How Administrative Burdens Can Harm Health

A man fills in a form at the reception area of a Department of Children and Family Serices office.

Health-promoting social welfare programs, such as unemployment insurance, food stamps, and Medicaid, are critical in a major recession. However, administrative burdens that block access to these benefits and create stress may undermine health.


What’s the Issue?

The COVID-19 pandemic and its related economic downturn—including massive unemployment, income loss, and terminated employer health insurance—have caused negative effects beyond the virus for many people. Especially during an economic crisis, existing social welfare supports help offset the large downstream health costs of economic insecurity. Income supplements—such as those noted above, plus others like the Earned Income Tax Credit and health insurance via Medicaid—have been shown to improve the health of infants, children, mothers, the working poor, and others.

The pandemic has exposed the pre-existing bureaucratic barriers to accessing our largest supportive programs. For example, in the wake of COVID-19, the nearly 50 million Americans who sought unemployment benefits encountered crashing websites, overloaded telephone lines, and confusing forms. Furthermore, the coronavirus-induced surge in demand for the Supplemental Nutrition Assistance Program has revealed long-standing access challenges—such as lengthy applications; in-person interviews; the need to recertify—which all undermine its ability to address increased food insecurity.

A health policy brief from Health Affairs with support from the Robert Wood Johnson Foundation examines the onerous administrative dysfunction of some safety-net programs, which can negatively affect a person’s health. The brief documents the role of social welfare programs in protecting health; defines and conceptualizes administrative burdens; and details how these barriers limit access to health-protective social welfare supports.

Administrative burdens cause challenges for those who most need services—including the tedious effort needed to learn about programs; understanding how to apply; compliance and retention of benefits; the degree of anxiety; loss of autonomy; and sense of stigma that can arise from interacting with programs.

What’s Next?

We know relatively little about the downstream health implications of negative encounters with bureaucracies, many of which are patterned by race. Psychological costs from stigma and discriminatory or belittling treatment may have long-term health consequences. Given evidence directly linking the experience of racial discrimination to poor health, it seems plausible that people who experience patterns of discrimination and negative bureaucratic encounters might also have worse downstream health.

The coronavirus-induced economic turmoil highlighted how hard it can be to access our largest social welfare programs. In just one example cited in the brief, even before the pandemic, only three out of four of those eligible for unemployment benefits actually received them, with significant documented race disparities already established.

The authors conclude if the way in which a program is administered limits access to health-promoting policies, it undermines health. The administrative state may be just as important a determinant of health as the policies themselves. Documenting the health effects of burdens is a compelling research opportunity that population health researchers are uniquely suited to address. Given the cumulative stress and psychological costs that people experience in attempting to navigate social support systems, public officials should look to minimize burdens.