By: Hope A. Lane-Gavin, Fellow, Health Equity, The Center for Community Solutions
Katherine Ungar, Policy Associate, Children’s Defense Fund – Ohio
Over the past several months, The Center for Community Solutions and Children’s Defense Fund-Ohio have worked together to evaluate the Special Supplemental Nutrition Program to Women, Infants, and Children (WIC). WIC is a critical program, with a proven track record for not only improving infant mortality and maternal health, but for contributing to the long-term health, growth, and cognitive development benefits to children. To learn more about the personal experiences and impressions of OhioWIC, we are speaking with both WIC participants and WIC program directors across the state. In these conversations, WIC participants and directors have identified a number of barriers to accessing or utilizing the program. Our hope is to bring awareness to these challenges, remove or mitigate them, and improve user experience through public policy.
Ohio’s overall WIC enrollment decreased by 15.92 percent.
Offline WIC program negatively impacts enrollment
In our last blog, we detailed how an offline benefit delivery system during a public health emergency in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) adversely impacted our WIC caseload in Ohio – that is the number of eligible WIC participants in our state compared to the number actually enrolled. Based on data from the Ohio Department of Health, Ohio’s overall WIC enrollment decreased by 15.92 percent or 29,737 participants from December 2019 – right before the pandemic – to December 2021. WIC participants and directors described the offline benefit reloading as a significant challenge negatively impacting WIC participation. Challenges with offline benefit reloading—in combination with the inability to apply online, make appointments online, or shop online —pose significant access hurdles.
We spoke with one WIC participant who lives in Athens County in Southeastern Ohio. While she appreciated the benefits that WIC provides, including nutritious food for her daughter who has Cerebral Palsy, she noted the challenges she faces while grocery shopping and using her WIC card. She works the night shift and likes to do her grocery shopping right after her shift, that way she doesn’t have to find additional childcare for her daughter (bringing her grocery shopping with her can be difficult). Her shift ends at 7:00 am, but she must wait an additional hour to purchase her groceries (until 8:00 am), because her local Walmart doesn’t accept WIC through self-checkout and that is the time when an employee opens a person-operated check-out lane. Another WIC participant voiced a similar concern, noting that they prefer to shop at Kroger where they can use their WIC card at any lane, automated or not.
Many other WIC participants who we spoke with noted that they use curb-side pickup and grocery delivery services to grocery shop as it’s much easier to do with small children. WIC, however, requires these families to make special trips inside retailers. Other food assistance programs though, such as the Supplemental Nutrition Assistance Program (SNAP), have allowed beneficiaries to utilize benefits at approved online retailers throughout the pandemic.
WIC directors noted that the antiquated offline system posed significant barriers for accessing and staying enrolled in the program:
- “At first, [enrollment decreased because of] the offline WIC system that required participants to come to WIC clinic (COVID fear kept people away). Fears also kept people from coming to WIC for benefits they could not redeem through curbside shopping or self-checkout at stores.”
- “[Enrollment declined due to] lack of availability of store registers being open with a cashier. Some stores started to only have self-check-out open during certain hours of store operations and WIC was unable to be used.”
Federal COVID-19 relief legislation included significant investments in WIC modernization.
When asked about the biggest challenge OhioWIC is currently facing, WIC directors said:
- “[One of the biggest challenges to WIC enrollment is] outdated enrollment process and requirements (no online application). It is difficult for many to navigate our antiquated application and enrollment process; transportation challenges; perceived value of WIC declines as child becomes older (after age one); no resolution of issues with authorized foods and unresolved vendor-related problems cause frustration and people give up on us.”
- “Not being up to date in technology—virtual card loads, curbside pickups, ordering online, etc.”
- “[We are] behind the times on technology, [we need to] get better on links/sharing to/with other agencies that do similar education—at the federal level WIC needs better connection to SNAP.”
- “Offline WIC certification system making non-in person appointments more challenging – especially with the last-minute approval federally with CVB increase. Difficulties within the current Certification System.”
Federal COVID-19 relief legislation included significant investments in WIC modernization, which will flow to the states through the United States Department of Agriculture (USDA)-Food Nutrition Services (FNS) in grant funding. We are hopeful that Ohio will apply for the funding and use the modernization dollars to truly renovate OhioWIC, bringing benefit reloading, and other aspects of the WIC program (e.g. applying for, scheduling appointments, accessing educational materials, etc.) online and rethinking the way users navigate the system and can use their WIC benefits.
In addition to modernizing the program and bringing it online, WIC participants and directors identified other challenges and opportunities to improve the program and help more people access the important benefits of the WIC program.
Transportation challenges balloon with frequent in-person demands of an offline system
Offline delivery systems require participants to visit a WIC clinic in the county where they are currently receiving their services to simply get their benefits loaded onto their card. This is in addition to their re- or mid- certification and health assessment appointments that may, depending on the recipient’s county, also occur in-person in their WIC office. The frequency in which OhioWIC participants must present in person to maintain their enrollment is not only a barrier for participants but unprecedented for any other public benefit program. It requires WIC participants to navigate finding and many times paying for transportation, and this presents another key barrier for access to the program.
We spoke with a WIC participant in Franklin County who, despite being enrolled in the program for much of the last decade, had to forgo participating when she gave birth during the pandemic and access to WIC clinics shuttered. This participant primarily relied on a Medicaid Managed Care Organization’s (MCO) transportation services to travel to and from health and WIC appointments. The challenge, however, is that when WIC clinics restricted in-person access of participants to minimize the spread of COVID-19, participants still needed to physically go to the clinic to present their card for a reload. In most cases, reloading does not require a formal appointment and is done on a “come when you’re able” basis. But during the height of the pandemic, for most WIC projects in Ohio, this meant that WIC recipients had to drive to the clinic, then call the clinic to let them know they had arrived, and have an employee of the clinic come to the parking lot to retrieve their card for benefit reload. Participants then had to wait in their vehicles for an indefinite amount of time for the employee to return their card. In the case of this WIC participant, the MCO transportation service was not able to wait indeterminately for card reloads. Therefore, she and her newborn’s access to the program was diminished.
WIC Directors identified transportation as a major barrier, too, as enrollment numbers declined during the pandemic. When asked, “If your enrollment number(s) declined during the pandemic, why do you think that is?” WIC Directors across the state had varying responses. However, the issue of a cumbersome administrative system coupled with the realities of the social determinants of health brought transportation to the forefront. WIC Directors reported:
- “…some of our community members have [a] hard time finding transportation.”
- “People were getting so much more assistance from other agencies they did not think they needed WIC, they could go to one site to get cash and food assistance which loaded without them having to go there every 3 months so I believe they felt it was easier.”
- “People spending more time at home to protect themselves from the virus, increase in SNAP benefits.”
- “Phone appointments were completed but having an offline WIC certification system, WIC participants never made the drive back into the WIC office to load benefits to their card.”
- “At first, it was the offline WIC system that required participants to come to WIC clinic ([COVID] fear kept people away). There are also numerous food programs available to help families in need and WIC is likely the most complicated.”
WIC packages could use more flexibility
As discussed in the first blog in our WIC series, pregnant women, infants and children are assigned an individualized monthly WIC package based on a myriad of factors including nutritional needs and age.
Many of the WIC participants we interviewed discussed how simple it was to make a substitution, if needed, such as one participant in Athens County who discovered her newborn had jaundice, lung issues, and gastrointestinal issues and was able to switch from a traditional formula package to a soy formula package with ease.
One participant in Clermont County noted that although you are able to easily substitute, more flexibility in substitutions would mean less food going to waste in her home and in her package. In her case, her 2.5-year-old is currently receiving a WIC package which she believes has an overabundance of milk. While she has been able to substitute one gallon of milk for yogurt and cheese, her child doesn’t eat the offered yogurt and thus it goes to waste every month. Allowing for a full cheese substitution, for example, could be beneficial to participants.
This same participant also noted that she doesn’t feel the program has many options for special dietary needs, such as those required for diabetes or celiac disease, and thus she has had to utilize other financial resources to ensure her child meets their nutritional goals.
In Spring 2021, the United States Department of Agriculture (USDA) announced as part of the American Rescue Plan Act (ARPA) they would allow state agencies to increase the monthly cash value of the fruit and vegetable benefit. All states made the change. This temporary increase took the benefit from $9 per child and $11 for pregnant, postpartum and breastfeeding women to $24 per month for children, $43 per month for pregnant and postpartum recipients and $47 for breastfeeding participants.
All interviewees noted that increased fruit and vegetable cash value has been beneficial and fully utilized every month in their household.
All interviewees noted that increased fruit and vegetable cash value has been beneficial and fully utilized every month in their household.
Many WIC directors across the state feel the decline in participation is due to the packages not being worth the administrative burden. When asked, “In your experience with clients and families, what are the biggest challenges to enrolling in WIC and remaining a participant for the first 5 years of a child’s life?”, they said:
- “Dollar amount of food package is no longer worth the time/effort to continue WIC visits.”
- “…time – the amount of time needed to enroll for the benefits received is too great. It is not worth enrolling for such little benefit. Families to not value the nutrition education as much. As the kids age, the value becomes less and families get involved with preschool, activities, parents return to work.”
- “Coming in for visits, limited food choices, formula changes.”
- “Past age one, WIC benefits are low in value; the visits take a long time to complete; too many questions on the health assessment.”
- “Getting the parents to bring in documentation and getting cards loaded. Parents not feeling that WIC is beneficial for anything other than formula. Food packages not worth the hassle of the appointment. Transportation costs versus the food package not worth it.”
Shopping experiences vary by store, time of day, and supply challenges
While on the surface utilizing the benefits seems like it would be the easiest part of the WIC experience, we discovered through our interviews that for many participants it’s actually the most difficult. Some interviewees report ease of access in locating a WIC vendor, but knowing what is available for use on your card is a needlessly complex hurdle. Participants have few options to check their WIC balance: they can go to the clinic, go to the register at a WIC retailer, save their receipt from the last time they shopped using WIC benefits, or use the WIC shopper’s smartphone application. Due to our offline system, however, the smartphone app has a 24-48-hour delay to reflect their most current balance after shopping.
Supply chain issues, largely brought on by the COVID-19 pandemic and a recent formula recall, are having a greater impact on WIC participants who have very prescriptive food packages.
In an interview with a WIC participant in Athens County, we learned her local Walmart has had to limit the purchase of baby formula to three cans per customer. While limiting sales is common practice when there are supply chain shortages, the WIC program operates on a “use it or lose it” basis, meaning if your infant is prescribed nine cans of formula per month, but you are only able to get to a WIC vendor once during that month and have a limit of three cans, you lose out on those other six cans as the remainder of the benefit does not carry over.
Additionally, retailers have been forced to get some items from unfamiliar vendors to ensure items are in stock, but don’t always ensure the bar/UPC codes are not entered into the WIC system.
A WIC participant in Wayne County shared this happens regularly with produce. While she is aware of what qualifies as “fresh produce” she can scan a barcode using the smartphone WIC application, a different brand may show up as ineligible for WIC, simply because it’s not entered into the system correctly. This causes immense frustration and can throw off an entire shopping trip, and days of carefully planned meals.
While grocery shopping alternatives were popularized during the pandemic to reduce the spread and accommodate social distancing guidelines, amenities like curb-side pickup, grocery delivery and even self-checkout are largely unavailable to WIC participants.
A WIC participant in Perry County shared that using self-check-out is preferable when shopping with benefits because they are less likely to be judged and experience stigma for participating in the program. She shared that she was once told by a cashier at Walmart that they didn’t accept WIC at all, and even though she knew this wasn’t true, she ended up leaving and went to Kroger’s self-check-out instead.
Many interviewees uplifted Kroger as their preferred WIC retailer citing their effort in providing “WIC Eligible” stickers and tags on WIC eligible items. And, as noted above, interviewees also prefer that Kroger allows shoppers to use their WIC cards in the self-check-out lanes.
Many interviewees uplifted Kroger as their preferred WIC retailer citing their effort in providing “WIC Eligible” stickers and tags on WIC eligible items.
WIC Directors likewise noted these obstacles as reasons for declined enrollment. When asked what they attributed to the WIC enrollment declines, they responded:
- “WIC does not provide curbside services. [There are] problems with using their WIC in stores— foods not correctly marked. Misinformation with the WICShopper App and the store on fresh fruits/vegetables.”
- “Struggles using the WIC card (not being able to do curbside pickup, single parent households having to take children inside the store during the pandemic, additional time inside a store having to look for WIC approved food only to have that WIC approved food declined at the register). Availability of store registers being open with a cashier. Some stores started to only have self-check-out open during certain hours of store operations and WIC was unable to be used.”
- “Fear of being out, lack of a benefits card that could be used for curbside pickup or ordering online and increase in SNAP benefits.”
- “1. At first fear of the virus 2. Increased food from other programs that do not require a long visit time and tons of paperwork leading to being in clinic for extended periods of time 3. No ability to load online and no ability to shop online 4. The length of the appointment required to sign up for WIC has increased, not decreased 5. Hard to shop for foods and foods were not on the shelf 6. Cannot schedule clients in our WIC system”
- “Difficulty shopping for WIC items, difficulty with WIC card.”
As we continue to talk with individuals enrolled in WIC, we may learn about additional barriers to accessing and navigating WIC.
As we continue to talk with individuals enrolled in WIC, we may learn about additional barriers to accessing and navigating WIC and raising awareness of these on-the-ground challenges will be a continued aim in this blog series. The users we talk to possess critical firsthand knowledge and lived experience navigating WIC. Their deep understanding and practical expertise with the program are essential to identifying effective strategies and solutions to help remove barriers and strengthen the program. Through thoughtful policy changes and human-centered design, WIC can more effectively serve Ohio families and children.