You asked (1) what the state is doing to encourage TFA recipients who can work to enter the health care workforce, (2) if there are obstacles to these recipients taking such jobs, and (3) if other states are looking to their Temporary Assistance for Needy Families (TANF) caseloads to help address their own health care worker shortages.

SUMMARY

The state appears to have done little to encourage TFA recipients to enter the health care workforce, although it is offering some training opportunities. Despite this lack of encouragement, Department of Labor (DOL) statistics for the period between October 2000 and mid-June 2002 show that 13% of Jobs First Employment Services participants who were employed worked in health care. This percentage actually exceeds the percentage of health care workers statewide (8%--not including indirect care positions), according to the DOL's John McCarthy.

Although the state has not made a concerted effort to encourage recipients to take health care jobs, its Jobs First program is designed to help them find employment. This includes offering a number of work incentives that could be useful to someone entering the health care workforce. For example, it allows TFA recipients to earn up to the federal poverty level without seeing a reduction in their TFA cash benefit. And it offers some training opportunities and support services, such as child care and transportation. Jobs First offers some training for TFA recipients wishing to enter the health care field. But these slots appear to be limited and fill up quickly. Most of the training opportunities tend to be tied to the labor demand for the area. For example, TFA recipients living in the southwestern part of the state receive customer service training (cashier, retail sales, counter clerks) because the labor demand for these jobs is the highest in that region.

Like the work incentives, the obstacles facing employment-seeking TFA recipients are not specific to those pursuing jobs in health care. They may encounter the following difficulties: (1) the education or training necessary to get a job may not meet the program's eligibility requirements and many of these recipients lack the basic reading and math skills that would be pre-requisites to entering an educational or training program; (2) TFA program limitations may not provide enough time to complete certain job training; (3) limitations on child care and other support services; and (4) the only jobs they qualify for may be low-paying, unskilled jobs that do not meet their financial needs.

Moreover, two different state agencies, as well as local workforce investment boards and their contractors, run the program. And each has its own set of rules, which can be confusing for participants or difficult to follow. Lastly, the funding that is available for health care-related job training and education comes from a variety of sources, potentially making access to it difficult. (If you would like more information about this funding, including how it is allocated for health care-related training and education, let us know. )

New York has used a substantial amount of TANF block grant funds to encourage welfare recipients to enter the health care workforce, with an emphasis on training and retention. Smaller-scale initiatives are under way in several other states. And while not specifically aimed at welfare recipients, several states have begun initiatives that help support people who take jobs, such as offering health insurance benefits.

The 2002 legislature considered at least two proposals that would have opened up education and training opportunities for TFA recipients. One would have established a work-study program in established certified job training programs, including those that prepare people for occupations in demand in the state (e. g. , health care). The other would have codified the Jobs First "balanced work first" approach and relaxed some of the rules around educational and training opportunities for TFA recipients. Neither passed.

BACKGROUND

TANF, Jobs First, and TFA

The state's welfare-to-work initiative is called Jobs First. Much of its funding comes from the state's TANF block grant. These block grants were authorized under the federal Personal Responsibility and Work Opportunities Reconciliation Act of 1996.

Jobs First consists of two main parts: TFA, which DSS administers, is the program's cash assistance component that pays a monthly benefit to low-income families with children who meet certain eligibility criteria. Most families qualify for a maximum of 21 months of assistance, but some can get extensions in certain circumstances. Jobs First Employment Services (JFES) is the employment piece of the program. It provides TFA recipients with the help they need to find and keep jobs that will make them independent of TFA within the time limits. The DOL, which runs the JFES program, uses what it calls a "balanced work first" approach to move clients from welfare to work. Although DOL and DSS, along with the local workforce investment boards, are partners in the state's welfare-to-work initiative, DSS is the state agency with the ultimate responsibility for ensuring that the state complies with the TANF law.

ENCOURAGING JOBS

The state's Jobs First program provides incentives to all TFA recipients who work or look for work, regardless of the types of jobs they take or seek.

Perhaps the greatest incentive is that it allows TFA recipients to work and earn up to the federal poverty level and continue to receive their full cash benefit.

The program offers Medicaid to both the Jobs First participant and her family for up to two more years after she stops receiving cash assistance if she is working. This can be extremely important as many lower-level jobs often do not provide medical benefits.

For many families child care is an absolute necessity. The Jobs First program responds to it by offering subsidies when the caretaker relative is working. Families that leave TFA can continue to receive the subsidy until their income reaches 75% of the state median income (with

contributions required at certain levels). Even in those cases where the person is engaged in a non-work activity, such as job search, the state will provide some limited child care assistance (see below).

Finally, Jobs First offers some transportation assistance, such as bus tokens.

To entice employers to hire TFA recipients, the state offers Connecticut corporations, including health care providers, with a state tax credit of $ 125 per month for up to 12 months ($ 1,500 maximum) for each newly hired individual who has received more than nine consecutive months of TFA and works at least 30 hours per week. (Two federal tax credits are also available to businesses that hire these individuals. )

OBSTACLES FOR WOULD-BE HEALTH CARE WORKERS

There are at least six obstacles for Jobs First participants to overcome if they wish to work in a health care job, especially when they might need training or education to prepare for the job. Most of these would affect participants looking to work in all areas, not just health care. These obstacles include (1) federal limitations on participation in vocational education and job skills training (tools that get participants job ready); (2) state priorities that tend to favor any employment over training and education; (3) TFA program lengths that may make completion of training and education programs difficult; (4) the lack of safe and affordable child care and transportation; (5) the lack of housing; and (6) minimum training requirements for many of the lower-skilled, but higher paying, health care jobs.

TFA Work Participation and Allowable Activities Rules

The Jobs First program requires most adults in families receiving TFA benefits who can work to do so. The federal TANF rules require that 50% of adults in families receiving cash assistance be engaged in work activities for at least 30 hours per week.

The federal law does not define "work" but instead lists the categories of activities that states can count towards the work requirement (see a copy of OLR Report 99-R-0185 for this list). Although participation in vocational education and jobs skills training qualify as work under TANF, the rules limit participation in each. Vocational education is limited to 12 months and only 30% of the people considered "working" can be involved in it at any one time. Job skills training is allowed only after a participant has worked for the first 20 (of the required 30) hours in other activities. Although states have even more flexibility to offer this type of activity if they choose to pay for them with state-only funds, Connecticut has not chosen to do so.

Moreover, the DSS TANF state plan states that post-secondary education (two- or four-year degree programs), which could also prepare someone for a skilled health care job, is not an allowable activity. The plan requires participants to pursue this education as they work, provided it is funded with other resources and does not interfere with an employment plan.

Jobs First Employment Services (JFES) Structure

A TFA recipient wishing to enter the health care field who lacks the necessary skills for a particular job would not necessarily receive assistance that would get her that job.

TFA recipients subject to the 21-month time limit who have employable skills or training are expected to take a job, regardless of the area of employment. While this expectation helps the state meet the TANF work participation rules, it serves as an obstacle to recipients who may want training in a different field, like health care.

However, the Jobs First program has begun to allow for education and training of participants whose existing skills or training would not enable them to earn up to the federal poverty level (see DSS TANF State Plan, Section A Part I (C) (9)(C)). Despite this new trend, it appears that few participants have gotten the opportunity to receive the training or education to prepare them for many occupations, such as skilled health care jobs. (The Jobs First annual report for FY 2000-01 shows that over three-quarters of participants engaged in employment or job search during that time versus less than 10% in skills training. )

Time Limits

A TFA recipient's job search may be jeopardized by delayed employment services assistance. Some do not receive this assistance until several months after the family starts receiving cash assistance, leaving little time for customized work preparation before TFA program eligibility expires. For example, the Southeastern Connecticut Workforce Investment Board reported recently that in many instances, TFA clients were referred for employment services six or more months after they began receiving cash assistance.

Lack of Child Care, Housing, and Transportation

Although child care subsidies are available to Jobs First participants who work, support is limited (generally up to $ 10 a day) for women who engage in non-work activities, such as job search. Although this assistance is available, many women often must rely on informal, unlicensed care arrangements, either because licensed care is too expensive, too far from work or home, or simply unavailable.

Transportation presents another obstacle to Jobs First participants since many of them live in urban areas and need to get to suburban jobs that are available during non-traditional work hours, when buses (major mode of transportation) may not be running. While the state has made some improvements to the public bus system, such as adding or extending routes, and subsidizes a vehicle donation program, gaps still exist, especially for people who need transportation to and from several destinations (e. g. , from home to child care to work and back). And unlike child care assistance, transportation help is available for someone engaged in a non-work activity but stops once a participant gets her first paycheck, according to DOL draft JFES regulations.

Housing

In the most recent DOL monthly publication on the JFES program, case managers reported that 12% of JFES participants reported housing as a barrier to employment. The state's major housing assistance program, RAP, is currently closed with a waiting list of a few thousand. And those people who are lucky enough to get subsidies are finding it more difficult to locate affordable rental units in this tight real estate market.

Health Care Employers-Nursing Homes and Home Health Care Agencies

Many of the health care jobs for which a Jobs First participant might qualify are lesser skilled jobs in nursing homes and home health agencies. For example, nursing homes employ certified nurse's aides, for whom the training requirements are not terribly burdensome and wages are fairly competitive. But many of these health care facilities have been experiencing financial hardship during the last few years because the government payments that they rely on (Medicare and Medicaid) have been shrinking, making it harder for them to sponsor training programs or offer other benefits that could entice Jobs First participants.

OTHER STATE AND LOCAL INITIATIVES

New York

Last year, New York targeted $ 80 million of its TANF funds to shore up growth in the state's health care workforce. The funds are available for worker recruitment, retention, and training and targets people eligible for or receiving TANF-funded assistance. The state's health and labor departments issued a request for proposals, which came from hospitals, nursing homes, and home health care agencies that developed model programs for workers with family income under 200% of the federal poverty level.

Preference was given to organizations that demonstrated an ability to partner with labor unions, local social service districts, Workforce Investment Act agencies, and other appropriate community resources. The successful bidders were a consortium of educational partners and employers. They use the money to provide hospital jobs, as well as training for people enrolled in college health care training programs.

Regional Employment and Training Initiative (RETAIN)

The International Association of Jewish Vocational Services (IAJVS) administers RETAIN, an integrated work and learning program that places long-term welfare recipients in jobs in the health care industry. IAJVS offers services in Boston, New Jersey, Minneapolis, Massachusetts and Philadelphia. The program consists of three phases:

· A six-week pre-employment assessment, job readiness training, and job search program.

· Eight weeks of integrated work and learning with a focus on soft skills. Part-time employment is combined with 10 hours of instruction per week.

· Full-time employment supplemented with post-employment services such as home health aide and nursing assistance certification, case management services, and further vocational training.

Each IAJVS agency has created a network of employers interested in hiring RETAIN clients. These employers include nursing homes, home health care providers, hospitals, health care manufacturers, pharmacies, and managed care organizations.

Arkansas

Arkansas Enterprise Group was awarded a grant to implement a business expansion model designed to expand the Careers in Health Care (CHC) Program based in Pine Bluff, Arkansas. This project will create 83 new permanent paraprofessional jobs in the health care industry. The target population will include low-income residents of seven economically distressed counties. CHC will train and assist TANF recipients, income-eligible non-custodial parents, and other low-income individuals in securing full-time permanent employment as certified nursing aides and mental health aides. CHC will assist trainees in securing reliable transportation and child care during training and after they are employed.

Hamilton County, Ohio

Cincinnati State Technical and Community College and the Hamilton County Department of Human Services have developed the Health Care 2000 program which trains welfare recipients to work as nurse's aides and home health care aides. Participating employers sponsor promising job candidates and agree to employ them on a trial, part-time basis. The employer pays for training provided by Cincinnati State Technical and Community College. Once training is complete, the employer enters into a contract with the Department of Human Services. In return for providing recipients with full-time employment, the employer receives $ 350 per month per person for a maximum of nine months, paid by the department. More than 90 percent of individuals entering the program are employed in the health care field.

San Mateo County, California

The Caregiver Training Initiative (CTI) is a collaboration of San Francisco and San Mateo County public agencies, local employers, community-based organizations and public education institutions. CTI is designed to increase enrollment in in-home support services training programs that target TANF recipients. The program is paid with Welfare-to-Work and WIA funds. The goal of the program is to fill the need for qualified caregivers in the Bay Area.

Other States

Rhode Island is using TANF money to train certified nursing assistants and phlebotomists. Maine uses TANF money to pay for health field-related training for TANF recipients, such as nursing assistants or medical transcriptionists. Tennessee trains TANF recipients for careers in the health care field. The training for most participants is funded by federal Pell grants. In cases where Pell grants do not cover training costs, TANF funds are used. The Massachusetts FY 2001-02 state budget calls for the state's Department of Transitional Assistance to use TANF and maintenance of effort funds on certified nurse's aide training programs and for adult education programs targeted to assist recipients who wish to become certified nurse's aides but have insufficient reading or math skills. Vermont uses TANF money to provide entry-level medical training for nurse's assistant programs through the state's vocational-technical schools.

Non-TANF Initiatives

The National Center on Caregiving, in a brief published in 2000, suggests that the offer of health insurance assistance is a powerful inducement to attract more health care workers. New York was cited for offering health insurance for uninsured home care workers. And New York, Minnesota, and Washington were mentioned for developing initiatives to assist small employers-including long-term care providers-in gaining coverage for themselves and their employees.

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