August 2008

Grant Results


From 2004 to 2007, the National Academy for State Health Policy conducted an examination of financial and coverage issues related to the major public programs providing health coverage to low-income children and families. The project focused on Medicaid's fiscal integrity and steps to ensure continuous coverage for children.

Key Results
Project staff produced two reports:

The Robert Wood Johnson Foundation (RWJF) provided $397,309 for this project. The David and Lucile Packard Foundation also provided support for one part of the project.

 See Grant Detail & Contact Information
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Two public programs form the backbone of health care coverage for low-income individuals and families:

  • Medicaid, which covered more than 52 million people in 2004, according to the Kaiser Commission on Medicaid and the Uninsured.
  • The State Children's Health Insurance Program (SCHIP), which provides coverage for children whose families do not qualify for Medicaid. It covered 4 million children in 2004, according to the commission.

Federal and state governments share responsibility for funding these programs, creating tensions over financing issues, according to the National Academy for State Health Policy. States complain that federal rules are murky and inconsistent, sometimes encouraging fiscal practices that are later ruled impermissible. From the federal perspective, states often are seen as trying to stretch financing rules to their own advantage.

There are also inconsistencies and gaps in coverage, with each state operating its own programs. More than 60 percent of uninsured children are eligible for coverage under a public program, but they are not enrolled, according to the academy.

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Since the 1970s, RWJF has been concerned about Americans' lack of access to affordable and stable health care coverage. RWJF has funded studies, demonstration projects and symposia about this problem.

In 1997, Congress funded the State Children's Health Insurance Program with the aim of providing health insurance coverage to children who were not eligible for private or other public insurance programs. That same year, RWJF created Covering Kids® (see the Grant Results). In 2001, RWJF reshaped the program and renamed it Covering Kids & Families®, reflecting the Foundation's commitment to help states also cover parents and other adults who work at jobs that do not provide health coverage for them or their children.

Through a series of State Coverage Initiatives, RWJF assisted states in developing and implementing policies that made health care insurance more available and affordable to low-income residents. RWJF also created State Solutions: An Initiative to Improve Enrollment in Medicare Savings Programs, a national program to maximize enrollment in Medicaid, Medicare and other health insurance programs. Communities in Charge: Financing and Delivering Health Care to the Uninsured is a national program to help cities or counties improve access to care for low-income, uninsured individuals by changing the organization and financing of local care delivery (for more information see Grant Results). The Access Project began work to improve health and health care in 1998 (for more information see Grant Results).

RWJF also has supported other efforts to enhance Americans' access to health care coverage, including:

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The National Academy for State Health Policy, based in Portland, Maine, is a nonprofit organization of state health policy-makers that works to identify emerging issues, develop policy solutions and improve state health policy and practice. This grant supported academy efforts to examine financial and coverage issues related to Medicaid and SCHIP.

Much of the project's work focused on two issues:

  • Improving Medicaid's Fiscal Integrity. The academy convened a work group of 14 congressional staff, state Medicaid officials, health financing experts, federal health officials and other policy and program experts to discuss issues, find common ground and generate ideas for further analysis related to Medicaid's fiscal integrity. The work group met on November 1, 2005, in Washington.

    With feedback from the work group, project staff prepared a report, Moving Beyond the Tug of War: Improving Medicaid Fiscal Integrity, issued in August 2006.
  • Using Medicaid and SCHIP to Cover Children Continuously. Project staff pooled resources from RWJF and the David and Lucile Packard Foundation to host a two-day invitational symposium and produce a report on child health coverage.

    Some 22 representatives of state health agencies, foundations, managed care organizations, research groups and the federal government reviewed progress and generated ideas for further achievements in covering children during the meeting, which took place on March 21–22, 2006, in Washington.

    Project staff prepared a report, Seven Steps Toward State Success in Covering Children Continuously.

For more information about both reports, see Results.

The academy also had planned to examine policies designed to coordinate Medicaid and SCHIP better with employer-provided health coverage. Rather than pursue this work itself, it collaborated with the Health Insurance Reform Project at George Washington University on a RWJF-funded project studying the possibility of combining tax credits with an expansion of public insurance programs.

Academy staff helped plan working group meetings and co-authored a report, Administering a Medicaid + Tax Credits Initiative. For more information, see Grant Results on ID# 053788.

Toward the end of the grant period, the academy began work on the issue of extending Medicaid to youth who are leaving the juvenile justice and foster care systems. On February 16, 2007, it convened a meeting in Washington of 16 state officials in the juvenile justice and Medicaid systems as well as health insurance coverage experts to gather information on how states approach the problem of providing health coverage to these youth. For more information, see After the Grant.

Other Funders

The David and Lucile Packard Foundation supported the academy's work around children's coverage, including partial support for the symposium on covering children, with a grant of $679,359.


The project held two webcasts on key coverage issues:

  • "Redesigning Coverage in Medicaid" (held January 29, 2007, with 206 registrants): Speakers from Idaho and Kentucky discussed how they are using the Deficit Reduction Act of 2005 to improve their Medicaid programs. An online archive of the webcast is available.
  • "The Politics of Creating and Sustaining Comprehensive Health Care Coverage Initiatives" (held February 5, 2007, with 243 registrants): Speakers from California, Maine and Massachusetts examined the process of getting to (and sticking with) comprehensive coverage. An online archive of the webcast is available.

In addition to the reports mentioned earlier, project director Alan Weil, J.D., M.P.P., published an article in The Future of Children, "A Health Plan to Reduce Poverty," based in part on the work of this project. See the Bibliography for details about all publications.

On September 15, 2006, the National Health Policy Forum sponsored a forum in Washington, "Where You Stand Depends on Where You Sit: Perspectives on Medicaid Fiscal Integrity and Intergovernmental Relationships," that focused on the report Moving Beyond the Tug of War: Improving Medicaid Fiscal Integrity. About 225 senior staff in Congress, the executive branch and congressional support agencies attended.

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The project produced two reports:

  • Moving Beyond the Tug of War: Improving Medicaid Fiscal Integrity examines fiscal integrity issues from both federal and state perspectives, offers a brief history of efforts to improve Medicaid's integrity and suggests four key features of a better approach:
    • Clear rules from the federal government, applied equally. Clear rules would help states comply with the law and protect them from fiscal hardships caused by unexpected changes in federal policy.
    • A structure for implementing new rules. Formal federal rule making—rather than reliance on letters to states and negotiations about program changes—would give states notice of impending changes and an opportunity to comment on those changes before they are implemented.
    • Federal monitoring to ensure compliance. The federal government needs more information about state compliance with Medicaid rules. States should be required to certify their compliance and make their policies and practices more transparent.
    • Accountability mechanisms. States should receive financial incentives for complying with Medicaid regulations and face penalties for noncompliance. The federal Centers for Medicare & Medicaid Services, which administers Medicaid, should face independent review of its fiscal integrity efforts.
  • Seven Steps Toward State Success in Covering Children Continuously summarizes key suggestions about lessons learned over the past decade of state efforts to increase rates of children's health coverage:
    • Keep enrollment and renewal procedures simple.
    • Use community-based efforts as a key to enrollment.
    • Use technology to coordinate programs and reduce administrative burdens.
    • Change agency culture.
    • Engage leaders who can articulate a clear vision.
    • Engage partners.
    • Use marketing as an essential tool.

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  1. Bring together people who can move beyond rhetoric in order to stimulate real discussion of issues. Researchers found a great deal of "overblown" rhetoric about Medicaid fiscal integrity. Some people thought the states did little more than steal. Others thought the federal government wielded power arbitrarily and did not always negotiate in good faith. "We were able to bring together people who could move beyond these characterizations and promote a real discussion of what is at stake in state-federal relationships and what policy options could be considered to improve those relations," said Project Director Weil. (Project Director)
  2. Expand your communications strategy beyond issuing publications. The project relied upon traditional communications mechanisms: writing and releasing reports and informing the health policy community that they were available. However, the project director believed that the reports could have had more policy impact if staff had found a way to keep conversation about the report going, such as finding a national organization interested in promoting the issue. (Project Director)

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The academy has received two grants from RWJF for related work:

  • In February 2007, the academy received a grant (ID# 057867) to help states use Medicaid, including new rules established by the federal Deficit Reduction Act of 2005, to cover more of the uninsured. Young adults and youth transitioning out of institutional settings (foster care, juvenile justice) are a key focus of the project.
  • In August 2007, the academy began working with RWJF's Coverage Team (under Grant ID# 062427) on planning for a national program aimed at maximizing enrollment of children in Medicaid and SCHIP.

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Convening and Research to Consider How Medicaid and SCHIP Could be Used to Provide Health Coverage for More Americans


Center for Health Policy Development/National Academy for State Health Policy (Portland,  ME)

  • Amount: $ 397,309
    Dates: December 2004 to February 2007
    ID#:  052038


Alan R. Weil, J.D., M.P.P.
(202) 903-0101

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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)


Weil AR. "A Health Plan to Reduce Poverty." The Future of Children, 17(2): 97–116, 2007. Available online.


Etheredge L, Moore J, Schwartz S and Weil A. Administering a Medicaid + Tax Credits Initiative. Washington: Health Insurance Reform Project and the National Academy for State Health Policy, 2007. Available online.

Moving Beyond the Tug of War: Improving Medicaid Fiscal Integrity. Portland, ME: National Academy for State Health Policy, August 2006. Available online.

Seven Steps Toward State Success in Covering Children Continuously. Portland, ME: National Academy for State Health Policy, October 2006. Available online.

Summary Brief: Moving Beyond the Tug of War: Improving Medicaid Fiscal Integrity. Portland, ME: National Academy for State Health Policy, August 2006.

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Report prepared by: Lori De Milto
Reviewed by: Robert Narus
Reviewed by: Marian Bass
Program Officer: Nancy Barrand