022). Households—with or without children, elderly, or disabled members—are eligible for benefits if their gross income is less than or equal to 130 percent of the federal poverty line, their net income after deductions is less than or equal to the poverty line, and the value of their assets falls below a specified threshold (Center on Budget and Policy Priorities 2022). As an entitlement program, the federal government funds SNAP benefits. However, states share administrative costs for the program.
Medicaid and SNAP Policy Design: Efficiency and Accuracy
Unlike WIC, Medicaid defines the core function of workers as processing cases in a timely and accurate manner. Accordingly, the Affordable Care Act emphasizes efficient eligibility determination processes in the effort to expand access to health care (Centers for Medicare and Medicaid Services 2012). States must process standard applications within 45 days and applications for individuals with disability within 90 days (Centers for Medicare and Medicaid Services 2012). Federal policy requires states to develop and monitor “timeliness” performances to ensure that applications and redeterminations are processed accurately before these deadlines. In addition, federal policies now promote eligibility determination processes that require little-to-no manual input from caseworkers by encouraging states to use matching dollars for administrative systems and software that facilitates “no-touch” or “limited-touch” eligibility determination.
SNAP policy also emphasizes efficiency and accuracy in processing cases. The reauthorization of the Food and Nutrition Act of 2008 requires workers to process emergency cases within 7 days of the application’s submission date and to process standard submissions within 30 days (USDA 2016). To contain costs, the FNS’s quality control system works to minimize errors in eligibility determination by monitoring fraudulent cases and agency errors that lead to under- and overpayments of benefits (USDA 2016). FNS rewards states with monetary bonuses for low error rates and efficient processing times and penalizes states that do not meet federal benchmarks (USDA 2016).9
Furthermore, states are penalized if they do not meet processing deadlines. FNS requires states to process 95 percent of SNAP applications within statutory deadlines (USDA 2016). States that fail to meet these deadlines for 3 consecutive months must develop a corrective action plan that identifies the “root cause” of delayed applications (USDA 2016). States receive advanced and formal warnings if error rates and average processing times do not improve, after which the federal government determines whether and how much administrative funding it will suspend (USDA 2016). These federal requirements lead states to monitor error rates and processing times closely for county SNAP offices. For example, North Carolina’s Department of Health and Human Services (NCDHHS) issues specific deadlines to SNAP directors for eligibility determinations and requires units to report both the “average processing time … for cases” each month and the percent of their caseload that is processed within federal deadlines (NCDHHS 2014). If county workers do not meet federal benchmarks for 3–5 consecutive months, the state imposes its own corrective action by monitoring units, cutting county administrative budgets, and—in some instances—replacing workers (NCDHHS 2022).10
Methods
Our in-depth interpretive study of bureaucratic encounters is designed to provide thick descriptions of program experiences and to examine how the abovementioned policy design differences can shape experiences across WIC, SNAP, and Medicaid. We conducted qualitative interviews with policy beneficiaries and agency bureaucrats. Our data come from 83 in-depth interviews with WIC beneficiaries who also received Medicaid and SNAP. The data also include 25 staff interviews across three WIC offices and 35 interviews with SNAP workers in North Carolina. Interviews were conducted from October 2015 through January 2020. Pseudonyms are used for the names of staff and WIC participants to protect the identities of study participants.
The research team recruited WIC participants by posting fliers at WIC offices or in person by recruiting participants at WIC offices following their appointments. Interviewers obtained consent to conduct the interviews and conducted interviews at locations preferred by the respondent. In many instances, participants were interviewed on site in available WIC offices directly following WIC appointments. Interviews ranged from 30 to 60 minutes, and a $30 cash incentive was provided to each participant. The study participants included program veterans and new applicants. We describe participants’ characteristics in table A1.
Given our emphasis on rich description and inductive connections between program design and bureaucratic encounters, we do not pursue a probability sample or aim for generalizability. The goal of this analysis is to generate insights grounded in the perspectives of staff members and program beneficiaries that can advance theory, incisively describe the phenomena of interest, and motivate quantitative and mixed-methods research. As such, our cases capture a range of staff and beneficiary experiences. Our sample of WIC participants mirrors the national demographic makeup of WIC participants in age, but it differs in race. National trends in program participation indicate that most WIC participants are non-Hispanic White (58.7 percent). Program participants’ rates in North Carolina show similar levels of program use among Whites (58 percent). However, most participants in our sample were Black (62.7 percent). This overrepresentation stems from our aim to select counties that would have a high percentage of WIC-eligible populations—which included low-income counties with large Black populations.
The women in our sample had multiple children enrolled in the program—two children on average. National estimates do not capture this program use, as national US Department of Agriculture estimates capture a cross section of uptake by an eligibility group for any given year (Kline et al. 2022). As a result, women in our sample also reported collective program experiences that are not captured by national estimates—an average of 5 years of program experience (roughly 15–20 appointments). Over one-third of our sample of participants were new to the program—they had less than a year of program experience or fewer than two in-person appointments. However, most participants reported varied spells of program use across multiple children. For example, a participant may have used the program for a short 3-month spell during pregnancy, enrolled an infant in the program for a year, and left the program once the infant turned one. That same participant may return to the program years later for a second pregnancy and exhibit similar intermittent patterns of program use. In some ways, cross-sectional data (which indicate high participation rates for infants followed by lower participation rates for children between one and five) supports the intermittent program enrollment we see among our study participants (Kline et al. 2022). Given how prevalent this pattern of program use is among program veterans in our sample—those who have over a year of program experience—we believe intermittent program use across time may be more of the norm and a more accurate picture of WIC program participation that cross-sectional uptake data obscure.
Of the 35 SNAP and Medicaid workers we interviewed, 8 worked solely for SNAP and 11 had full-time positions as Medicaid caseworkers. Fourteen workers held positions as universal intake workers for multiple programs that included Medicaid and SNAP. We interviewed a person who supervised both programs and one worker who monitored both programs for fraud. At the time of the interviews, North Carolina had implemented universal intake processes for SNAP and Medicaid in which workers rotated between processing applications for one program and completing initial intake processes for both programs. Staff interviews typically followed observations of appointments and were conducted in a private office on site. Staff received a $30 incentive for completing the interview. Table A2 displays staff characteristics.
The research team conducted semistructured participant interviews that asked WIC, SNAP, and Medicaid beneficiaries to describe how they learned of the program, their appointments, and their experiences with staff. Semistructured staff interviews focused on each program’s mission, employees’ daily routines and practices, and how they interacted with beneficiaries. For instance, staff members were asked to describe their primary responsibilities within the program and a typical day at each office. Staff members were also asked to describe their relationships with program participants. (Sample questions from participant and staff interview guides can be found in appendix B.) Interviewers wrote field notes after each interview and analysis memos that highlighted key themes as they collected more data. All interviews were audio recorded and transcribed.
Analysis
The research team analyzed transcripts, memos, and field notes in a qualitative software package, NVIVO-12. We followed an interpretive approach to analysis, which emphasizes the lived experiences of program participants and staff (Schwartz-Shea and Yanow 2012). Our analytic approach was abductive (incorporating deductive analysis informed by the administrative burden literature and social policy research) and inductive (directed by a close read of interview data that allowed for emergent concepts; Haverland and Yanow 2012). Coders initially organized the data by a priori codes drawn from the interview guide topics and previous research. Within those broader codes, we conducted a line-by-line reading of transcripts. We then allowed broader descriptive and analytic categories to emerge from the data and refined them through an iterative comparison of client and staff member responses (Glaser and Strauss 2017). Given the large number of interviews, we constructed matrices to further aid analysis. Unit-by-code matrices helped coders to see patterns across participants and across different types of evaluations. Throughout this process, transcripts were reread and reevaluated (Ryan and Bernard 2000; Miles and Huberman 1994).
The analysis examined how clients and staff described their interactions in WIC, SNAP, and Medicaid program offices. Emergent codes for beneficiaries’ responses included their cumulative experiences with the program and whether their experiences with staff were positive or negative. We also coded instances in which participants described personal conversations with staff beyond standard intake questions and procedures. Similar codes on the valence and nature of relationships with clients emerged from staff interviews. We coded instances in which staff reported personal conversations with clients (e.g., discussing family, relationships, personal hardships) and how often staff engaged in these kinds of conversations. We also examined how staff members understood these interactions—whether they viewed personal interactions as the norm or as exceptions. Finally, we examined the factors that staff viewed as shaping their interactions with participants.
Findings
Caseload Benchmarks And Customer Service
Observations and interviews with WIC staff members revealed the importance of caseload retention and customer service. At the time of our interviews, Nadine, a WIC director, worried about maintaining her dwindling caseload. She aimed to retain 94 percent and often commented that she risked losing administrative funding and positions in her clinic if she did not retain clients. To maintain clients, Nadine and her staff closely monitored participants who had missed recent appointments, with processing clerks starting their days by calling participants to remind them of appointments. Staff members were also flexible with participants on scheduling, often taking walk-ins, accommodating last-minute changes in participants’ availabilities, and fitting participants in during lunch breaks.
Carol, a WIC worker from an urban county, similarly emphasized the importance of caseload retention. Despite having the largest WIC program in the state, the agency’s caseloads have declined slowly over the years. As Carol explains, “There’s been a decline, and it’s been happening for the last 5 years. It’s been trickling down and down and down. And so if the numbers go down, the participants go down, so will the funding. Pretty much, the state will cut the funding for the program. And so they haven’t been able to really hire any more staff on because of that.” A frontline worker echoes this, noting that the chief concern for the agency is “get[ting] the numbers up.” Consequently, workers spend time doing outreach to community organizations and churches and aim for greater flexibility in accommodating WIC participants’ schedules for appointments. “Outreach is going on, it’s being conducted, especially with our new manager, it’s being conducted on the regular now it’s like mandatory, because the main thing is bringing up our numbers in reference to our clients.”
From the clients’ perspective, appointment reminders and flexibility were helpful and contributed to their positive experiences with the program. For example, client Jane explained, “If you’re running late or if you’re not really close to there, you can call them [and say,] ‘Oh, do you have enough space for me to come in right now?’ They say, ‘Yes, sure, come on.’ Yeah. They’re always nice.” Another client, Annalise, similarly remarked on the staff’s flexibility and customer service when describing her interactions with her WIC nutritionist: “She’s very sweet. She calls us. She knows we have a lot of kids. She’ll call and be like, ‘Oh, you know you have your appointment tomorrow,’ and I’ll be like, ‘Oh my God, I forgot.’ She’ll be like, ‘Don’t worry about it. We can schedule it for whatever day you’re free.’ You know she’s always about us. She has great customer service and you know she’s just very good with people.”
Staff Practices at WIC: Time and Rapport
Most of the WIC staff viewed their relationships with participants as both personal and professional. As professionals, staff executed required work tasks, which included formal intake processes, adhering to formal nutritional education guidelines, and distributing food vouchers. However, staff often viewed themselves as a listening ear and described this informal role as a part of the job.
Staff attributed these personal interactions to the structure of the WIC program. In particular, staff identified the routine interactions over a long period as cultivating personal relationships and viewed the role of rapport as essential in achieving the agency goals of customer service. This perspective was especially the case for mothers who had multiple young children in the program. Long-term service delivery and routine communication with participants led to more personal ties with staff, and they generally cited the program’s design as encouraging personal relationships with participants. For example, Linda, a processing clerk, explains that she “gets to know” participants after she’s “been seeing them for a while.” Denise, a nutritionist, also shared this experience and attributed her personal relationships with participants to time. Her 11-year tenure as a WIC nutritionist has allowed her to see children from infancy until they age out of the program: “I think over my 11 years here I’ve seen clients where their children have graduated our program and I think I’ve become a little bit more um, personal with them. Some of them just, you know, feel like they can come to me and easily talk to me.”
Linda and Denise’s perspectives reflect the views of many of the staff interviewed. Andrea’s remarks also illustrate this point. As an experienced nutritionist, she developed personal relationships with several WIC participants. As such, Andrea does not start her appointments with the standard questions about diet. Instead, she follows up on personal details participants have shared at their last office visits:
I personally like to think I have a good relationship with WIC clients. One thing I like about our clients is that you get to see them every three months and so it’s great that I’ve been here, like, several years now, that I’ve seen women pregnant, now seeing their kids have aged off the program to having their second or third child now. And so, I like to—usually, when I start my nutrition appointments, it’s not, like, “Okay. What have you been eating?” I’m kind of, like, “Oh, so what have you been doing?” Or if they’ve told me a story about something the last time they were there, I kind of, like, check in with them, how things are going. If they told me they were going on a trip or ask about how their trip went or ask how their children are doing. So it’s more, like, a family to me instead of my clients or participants.
This pattern was evident among urban workers as well. When asked to describe her relationships with WIC participants, an urban WIC worker named Crystal described them as “very good” and notes that “you just kind of get to know the person.” Participants become “repeat” clients, which allows her and other WIC staff to “get to know the person.” Crystal explains, “You know, I mean, most of the times we’re laughing, talking, you just kind of get to know the person. Sometimes clients are repeat. So, you kind of know them because they come. So, you kind of do develop and sometimes we do get them again, but it’s no guarantee you will, but just kind of make them feel comfortable and let them know that you’re here to serve them and to help them in any way possible.”
Building Rapport
Rapport-building also emerged as a distinct aspect of customer service. Staff regarded WIC offices as spaces of social interaction and bonding among themselves, WIC participants, and their children. For example, most staff at each office reported norms of rapport and social interactions between clients and staff; they even occasionally expressed disappointment with clients who did not adhere to those norms. Marisol, a young Latina processing clerk, described participants who “share their life stories”: staff “know all about their personal life.” She described conversations with participants as “fun,” covering topics such as “life” and “family.”
Among WIC staff members who regarded themselves as closely adhering to their professional roles, rapport still emerged as an element of interactions. For example, Linda quoted office protocol to describe how she engages clients. During WIC appointments, she makes “sure that [she] goes through everything [she] is supposed to do,” and she noted that personal conversations and advice-giving extend beyond her tasks as a processing clerk. Yet, Linda confessed that her interactions with clients become personal. She takes time to listen to clients and often plays with children. During our interview, she rummaged through her file cabinet for a folder of pictures drawn by children, sharing stories about each child. Her love for children breaks the barrier of professionalism, but she acknowledged that participants need a listening ear: “I try to be friendly with all of them anyway. Especially if they’ve got babies. Because I might want to hold them! I may take a little bit more time with the children in here if they’re in here than I would if it was just a pregnant woman… . Sometimes someone will just sit there and try to tell you the whole life story. Like if they’ve got a bad situation going on at home or something. It’s just like they don’t have anybody else to talk to.” Unlike welfare bureaucrats in most studies of means-tested programs, Linda does not view these personal interactions as bogging down office efficiency or hindering her work. She explained, “I’ve never had one that slowed me up… . Not one.”
In many instances, staff reported rapport with participants as an element of customer service that is useful to achieving the goals of case retention and healthful behavior for program participants. Since WIC appointments include counseling clients toward healthier food choices, Beverly viewed rapport as facilitating the success of nutritional education. For Beverly, the “overall health of the client” is a priority, and achieving that goal requires personal connections with WIC participants. Clients need to trust nutritionists to be receptive to advice on how to address poor eating habits and nutritional risks. She explained how she can tell if she has struck the right balance between professionalism and personal connections with WIC participants.
Okay. Oh goodness, how can you tell when the client trusts you? … How can you tell? Well, communication, their body language, they’re not, they’re not crossing their hands, laughter. You know, they might even tell me a joke sometimes or they talk more about their families or their children or what their child is doing in school. So that’s getting more on that personal level, but you have to have balance too. You still have to have that professionalism, because you can’t cross certain boundaries; you understand what I’m saying? So you’re going to keep it professional and you will have a little bit of [the] personal… . The first thing is the overall health of that client, but you have to be approachable.
Even among staff members who preferred professional interactions with participants, rapport emerges as an important aspect of interactions that help meet program goals. For example, this urban WIC processing clerk worked to make participants feel listened to and not “rushed” as a component of good customer service: “My whole thing to me is listening, acknowledging, and listening to what the client is saying and what they are offering, and what they are requesting. Being there for that client. Allowing them to—if they want to—open up and talk to you. If you got that face, then listen just a little, don’t rush people off. Don’t—don’t do that. Just take your time. There’s a way to speed up the process, but you just have to know how to do it. You have to know how to do it.”
Shannon, a WIC nutritionist, viewed her role as empowering parents to make better decisions about health and nutrition for their families. She commented that participants are “open or receptive to behavior change” when staff build trusting relationships with participants. She explained how some participants “really appreciate” the information. Other WIC participants are less receptive when they are “brand new” to the program and “really don’t know what to expect.” Over time, participants become more open to nutritional education, but staff efforts to build trust with WIC participants can also help bring about “behavior change.”
Over a period of time, they seem to be more receptive. You know, it takes time, it’s trust. You have to be able to [have] trust with the client.
Okay. How do you do that?
By being honest, and being open, and just sharing, and then listening. It’s not about me always talking, because the thing that behavior change is basically letting the client come up with their own ideas.
On the whole, nutritionists and processing clerks do not face trade-offs between developing personal supportive relationships with participants and achieving the program’s goals. WIC staff regarded personal rapport with clients as an important aspect of their professional roles and a way to achieve the program’s goals. Key elements of WIC program design and caseload retention incentives, coupled with long-term routine interactions and tailored personal communication between staff and program participants, encourage WIC staff to forge personal relationships with participants.
SNAP and Medicaid Workers: Processing Cases and Managing Deadlines
Although WIC staff expressed concerns about keeping participants in the program, the top priority for SNAP staff was processing cases in an accurate and timely manner—often at the expense of connecting with clients. Although the federal guidelines set timeliness standards, county programs had their own deadlines to ensure workers met federal deadlines. One particular office required Medicaid workers to process applications for pregnant women immediately, children and families’ Medicaid applications within 45 days, and adult Medicaid applications within 60 days. SNAP workers had to process emergency SNAP applications within 4 days of clients’ submission and within 25 days for typical applications.
Medicaid workers overwhelmingly commented on the stress of meeting processing deadlines. For example, Eleanor shared that she spends most of her time managing various Medicaid deadlines. Her caseload consists of newborns, children, adults, and recertifications—all of which have different processing deadlines. Eleanor explained that she must keep track of deadlines for each program and ensure her cases are processed within a “certain time period”: “I have to make sure that my newborns have to be done within 5 business days’ notification. [With] my recertifications[,] I have to send out notices and things, and then the presumptive ones have a certain time period that I have to get those done. So for me, it’s just making sure that those are done in the right time period.”
Pressure to meet deadlines is equally salient among SNAP workers. Mary, a SNAP worker, reported difficulty in “keep[ing] up with all the work” in light of tight time constraints. She must process 90–100 cases in less than 30 days, change clients’ eligibility information, and call and meet with clients. Mary viewed these tasks as “overwhelming” and worried about falling behind and getting into “trouble” with the state. She explained:
We average—a good average would probably be 90 to over 100 cases a month that we have to process within those 30 days or however long that month is. And then we have to do the changes. We have phone calls. We have to come see clients. So it’s a lot to it. So sometimes it’s very overwhelming. And sometimes we feel like we can’t take a vacation or take a day off because this—if we don’t get it done, we’re going to get in trouble. And of course, we all—we want our records to look good, but sometimes I just feel rushed, like I have to do these things in a certain amount of time.
For example, enhancing the capacity of Medicaid and SNAP bureaucracies by employing more workers is one response to high caseloads that might minimize the need for workers to process people quickly, thus providing room for more positive citizen-state interactions. Of course, this kind of investment in administrative capacity is contingent on whether such positive interactions are an important goal for policy makers and administrators. The evidence we offer here instructively juxtaposes what a program is like when engaging people is prioritized as the goal (e.g., WIC) with what programs are like when they focus more exclusively on processing cases (e.g., Medicaid, SNAP).
Staff Practices at Medicaid and SNAP: Disconnection and Suspicion
Given the programs’ emphasis on accurately processing cases within policy deadlines, Medicaid and SNAP workers primarily interacted with clients to gather information that would help them determine eligibility quickly. This interaction included frequent requests for additional information if applications were incomplete or if the applicant provided inaccurate information.11 In this sense, SNAP and Medicaid workers mirror the behavior of AFDC and TANF workers in previous studies (Watkins-Hayes 2009, 2011; Soss 1999a; Brodkin and Majmundar 2010; Soss et al. 2011). Workers assessed the quality of their relationships with clients by how well clients followed agency directives, which, in this case, meant clients’ willingness to provide accurate information on time.
When clients complied, they helped workers meet their deadlines. When they did not, they became burdensome to workers and put the agency at risk for corrective action. For example, Amy, a SNAP worker, described half of her caseload as “frustrating cases” since they were dishonest or did not submit paperwork on time. She explained that, with these cases, “you know something that is not right,” and applicants are “not forthcoming.” She added, “People not turning stuff in, people contradicting themselves. Also, in conversation with people, it can be very frustrating because you know that they’re not telling the truth.”
In theory, the emphasis on efficiency should ensure a speedier process of getting benefits to clients. However, remarks from WIC clients who receive SNAP suggest that the staff’s emphasis on efficiency can compromise the quality of their interactions with clients. Indeed, the interactions—if they occur at all—reflect exchanges of information pertaining to eligibility (Hasenfeld 1972). Furthermore, workers manage the pressure of deadlines and the threat of corrective action in light of the typical working conditions that constrain bureaucrats: large caseloads, antiquated administrative systems and software, and poor training (Lipsky 1980; Brodkin et al. 2005; Brodkin and Majmundar 2010). As a result, they are often inaccessible and seldom engage clients beyond determining eligibility.
For Claudia, a Medicaid worker, the stress of meeting these goals leaves her feeling disconnected from her clients. In contrast to WIC workers who emphasize connecting with and helping clients, Claudia viewed her role as “pushing papers” and “keying” clients’ applications into the system: “Sometimes I don’t feel like I help people because I just stay so busy. I feel like I’m pushing numbers, pushing papers, keying all day long, just frantically trying to get it done. Sometimes I don’t know who I’m helping.” Processing cases accurately and within policy deadlines are workers’ priority. Federal Medicaid and SNAP policy rewards accurate and efficient processing and punishes states that perform poorly with the threat of corrective action and administrative budget cuts. In light of these stark differences in how staff in WIC, SNAP, and Medicaid interact with clients, we now turn to how clients describe their interactions with WIC staff and with Medicaid and SNAP case workers.
How Participants Experience WIC Staff: Warmth and Personal Conversations
Of the 83 interviews with WIC clients, most respondents reported positive or neutral WIC experiences. Unlike the respondents discussed in the literature on means-tested programs, clients rarely reported feeling demeaned or disrespected by WIC staff. Rachel’s comments demonstrate WIC participants’ personal interactions with staff members during office visits. Rachel has used WIC for over a decade, for each of her three children. She described how her WIC nutritionist asks about her extended family during her office visits and lets her “just talk” if “there’s anything that [she] needs.” She emphasized the importance of both the food assistance and these personal conversations for those who lack family support: “I know a lady [who’s] been there for a while. She always asks about my grandma. She always says something… . Certain people don’t have the ability to have help from their family for certain foods. Certain families have the support to encourage you because it can be hard. Some people are single and don’t have the other parent there to help them.”
Many clients echo Rachel’s comments, expressing satisfaction with WIC staff members’ warmth and personal conversations that extend “beyond eligibility” (Watkins-Hayes 2011, i246). Jessica, a mother of three and a long-term WIC participant, described how WIC staff “try to get to know” her family. Although WIC staff must inquire about family meals and nutritional needs, Lauren remarked on staff efforts to get to know her children and her “family as a whole.” She explained: “Well, we definitely talk about the kids a lot. And wow … it’s a lot about the kids and about your family as a whole… . It’s like getting the information from you about your nutritional needs and everything as well as, ‘Oh, I’m trying to get to know your family as well.’” In addition, Jessica remarked on how the WIC staff know her name—a sign of staff attentiveness. “And when you come in the door, they can call you by name without even looking at the paper [or] anything. That tells you something, that they’re paying attention, that they’re really in tune with what they’re doing, you know what I mean?”
Personal interactions with staff were important for clients who reported mixed experiences as well. Indeed, this group of WIC participants reported variation in staff demeanor as detracting from the quality of their program experiences. Those with mixed experiences distinguish staff members who are warm and engaging from staff who approached participants with an impersonal professional tone. These WIC participants had come to expect personal tailored interactions from WIC staff and expressed disappointment when staff members did not meet these expectations.
Annie, a new WIC participant, regarded staff as generally polite. “Yeah, everybody else is pretty nice. They’re nice and they always smile and laugh if you’re here… . Everybody else is just nice and understanding with everything, and smiling.” But she also noted the rude and harsh demeanor of one nutritionist: “The lady in the back’s pretty rude, but everybody else is nice… . She cuts you off… . She just looks at you funny… . But she does her job, I guess. I guess she just needs to get it over with. She’s just like, ‘OK well, that’s not what I’m asking you.’ [I’m like,] ‘Alright well, I’m sorry.’” She laughs. “But she was OK, I guess.”
Sharon, who has used WIC for 2 years, also regarded a nutritionist as rude since she lacked warmth and emotion throughout their interactions. She described the worker as having a “clipped” tone when asking intake questions and quickly processing clients to get them “in and out.”
I think she was just determined to get people in and out as fast as she could, if that … if that is a nice way to put it… . She’s just very short-clipped… . When we did the interview and she was asking questions about … how I was eating and, uh, like if I had any sedatives or … if I was eating fruits and vegetables and stuff like that… . You know—there was no emotion… . I think she was just trying to get people in and out of there, and it was just kinda a clipped tone. So, I just answered her questions the best that I could so we could get out of there.
The Benefits of WIC Encounters: Advice and Referrals
Contrary to prevailing critiques of WIC’s paternalistic program design, most WIC participants did not view nutritional counseling sessions as intrusive or undermining their own agency in feeding their children (Mink 1995). Instead, most participants interviewed described the nutrition education sessions as helpful information and a form of advice about rearing young children. This is Regina’s respective. As a new mom and a new WIC participant, Regina described her nutritionist as giving “good advice.” When asked to elaborate on the kinds of advice she received, she described the standard information provided in nutritional education sessions—recommended foods to address nutritional risks and information about breastfeeding. “Last time I saw her she told me that—it’s about breastfeeding. She told me that if I breastfeed, the baby’s immune system would be better and that it’s healthier than most formula milk.”
Shera, a new mother, similarly regarded nutritional education as a form of advice and sought out guidance on motherhood from her nutritionist, Beverly. She described how Beverly served as a parenting role model and a source of advice when her family members were unavailable to answer questions: “She told me her own stories about breastfeeding and about being a mother… . She asked me a lot of questions about myself. She helped me out a lot with different things… . I have a sister, but she’s busy; she has three kids, she’s a single mom, so I just can’t call her and sit on the phone and say, ‘Can you give me detail by detail what to do here?’ So I can ask Beverly.”
Vanessa—a veteran WIC participant—also viewed WIC staff as a source of advice and counsel; she was especially drawn to a WIC staff member who reminded her of her mother and commented on how this staff member listened to her concerns and made efforts to connect her to resources: “Now, there’s one I think reminds me a lot more of my mom, and that’s the lady that was just in here. I like her. She’s very nice, and she listens to you and she tries to understand where you’re coming from and she tries to help. She suggests a lot of programs for you. If you just talk in a one-on-one conversation she’ll say, ‘Well, I know someone who can help you with this.’ Just help from the outside, not only just from WIC.” Nutritional education, information about breastfeeding, and direct referrals to other assistance programs are standard components of the WIC program. But for clients, these aspects of WIC have socially supportive significance. Clients viewed these elements of the WIC program as much-needed support as they raise young children.
These positive assessments of WIC encounters were not concentrated among veteran WIC participants. Respondents who had less than a year of program experience—the equivalent of two in-person appointments or fewer—also shared these views. Among new WIC participants (), all but one reported positive experiences with WIC staff. Cassandra, who recently started the WIC program, viewed the recommendations she received during her nutritional education session as helpful advice as she navigates being a new mother. She explained, “She gave me lots of advice about how much formula [my child] should be drinking and how many bowel movements a day she should get. She had a lot of information, so that was nice because I don’t know a whole lot because it’s my first kid.” Amber, who had been using WIC for 3 months, described WIC staff members as “pleasant” and “kind.” She shared how she felt “comforted” and welcomed by the staff. “Very kind, very pleasant. Never felt disrespected or anything like that. They were always sweet, just made me feel comforted. Asked about breastfeeding, all that good stuff. Interested in the pregnancy, which just makes you feel welcome.” In sum for most participants, whether they were new to the program or had previous WIC experiences, WIC reflected a significant departure from their typical experiences with assistance programs. The staff were respectful, helpful, and supportive.
The Costs of Claiming SNAP and Medicaid: Stigma, Inaccessible Workers, and Delayed Benefits
Most clients distinguished WIC from SNAP and Medicaid by the extent to which staff are warm and engage in conversations about personal matters and family life. Most WIC participants interviewed receive SNAP. Almost one-third of participants reported limited interactions with workers since they were in a household that received SNAP, but they themselves did not apply or they submitted their applications through the mail. However, most of these participants reported negative interactions with Medicaid and SNAP staff members. In contrast, no participant reported uniformly negative experiences with WIC staff members.
Positive experiences with SNAP or Medicaid workers were less common. For example, Rachel “loved” her SNAP caseworker because she was friendly, prompt, and accessible. She explained, “I loved my case worker… . She was really friendly and very outgoing. I really liked her a lot. I didn’t have all the information that I needed for [child’s name]. I still got emergency food stamps… . Everything was taken care of the next day. I didn’t have to keep calling to try to get ahold of her.” However, participants typically described workers as distant, inaccessible, or rude. Revisiting Sharon’s perspective illustrates this point. Although she generally views WIC staff as warm, supportive, and personal, she found her SNAP and Medicaid workers at the Department of Social Services (DSS) to be “very rude” and “very short.” She noted that her WIC and DSS experiences were “night and day.”
Sharon recounted a particularly negative experience with her SNAP worker 2 weeks before her interview. She received a renewal notification in the mail and an inquiry about her father-in-law’s earnings, as she frequently borrowed money from her father-in-law to make ends meet. Sharon described how she was demeaned by her SNAP worker when she submitted the paperwork late:
I didn’t get it in on time, which was my fault … so, you know I was prepared to let it go ’cause I was already getting WIC, you know, and WIC was helping us out… . [Not getting SNAP] would be really tight for us, but we would try to find a way to make it somehow. So I was prepared to let it go. I don’t know what it is, but I certainly do not deserve that attitude. You know? It makes me feel like … it … it almost makes me feel ashamed that I’m on …
Sharon began to cry. “It makes me feel embarrassed to go to somebody and ask them for help… . I never had anybody so rude … treat me … somebody like that … until I came up here to the social services office. I have never had that problem in the WIC office.” In addition to treating her poorly, Sharon also added that her Medicaid worker—although more polite than her SNAP worker—was often inaccessible. Her worker rarely answered the phone or returned her phone calls:
She does not return messages. I don’t know if it’s because she’s very busy … because I know it stays busy up there a lot, … but I’ve called three or four times… . I know I’ve left a message three times … and nobody has gotten back to me. Um, so I finally had to call and … speak to someone after that… . They were gonna send me to the supervisor, but the supervisor wouldn’t answer her phone either. I’m like, “I’m not gonna leave a message when nobody returns messages.”
Conclusion and Discussion
This qualitative study of WIC, SNAP, and Medicaid program experiences demonstrates how key policy features shape the nature of service-seeking bureaucratic encounters. We add nuance to the scholarly discourse on means-tested programs by demonstrating how elements of policy design—caseload retention incentives and long-term interactions for WIC and efficiency and accuracy incentives for SNAP and Medicaid—shape citizen-state interactions. In doing so, we extend the study of administrative burden and social policy administration to demonstrate how policy objectives and incentives can shape administrative burdens and, in some cases, yield benefits.
We find that, in contrast to bureaucratic encounters in other means-tested programs, WIC staff members—whether they are eligibility workers or nutritionists—describe the program as facilitating rather than constraining personal interactions with clients. WIC staff members note the importance of long-term interactions and personal rapport with clients in supporting the change-oriented aims of the agencies. In contrast, SNAP and Medicaid workers describe their work as “managing” processing deadlines and interacting with clients merely to gather information to determine eligibility. Staff members are pressured to process clients expeditiously and accurately, leading several caseworkers to express frustration with—and even suspicion of—the information provided by recipients.
WIC participants experiencing both programs report the benefits of WIC policy features and the costs of accessing SNAP and Medicaid. Most WIC participants described interactions with WIC staff as helpful, warm, personal, or supportive, and viewed key aspects of the WIC program—nutrition education, breastfeeding information, and service referrals—as sources of social support. In this sense, the program offers psychological benefits rather than the costs typically incurred through clients’ interactions with agency staff. In contrast, participants reported negative experiences with SNAP and Medicaid workers. Participants not only faced psychological costs from stigmatizing encounters with SNAP and Medicaid staff but also expressed difficulty accessing encumbered caseworkers. These experiences diverge sharply from participants’ personal interactions with and support from WIC workers and reflect the costly encounters of means-tested programs.
Like all research, our study has some limitations. We focus on service-seeking encounters, where individuals interact with welfare bureaucrats within agencies to apply for benefits. We do not examine individuals’ experiences redeeming benefits (Barnes 2021). Research shows that bureaucratic encounters fall into four categories: transactions among organizational actors (organizational behavior), transactions in which an individual seeks out a bureaucrat for services (service seeking), transactions where members of an organization engage the public (reaching out), and transactions that occur beyond the organization (Kahn, Katz, and Gutek 1976; Heinrich 2015; Nisar 2018). Thus, the quality of experiences for any given program may vary across these kinds of bureaucratic encounters. In the case of WIC, participants may have positive service-seeking encounters but negative extraorganizational encounters when trying to redeem benefits. Indeed, research demonstrates the challenges WIC participants encounter when redeeming benefits in stores (Barnes 2021). In contrast, SNAP participants may have negative service-seeking encounters but positive experiences using benefits in grocery stores. In sum, satisfaction with bureaucratic encounters may be more nuanced than what our analysis shows or what other accounts of conventional citizen-state interactions describe. Future research could examine how experiences vary within a program across these kinds of encounters.
We acknowledge that we do not consider race in sufficient depth. Although the racial political economy of social programs is a vital topic, it did not fit parsimoniously within the theoretical scope of this work. However, some work suggests that WIC participants’ perceptions of racial discrimination in rural southern contexts can deter program participation (Barnes, Garrett-Peters, and Carr 2020).
We also do not deeply engage critiques of the WIC program’s paternalistic nature. Feminist theorists, along with historical accounts on the antecedents of the WIC program, point to how WIC patronizes low-income mothers by prescribing feeding and parenting practices (Skocpol 1995; Mink 1995; MacKay 2019). Yet our analysis shows that the WIC participants we interviewed seldom interpreted nutrition education as overreach. Positive impressions of WIC staff members do not preclude participants from experiencing difficult shopping experiences as a result of paternalistic food restrictions that can prompt early exits from the program (Barnes 2021; Chauvenet et al. 2019).
Ultimately, we describe WIC as a positive program and do not emphasize its paternalism because such a perspective is reflective of what the WIC beneficiaries we interviewed conveyed to us. We refrained from imposing a lens of paternalism where our research participants did not. Of course, this study is not designed to be representative. So, there may be a subset of WIC beneficiaries who do experience the program as paternalistic but who were simply not in our study. At minimum, however, this research suggests that WIC is sometimes experienced as supportive and positive—and not as paternalistic. Notably, it is also possible for WIC to be experienced as both.
Our interviewees come from North Carolina—a southern state with unique administrative practices for all three programs. Though this study includes a significant number of cases relative to most qualitative studies, we cannot make claims about the generalizability of our findings. Rather than breadth, this research offers a depth of insight into participants’ and staff members’ experiences (Lareau 2012). In doing so, we show how specific features of policy shape social policy experiences. This foundation could be extended to future larger-scale research (Small 2009).
Our study was conducted before the coronavirus pandemic. After COVID-19, federal legislation like the Families First Coronavirus Response Act and the Coronavirus, Aid, Relief, and Economic Security Act permitted states to ease intake processes for all three programs. These policy changes—though temporary—significantly altered bureaucratic encounters by facilitating remote appointments for WIC and waiving interview and document requirements for SNAP and Medicaid. Qualitative research shows positive experiences with remote WIC appointments while also highlighting some participants’ preferences for in-person connections with workers (Barnes and Petry 2021). With regard to SNAP and Medicaid, qualitative analysis suggests that efforts to ease access to programs were undermined by the agency’s poor communication of policy changes and strained administrative capacity in the face of growing demand. Simply stated, eligible families were unaware of program changes, or they experienced inaccessible workers who were inundated (Barnes and Riel 2022). In this sense, the pandemic may have improved WIC experiences by providing more convenient interactions with staff and exacerbated some of the negative aspects of SNAP and Medicaid encounters.
Although our study does not capture the effects of the pandemic on service delivery, findings point to the importance of understanding how specific policy features inform the nature of administrative burdens across a range of means-tested social programs. This work also points to the mechanisms in policy design that underlie the positive relationships between WIC and child and maternal health outcomes found in previous research (Buescher et al. 2003; Bitler and Currie 2005; Siega-Riz et al. 2004; Hoynes, Page, and Stevens 2011). Among low-income women, socially supportive staff-client interactions may prove to be a cost-effective way to improve maternal and child health outcomes (Engle 2009; Rahman et al. 2013; Wachs, Black, and Engle 2009). Although WIC’s program design is not free of costs that fall under the umbrella of “administrative burden” (some clients reported mixed WIC experiences and noted costs of claiming WIC benefits), our research does suggest that psychological costs are reduced when the policy is designed to incentivize positive personal encounters with staff.
Looking to future research, our analysis highlights important new questions and emphases concerning administrative burdens and bureaucratic encounters. In particular, our work underscores the role of policy objectives, functions, and incentives in shaping client-staff interactions and suggests that studies should revisit means-tested programs with these policy features in mind to understand the mechanisms that structure bureaucratic encounters.
This study also suggests a reframing of the social policy and administrative burden literature to include a nuanced analysis of the benefits of policy implementation. Insights from studies with a “benefit”-focused analysis can yield useful insights into how to design policies that not only reduce costs but also enhance client experiences beyond the material assistance provided. Doing so may increase program uptake and the effectiveness of policy interventions.
We provide exploratory evidence of the benefits of policy designed to promote personal interactions between bureaucrats and clients and to incentivize caseload retention. These policy designs can be adopted by other means-tested programs to improve bureaucratic encounters with entitlement programs such as SNAP. Policy makers could create incentives that reward staff efforts to connect with clients personally. For example, means-tested programs can incorporate client satisfaction with staff interpersonal skills as a performance standard rather than caseload benchmarks or efficiency in processing applications.
Of course, such policy interventions assume the goal of improving the quality of citizen-state interactions. However, the appropriate goal of social programs remains an open question and a point of contention. A minimalist perspective on the goals of social policy might suggest that getting benefits to people in need via the least invasive means possible is ideal. A more maximal approach would interpret interactions between the state and its low-income citizens as opportunities to enrich their lives by supporting and expanding their social rights and civic status. Under this formulation, quick and efficient delivery of benefits is not as ideal as cultivating a positive experience with the state. A middle-of-the-road approach might involve balancing these intentions. Determining the “best” approach depends in part on normative commitments and goes beyond the scope of any single article. However, we present evidence that can contribute to the adjudication of claims about what public programs ought to accomplish by richly describing program experiences to inform thinking about these approaches and trade-offs. In doing so, we emphasize a “bottom-up” approach to understanding and conceptualizing the role and functions of the welfare state (Michener, SoRelle, and Thurston 2022).
Although social programs face different political contexts and constraints, the insights from our evidence on policy design and citizen-state interactions can inform the implementation of means-tested programs. These findings are especially pertinent for bureaucrats and other policy leaders seeking to maximize the social, economic, and health benefits of social policy for women at the economic and racial margins (Michener and Brower 2020).
Carolyn Barnes is an assistant professor of public policy and political science at Duke University. Her research examines administrative burden and the policy feedback effects of safety-net programs. She is the author of the book State of Empowerment: Low-Income Families and the New Welfare State.
Jamila Michener is an associate professor of government and public policy at Cornell University. She investigates poverty, racial inequality, and public policy. She is the author of Fragmented Democracy: Medicaid, Federalism, and Unequal Politics.
Emily Rains is an assistant professor at Louisiana State University. She specializes in urban politics and development in the global South. Emily uses mixed methods to examine how poverty and informality (living and working in spaces unprotected by government regulations) shape both the policy needs and the political behavior of urban citizens.
This project was funded by the William T. Grant Foundation, the Winer Family Foundation, the Pinetops Foundation, and the Blue Cross Blue Shield of North Carolina Foundation. We would like to thank Kristin Goss, Judith Kelley, Anna Gassman-Pines, and Elizabeth Ananat for their comments on an earlier version of this article. We would also like to thank Kerry Condon, Sarah Petry, and Mari-Kate Mycek for their assistance in conducting interviews and analysis. The authors would like to thank the editor and the anonymous reviewers for their wonderfully constructive feedback.
Appendix A.
| Age | 30.6 (17, 63) |
| Gender: | |
| Male | 3 (3.6%) |
| Female | 80 (96.4%) |
| Race and ethnicity*: | |
| Black/African American | 52 (62.7) |
| White | 30 (36.1) |
| Hispanic | 12 (14.5%) |
| Average number of children | 2.29 (0, 5)† |
| Caring for grandchildren | 3 (3.6%) |
| Average years of WIC experience | 5.8 (0, 20) |
| Less than a year of WIC use | 27 (32.5%) |
| Employed | 40 (48.2%) |
| Program use: | |
| WIC only | 8 (9.6%) |
| WIC, SNAP/Medicaid | 75 (90.4%) |
| WIC | SNAP and Medicaid | |
|---|---|---|
| (n = 25) | (n = 35) | |
| Average age | 42 | 39 |
| Urban | 16 (64%) | 16 (45.7%) |
| Rural | 9 (36%) | 19 (54.3%) |
| Male | 3 (12%) | 4 (11%) |
| Female | 22 (88%) | 31 (89%) |
| Race/Ethnicity: | ||
| Black/African American | 18 (72%) | 16 (46%) |
| White | 5 (20%) | 19 (54%) |
| Asian/Pacific Islander | 1 (4%) | 0 |
| Native American/Alaskan Native | 0 | 0 |
| Hispanic | 1 (4%) | 4 (11%) |
Appendix B. Interview Questions
WIC program use:
1. Let’s talk about WIC. How long have you been using WIC?
2. For which child do you use your WIC benefits? (Respondent should list children in order of age, length of time using WIC.)
3. How did you find out about the WIC program?
4. What do you need to apply for the program? Can you walk me through how you applied for your benefits? PROBE: Where did you get an application?
5. Did anyone help you complete the application? PROBE for relatives, friends, church members, and health workers (nurses/doctors).
6. Can you tell me how long it took for you to get your benefits? (If the respondent mentions delays, PROBE: What do you think caused the delay?)
7. How do you stay in the WIC program? Can you lose your benefits?
8. Can you tell me a little bit about the WIC office? PROBE: Do you ever contact the WIC office for any reason? What do you typically talk about? Probe for specific questions/concerns.
9. How would you describe your interactions with the WIC staff?
SNAP use:
1. How about SNAP? How long have you been using SNAP?
2. How much do you receive in SNAP each month?
3. How did you find out about the SNAP program?
4. What do you need to apply for the program? Can you walk me through how you applied for your benefits? PROBE: Where did you get an application?
5. Did anyone help you complete the application? PROBE for relatives, friends, church members, and health workers (nurses/doctors).
6. Can you tell me how long it took for you to get your benefits? (If the respondent mentions delays, PROBE: What do you think caused the delay?)
7. How do you stay on the SNAP program? Can you lose your benefits?
8. Can you tell me a little bit about the SNAP office? PROBE: Do you ever contact the SNAP office for any reason? What do you typically talk about? Probe for specific questions/concerns.
9. How would you describe your interactions with the SNAP staff?
Other public assistance use:
1. What other programs do you receive from the DSS? Probe for Medicaid, WorkFirst, and the Child Care Subsidy.
2. How long have you been using this program?
3. How much do you receive in X PROGRAM each month? (This applies only to WorkFirst and the Child Care Subsidy.)
4. How did you find out about this program?
5. What do you need to apply for the program? Can you walk me through how you applied for your benefits? PROBE: Where did you get an application?
6. Did anyone help you complete the application? PROBE for relatives, friends, church members, and health workers (nurses/doctors).
7. Can you tell me how long it took for you to get your benefits? (If the respondent mentions delay, PROBE: What do you think caused the delay?)
8. How do you stay in this program? Can you lose your benefits?
9. Can you tell me a little bit about the program office? (This will likely be DSS.) PROBE: Do you ever contact this office for any reason? What do you typically talk about? Probe for specific questions/concerns.
10. How would you describe your interactions with this program’s staff?
Notes
1. We use the term “citizens” in the most capacious way to indicate people who reside in the United States and are therefore members of relevant political and social communities. This term does not denote formal citizenship or documentation status.
2. We use various terms throughout this article to describe people who receive benefits from public programs, including “clients,” “participants,” “recipients,” and “beneficiaries.” Each of these terms has distinct connotations depending on one’s perspective. Because there are few agreed-upon best practices, we use these terms as synonyms.
3. Nutritional risks can also include nutritionally related medical conditions (e.g., obesity, diabetes, dietary deficiencies) and conditions that compromise nutritional health (e.g., alcoholism, drug abuse, homelessness).
4. Ideally, nutritionists tailor nutrition education to participants’ nutritional needs, backgrounds, households, language, and cultural preferences.
5. Instead of “processing clerk,” states and local WIC offices may also use other terms such as “nutrition assistant.”
6. Anthropometric data include height, weight, and taking blood samples to determine iron deficiency.
7. North Carolina requires local WIC agencies to maintain 97 percent of caseloads and to monitor caseloads each month (North Carolina Division of Public Health 2022).
8. WIC program participation peaked in 2010 with 10 million and had declined to 6.2 million by 2020 (Kline et al. 2022).
9. In 2017, the Justice Department initiated an investigation into fraudulent error rates reported by states. FNS conducted its own investigation of eight states and found biased procedures in collecting information on error rates and reporting error rates (DOJ 2017).
10. Counties can apply for a waiver for failing “application report cards” in which counties must provide convincing evidence that “it took all steps possible to process applications in a timely manner in the categories and months of failure.” Counties can identify “factors beyond county control” as reasons for delayed applications (NCDHHS 2007).
11. Workers typically requested additional information from clients within 10 days of the clients’ submissions. In contrast, WIC eligibility is determined during the initial certification appointment. Applicants do not fill out an application, but instead undergo an intake process in which WIC staff members verify address, income, and nutritional risks. Food vouchers are issued to participants at the end of their appointments.
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