1    

 

 

Public  Health  Block  Grants  and  Related  Care  Provision  in  Iowa    

Impact  of  the  ACA  and  Health  System  Change  on  the  Iowa  Safety  Net  

Peter  C.  Damiano  

Suzanne  E.  Bentler  

Astha  Singhal  

Peter  Schumacher  

 

The  University  of  Iowa  Public  Policy  Center    

 

Last  Updated  September  27,  2013  

Public Health Block Grants and Related Care Provision in Iowa

Introduction This is a report that inventories all the information we have collected on Public Health Block Grants in Iowa. This information was collected as part of a study funded by The Commonwealth Fund to study the implications of the Affordable Care Act (ACA) on safety net health care providers.

The federal government provides states with several public health-related block grants that can be used for the direct delivery of services and prevention. Under the implementation of the Affordable Care Act (“ACA”, Pub.L. 111-148) health insurance coverage will be significantly expanded, potentially changing the financing of health care, distribution of funds, or both. This report focuses on three particular block grants to Iowa and the services provided from the grants. The largest (total funding amounts) is the Title V Block Grant but also of significance are the Preventive Health and Health Services Block Grant and the Social Security Block Grant.

Block Grant Programs

Title V Title V (42 U.S.C.§700 et seq.) of the Social Security Act authorizes the Maternal Child Health Block Grant (“MCH”), which is administered through the Iowa Department of Public Health’s (“IDPH”) Bureau of Family Health (“BFH”). The MCH allows IDPH to assure access to preventive and primary health care for mothers, infants, children, and children with special health care needs. Title V also facilitates collaboration among public health professionals, human services, and health care providers for assessing Iowa's community and family health status.

By facilitating coordination, the MCH program assists local public health departments, community-based organizations, statewide organizations, and private providers to assure quality health services are provided to mothers, children, and families in Iowa. The MCH focus areas include:

• Ensuring access to quality maternal health and child health preventive health services (including oral health care);

• Coordinating care services to assist families in accessing appropriate medical and dental homes for preventive and specialty care;

• Reducing infant mortality and the incidence of preventable diseases and disabling conditions;

• Increasing the number of immunized children; and • Promoting coordinated care for children and youth with special health care needs and

facilitating the development of community-based systems of service for children and their families.

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Some of the MCH services provided in 2009 included: early entry into prenatal care, maternal depression screening, newborn hearing and metabolic disease screening, family planning, oral health, and blood lead testing.1

Regarding newborn and maternal screening, phenylketonuria, congenital hypothyroidism, galactosemia, and sickle cell disease were all performed annually from 2005 to 2009.2 Additional infant screenings (which were not performed annually between 2005 and 2009) included: biotinidase deficiency; congenital adrenal hyperplasia; cystic fibrosis; fatty oxidation disorders; and organic acidurias.3

Financing Title V Title V is a partnership between Federal, State, and local governments. For every $4 of Federal funds, at least $3 must be matched by State and local funds (that is, at least a 75% match). In Iowa for 2009, Title V federal funding totaled $6.5 million with matching state funds totaling $5.3 million (for a match of 82%).4 The Title V expenditures in 2010 totaled $6.0 million in federal funds and $5.1 million in state fund.5

For the 2011 fiscal year, the Iowa legislature (Iowa Senate File 508) appropriated $6.5 million from Title V to maternal and child health services. From these Title V appropriations, $300,291 was appropriated to the perinatal care program and approximately $804,504 is appropriated to the University of Iowa for mobile and regional child health specialty clinics. Iowa Senate File 508 was signed by the Governor, after an un-related item veto, on 18 July 2011.

In addition to direct funding from Title V, the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau awards discretionary grants. Total federal funds for discretionary grants in Iowa in 2005 were approximately $5.5 million decreasing 55 percent to approximately $2.5 million in 2010.6 Total state matching funds for discretionary grants in Iowa for 2005 were approximately $5 million decreasing 95 percent to $251,753 in 2010.7

For the 2009 fiscal year, the largest source of funds provided to the Title V program came from the state match ($7.1 million) followed by the federal allocation ($5.8 million), other funds ($4.4 million) and program income ($1.1 million) (Figure 1).

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Figure 1. Title V Expenditure in Iowa by source, Fiscal Year 2009

Source: HRSA, Maternal and Child Health Bureau, 2012.

Presenting a slightly different picture for Title V programs in Iowa, the largest proportion of funds in the 2011 fiscal year budget is from the federal MCH allocation ($6.5 million), followed by state matching funds ($5.4 million) and other non-MCH funds ($4.5 million) (Figure 2).

Figure2. Title V Budget in Iowa by source, Fiscal Year 2011

Source: Iowa Department of Public Health, Title V 2010 Annual Report 2012 Application

For Title V program expenditures in the 2009 fiscal year, the greatest proportion of dollars were spent on infrastructure (33%, $6 million), followed by direct health services (28%, $5 million), enabling services (23%, $4 million) and population based services (16%, $3 million)(Figure 3).

$5,829,198 , 32%

$7,094,149 , 38%

$4,449,314 , 24%

$1,079,449 , 6%

Federal Allocation

Total State Funds (Matchand Overmatch)

Other Funds

Program Income

Title V Block Grant Expenditure FY 2009 By Source of Funds

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Figure 3. Title V Expenditure in Iowa by category of service, Fiscal Year 2009

Source: Iowa Department of Public Health, Title V 2009 Annual Report 2011 Application

Similar to 2009 expenditures, a large proportion of Iowa’s 2011 Title V funds (39%) were allocated for infrastructure, followed by direct health services (26%), enabling services (23%) and finally population-based services (12%) (Figure 4).

Figure 4. Title V Budget in Iowa by source, Fiscal Year 2011

Source: Iowa Department of Public Health, Title V 2010 Annual Report 2012 Application

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Other MCH-related funds

Other MCH-related Federal programs overseen by Title V administrator include: Social Security Disability Insurance (“SSDI”); Special Projects of Regional and National Significance (“SPRANS”); Community Integrated Service Systems (“CISS”); abstinence education; Healthy Start; Emergency Medical Care for Children (“EMCS”); AIDS; Supplemental Nutrition Program for Women, Infants and Children (“WIC”); Centers for Disease Control and Prevention (“CDC”) programs; and education programs.8 SPRANS, CISS, abstinence education, Healthy Start, abstinence education, EMCS, WIC, and AIDS did not receive any funding from other federal MCH-related funds in the 2011 fiscal year.9

Table 1. MCH-related funds in Iowa under control of Title V administrator, Fiscal Year 2011

SSDI CDC Education Total $100,000 $180,042 $157,317 $437,359

Source: IDPH, Annual Report, 2012.

Regarding HRSA Maternal and Child Health Bureau’s discretionary grants, between 2005 and 2010, thirteen programs in Iowa received at least one discretionary grant.10 The programs receiving discretionary grants included (years receiving the grant): the Iowa LEND project (2005-2010); EMSC Partnership grants (2006-2010); and MCH data enhancement (2005, 2007-2010).11

Title V Provider Network Title V funds are provided to many different health care providers; the main providers include maternal and child health centers in addition to local public health departments (“LPHD”).

Maternal Health Centers The Maternal Health Services's maternal health clinics provide prenatal and postpartum care to Medicaid-eligible and low-income women. Within Iowa, 24 maternal health centers (divided into 21 regions) provide services to Iowans (Figure 5). Through this division, all 99 Iowa counties have access to publicly funded maternal health services. The Iowa Department of Public Health, Bureau of Family Health (“BFH”) provides technical assistance and monitors performance standards for maternal health centers.

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Figure 5. Maternal Health Regions in Iowa

Source: Iowa Department of Public Health

Maternal health clinics utilize several modes of service delivery including: traditional clinic settings; purchase of medical service models with active public health nursing participation; in addition to two clinics providing direct ambulatory obstetric medical care for pregnant women (Woodbury and Scott counties).

Services provided at maternal health clinics include: medical and dental assessment; health and nutrition education; psychosocial screening and referral; care coordination; assistance with plans for delivery; and postpartum home visiting. Title V funds a contract between the BFH and the University of Iowa, Department of Obstetrics and Gynecology for consultation.

The maternal health centers may authorize payment for antepartum and postpartum care and for a normal or cesarean section delivery for pregnant women who are Iowa residents living in most counties (except Clinton, Cedar, Scott, Muscatine, Louisa, Washington, Iowa, Johnson, or Keokuk), whose family income is less than 185 percent of poverty, and who are not eligible for Title XIX. Maternal health staff determine eligibility for the OB Indigent Care Program, which has limited funds and is only available until funds have been expended.

Four of the eight priority needs identified by Iowa’s Department of Public Health relate to service providers including: lack of coordinated systems of care for preconception and interconception care for high-risk and low-income women; barriers to access to health care, mental health care, and dental care for low-income pregnant women; lack of access to preventive and restorative dental care for low-income pregnant women; lack of providers to do restorative dental treatment for children age 5 years and younger.12

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Child Health Centers

The Title V Child Health program funds 24 child health centers and 13 child health specialty clinics in Iowa. Children and youth ages 0 to 22 years can receive services in all 99 counties (Figure 6).13

Figure 6. Child Health Regions in Iowa

Source: Iowa Department of Public Health, 2012.

The child health program provides care coordination services to families aiding access to the following regular and periodic screening services for children:

• History; • physical examinations; • vision and hearing screening; • dental screening, sealants, and education; • anticipatory guidance; • immunizations; • psychosocial screening; • developmental screening; • nutrition counseling and assessment; and • laboratory tests including blood lead testing.14

The Child Health Specialty Clinics (“CHSC”) provides care for children with special health needs. CHSC clinical services are available to children and youths up to 21 years old.15 The CHSC system comprises: 1) direct clinical services to children and youth when services are not already available in the community; 2) care coordination; 3) family support; and 4) infrastructure building to improve the health care system.16 CHSC are located in 13 regional centers located throughout Iowa including four centers that are primarily dedicated to improving children’s mental health services.17

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Various health care providers staff regional CHSC including: Advanced registered nurse practitioners, nurse clinicians, medical assistants, registered dietitians, and family navigators.18 Regional CHSC provide developmental screening, assessment, and follow-up to children who are vulnerable to developmental delay.19 CHSC prioritizes developing infrastructure for family to family support, early hearing detection, and premature infants.20 Additionally, CHSC is concerned with developing infrastructure to address health outcomes related to cultural diversity and health literacy.21

Local Public Health Departments A Local Public Health Department (“LPHD”) is a unit of either local or state government; a LPHD has some responsibility for the health of a jurisdiction smaller than the state.22 Iowa has 101 LPHDs, which are controlled by either a county or city government.23

The total expenditures for all LPHDs during the 2010 fiscal year were $84.4 million and the total revenue was $69.2 million.24 The funding comes from a wide variety of different sources; the largest proportion of funds (25%) is from either city or county sources (Table 2). This proportion is almost equivalent to the source of revenue for all LPHDs nationally, which was 26 percent from either city or county sources.25

Table 2. Sources of Revenue for Local Public Health Departments in Iowa

Source of Revenue Dollars Percent Local $18,204,106 25.3%

State $10,214,973 14.2% Federal $9,486,439 13.2% Public Health Emergency Response (PHER) funds

$5,677,953 7.9%

American Reinvestment and Recovery Act (ARRA)

$752,614 1.0%

Medicaid $8,523,479 11.8% Medicare $7,093,328 9.8% Private health insurance $1,499,774 2.1% Other $10,617,120 14.7% TOTAL $72,069,786 100%

Source: Personal communication to authors.

Although every Iowa county offers local public health services, the Iowa Department of Public Health (through the Bureau of Local Public Health Services) advises and supports county public health services based on six regional divisions (Figure 7).26

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Figure 7. Regional Division for Local Public Health Services

Source: Iowa Department of Public Health, 2012.

Various health care providers provide services to Iowa LPHDs. Among responding Iowa LPHDs, public health nurses represented the largest proportion (by Full Time Equivalents- FTEs) of health care providers providing services at Iowa LPHDs (Table 3).27

Table 3. Health Care Providers at Local Public Health Departments in Iowa

Total for all LPHDs PH Manager

(FTEs) PH Nurse PH Physician Health Educator (n=60-67) 104.3 306.2 1.75 23.27

Source: Personal communication to authors.

The services provided by Iowa LPHDs also vary substantially. Child immunizations were provided by most Iowa LPHDs compared to behavioral health, which was provided by very few Iowa LPHDs (Table 4). Few LPHDs provide services directly, while many other LPHDs contract out services.

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Table 4. Direct Services Provided by Local Public Health Departments in Iowa

Number of LPHDs providing direct services IMMUNIZATIONS Adult Immunizations 66

Child Immunizations 74 SCREENING HIV 12

STD 13 TB 54 Cancer 9 CVD 19 Diabetes 27 High BP 62 Blood Lead 42

TREATMENT HIV 4 STDs 12 TB 54

MCH Services Family Planning 12 Prenatal Care 22 Obstetric Care 4 WIC 11 Home Visits 39 EPSDT 25 Well Child 12

Other Health Services

Comprehensive Primary Care

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Home Health Care 56 Oral Health 21 Behavioral Health 4 Substance Abuse 6

Source: Personal communication to authors

Population Served In 2010, Iowa programs funded by Title V grants served: 9,482 pregnant women; 37,838 infants younger than 1 year (not including special needs); 136,100 children between 1 and 22 years old; and 4,734 children with special health needs (Figure 8).28

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Figure 8. Populations served by Title V grantees in Iowa

The percentage of all Iowa deliveries served by Title V was 24 percent29; however, the percentage of all Iowa infants served by Title V in 2010 was 94 percent (Figure 9).30

Figure 9. Deliveries and infants served by Iowa Title V grantees

Source: HRSA, Maternal and Child Health Bureau, 2011.

In 2010 most deliveries served by Title V in Iowa were to whites representing 82 percent of the total deliveries served by Title V (Figure 10). The second largest racial group with deliveries served by Title V in 2010 were Blacks (Figure 10).

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Figure 10. Racial Distribution for Total Deliveries

Source: HRSA, Maternal and Child Health Bureau, 2012.

Similar to total deliveries served by Title V in Iowa, the largest percentage of infants served by Title V in Iowa during 2010 was to whites (Figure 11). The second most common, known, racial group belonged to Blacks, similar to total deliveries served by Title V (Figure 11).

Figure 11. Racial Distribution for Local Public Health Services

Source: HRSA, Maternal and Child Health Bureau, 2012.

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Preventive Health and Health Services Block Grant

Financing The second major federal funding source for local Public Health Departments comes from the CDC’s Preventive Health and Health Services Block Grant (42 U.S.C. §§300w-300w-10). The most recent report from the National Association of Chronic Disease Directors indicated that Iowa had $1,002,272 in total PHHS funding in 2010. Within the PHHS Block Grant, education and community-based services received $379,071, unintentional injury/emergency medical services program received $371,720, sexual violence protection received $68,220 and fluoridation and HIV prevention programs received $52,558 and $48,751, respectively.31

For the 2011 fiscal year, the Iowa legislature appropriated $1,102,464 for the Preventive Health and Health Services block grant.32 Iowa Senate File 508 specified the use of PHHS grant funding for, in part: nutrition programs, emergency medical services, monitoring of water fluoridation and HIV services.33

Social Security Block Grant

Financing The third major federal funding source for local public health services is the Social Security Block Grant (42 U.S.C. §1397 et seq.), which funds maternal and child health services, adult protective services and home-based services. Total funds allocated from the Social Security Block Grant (“SSBG”) for 2007 equaled $15,075,460; total funds transferred to the SSBG in 2007 equaled $11,734,639.34 In comparison, total funds allocated from the SSBG for 2010 equaled $15,681,905, which is a four percent increase from 2007; total funds transferred to the SSBG in 2010 equaled $11,055,490 which is a six percent decrease from 2007.35

Patients and Utilization In 2007 SSBG funds allowed services for: 73,490 children; 5,971 adults younger than 60; 2,681 adults older than 60; and 3,999 adults of unknown age.36 In comparison, SSBG funding in 2010 allowed services for: 62,368 children (15 percent decrease from 2007); 4,554 adults younger than 60 (24 percent decrease from 2007); 2,160 adults older than 60 (19 percent decrease); and 4,654 adults of unknown age (16 percent increase from 2007).37 Regarding SSBG funded services, adult protective services experienced the largest decline in recipients with a 87 percent decrease from 2007 to 2010 (1,670 and 225, respectively); and home-based services experienced the largest recipient growth with a 351 percent increase from 2007 to 2010 (3,428 and 15,447, respectively).38

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Additional Data Resources Organization Web site Health Resources and Services Administration, Maternal and Child Health Bureau

http://mchb.hrsa.gov/

Iowa Department of Public Health, Bureau of Family Health

http://www.idph.state.ia.us/hpcdp/family_health.asp

National Association of City and County Health Officials

http://naccho.org/

The University of Iowa Public Policy Center, Iowa Child and Family Household Health Survey

http://ppc.uiowa.edu/pages.php?id=31

References

1HRSA, Maternal and Child Health Bureau, Funding and Expenditure Profile; available online at: https://perfdata.hrsa.gov/mchb/TVISReports/FinancialData/FinancialSearch.aspx?FinSearch=K [accessed 6 October 2011]. 2HRSA, Maternal and Child Health Bureau, available at: https://perfdata.hrsa.gov/mchb/TVISReports/ProgramData/StandardScreening.aspx [accessed 6 October 2011]. 3HRSA, Maternal and Child Health Bureau, available at: https://perfdata.hrsa.gov/mchb/TVISReports/ProgramData/StandardScreening.aspx [accessed 6 October 2011]. 4HRSA, Maternal and Child Health Bureau, Funding and Expenditure Profile; available online at: https://perfdata.hrsa.gov/mchb/TVISReports/FinancialData/FinancialSearch.aspx?FinSearch=K [accessed 6 October 2011]. 5 HRSA, Title V Information System, available at: https://perfdata.hrsa.gov/mchb/TVISReports/FinancialData/FinancialSearch.aspx?FinSearch=F [accessed 27 February 2012]. 6HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 6 October 2011]. 7 HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 6 October 2011]. 8 HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 29 March 2012]. 9 HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 29 March 2012]. 10HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 10 October 2011]. 11HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 10 October 2011]. 12 HRSA, Maternal and Child Health Bureau, available at: https://perfdata.hrsa.gov/mchb/TVISReports/ProgramData/PriorityNeedSearch1.aspx [accessed 2 April 2012]. 13 HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 6 October 2011]; Iowa Department of Public Health, available at: http://www.idph.state.ia.us/webmap/default.asp?map=epsdt [accessed 5 January 2012]. 14 Iowa Department of Public Health, Bureau of Family Health, available at: http://www.idph.state.ia.us/hpcdp/child_health_centers.asp [accessed 2 April 2012]. 15 Iowa Department of Public Health, Maternal and Child Health Services Title V Block Grant, State Narrative for Iowa, Application for 2012, Annual report for 2010, available at: http://www.idph.state.ia.us/hpcdp/common/pdf/family_health/2012_state_narrative.pdf [accessed 9 April 2012].

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16 HRSA, Maternal and Child Health Bureau, Discretionary Grant Information System, available at: https://perfdata.hrsa.gov/MCHB/DGISReports/Default.aspx [accessed 6 October 2011] 17 Iowa Department of Public Health, Maternal and Child Health Services Title V Block Grant, State Narrative for Iowa, Application for 2012, Annual report for 2010, available at: http://www.idph.state.ia.us/hpcdp/common/pdf/family_health/2012_state_narrative.pdf [accessed 9 April 2012]. 18 Iowa Department of Public Health, Maternal and Child Health Services Title V Block Grant, State Narrative for Iowa, Application for 2012, Annual report for 2010, available at: http://www.idph.state.ia.us/hpcdp/common/pdf/family_health/2012_state_narrative.pdf [accessed 9 April 2012]. 19 Iowa Department of Public Health, Maternal and Child Health Services Title V Block Grant, State Narrative for Iowa, Application for 2012, Annual report for 2010, available at: http://www.idph.state.ia.us/hpcdp/common/pdf/family_health/2012_state_narrative.pdf [accessed 9 April 2012]. 20 Iowa Department of Public Health, Maternal and Child Health Services Title V Block Grant, State Narrative for Iowa, Application for 2012, Annual report for 2010, available at: http://www.idph.state.ia.us/hpcdp/common/pdf/family_health/2012_state_narrative.pdf [accessed 9 April 2012]. 21 Iowa Department of Public Health, Maternal and Child Health Services Title V Block Grant, State Narrative for Iowa, Application for 2012, Annual report for 2010, available at: http://www.idph.state.ia.us/hpcdp/common/pdf/family_health/2012_state_narrative.pdf [accessed 9 April 2012]. 22 NACCHO 2010 National Profile of Local Health Departments. Available at: http://www.naccho.org/topics/infrastructure/profile/resources/2010report/loader.cfm?csModule=security/getfile&PageID=209794 [accessed 30 October 2011]. 23 NACCHO 2010 National Profile of Local Health Departments. Available at: http://www.naccho.org/topics/infrastructure/profile/resources/2010report/loader.cfm?csModule=security/getfile&PageID=209794 [accessed 30 October 2011]. 24 LPHD Profiles. Excel database and codebook obtained from Tanya Uden-Holman and Graham Dameron 25 NACCHO 2010 National Profile of Local Health Departments. Available at: http://www.naccho.org/topics/infrastructure/profile/resources/2010report/loader.cfm?csModule=security/getfile&PageID=209794 [accessed 30 October 2011]. 26 Iowa Department of Public Health, available at: http://www.idph.state.ia.us/hpcdp/common/pdf/local_public_health_services/Region_Map.pdf [accessed 5 January 2012]. 27 NACCHO 2010 National Profile of Local Health Departments. Available at: http://www.naccho.org/topics/infrastructure/profile/resources/2010report/loader.cfm?csModule=security/getfile&PageID=209794 [accessed 30 October 2011]. 28HRSA, Maternal and Child Health Bureau, Title V Information System, state reports. Available at: https://perf-data.hrsa.gov/mchb/TVISReports/Snapshot/snapshot.aspx?statecode=IA [accessed 12 April 2012]. 29HRSA, Maternal and Child Health Bureau, Title V Information System, program data. Available at: https://perf-data.hrsa.gov/mchb/TVISReports/ProgramData/DeliveriesServed.aspx [Accessed 12 April 2012]. 30HRSA, Maternal and Child Health Bureau, Title V Information System, program data. Available at: https://perf-data.hrsa.gov/mchb/TVISReports/ProgramData/InfantsServed.aspx [Accessed 12 April 2012]. 31National Association of Chronic Disease Directors, available at: http://www.chronicdisease.org/policy/policy-statements/preventative-health-and-health-services-block-grant-sate-reports-1/iowa/view [accessed 6 October 2011]. 32Senate File 508, Division 1, Section 4(1). 33Senate File 508, Division 1, Section 4(4) 34Social Security Block Grant Program, Annual Report for 2007. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011]; Social Security Block Grant Program, Annual Report for 2010. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011].

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35Social Security Block Grant Program, Annual Report for 2007. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011]; Social Security Block Grant Program, Annual Report for 2010. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011]. 36Social Security Block Grant Program, Annual Report for 2007. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011] 37Social Security Block Grant Program, Annual Report for 2010. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011]. 38 Social Security Block Grant Program, Annual Report for 2007. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011]; Social Security Block Grant Program, Annual Report for 2010. U.S. Department of Health and Human Services, Administration of Children & Families, available at : http://www.acf.hhs.gov/programs/ocs/ssbg/ http://www.acf.hhs.gov/programs/ocs/ssbg/ [accessed 10 October 2011].

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