Redeeming WIC Benefits: An Analysis of Administrative Burdens and Opportunities for Burden Reduction

Isha Arora, Louisa Sholar, and Kathryn Vaughn

Abstract: Designed to provide benefits to highly targeted categories of individuals, the Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, has demonstrated great impact in the health benefits it delivers to program participants, but also great disappointment in low national levels of uptake and redemption. We employ the administrative burdens framework to better understand why participation is lacking, and often challenging for enrollees, assessing learning, compliance, and psychological costs. COVID-19-related adjustments and individual states’ innovations have lessened the specificity of the program’s food choices, loosened application requirements, and eliminated barriers to in-person meetings associated with the program, although challenges associated with online access and rural locations persist. In order to more efficiently and effectively administer WIC, a national push to streamline service provision, especially towards online formats, and to continue to accept flexible eligibility documentation, is recommended.

Executive Summary

For almost two years, American citizens have watched the underground complexities of poverty in our country come to light. Employment and economic crises, brought on by the COVID-19 public health emergency, have forced all of us to stop and ponder the ease (or lack thereof) with which we are able to access the government resources we need to care for ourselves and our loved ones. Often, the conversation around government benefits and assistance fluctuates between concerns about providing for those we deem “deserving,” while locking out those whom we believe are not. The Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, is an example of one such policy. As a policy reform, WIC seeks to provide nutrition and health benefits to highly targeted categories of individuals. To that extent, it has both demonstrated great impact, but also great disappointment, as only about half of all eligible recipients are currently enrolled (Badaracco 2020). This is a trend that existed before the pandemic, and will likely continue if proper measures  to simplify the receipt and use of program benefits are not undertaken nationally.

WIC provides needed supplemental nutrition and health care access for families, ensuring that children have safe and supportive environments to develop. The evidence on the impact of the program is clear: eligible individuals who participate fare much better than those who do not. Pregnant women who access the program are known to give birth to healthier babies, and are more likely to purchase and eat more fruits, vegetables, whole grains, and low-fat dairy products than their unenrolled counterparts. The program also makes great strides in closing health and other equity gaps: low-income children participating in WIC are just as likely to receive scheduled immunizations as higher-income children, as well as preventative medical care. Finally, children whose mothers participated in WIC while pregnant score higher on certain educational assessments, demonstrating impact in other arenas of the social determinants of health (Badaracco).

A combination of learning, compliance, and psychological costs serve as inhibiting factors that produce the low rate of uptake for such an impactful program. Confusion around benefit use, the duration of benefits, and stigma all disincentivize enrollment among these vulnerable populations. However, we also believe that this low uptake is simultaneously attributable to a lack of attention and effort at making the program more accessible and efficient. It is less about barriers that states have created, and more about those which they have not worked to remove. As we will discuss in our report, numerous low-burden states, including California and Vermont, serve as exemplars in their efforts to simplify the use of WIC benefits in their streamlined data-sharing between welfare systems, and the use of electronic benefits transfer systems and other technological solutions. States with low uptake (and higher burdens) such as Utah, Alaska, New Hampshire, and Montana, have much to learn from these practices. In light of the ongoing pandemic-induced crisis, we believe that a clear window of opportunity has presented itself at both the state and federal level to more carefully examine evidence-based solutions that are likely to increase uptake and improve community health. 

I. Introduction

WIC is a supplemental nutrition program for pregnant or up to six months postpartum women, and infants and children up to age 5 (USDA FNS n.d.). It is the third-largest food assistance program in the United States, serving 6.2 million families in 2020 (ERS 2021). It is not to be confused with the SNAP program, a supplemental nutrition program designed to assist low-income individuals, families, and seniors; the most notable difference between the two programs is their targeted eligibility populations. Neither program is intended to fully cover the nutritional needs an individual has in a given time, but are meant to supplement existing household purchases (WIC Assistance 2021). Applicants for WIC must meet four eligibility criteria to register: categorical requirements, or being a qualifying woman, infant or child; residential requirements, or residing within the state in which they are applying; income-based requirements, or making between 100 and 185 percent of the federal poverty line; and confirmation of being nutritionally at-risk by a health professional (USDA FNS 2013). 

Both programs are administered by the Food and Nutrition Services department within the United States Department of Agriculture (USDA). The federal government sets the program’s income eligibility limits, and also pays the full cost of benefits and national administration (USDA FNS 2020). States implement the programs, however, and are allowed to tailor policy options in ways that often affect eligibility and participation. Individuals can be enrolled in both SNAP and WIC programs at the same time, but this criteria can be unclear or uncertain depending on the state (USDA FNS 2016).

Eligible foods differ between programs, as well. SNAP benefits can be used on a broader variety of foods within the four staple food categories: fruits and vegetables; meat, poultry, and fish; dairy; and bread or cereals. WIC is intended to encompass a more holistic consideration for what goes into providing the best possible nutritional environment for a developing child; however, only specific, pre-approved foods are eligible to be purchased with WIC benefits (John 2011). Those enrolled in the program must attend certain courses and appointments to maintain enrollment, among other requirements (USDA FNS 2006).

II. History

WIC was first established as a pilot program in 1972, placing its origins at the tail end of the Great Society effort and President Johnson’s War on Poverty. It was introduced by then-Senator Hubert Humphrey, a Democrat from Minnesota, as an amendment to the Child Nutrition Act of 1966. The inspiration for the program came from a 1969 White House Conference on Food, Nutrition, and Health, which reported that hunger and poverty existed on a "disgraceful scale" in the United States and recommended that special attention be given to the nutritional needs of low-income pregnant women and preschool children (Oliveira 2002). WIC became permanent on October 7th, 1975, and eligibility was extended to cover women who were not breastfeeding and had children under 5 years of age (USDA FNS 2013a. Over time, the program has seen several updates: nutrition education became required for participants in 1978, income requirements were instituted in 1989, and in 2000, immunization screenings were implemented. Revisions to the eligible food packages in 2009 were both an attempt to ensure specific nutrient intake for pregnant women and their infants and one of the program’s most significant adjustments with major implications for program compliance (National WIC Association 2018). Today, the WIC program provides non-cash benefits for supplemental food purchases, nutritional counseling at WIC clinics, and screenings and referrals to other health, welfare, and social services. 

III. Application and Eligibility

To apply for WIC benefits, federal guidelines instruct prospective participants to seek out “state or local agencies” to set up an appointment and begin an application (USDA FNS 2021b). As a result, the application process often varies across states. Once the agency has been identified and the participant has set up an appointment, the applicant will need to furnish a variety of documentation for proof of eligibility (USDA FNS 2020; New York State Department of Health 2017). To start, eligible women and children must be able to demonstrate income at or below “a level or standard set by the State agency” (WIC Eligibility Requirements 2020). Some states that have begun to update their eligibility processes allow adjunct eligibility-based participation in other public benefit programs, (TANF, Medicaid, etc.). Applicants must also obtain documentation confirming that they are experiencing nutritional risk. According to the USDA, nutritional risk means that “an individual has medical-based or dietary-based conditions. Examples of medical-based conditions include having anemia (low blood cell levels), being underweight, or having a history of poor pregnancy outcomes. A dietary-based condition includes, for example, a poor diet.”. Individuals can obtain this information by visiting their physician or undergoing evaluation with an on-site physician in the WIC clinic, if one is provided (USDA FNS 2013b). 

Next, applicants must confirm their identities, and their children’s identities, via birth certificate, current WIC card, or other eligible documents. Pregnant women have to prove they are pregnant via sonogram or other record of care (7 CFR § 246.7 (c2ii)). Current mothers must have a formal WIC referral from a physician or other hospital discharge papers; their infants and children also need referral forms. Applicants can prove residency through a range of eligible documentation, from mortgage papers to utility bills; this variety in acceptable documentation contributes to further differences in implementation across states. One constant in all cases, however, is that the child must be present at the initial meeting, and that in-person attendance to all meetings thereafter is the default expectation. WIC offers nutrition education, breastfeeding support, and other programs, and in some states, attendance is mandatory to remain on the program. 

Systems for benefit disbursement and receipt have seen some change over time. Until the passage of the Healthy, Hunger-Free Kids Act in 2010, benefits were distributed inconsistently across the country through paper check or Electronic Benefit Transfers (EBT) cards. This legislation mandated that all states must transition from paper check systems to EBT by October 1, 2020 (USDA FNS 2016). As we discuss later on, implementation of this mandate has moved at an inconsistent pace; roughly ten states had not made the transition by the start of the COVID-19 pandemic. 

Finally, the length of time in which an individual may participate in the program, as well as required certification periods, also vary based on state and individual dependencies. Whether a person is pregnant, postpartum or breastfeeding, or an infant or child will determine when their benefits run out and what information is needed in order to reapply (USDA FNS 2013b).

IV. Burdens and Costs

The administrative burdens framework highlights the role of specific learning, compliance, and psychological costs of accessing public goods or services. Such burdens can effectively serve as “policymaking by other means” via their restrictive or complicated nature. Next, we define each of the aforementioned costs within the context of the WIC program and note their origins. 

Learning Costs

A 2021 study completed by Duke University researcher Carolyn Barnes identified administrative burdens relating to the WIC program that functioned to “discourage program use and undermine policy goals” (Barnes 2021). Given the many provisions of WIC as well as the sometimes-lengthy enrollment processes, learning costs are high for applicants who seek to understand the bounds and ecosystem of the program. Barnes (2021) identifies learning costs related to the redemption of program benefits, specifically the limited portability of food options and a reliance on third-party agents, or retailers that stock and sell WIC-approved food items. Limited portability refers to the knowledge of which vouchers restrict beneficiaries to specific services and goods, like time constraints and brand or service-type restrictions (i.e., the stringent food lists that control which kinds and sizes of products can be purchased). Third-party agents, such as retailers, control the selection and availability of WIC-approved items, customer interactions, and compliance with WIC guidelines that can severely hamper a participant’s understanding of the shopping experience. Interviewed participants describe the large quantity of information they had to sift through, learn, and implement; one summarized her experience by saying “[it] takes a while to get used to it.” Another shared that, as an individual eligible for both SNAP and WIC, she would sometimes purchase food with her SNAP stamps instead because the cash-like benefits allowed for greater flexibility, saying that “I might as well…..[it’s] way less trouble” (Barnes 2021).

As WIC is a time-bound program and serves women and their children through the first five years of a child’s life, participants also have to manage a transition to the SNAP program once their child/children age(s) out of the program. This represents another body of information that participants need to understand, and such transitions have been severely understudied. 

Compliance Costs 

 Compliance costs within the WIC program exist in the application and benefit redemption stages of the program. To apply, receive doctor’s verification of nutritional risk, complete regular check-ins, and, in some cases, receive paper slips that function to transfer benefit, participants must visit a physical WIC clinic. While the pandemic brought adjustments to that requirement that we note later on, these visits create obvious time and transportation costs that can be out-of-reach for working-class and low-income women (Barnes 2021; Henchy 2019).

WIC food package changes enacted in 2009 affected infants and children up to age 5 by prohibiting juice consumption during infancy, allowing some formula from 6-11 months, and allowing new food choices that emphasize whole grains, fruits, and vegetables overall (National WIC Association 2018; Oliveira and Frazão 2015). The changed food lists were intended to adequately supplement intake of key nutrients known to be lacking in target WIC populations: calcium, vitamin D, fiber, potassium, and iron (Rasmussen, Latulippe, and Yaktine 2016). While the new lists have accomplished the goal of providing more nutrient-dense foods to participants,  the specificity of the new food packages can sometimes present a challenge during benefit redemption (Schultz, Byker Shanks, and Houghtaling 2015; Rasmussen 2016; Gleason and Pooler 2011). Detailing the size and the brands of products eligible for purchase also intersects with learning costs – participants must first learn which items are covered, and then ensure they choose the right options within what is stocked at their local store. 

Psychological Costs

Redeeming WIC benefits induces substantial psychological costs on individuals and families in need of government assistance. Participants must calculate what foods and quantities to buy while shopping for groceries based on program specifications. The process of shopping is frustrating, and induces feelings of helplessness among beneficiaries (Barnes 2021). Participants are often stereotyped as lazy or lacking ambition, disincentivizing them from claiming benefits (Manchester 2012). Individuals also report demeaning interactions with bureaucrats and a sense of lost autonomy when applying for government services (Barnes 2018).

Additionally, not all grocery stores carry WIC-labeled products, and those that do may not update their stock often. This forces beneficiaries to visit multiple locations for one grocery trip, where sifting through stores and ensuring that the foods on sale are not dated can be psychologically taxing. Some beneficiaries report forgetting to claim their entire benefit due to miscalculation or in a bid to quickly exit stores. Individuals also report stigma at check-out counters, where the use of paper WIC vouchers is visible and looked down upon by others. They may avoid claiming benefits entirely or look for stores that aren’t frequented by too many people (Barnes 2021). Poor labeling contributes to further stigma, when mistakenly attempting to purchase a non-WIC labeled product at a store check-out counter causes enough embarrassment to encourage beneficiaries to opt out of the program entirely (Henchy 2019). Finally, decision fatigue, or the point at which a person becomes saturated with too many complicated decision-making processes, encourages individuals to avoid the program. If the process of selecting WIC-eligible items is too cumbersome, enrolling and using WIC may not seem worth the economic benefits (Barnes 2021).

V. Sub-Group Concerns

Ethnic Minorities and People of Color

Traditionally, minority communities, including immigrants and individuals of color, tend to face greater burdens in accessing government programs (Smelser et al. 2001). To that extent, Latin Americans and Asians face linguistic hurdles in navigating the WIC system and availing its services. Often, the administrative staff involved in scheduling appointments speak only in English, preventing most non-English speakers from understanding instructions or communicating their needs. Asian and Pacific Islander women face stigma within their own communities, as receipt of government benefits is culturally looked down upon. A greater number of Blacks and Hispanics have difficulty getting off work for scheduled appointments, as compared to their White peers, perhaps due to underlying racial discrimination across workplaces (Liu and Liu 2016). Finally, certain WIC food requirements are often inconsistent with cultural dietary norms, limiting uptake among individuals from varying ethnicities (Schepper et al. 2006). 

Misinformation and misconceptions around eligibility incentivize low uptake among immigrants, in particular. Pelto et al. (2019) found that a statistically significant number of Latinx American families believed “if someone uses food stamps or WIC, the people in the family who don’t have documents could be reported to the government.” Individuals who perceived this to be true were 85% less likely to enroll in the WIC program. This hints at an underlying fear of deportation that immigrants face while residing in the US, discouraging them from accessing services to which  they are otherwise entitled. Misinformation, at large, is responsible for an average decrease of 27% in enrollment probability by immigrants (Pelto et al.).

The Rural vs. Urban Divide

The cost of redeeming WIC benefits is substantially higher in rural areas compared to suburban areas, as the latter have more retailers, greater selections of WIC-approved food items, and better trained staff in stores (Barnes 2021). Further, many rural communities have diminished access to retailers who even accept WIC or SNAP benefits. Women in rural areas also attach more stigma to participation in government assisted programs than their urban counterparts (Smith 2016). Although SNAP participation rates in rural areas are higher than in metropolitan environments, WIC participation rates are dependent on state demographics at large (Reinhardt 2018). For example: while agriculture is a leading employer within the state of Colorado, 12 percent of rural Coloradans experience food insecurity, compared with 9.3 percent of urban residents (Gilbert 2020). Conversely, rural residents in North Carolina have benefitted immensely from state efforts to combat this divide, namely through the implementation of remote appointments. In April 2020, North Carolina eliminated the physical presence requirement for WIC appointments. This allowed workers to collect information related to certification remotely, helping individuals access services with ease and freeing staff at appointment centers to be more responsive (Barnes 2021). 

VI. Levels of Burden – A State-by-state Comparison

WIC reached an all-time enrollment high of nearly 9.2 million in 2010, and while the number of eligible participants has remained steady over time, the coverage rate (the number of eligible participants who are enrolled) has fallen by more than five percentage points over the past 15 years (Badaracco 2020). Given the great disparity in administration and uptake across states, analysis of burden is better suited to state-by-state comparisons rather than broad, all-encompassing trends. Accordingly, we examine a group of states we have deemed “high-burden,” due to low coverage rates, and “low-burden,” due to higher coverage rates. 

High-Burden States

In 2017, Montana, New Hampshire, Utah, and Alaska had the lowest WIC coverage rates in the nation, as each state had less than 40 percent of all eligible recipients enrolled (Badaracco 2020). To start, each has significant rural populations, and while they are not the only rural states in the nation, they have not taken appropriate measures to make WIC and other systems that provide access to quality food and nutrition more accessible. A study from the University of New Hampshire found that many small towns in the state lack access to grocery stores and farm stands at which to purchase food. While this creates challenges for anyone attempting to access food and grocery services, it disproportionately impacts enrollees when some stores do not participate in WIC or SNAP programming (Moon 2019).  Additionally, rural states that rely heavily on locally-sourced goods for affordability, like Alaska, unintentionally disincentivize use of the program as those products are not eligible for WIC coverage – federal requirements specify the types of foods eligible for coverage under the program, and often exclude certain fresh proteins, grains, and vegetables in favor of packaged goods and formulas (Congressman Don Young 2019).

Largely, high-burden states were late adopters of the 2010 federal EBT mandate, meaning that they continued to distribute benefits via paper check until new programs were designed and implemented. As we have previously noted, paper checks contribute to high learning costs and psychological concerns regarding stigma, explaining the low uptake in these four states (Odorczyk 2021). Stigma aside, paper voucher systems often require individuals to use their entire voucher at once, enhancing difficulties in using benefits. New Hampshire did not implement an electronic system until 2018, and Montana and Alaska were late adopters, as well (Gibson 2018; Solutran 2017; Greenman 2019). And while eWIC implementation had taken place slightly earlier in Utah, the state still required that participants physically visit WIC offices to reload cards every three to four months, even during the pandemic (Hester 2021). 

Three out of our four high-burden states engage in sub-optimal data-sharing practices with other state benefit programs, like SNAP and Medicaid. Individuals eligible for one program are likely to be eligible for others, and enrollment can be streamlined and improved by communicating this upon the first point of contact with a state agency practitioner. Pilot projects conducted in four states from 2018-2019 found that between 44 and 63 percent of WIC-eligible individuals enrolled in Medicaid or SNAP were not enrolled in WIC (Neuberger 2021). The same project discovered that about half of the nation’s SNAP, WIC, and Medicaid agency representatives meet regularly to discuss data sharing agreements and coordination to foster greater efficiency and outcomes. Montana, Utah, and Alaska are excluded from that count, and have yet to establish clear identification pathways for individuals deemed eligible based on their participation in other programs. Both Montana and Utah lack memoranda of understanding between Medicaid, SNAP, and WIC regarding data-sharing on eligibility or potential eligibility of individuals enrolled (Ibid). Utah does not even convene its state-level WIC representatives, or representatives from other social services, to discuss implementation pathways, and provides little information in the clinical setting to enrollees of these programs who are dually-eligible. It is unknown as to whether Alaska or Montana make any strides to provide this information directly to potential enrollees, either. Montana’s current programs that seek to address these concerns solely exist thanks to a separate study they joined in 2018 – without that pilot, it is unclear whether these programs would have come to fruition. 

Low-Burden States

A significant opportunity for burden reduction is the transfer to online provision of program elements through the use of EBT cards, and the ability to offer nutrition courses virtually. As of 2016, 34 states and 5 intertribal councils used some form of online nutrition education (Weber 2018). EBT cards that function like debit cards in the checkout line can be less conspicuous, and less stressful, for program participants. Additionally, online access helps lower compliance and learning costs. New mobile applications clarify which foods in a given store are WIC-compliant, and allow participants to check their balances conveniently. As of December 2018, 30 states, 3 US territories, 3 tribal nations, and the District of Columbia use these apps, though there are slight differences in implementation given that each state designs its own (Ibid).

Specific examples of low-burden states include Vermont, California, and Maryland, each with a coverage rate of 62% or greater (USDA 2018; America’s Health Rankings (n.d.)). California’s WIC program maintains a reputation of accessibility and ease, in both the application process and physical convenience. WIC offices are described as being embedded and widespread within community landscapes: “[a] local WIC site – whether a permanent clinic, a small storefront, or a folding table in a firehouse or church basement – is a fixture of nearly every small town, low-income neighborhood, and reservation in California” (Jacobson, Testa, and Horner 2003). This may be due to the state's emphasis on contracting out some of its work to nonprofits. Today, local WIC agencies are managed by six types of parent organizations: 39 county health departments serve approximately 38 percent of WIC participants, nonprofit agencies serve about 37 percent, federally qualified health centers (FQHCs) serve another 20 percent, and six Native American health centers, three city health departments, and two hospitals served the remaining five percent of WIC’s caseload. Additionally, close proximity to WIC offices has helped to remove transportation and learning costs. California’s statewide technological infrastructure, an automated data system known as ISIS (Integrated Statewide Information System), supports and connects its offices. The state has plans to create a single electronic information system and application portal by the end of 2024. Finally, California has made modernization adjustments to the WIC program, including the acceptance of electronic documents and the use of texting for appointments and messages, and plans to have a videoconferencing option for participant education soon (Jacobson 2003).

Vermont represents a case of rapid improvement in coverage facilitated by responsive system change. The state increased coverage rates from 55 percent in 2016 to 75 percent in 2021 by: eliminating “proof of pregnancy” documentation, assessing Medicaid participation to determine adjunct eligibility ahead of certification appointments, revising the food guide and developing video series to improve shopping experience, translating the food guide and videos into multiple languages, implementing a mobile shopping app, expanding texting services to two-way communication, and offering web-based options for nutrition education classes (Levine 2019).

Pandemic Adjustments

While the pandemic created obvious barriers to in-person meetings and benefit use, and the overall number of participants in the program decreased, some states took the opportunity to make helpful adjustments. In March 2020, the Families First Coronavirus Response Act provided the USDA with needed flexibility to approve state waivers for SNAP and WIC programs. Some helpful waiver adjustments include: remote receipt of WIC benefits, remote enrollment and re-enrollment (and the ability to defer certain requirements typically necessary to determine nutritional risk), permitting purchases without the presence of a cashier, including online grocery and curbside pickup options, and more (Food Research & Action Center 2020). Thanks to further advocacy from the National WIC association and others, these waivers will remain valid 30 days beyond the end of the national public health emergency, which expires in January 2022 (Gerald 2020; Bryant 2021).

The shift towards online benefit redemption is notable, particularly in the removal of transportation and compliance costs associated with in-person visits, and it comes as no surprise that the removal of such barriers yielded higher participation rates. A recent study estimated that as of January 2021, WIC participation was 14% lower in “offline EBT'' states (where individuals must visit a physical location to reload their EBT card) relative to “online states” (where WIC benefits are automatically reloaded onto EBT cards remotely; Vasan, et al. 2021). The nine “offline” states (Arkansas, Louisiana, New Mexico, Missouri, Ohio, Pennsylvania, Utah, Texas, and Wyoming) still require WIC beneficiaries to present their EBT cards in-person at their local WIC office every 3-4 months to reload their benefits.

VII. Conclusion

WIC’s participation rates have only increased by 2 percent from 2020 to 2021 in spite of the economic recession generated by the pandemic, which theoretically should have increased enrollment. According to the USDA’s Food and Nutrition Service estimates, about 57 percent of the eligible population is participating in the WIC program, which is especially concerning given the efficiency barriers discussed in our report (USDA FNS 2021a). In 2008, research from the Brookings Institute found that the overall administrative cost of WIC is up to 41.4 cents per dollar of food benefits issued, higher than that of SNAP (Isaacs 2008). In spite of this, WIC still manages to deliver returns of at least $2.48 in medical, education and productivity benefits for every $1 invested (National WIC Association 2021). With that in mind, improving WIC and implementing ways for the program to run more smoothly and effectively should be an institutional priority. It is possible that COVID-19 response funding will continue to contribute to long-term policy changes and innovation to streamline the program. The American Rescue Plan Act, passed in March of 2021, provides $390 million from 2021 to 2024 to support outreach, innovation, and program modernization that aims to boost WIC participation and benefit redemption (Barnes 2021). With greater attention paid to internet access disparities, while prioritizing efficient use of benefits, transitioning WIC service provision online and re-evaluating eligibility requirements could profoundly change these gaps in coverage.