Evaluation: Covering Kids & Families®

The Covering Kids & Families (CKF) initiative of the Robert Wood Johnson Foundation (RWJF) had two goals: to reduce the number of uninsured children and adults eligible for Medicaid or SCHIP programs who remain uninsured, and to build the knowledge, experience and capacity necessary to sustain the enrollment, and retention, of children and adults on those programs after the CKF program ended (Grant and Ravenell, 2002).

Mathematica Policy Research, Inc. and its partners the Urban Institute and Health Management Associates independently evaluated the impact of the Foundation's investment and assessed the factors that may have contributed to, or impaired, CKF's efforts. The results of their work are available below.

Exploring Medicaid and SCHIP Enrollment Trends and Their Links to Policy and Practice

During the Covering Kids & Families™ (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. 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, the evaluation team prepared graphs showing trends in new enrollment in SCHIP and Medicaid. During the visits, the team asked state officials and CKF state grantee staff members what they thought were the reasons for certain directions in these trends. Combined with statistical analysis of these trend data, the team used the information provided by interview respondents to identify the factors that had contributed to these changes.

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As gains have been made in coverage, it has become increasingly apparent that having health insurance does not in itself assure access to needed health care.

Covering Kids & Families Access Initiative (CKF-AI) was developed in 2003 to learn more about the variety of access barriers that can prevent meaningful use of insurance coverage even after children and families are formally enrolled

Supported by $4 million in Foundation funding, the program was carried out during 2003 – 2005 with 18 grantee organizations in 15 states. The National Program Office guiding CKF-AI was the Center for Health Care Strategies (CHCS), an organization with extensive experience in research and technical assistance to improve the quality of publicly financed health care.

Covering Kids & Families® (CKF) aimed to increase enrollment of eligible children and families by utilizing various outreach strategies, the most effective being targeted, viable, measurable and adaptable.

Partnerships with schools and health care providers were among the most important and the most successful CKF strategies to expand access to health insurance to low-income children and their families. Diverse and creative means of outreach were particularly valued during times of limited funding availability, and grantees reported that many activities undergone in partnership with schools and providers would be sustainable after the termination of CKF funding.

CKF grantees developed a variety of creative means to reach vulnerable populations, but many grantees have struggled to effectively reach out to some populations. Barriers to reaching these populations included issues of trust and stigma, cultural and language barriers, and the accessibility of the target population to both CKF programs and medical care.

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Over the course of the Covering Kids & Families® (CKF) evaluation, three telephone surveys were conducted with Medicaid and SCHIP officials in all 46 states with CKF grantees. The surveys asked state officials to discuss the most important policy changes that CKF had directly influenced.

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State Medicaid and State Children’s Health Insurance Program (SCHIP) agencies provide vital health coverage to low-income populations and other groups, but have limited administrative resources to support enrollment and renewal functions for these programs. Streamlining and enhancing the effectiveness of their administrative procedures and processes can help state programs do more with less and can ease the burden on individuals who apply to these programs by clarifying instructions or allowing phone or Internet applications or renewals. In short, everyone could benefit from improved procedures.

In these materials, researchers looked at the experience that some state Medicaid and SCHIP agencies have had in using a process change model developed by the Institute for Healthcare Improvement (IHI), and adapted by the Southern Institute on Children and Families (Southern Institute), to strengthen the way they approach enrollment and retention administrative processes. IHI’s model, known as the Breakthrough Series, has helped numerous health care providers improve quality and efficiency in various ways, including reducing patient waiting times by 50 percent, reducing intensive care unit costs by 25 percent and reducing hospitalizations for patients with congestive heart failure by 50 percent (Institute for Healthcare Improvement, 2003). The Breakthrough Series uses a “process improvement collaborative” or “learning collaborative.” It has not been widely applied to improve purchaser administration.

Assessing sustainability is a key component of the Covering Kids & Families (CKF) evaluation. The evaluation team discussed the appropriate times and manner for data collection and review of this issue. or evaluation year one, the team decided to include two questions on sustainability in a survey of coalitions and not to include any related questions in the site visits.

The survey results indicate that coalition leaders are much more likely to have an opinion on whether there are efforts to sustain the coalition than grantee staff or coalition members in general. The leadership is also more likely than other respondents to indicate their coalition has begun discussions about future funding or efforts to secure future funding. This result suggests that the leadership of these coalitions has begun discussions and efforts to find future funding for their coalitions that have not yet been discussed with coalition members at large.

This brief examines the extent to which Covering Kids & Families® (CKF) coalition leaders expect their coalition and/or coalition activities to continue beyond the CKF grant period and the extent to which they have secured resources to continue. This brief also looks at coalition structure and the roles taken by coalition leaders, and examines whether these factors appear to affect the likelihood of sustainability. The survey of state coalition leaders conducted in July 2005 revealed that:

• More than half of state coalition leaders (57%) believe their state CKF coalition will continue beyond the grant period, but a lesser number (51%) said their coalition has a plan in place to do so.
• Only 11 percent of coalition leaders say their state CKF coalitions have secured resources to operate after the CKF grants end.
• More than half (55%) of the coalition leaders surveyed believe local coalitions and their activities will continue, while a third (34%) don't yet know what will happen to their local coalitions and projects.

Over the 12 months beginning July 2005, which mark the end of Robert Wood Johnson Foundation (RWJF) funding for more than 60 percent of CKF projects, the vast majority (92%) of coalition leaders plan to continue or even increase their level of participation in CKF, a possible positive indicator of the likelihood of sustainability. At the same time, very few coalition leaders indicated they have contributed or plan to contribute funding to CKF, or plan to help gain access to outside funding.

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