oversight

Food Assistance: A Variety of Practices May Lower the Costs of WIC

Published by the Government Accountability Office on 1997-09-17.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                  United States General Accounting Office

GAO               Report to the Chairman, Committee on
                  the Budget, House of Representatives



September 1997
                  FOOD ASSISTANCE
                  A Variety of Practices
                  May Lower the Costs
                  of WIC




GAO/RCED-97-225
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Resources, Community, and
      Economic Development Division

      B-277615

      September 17, 1997

      The Honorable John R. Kasich
      Chairman, Committee on the Budget
      House of Representatives

      Dear Mr. Chairman:

      The Special Supplemental Nutrition Program for Women, Infants and
      Children (WIC) is a federally funded nutrition assistance program
      administered by the U.S. Department of Agriculture’s Food and Consumer
      Service (FCS). This program provides lower-income pregnant and
      postpartum women, infants, and children up to age 5 with supplemental
      foods, nutrition counseling, and access to health care services. The food
      benefits are typically provided in the form of a voucher that can be used to
      obtain approved foods at authorized retail outlets (food stores and
      pharmacies), commonly referred to as vendors. Food costs accounted for
      about $2.7 billion, or about 74 percent, of the WIC program’s total costs in
      fiscal year 1996. In administering WIC, the states1 are allowed some
      flexibility in the policies and procedures they use. Since WIC is a
      discretionary program that serves as many individuals as the available
      funding permits, any actions the states can take to reduce the program’s
      costs will allow them to serve more eligible people.

      This report is the second in a series of reports responding to your
      December 20, 1996, request for information on certain aspects of WIC.2 In
      this report, we (1) describe and assess the practices that the states use to
      contain costs by controlling the foods approved for use in the WIC program
      and by more closely selecting and regulating participating vendors and
      (2) examine practices that the states use to ensure that WIC applicants’
      incomes meet the program’s eligibility requirements. As a part of our
      review, we surveyed the WIC directors in the 50 states and the District of
      Columbia and analyzed the information provided by the 48 who
      responded.3




      1
       As treated in the FCS regulations, “states” includes the District of Columbia.
      2
       Our first report was entitled WIC: States Had a Variety of Reasons for Not Spending Program Funds
      (GAO/RCED-97-166, June 12, 1997).
      3
       We did not receive responses to our questionnaire from the state WIC directors in Minnesota, Oregon,
      and South Dakota. Also, we did not include the 33 Indian tribal organizations and the U.S. territories in
      our survey because of regulatory and program differences.



      Page 1                                                           GAO/RCED-97-225 Food Assistance
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                   The states are using a variety of cost containment initiatives to control the
Results in Brief   WIC program’s costs. For example, 10 states have contracted with
                   manufacturers to obtain rebates on WIC foods in addition to infant formula,
                   and some states have placed greater limits on WIC participants’ food
                   choices than other states. Separately, or in conjunction with efforts to
                   contain food costs, 39 states use various practices to restrict the number
                   of vendors and/or ensure that the prices vendors charge for WIC food items
                   are competitive. These and other practices to contain food costs have
                   saved millions of dollars annually and enabled more individuals to enroll
                   in the program, according to WIC directors. While the use of cost
                   containment practices could be expanded, certain obstacles, including the
                   states’ concern with how the program allocates the additional funds made
                   available through cost containment initiatives, may discourage the states
                   from adopting or expanding their use.

                   Federal regulations provide that WIC program applicants who participate in
                   the Food Stamp Program, Medicaid, and the Temporary Assistance for
                   Needy Families Program automatically meet the income eligibility
                   requirements of the WIC program. The states use a variety of procedures to
                   certify the income eligibility of the applicants who do not participate in
                   these programs. Thirty-two of the 48 state WIC directors responding to our
                   questionnaire reported that their states generally require these applicants
                   to provide documents, such as pay stubs and letters, to verify their
                   income. Of the remaining 16 WIC directors, 14 reported that their states do
                   not require documentation. These states allow applicants to declare their
                   income without providing supporting documentation. The other two
                   directors reported that income documentation procedures are determined
                   individually by the local WIC agencies.


                   Established in 1972, WIC is designed to improve the health and nutritional
Background         well-being of participants by providing nutritious supplemental foods,
                   nutrition education, and referrals to health care services. The program is
                   available in each state, the District of Columbia, 33 Indian tribal
                   organizations, Puerto Rico, the U.S. Virgin Islands, American Samoa, and
                   Guam. FCS administers the program in cooperation with state and local
                   health departments and related agencies.

                   The supplemental foods that WIC provides include milk, cheese, fruit and
                   vegetable juices, iron-fortified adult and infant cereals, dried beans or
                   peas, peanut butter, eggs, and infant formula. Special infant formulas are
                   also available to meet unusual dietary or health-related conditions. Each



                   Page 2                                         GAO/RCED-97-225 Food Assistance
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state designates the types and amounts of foods that local WIC agencies
can prescribe to meet each participant’s nutritional needs. The WIC food
benefit (referred to as a food package) can be provided through local WIC
health clinics or home delivery. More commonly, participants receive their
food benefits in the form of a check or a voucher that is used to purchase
the specific foods at authorized retail vendors. These vendors have been
selected by the state to participate in the program for a period of time.

FCS requires the states to operate a rebate program for infant formula. By
negotiating rebates with infant formula manufacturers for each can of
formula purchased through WIC, the states greatly reduce their average per
person food costs so that more people can be served. In fiscal year 1996,
infant formula rebates to all states totaled about $1.2 billion.

Federal WIC appropriations totaled $3.47 billion in fiscal year 1995 and
$3.73 billion annually in fiscal years 1996 and 1997. The program is
primarily funded by federal appropriations; some states supplement the
federal grant with their own funds. In fiscal years 1995 and 1996, the
average monthly WIC participation nationwide was about 6.9 million and
7.2 million, respectively, and in fiscal year 1997, the average monthly
participation was about 7.4 million through February 1997.

Grants to the states are divided into food grants and nutrition services and
administration grants. Food grants cover the costs of supplemental foods
and are allocated to the states through a formula that is based on the
number of individuals in each state who are eligible for WIC benefits
because of their income. The nutrition services and administration grants
are allocated to the states through a formula that is based on factors such
as the state’s number of projected program participants and WIC salary
costs. Nutrition services and administration grants cover costs for
program administration, start-up, monitoring, auditing, the development of
and accountability for food delivery systems, nutrition education,
breast-feeding promotion and support, outreach, certification, and
developing and printing food vouchers.

State WIC agencies establish program eligibility criteria that are based on
federal guidelines. To qualify for the program, WIC applicants must show
evidence of nutritional risk that is medically verified by a health
professional. In addition, participants may not have incomes that exceed
185 percent of the poverty guidelines that are established annually by the




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                          U.S. Department of Health and Human Services.4 In 1997, for example, the
                          annual WIC income limit for a family of four is $29,693 in the 48 contiguous
                          states and the District of Columbia.5 Federal regulations allow the states to
                          individually determine their income documentation requirements for
                          applicants seeking to participate in WIC. The states are also required by
                          federal regulations to automatically certify as income eligible those
                          individuals who document their participation in the Food Stamp Program,
                          Medicaid, and the Temporary Assistance for Needy Families Program.
                          Approximately two-thirds of all WIC participants were enrolled in one or
                          more of these programs in fiscal year 1994, the last year for which
                          complete data were available at the time of our review. In addition, WIC
                          participants are required by federal regulations to reside in the jurisdiction
                          of the state where they receive benefits, and the states are required to
                          check the identification of all participants when they seek certification for
                          program participation and when they receive their vouchers. Although the
                          applicants who meet the program’s health and nutrition, income, and
                          residency requirements may be certified as eligible to participate in WIC,
                          the number of participants that are actually served each year primarily
                          depends on the total amount of funds available to the states. According to
                          FCS’ estimates, about 75 percent of the eligible women, infants, and
                          children actually participated in WIC during fiscal year 1995.


                          States’ initiatives to control food costs by limiting the types and package
Efforts to Control        sizes of WIC foods and by more carefully selecting and regulating vendors
Food Costs and            have reduced the program’s costs by millions of dollars. These practices
Manage Vendors Have       could be expanded in the states that have already implemented them and
                          could be adopted by other states. However, the National Association of WIC
Reduced Costs, but        Directors6 and some WIC directors we spoke with are concerned that,
the Program’s             among other things, the program’s regulations can constrain a state’s
                          ability to effectively use the additional funds that become available as a
Structure May             result of cost containment initiatives.
Discourage Wider Use
States’ Efforts to Hold   Two practices that some states are using to contain food costs are
Down Food Costs Have      reported by state WIC directors to be saving millions of dollars. These two
Been Successful           practices include (1) contracting with manufacturers to obtain rebates on

                          4
                          In fiscal year 1996, only one state set WIC income eligibility below 185 percent of poverty: South
                          Dakota used 175 percent of poverty.
                          5
                           Poverty guidelines are established separately for Alaska and Hawaii.
                          6
                           The National Association of WIC Directors, located in Washington, D.C., is a voluntary membership
                          organization of state and local WIC directors, WIC nutrition coordinators, and members of corporate
                          organizations that provide leadership to the WIC community.


                          Page 4                                                          GAO/RCED-97-225 Food Assistance
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                                        WIC foods in addition to infant formula and (2) limiting authorized food
                                        selections by, for example, requiring participants to select brands of foods
                                        that have the lowest cost.

Use of Competitively Bid                In fiscal year 1996, nine state agencies received rebates for two
Rebate Contracts                        WIC-approved foods—infant cereal and/or infant fruit juices. Table 1 shows
                                        the states that were receiving rebates during fiscal year 1996 from the
                                        expanded use of rebates through individual or multistate contracts.

Table 1: State WIC Agencies Receiving
Infant Cereal and/or Infant Juice                                                                                   Total
Rebates Through Individual or                                                                                    rebates        Food
Multistate Contracts During Fiscal                                                            Rebates for     (including expenditures
Year 1996                               State                  Infant               Infant   infant cereal         infant     (minus
                                        agency                 cereal               juice     and/or juice      formula)     rebates)
                                        California             Xa                             $2,144,741 $184,928,836 $437,729,886
                                        Connecticut            X                                  149,791      8,213,539    25,272,861
                                        District of            Xa                   Xb             32,757      3,511,162     6,574,543
                                        Columbia
                                        Indiana                X                                  276,369     22,318,364    46,232,572
                                                                a                    b
                                        Maryland               X                    X             236,793     16,769,477    34,033,689
                                        Nevada                 Xa                                  76,116      6,375,653    11,361,869
                                        New York               X                                2,398,888     88,507,822   200,143,479
                                        Texas                  X                                  733,483    122,908,887   194,499,363
                                                                a                    b
                                        West Virginia          X                    X             154,714      7,501,982    19,816,154
                                        Total                                                 $6,203,652 $461,035,722 $987,026,285
                                        a
                                        Multistate contract for infant cereal.
                                        b
                                            Multistate contract for infant juice.



                                        The cost savings resulting from these infant cereal and juice rebates are
                                        relatively small in comparison with the savings resulting from infant
                                        formula rebates. As shown by the figures in table 1, the rebates for infant
                                        cereal and juices represented about 1 percent of the total rebates received
                                        in these nine states in fiscal year 1996. The $6.2 million in infant cereal and
                                        juice rebates reduced total food costs in these states by about six-tenths of
                                        a percent in fiscal year 1996.

                                        Eleven states—Alaska, California, Delaware, the District of Columbia,
                                        Hawaii, Missouri, New Jersey, New York, Oklahoma, Rhode Island, and
                                        West Virginia—reported that their agencies were considering, or were in
                                        the process of, expanding their use of rebates to foods other than infant




                                        Page 5                                                       GAO/RCED-97-225 Food Assistance
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formula. In May 1997, Delaware joined the District of Columbia, Maryland,
and West Virginia in a multistate rebate contract for infant cereal and
juices. California was the first state to expand its rebate program to
include adult juices, adding this option in March 1997. California currently
spends about $65 million annually on adult juice purchases. California’s
WIC director told us that the state expects to collect about $12 million in
annual rebates on the adult juices, thereby allowing approximately 30,000
additional persons to participate in the program each month.

According to FCS officials, there is the potential to reduce WIC costs further
through the expanded use of rebates. They said that FCS has encouraged
the states to examine and aggressively pursue rebates to stretch food
dollars to serve a maximum number of eligible participants. In May 1997,
FCS sent its regional directors a memorandum outlining a strategy to
“manage, contain, and control” food costs using rebates on products such
as special infant formula and other WIC foods in addition to infant formula.
The officials told us that if federal funding for WIC remains constant or
declines, more states may consider expanding the use of rebate contracts
to provide funds for their WIC programs. FCS officials also told us that some
states’ WIC agencies may not be expanding the use of rebates because
other cost containment practices have proven effective in reducing food
costs. For example, the states that have elected to use only store brand
foods may be incurring lower costs than the states that receive rebates on
national brand products.

While these rebates reduce costs, the procurement process requires
additional administrative effort by the states. The California WIC director
and FCS officials told us that the process of entering into and monitoring
rebate contracts can be complicated and time-consuming. In addition, FCS
officials told us that bid protests filed by the manufacturers that are not
awarded contracts impose additional administrative burdens on the states.
The administrative burden associated with procuring and monitoring
rebate contracts can be exacerbated if a state contracts with more than
one manufacturer for rebates. For example, when California expanded its
rebate program to include adult juices, the state requested bids on rebate
contracts from juice companies for frozen and ready-to-drink apple, grape,
orange, and pineapple juices that were available in all parts of the state
and had to negotiate five separate contracts.

The states also need to use additional resources to manage the rebate
contracts. FCS officials told us that disagreements between the states and
manufacturers occur over the rebate billings that the manufacturers are



Page 6                                          GAO/RCED-97-225 Food Assistance
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                           obligated to pay the states. They said that the states must therefore
                           develop billing systems that track the amount of the manufacturers’
                           products selected by WIC clients using their vouchers. For example, the
                           California WIC director told us that before the state implemented its adult
                           juice rebate contracts, the state agency had to develop a system for
                           determining the amount and quantity of each type of juice selected by WIC
                           participants and a system for rebate billing that was acceptable to the juice
                           manufacturers.

                           FCS officials told us that the states could become increasingly dependent
                           on the funds provided by their rebate contracts. Historically, the annual
                           funds received by the states from their infant formula rebate contracts
                           have continued to increase, but this source of funding may not always be
                           reliable. If manufacturers begin offering lower rebates, the states could
                           have insufficient funds to provide program benefits to their current level
                           of WIC participants.7 According to FCS officials, such a decrease in rebate
                           funds would be similar to an increase in food prices because of inflation,
                           something which the program has experienced before. In such instances,
                           the states would need to make adjustments to the foods they offer to
                           contain the escalating costs and/or remove people from the program.

Limits on Food Selection   According to FCS officials, the prices of the food items provided by WIC can
                           vary dramatically, depending, for example, on the brand of the item or
                           how it is packaged. Individually wrapped sliced cheese can cost
                           substantially more than the same cheese in block form, and a national
                           brand of juice could cost substantially more than a vendor’s own brand.
                           All state WIC directors responding to our survey reported that their
                           agencies imposed limits on one or more of the WIC food items. The states
                           may specify certain brands; limit certain types of foods, such as sliced
                           cheese; restrict container sizes; and require the selection of only the
                           lowest-cost brands. Figure 1 shows the number of WIC directors who
                           reported that their states use various types of limits for one or more food
                           items.




                           7
                            Federal regulations permit the states to use up to 3 percent of their current year’s food funds to pay
                           their prior year’s food costs. This option is available to any state that experiences a reduction in its
                           rebates, according to FCS officials.



                           Page 7                                                            GAO/RCED-97-225 Food Assistance
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Figure 1: Types of Food Selection
Limits States Use to Control WIC Food   Number of WIC directors
Costs                                   50
                                                47
                                                        45
                                                                  44


                                        40




                                        30



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                                        As the figure indicates, some types of restrictions are more widely used
                                        than others. Forty-seven of the 48 WIC directors reported that their states’
                                        participants are allowed to choose only certain container or package sizes
                                        of one or more food items. For example, 27 of the 48 directors who
                                        responded to our questionnaire reported that their states limit the
                                        container or package size of infant juice. In addition, 8 states limit
                                        allowable types of infant juice, and 18 do not offer infant juice.8 Some
                                        states have also extended limits to non-infant foods.

                                        For example, Texas participants can select only cheese that is not
                                        packaged as individually wrapped slices or shredded, and milk must be in
                                        1-gallon or half-gallon sizes and must be the least expensive brand. In
                                        Pennsylvania, dry beans or peas must be in 1-pound packages,
                                        ready-to-drink juices must be in 46-ounce cans, and the price of a dozen
                                        eggs must not exceed $1.75.

                                        8
                                         The regulations require states to provide infants either single-strength adult juice or infant juice.



                                        Page 8                                                             GAO/RCED-97-225 Food Assistance
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                                     While all states have one or more food selection restrictions, 17 of the 48
                                     WIC directors responding to our questionnaire reported that their states are
                                     considering the use of additional food selection limits to contain or reduce
                                     costs in the WIC program.

                                     Most of the 48 WIC directors reported that placing selection limits on WIC
                                     foods has at least moderately decreased their food costs. Twelve of these
                                     directors reported that selection limits have greatly or very greatly
                                     reduced their WIC food costs. Figure 2 shows the range of food cost
                                     reductions that the directors reported from implementing these
                                     restrictions.


Figure 2: Impact on Food Costs
Resulting From States’ Use of Food   Number of WIC directors
Selection Limits                     20
                                                                         19




                                     15




                                                                                 10
                                     10
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                                     Texas, for example, which reported that the restrictions had a very great
                                     impact, uses a combination of food selection limits, including a least-cost
                                     brand policy. The policy requires participants to buy the cheapest brand of




                                     Page 9                                                            GAO/RCED-97-225 Food Assistance
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                             milk, evaporated milk, and cheese available in the store—usually the
                             store’s own brand. Texas also requires participants to buy the lowest-cost
                             46-ounce fluid or 12-ounce frozen fruit juices from an approved list of
                             types (orange, grapefruit, orange/grapefruit, purple grape, pineapple,
                             orange/pineapple, and apple) and/or specific brands. According to Texas
                             WIC officials, the least-cost brand policy has had a “tremendous” impact on
                             lowering the dollar amount that the state pays for WIC food products. For
                             example, in fiscal year 1989 (the first full fiscal year that the policy was in
                             effect), the cost of milk was reduced by about $3 million. In fiscal year
                             1996, Texas had a lower than average food cost per person among the 50
                             states and the District of Columbia even before rebates were factored in.
                             (See app. I.)

                             FCS headquarters officials told us that the selection by state agencies of the
                             foods available to participants is one of the states’ most powerful cost
                             containment tools. FCS encourages the states to approve WIC foods that are
                             low in price. However, the officials said that while cost efficiencies are
                             important, the states must maintain the nutritional integrity of the
                             program’s food package. The practice of limiting food items can have a
                             negative impact if participants do not select the food products or do not
                             eat them. For example, Texas WIC officials told us that they discontinued
                             the least-cost brand requirement for peanut butter when they discovered
                             that participants were not selecting the product.

                             In addition, FCS officials said that the restrictions may make food
                             selections more confusing for participants and burdensome for vendors.
                             For example, Texas WIC officials told us that participants and cashiers
                             often have difficulty determining which products have the lowest price. A
                             1995 study of participants’ selections of lowest-cost WIC foods performed
                             by a Texas WIC food chain found that 95 percent of the participants were
                             selecting one or more nonapproved food items that had to be exchanged
                             for the correct item. In response, the food chain, among other things,
                             upgraded the quality, location, and clarity of WIC labels and signs in all of
                             its stores, adding color displays and descriptions of approved WIC items.
                             The Texas WIC agency has also published and displayed a color brochure
                             of approved items that has helped participants to select the approved
                             foods. According to an official of the supermarket chain, these actions
                             have reduced exchanges of food items between 19 and 50 percent.


States’ Control Food Costs   Separately or in conjunction with measures to contain food costs, some
by Managing Vendors          state agencies have placed restrictions on vendors to hold down costs.



                             Page 10                                          GAO/RCED-97-225 Food Assistance
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                          Some states are also selecting alternatives to vendor distribution for
                          certain food products.

Restrictions on Vendors   Thirty-nine of the 48 states responding to our questionnaire reported that
                          they use special selection requirements or limits to contain the number of
                          authorized vendors. Twenty-nine WIC directors reported that they
                          considered it extremely or very important to contain the number of
                          vendors in order to control the program’s costs, and 9 reported that it is
                          moderately important. Of the 39 states, 34 reported using competitive food
                          costs as one of their criteria for selecting vendors. In addition, 27 states
                          have established price limits that vendors cannot exceed for allowable
                          foods, and 5 states require vendors to bid competitively for vendor slots.

                          The food prices of WIC vendors in Texas must not exceed by more than
                          8 percent the average prices charged by vendors doing a comparable
                          dollar volume in the same area. Once selected, vendors must maintain
                          competitive prices. According to Texas WIC officials, the state does not
                          limit the number of vendors that can participate in the WIC program.
                          However, Texas’ selection criteria for approving vendors exclude many
                          stores from the program. By approving only stores with competitive
                          prices, Texas officials said that they save WIC food dollars by paying
                          competitive prices for WIC products.9

                          Similarly, Delaware’s Project SAVE (Selecting Authorized Vendors
                          Efficiently) requires vendors to bid competitively for all authorized WIC
                          food items. Vendors that meet the minimum qualification requirements
                          and bid the lowest prices are selected to fill the available retail outlet slots.
                          Delaware selects vendors every 2 years.

                          Delaware’s WIC director said that while SAVE maintains the clients’ access
                          to vendors, administrative savings have been achieved by training and
                          monitoring vendors, and the number of potentially high-risk vendors has
                          declined. The director noted that SAVE enables the state to control
                          unexpected price increases because the prices are locked in for 2 years
                          through agreements with vendors, thereby allowing grant funds to be more
                          effectively and efficiently managed. Between fiscal years 1991 and 1996,
                          the director estimated, the agreements saved the program about
                          $1.8 million in food costs.




                          9
                           Texas does not have available data on the specific cost savings attributed to selecting vendors with
                          competitive prices.



                          Page 11                                                         GAO/RCED-97-225 Food Assistance
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                                       Eighteen WIC directors reported that their states use ratios of participants
                                       to vendors to restrict the number of vendors allowed to participate in the
                                       program. By limiting the number of vendors, the states can more
                                       frequently monitor stores and conduct compliance investigations,
                                       according to FCS and state WIC officials. For example, Delaware uses a ratio
                                       of 200 participants per store to determine the total number of vendors that
                                       can participate in the program in each WIC service area.

                                       Of the 39 states reporting that they contain the number of vendors, 31
                                       states reported that as a result, their programs’ costs have decreased
                                       somewhat or greatly. Figure 3 presents the WIC directors’ estimates of the
                                       cost reductions resulting from limits on vendors and selection policies.


Figure 3: Impact on the Program’s
Costs Resulting From States’ Use of    Number of WIC directors
Vendor Limits and Selection Policies   25                         24




                                       20




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                                       The WIC directors in 7 of the 39 states (Maine, Massachusetts, Nebraska,
                                       New Mexico, Rhode Island, South Carolina, and Wisconsin) that currently




                                       Page 12                                                                       GAO/RCED-97-225 Food Assistance
                                 B-277615




                                 contain the number of vendors allowed to participate in the program
                                 reported that they are planning to introduce additional initiatives, such as
                                 requiring competitive food pricing by currently authorized vendors, to
                                 contain the program’s costs. In addition, the directors in two other states
                                 (Connecticut and North Carolina) also reported that they plan to select
                                 vendors on the basis of competitive pricing.

                                 FCS headquarters officials told us that limiting the number of vendors and
                                 selecting vendors with competitive prices are important aspects of
                                 containing WIC costs. However, they told us that the retail community does
                                 not favor limits on the number of approved vendors. Instead, vendors have
                                 pressured state WIC agencies and FCS officials to allow all vendors that
                                 qualify to participate. According to the FCS officials, the amount that the
                                 WIC program spends for food would be substantially higher if stores with
                                 higher prices were authorized for the program.

Direct Distribution of Special   Upon a physician’s instructions, WIC infants with special dietary needs or
Infant Formula                   medical conditions may receive special infant formula. While only a small
                                 percentage of the WIC infants nationwide require these formulas, the
                                 monthly retail costs for them can be high—ranging in one state we
                                 surveyed from $540 to $900 for each infant. Twenty-one states avoid
                                 paying retail prices by purchasing the special formula at much lower
                                 wholesale prices and distributing it to participants.

                                 Opportunities exist to substantially lower the cost of special infant
                                 formula. Cost savings may be achieved if the states purchase special infant
                                 formula at wholesale instead of retail prices. Additional savings may also
                                 be possible if these states are able to reduce or eliminate the cost of
                                 authorizing and monitoring the retail vendors and pharmacies that
                                 distribute only special infant formula to WIC participants.

                                 Pennsylvania, for example, turned to direct purchasing to make special
                                 infant formula more available and to avoid the high cost of
                                 vendor-provided formulas. It established a central distribution warehouse
                                 for special formulas in August 1996 to serve the less than 1 percent of WIC
                                 infants in the state—about 400—who needed special formulas in fiscal
                                 year 1996. Pennsylvania purchases the special formulas directly from the
                                 manufacturers at wholesale prices, usually for between $300 to $500 for a
                                 1-month supply. The warehouse ships the special formulas, at the
                                 participant’s option, either directly to the participant or to the WIC clinic.
                                 According to the state WIC director, in many instances, the WIC warehouse
                                 delivers the formula faster than pharmacies do. The program is expected



                                 Page 13                                          GAO/RCED-97-225 Food Assistance
                        B-277615




                        to save about $100,000 annually. In addition, by relying on its warehouse,
                        the state can remove over 200 pharmacies from the program, resulting in
                        significant and measurable administrative cost savings, according to the
                        WIC director.


                        Appendix II provides information on the states’ use of cost containment
                        practices that affect the program’s costs.


WIC Funding Structure   According to the National Association of WIC Directors and some WIC
May Discourage the      directors we spoke with, the program’s funding structure can constrain a
Adoption of Cost        state’s ability to make effective use of the additional funds that become
                        available as a result of cost containment initiatives. FCS policy requires that
Containment Practices   during the grant year, any savings from cost containment accrue to the
                        food portion of the WIC grant, thereby allowing the states to provide food
                        benefits to additional WIC applicants. None of the cost containment savings
                        are automatically available to the states for support services, such as
                        staffing, clinic facilities, voucher issuance sites, outreach, and other
                        activities that are needed to increase participation in the program. As a
                        result, the states may not be able to serve more eligible persons or they
                        may have to carry a substantial portion of the program’s support costs
                        until the federal nutrition services and administration grant is adjusted for
                        the increased participation level—a process that can take up to 2
                        years—according to the National Association of WIC Directors.

                        FCS officials pointed out that provisions in the federal regulations allow the
                        states where participation increases to use a limited amount of their food
                        grant funds for program support activities. However, some states may be
                        reluctant to use the option. For example, according to a Texas WIC official,
                        states may not want to redirect food funds to support services because
                        doing so may be perceived as taking food away from babies.

                        Although California implemented cost containment initiatives during the
                        current and past year, the WIC director told us that the state received less
                        funding for support services this year compared with last year. As a result,
                        she said California has a large, multimillion-dollar imbalance between food
                        money and program support funds that is likely to get worse. She told us
                        that the California program has been hampered by the lack of adequate
                        support funds to sustain its caseload. Some WIC directors told us that such
                        shortfalls in funding for support services may discourage state agencies
                        from expanding the use of cost containment initiatives.




                        Page 14                                          GAO/RCED-97-225 Food Assistance
                       B-277615




                       FCS officials stated that while the WIC funding process does not
                       immediately adjust the amount of funds for support services to reflect cost
                       containment savings, such adjustments are generally made in the following
                       year’s funding allocation. FCS officials also noted that a major reason for
                       the lack of adequate funding for program support activities is an
                       insufficient appropriation level overall—a factor that affected California as
                       well as all WIC state agencies.


                       Federal regulations allow the states to establish their own documentation
States’ Requirements   requirements for applicants who do not automatically meet the income
for Obtaining Income   requirements for participation in WIC. Thirty-two of the 48 WIC directors
Documentation From     reported that their state agencies generally require documentation of
                       income eligibility for these applicants. Fourteen directors reported that
Applicants Vary, but   their states do not require documentation. These states allow applicants to
States Report          declare their income without providing supporting documentation. Finally,
                       two directors reported that income documentation procedures are
Obtaining              determined individually by the local WIC agencies. In addition, 20 state WIC
Documentation in       directors reported that their states do not require applicants to provide
Most Cases             proof of residency, and 12 reported that their states do not require
                       applicants to provide proof of identity when they seek certification for
                       program participation.

                       Thirty of the 32 states that generally require applicants to document their
                       income will waive this requirement under certain conditions. The
                       responses to our questionnaire and our review of state policies indicate
                       that waiving this requirement can be routine. For example, in some
                       instances when individuals report that they are homeless or lack any
                       income, the documentation requirement can be waived. We found that
                       some states also allow individuals to self-declare their income if they do
                       not bring income documents to their certification meeting.

                       While these states will waive their documentation requirements, 27 of the
                       32 state directors reported that 75 percent or more of the participants who
                       were not automatically income eligible provided documentation, such as
                       pay stubs and letters, to establish eligibility in fiscal year 1996. Appendix
                       III provides information on the states’ income documentation
                       requirements and the percentage of participants who were not
                       automatically income eligible and provided income documentation during
                       fiscal year 1996.




                       Page 15                                         GAO/RCED-97-225 Food Assistance
B-277615




In addition to meeting income requirements, WIC applicants must reside
within the jurisdiction of the state where they expect to establish eligibility
to receive benefits.10 FCS allows the states to accept an applicant’s
declaration of state residency without documentation. While 20 of the 48
WIC directors reported that their states do not require applicants to provide
any proof of state residency, 28 states do require applicants to provide
proof of state residency. The types of residency documentation accepted
by these states include utility bills, rent receipts, driver’s licenses, voter
registration cards, and bank statements. To prevent duplicate payments,
the program’s regulations require the local WIC agency to check the
identification of each participant at certification and when issuing food or
food vouchers.11 The types of identification accepted by states include
driver’s licenses, birth certificates, hospital records, pay stubs, voter
registration cards, or recent correspondence. Twelve of the 48 WIC
directors reported that their states do not require such proof of
identification at certification.

There has not been a study of the incidence and magnitude of errors in
determining income eligibility for the WIC program since 1988.12 The 1988
study found that 5.7 percent of the participants were not eligible.
According to FCS officials, there is potential for error in making income
eligibility decisions, and income documentation requirements may need to
be tightened. FCS has begun a nationwide study, scheduled to be
completed in 1999, that will develop a national estimate of the number of
people participating in the program who are not income eligible. The study
will also assess the extent to which various income documentation
procedures reduce the level of participation by individuals who are
ineligible. The information from this study will assist FCS in determining
what changes are needed in income documentation to ensure that the
states provide benefits only to applicants who are eligible.

FCS officials told us they strongly encourage the states to obtain income
documentation. However, they said that imposing stricter documentation
requirements could result in increased administrative costs for state and
local agencies and might discourage some eligible individuals from
applying for benefits. They also noted that certain subgroups of the WIC
population, such as aliens, may find stricter documentation requirements a



10
  7 C.F.R. 246.7(c)(1).
11
  7 C.F.R. 246.7(l)(2).
12
  WIC Income Verification Study (1988), U.S. Department of Agriculture’s Food and Consumer Service.



Page 16                                                      GAO/RCED-97-225 Food Assistance
              B-277615




              barrier to participation because individuals may be intimidated by the
              paperwork.

              FCS officials also expressed concern that the states not requiring proof of
              personal identification may not be able to ensure that they are complying
              with the federal requirement that they check the identification of
              participants when they are certified and when they receive vouchers. Also,
              FCS officials expressed concern that the states not obtaining evidence of
              participants’ residency may not be able to ensure that the participants are
              residents of their states as required by federal regulations.


              A number of the states are making effective use of a variety of practices to
Conclusions   contain the WIC program’s costs and to extend coverage to more women
              and children. However, these states have had to overcome various
              obstacles to implement cost containment. These obstacles include
              incurring the increased administrative burden associated with procuring
              and monitoring rebate contracts, ensuring that cost reduction does not
              result in a food package that is unacceptable to participants, and
              overcoming resistance from the retail community when attempting to
              establish special selection requirements or limits on vendors authorized to
              participate in the program. Given such obstacles, and the states’ concern
              with how the program allocates the additional funds made available
              through cost containment initiatives, some states may be discouraged
              from adopting or expanding the use of cost containment practices.

              As they seek to expand cost containment practices, FCS and the states can
              benefit from the experiences of those states that have implemented such
              practices effectively. Expanding cost containment depends, in part, on
              reducing or eliminating the obstacles that can discourage the states from
              initiating such practices. The expansion of these practices can have a
              substantial impact on the WIC program because for every 1-percent
              reduction in food costs that may result from these initiatives, the federal
              food expenditure of about $2.7 billion could be reduced by about
              $27 million annually. Cost savings could be used to provide benefits to
              additional participants, improve the quality of WIC services, and/or reduce
              the cost of the program to the federal government.

              The states that base income-eligibility decisions on WIC applicants’
              declarations of income without documentation may be allowing applicants
              who are not eligible to participate in the WIC program. It is clear that this
              policy may result in unintentional or deliberate misreporting of income



              Page 17                                        GAO/RCED-97-225 Food Assistance
                     B-277615




                     information. However, the extent of the problem is unknown because
                     there has not been a recent study of the number of participants in the
                     program that are not income eligible. Information from the new study FCS
                     has begun should enable the agency to determine what changes are
                     needed in the program’s income documentation requirements.

                     Similarly, WIC participants must reside in the jurisdiction of the state where
                     they receive benefits and provide identification at the time they are
                     certified to participate in the program and when they receive their
                     vouchers. However, some states are not requiring proof of residency or
                     identity. Without such proof, the states cannot ensure that these
                     requirements are being met.


                     To encourage further implementation of WIC cost containment initiatives,
Recommendations      the Secretary of Agriculture should direct the Administrator of FCS to work
                     with the states to identify and implement strategies, including policy and
                     regulatory and legislative revisions, to reduce or eliminate the obstacles
                     that may discourage such initiatives. These strategies could include
                     modifying policies and procedures that allow the states to use cost
                     containment savings for the program’s support services and establishing
                     regulatory guidelines for selecting vendors to participate in the program.

                     The Secretary should also direct the Administrator to take the necessary
                     steps to ensure that the state agencies are requiring participants to provide
                     evidence that they reside in the states where they receive WIC benefits and
                     to provide identification when their eligibility is certified and when they
                     receive food or food vouchers.


                     We provided the Food and Consumer Service with copies of a draft of this
Agency Comments      report for review and comment. We met with agency officials, including
and Our Evaluation   the Administrator, the Acting Deputy Administrator for Special Nutrition
                     Programs, and the Director of the Supplemental Food Program Division.
                     FCS generally agreed with the report’s findings and recommendations, but
                     FCS suggested revising the presentation of our first recommendation that
                     FCS work with the states to reduce or eliminate the obstacles that may
                     discourage the use of cost containment initiatives. FCS believed that the
                     clarity of our recommendation could be improved by emphasizing that a
                     variety of additional approaches could be taken by the agency to reduce or
                     eliminate cost containment obstacles or provide additional incentives to




                     Page 18                                         GAO/RCED-97-225 Food Assistance
              B-277615




              encourage more cost containment. In response to these concerns, we
              revised the wording of the recommendation.

              FCS also provided us with a number of technical comments that we
              incorporated into the report as appropriate.


              In developing information for this report, we spoke with and obtained
Scope and     documents from officials at FCS headquarters. We also spoke with officials
Methodology   at all seven of FCS’ regional offices. We interviewed state WIC officials in
              California, Delaware, Pennsylvania, and Texas. In addition, we collected
              pertinent information from the National Association of WIC Directors. We
              reviewed federal laws and regulations applicable to the establishment and
              operation of the WIC program. We also mailed questionnaires to the WIC
              agency directors in the 50 states and the District of Columbia. We received
              responses to our questionnaire from 48 directors (94 percent).

              We conducted our work from December 1996 through August 1997 in
              accordance with generally accepted government auditing standards. We
              did not, however, independently verify the accuracy of the state WIC
              agency directors’ responses to our questionnaire.


              We are sending copies of this report to the appropriate congressional
              committees, interested Members of Congress, the Secretary of Agriculture,
              and other interested parties. We will also make copies available upon
              request.

              If you have any questions, please call me at (202) 512-5138. Major
              contributors to this report are listed in appendix IV.

              Sincerely yours,




              Robert A. Robinson
              Director, Food and
                Agriculture Issues




              Page 19                                        GAO/RCED-97-225 Food Assistance
Contents



Letter                                                          1


Appendix I                                                     22

Average State Pre- and
Postrebate Monthly
Food Costs Per
Person for Fiscal Year
1996
Appendix II                                                    24

States’ Use of Cost
Containment
Practices That Affect
Their Programs’ Costs
Appendix III                                                   27

State Income
Documentation
Requirements and
Percentage of
Applicants Who Were
Not Automatically
Income Eligible and
Provided
Documentation
During Fiscal Year
1996
Appendix IV                                                    29

Major Contributors to
This Report


                         Page 20   GAO/RCED-97-225 Food Assistance
          Contents




Tables    Table 1: State WIC Agencies Receiving Infant Cereal and/or Infant         5
            Juice Rebates Through Individual or Multistate Contracts During
            Fiscal Year 1996
          Table II.1: Number of States Using Various Practices That Can            24
            Affect Their Programs’ Costs as Reported in Our Survey of State
            WIC Program Directors
          Table II.2: States Using Practices Described in Report to Contain        25
            Their Programs’ Costs


Figures   Figure 1: Types of Food Selection Limits States Use to Control            8
            WIC Food Costs
          Figure 2: Impact on Food Costs Resulting From States’ Use of              9
            Food Selection Limits
          Figure 3: Impact on the Program’s Costs Resulting From States’           12
            Use of Vendor Limits and Selection Policies




          Abbreviations

          FCS        Food and Consumer Service
          WIC        The Special Supplemental Nutrition Program for Women,
                         Infants and Children


          Page 21                                      GAO/RCED-97-225 Food Assistance
Appendix I

Average State Pre- and Postrebate Monthly
Food Costs Per Person for Fiscal Year 1996


                                      Prerebate average food   Postrebate average food
               State                         cost per person           cost per person
               Alabama                               $48.25                     $30.75
               Arizona                                 45.70                     29.69
               Alaska                                  47.78                     38.69
               Arkansas                                44.11                     29.03
               California                              45.45                     31.95
               Colorado                                41.32                     30.07
               Connecticut                             44.63                     33.69
               Delaware                                43.60                     30.17
               District of Columbia                    52.15                     34.00
               Florida                                 48.02                     32.45
               Georgia                                 41.46                     27.28
               Hawaii                                  62.72                     50.57
               Idaho                                   37.95                     26.94
               Illinois                                52.50                     36.21
               Indiana                                 43.10                     29.07
               Iowa                                    41.94                     29.66
               Kansas                                  43.65                     30.45
               Kentucky                                43.25                     30.04
               Louisiana                               50.96                     34.87
               Maine                                   39.39                     28.60
               Maryland                                48.13                     32.24
               Massachusetts                           39.90                     28.09
               Michigan                                44.91                     31.47
               Minnesota                               41.88                     29.09
               Mississippi                             28.38                     28.38
               Missouri                                45.80                     31.27
               Montana                                 39.35                     25.59
               Nebraska                                44.51                     32.21
               Nevada                                  41.84                     26.80
               New Hampshire                           37.52                     25.93
               New Jersey                              42.07                     30.71
               New Mexico                              43.01                     31.15
               New York                                50.18                     34.35
               North Carolina                          43.04                     27.74
               North Dakota                            43.97                     33.65
               Ohio                                    41.04                     26.64
               Oklahoma                                44.08                     30.34
                                                                            (continued)


               Page 22                                  GAO/RCED-97-225 Food Assistance
Appendix I
Average State Pre- and Postrebate Monthly
Food Costs Per Person for Fiscal Year 1996




                                      Prerebate average food         Postrebate average food
State                                        cost per person                 cost per person
Oregon                                                     38.79                       28.91
Pennsylvania                                               43.23                       31.00
Rhode Island                                               42.82                       29.95
South Carolina                                             41.07                       28.22
South Dakota                                               40.92                       29.64
Tennessee                                                  48.65                       33.00
Texas                                                      41.26                       25.28
Utah                                                       42.03                       31.39
Vermont                                                    32.44                       32.44
Virginia                                                   44.80                       32.18
Washington                                                 45.11                       32.30
West Virginia                                              42.02                       30.48
Wisconsin                                                  41.96                       30.47
Wyoming                                                    37.88                       27.54
Average                                                  $43.54                      $30.84

Source: Special Nutrition Programs Integrated Information System, FCS.




Page 23                                                     GAO/RCED-97-225 Food Assistance
Appendix II

States’ Use of Cost Containment Practices
That Affect Their Programs’ Costs

Table II.1: Number of States Using
Various Practices That Can Affect      Practice                                               Number of states using practice
Their Programs’ Costs as Reported in   Limiting participants’ selections for one or more WIC food items by:
Our Survey of State WIC Program
                                       Designating specific brands or disallowing                                         45
Directors
                                       specific brands
                                       Allowing only certain container or package                                         47
                                       size for one or more WIC food items
                                       Limiting allowable types of food (e.g., block                                      44
                                       rather than sliced cheese) for one or more
                                       WIC food items
                                       Setting a maximum purchase price for one                                           15
                                       or more WIC food items
                                       Requiring purchase of lowest cost brand for                                        20
                                       one or more WIC food items
                                       Direct distribution of food packages                                                5
                                       Home delivery of food                                                               5
                                       Contracted rebates on WIC foods other than                                         10
                                       infant formula
                                       Noncontracted rebates on WIC foods                                                 18
                                       Direct purchase of special infant formula                                          21
                                       Printing maximum price for each food item                                           3
                                       on WIC voucher
                                       Printing maximum price for the entire WIC                                          23
                                       food package on voucher
                                       Reimbursing vendors for actual costs, up to                                        29
                                       a state-set maximum
                                       Reimbursing vendors for reasonable costs,                                           9
                                       as determined by state, not actual shelf
                                       prices
                                       Using competitive food cost as a vendor                                            34
                                       selection criterion
                                       Vendor food prices cannot exceed limits set                                        27
                                       by the state
                                       Containing number of WIC vendors based                                             18
                                       on a ratio of number of vendors to
                                       participants or other ratios
                                       Competitive bidding for vendor slots                                                5
                                       Vendor monitoring                                                                  46
                                       Source: WIC Directors Questionnaire, GAO, Mar. 1997.




                                       Page 24                                                GAO/RCED-97-225 Food Assistance
                                          Appendix II
                                          States’ Use of Cost Containment Practices
                                          That Affect Their Programs’ Costs




Table II.2: States Using Practices Described in Report to Contain Their Programs’ Costs
                             Require                          Using
                             purchase of                      competitive
                             lowest cost      Ratios to       food cost as a                 Vendor food        Direct
                             brand for one    contain the     vendor          Competitive    prices cannot      purchase of
                             or more WIC      number of       selection       bidding for    exceed limits      special infant
State                        food items       vendors         criterion       vendor slots   set by the state   formula
Alabama                                                      X                                                  X
Arizona                                                      X                               X
Alaska                                      X
Arkansas                   X                X                                                                   X
California                                                   X                               X                  X
Colorado                                                                                                        X
Connecticut                X                                                                                    X
Delaware                                    X                X                 X
District of Columbia                        X                X
Florida                    X                                 X                               X                  X
Georgia                    X                                 X                               X                  X
Hawaii                                                                                                          X
Idaho
Illinois                   X                X                X                               X
Indiana                                     X                X
Iowa                       X
Kansas                     X                                 X                               X
Kentucky                                                     X                               X
Louisiana                  X                                 X                 X             X                  X
Maine                      X                                 X                               X
Maryland                                                     X                               X                  X
Massachusetts              X                X                X                 X             X
Michigan                                    X                X
Mississippi                                                                                                     X
Missouri                                    X                X                               X
Montana
Nebraska                                                     X                               X
Nevada                     X                                 X                               X                  X
New Hampshire              X                                 X
New Jersey                                  X                X                 X             X
New Mexico                 X                X                X                               X
New York                                    X                                                X
North Carolina             X                                                                                    X
                                                                                                                    (continued)


                                          Page 25                                            GAO/RCED-97-225 Food Assistance
                                 Appendix II
                                 States’ Use of Cost Containment Practices
                                 That Affect Their Programs’ Costs




                 Require                              Using
                 purchase of                          competitive
                 lowest cost      Ratios to           food cost as a                         Vendor food        Direct
                 brand for one    contain the         vendor             Competitive         prices cannot      purchase of
                 or more WIC      number of           selection          bidding for         exceed limits      special infant
State            food items       vendors             criterion          vendor slots        set by the state   formula
North Dakota
Ohio                              X                   X
Oklahoma         X                X                   X                                      X
Pennsylvania                      X                   X                                      X                  X
Rhode Island     X                                    X                                      X                  X
South Carolina                                        X                                      X                  X
Tennessee                                             X                                      X
Texas            X                                    X                                      X                  X
Utah             X                X                   X                                      X                  X
Vermont                                                                  X                                      X
Virginia         X                X                   X                                                         X
Washington
West Virginia    X                X                   X                                      X
Wisconsin                                             X                                      X
Wyoming                                               X                                      X                  X

                                 Note: Minnesota, Oregon, and South Dakota are not listed because they did not respond to our
                                 survey.

                                 Source: WIC Directors Questionnaire, GAO, Mar. 1997.




                                 Page 26                                                     GAO/RCED-97-225 Food Assistance
Appendix III

State Income Documentation Requirements
and Percentage of Applicants Who Were Not
Automatically Income Eligible and Provided
Documentation During Fiscal Year 1996
                                    Reported income documentation requirement
                       Documentation of                                                        Percentage of
                       income is                                                               applicants who were
                       required—but                                  Documentation is not      not automatically
                       requirement can be      Local agencies        required, self-           income eligible and
                       waived in certain       establish their own   declaration of income     provided
State                  circumstances           requirement           is allowed in all cases   documentation
Alabama                                                              X                         6-25
Arizona                X                                                                       76-95
Alaska                 X                                                                       76-95
Arkansas                                                             X                         0-5
California             X                                                                       76-95
Colorado                                       X                                               26-75
Connecticut            X                                                                       96-100
Delaware               X                                                                       76-95
District of Columbia   X                                                                       76-95
Florida                                                              X                         0-5
Georgia                                                              X                         0-5
Hawaii                 X                                                                       96-100
Idaho                  X                                                                       26-75
Illinois               X                                                                       96-100
Indiana                X                                                                       96-100
Iowa                                                                 X                         No basis to judge
Kansas                 X                                                                       96-100
Kentucky                                                             X                         0-5
Louisiana                                                            X                         No basis to judge
Maine                  X                                                                       96-100
Maryland               X                                                                       96-100
Massachusetts          X                                                                       76-95
Michigan               X                                                                       No basis to judge
Minnesota                                                                                      No response
Mississippi                                    X                                               No basis to judge
Missouri               X                                                                       76-95
Montana                X                                                                       96-100
Nebraska                                                             X                         0-5
Nevada                 X                                                                       No basis to judge
New Hampshire          X                                                                       76-95
New Jersey             X                                                                       96-100
New Mexico             X                                                                       96-100
New York               X                                                                       6-25
                                                                                                             (continued)


                                     Page 27                                           GAO/RCED-97-225 Food Assistance
                               Appendix III
                               State Income Documentation Requirements
                               and Percentage of Applicants Who Were Not
                               Automatically Income Eligible and Provided
                               Documentation During Fiscal Year 1996




                              Reported income documentation requirement
                 Documentation of                                                               Percentage of
                 income is                                                                      applicants who were
                 required—but                                         Documentation is not      not automatically
                 requirement can be       Local agencies              required, self-           income eligible and
                 waived in certain        establish their own         declaration of income     provided
State            circumstances            requirement                 is allowed in all cases   documentation
North Carolina                                                        X                         6-25
North Dakota     X                                                                              96-100
Ohio             X                                                                              96-100
Oklahoma                                                              X                         No basis to judge
Oregon                                                                                          No response
Pennsylvania     X                                                                              96-100
Rhode Island     X                                                                              96-100
South Carolina                                                        X                         0-5
South Dakota                                                                                    No response
Tennessee                                                             X                         0-5
Texas            X                                                                              96-100
Utah             X                                                                              96-100
Vermont                                                               X                         No basis to judge
Virginia         X                                                                              No basis to judge
Washington                                                            X                         0-5
West Virginia    X                                                                              96-100
Wisconsin        X                                                                              96-100
Wyoming          X                                                                              96-100

                               Source: WIC Directors Questionnaire, GAO, Mar. 1997.




                               Page 28                                                  GAO/RCED-97-225 Food Assistance
Appendix IV

Major Contributors to This Report


               Thomas Slomba, Assistant Director
               Peter Bramble
               Leigh McCaskill White
               Carolyn Boyce
               Carol Herrnstadt Shulman




(150267)       Page 29                             GAO/RCED-97-225 Food Assistance
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