Synthesis of 10 Case Studies: Exploring Medicaid and SCHIP Enrollment Trends and Their Links to Policy and Practice

After Congress established SCHIP in 1997 in response to large numbers of uninsured children in low-income working families, states took this unique opportunity to expand children’s coverage and introduce program innovations. To build on this opportunity, RWJF funded the national Covering Kids Initiative (CKI) in 1999 to increase children’s enrollment in SCHIP and Medicaid. In 2002 RWJF extended CKI to families, as well as children, and renamed it Covering Kids & Families (CKF).

RWJF funded 46 state CKF grantees, which included community-based organizations, service agencies, government agencies, academic institutions and health care providers. In turn, these state grantees funded 152 local grantees—at least two in each state—using half of their grants (the average state grant was $828,215). Local grantees were intended to be local laboratories for innovation that could report to state grantees on barriers to enrollment and the most effective types of outreach. The four-year grants began in 2002.

CKF required its grantees to use three strategies RWJF believed to be crucial for increasing enrollment of eligible, uninsured children and families in SCHIP and Medicaid:

• Outreach to encourage enrollment in SCHIP and Medicaid;
• Simplification of SCHIP and Medicaid policies and procedures to make it easier for families to enroll their children and keep them in the programs;
• Coordination between SCHIP and Medicaid to ensure that families transition easily between programs if they apply for the wrong program or their eligibility changes. CKF also encouraged community commitment by requiring every grantee to be embedded in a community coalition and it encouraged collaboration between grantees and state officials.

During the CKF evaluation, the study team selected 10 states as case studies to examine the interplay between children’s coverage in Medicaid and SCHIP, the state economic and political environment, the state’s policy and procedures related to coverage, and the activities of the state’s CKF grantees. Our goal was to assess the most important factors contributing to the coverage of children and to suggest the most effective ways of increasing enrollment of eligible children and families in Medicaid and SCHIP. The case study site visits, which took place between 2005 and 2007, included meetings with state officials, CKF state grantee staff and selected local project staff.

Before the visits, we prepared graphs showing trends in new enrollment in SCHIP and Medicaid. During the visits, we asked state officials and CKF state grantee staff members what they thought were the reasons for certain directions in these trends. For example, we might inquire about a sharp and sustained rise in new enrollment that had been evident among only some eligibility groups. Combined with our statistical analysis of these trend data, we used the information provided by interview respondents to identify the factors that had contributed to these changes. When we reached a consensus about these factors, we described them in a site visit report using the statistical analysis to further explore their credibility.