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object(Timber\Post)#3742 (44) { ["ImageClass"]=> string(12) "Timber\Image" ["PostClass"]=> string(11) "Timber\Post" ["TermClass"]=> string(11) "Timber\Term" ["object_type"]=> string(4) "post" ["custom"]=> array(5) { ["_wp_attached_file"]=> string(12) "R_215LBR.pdf" ["wpmf_size"]=> string(6) "405789" ["wpmf_filetype"]=> string(3) "pdf" ["wpmf_order"]=> string(1) "0" ["searchwp_content"]=> string(72458) "Enrollment in Health and Nutrition Safety Net Programs among California’s Children February 2015 Laurel Beck, Caroline Danielson, and Shannon McConville with research support from Marisol Cuellar and Landon Gibson Supported with funding from the Blue Shield of California Foundation Summary High enrollment in safety net programs for low -income children has long been a priority in California. In January 2014, majo r expansions in health insurance coverage programs under the Affordable Care Act (ACA) catalyzed efforts to better integrate safety net program s. Because these programs serve overlapping populations, integrating administration across them can increase part icipation, improve the client experience, and lower administrative costs. This report focuses on enrollment in public health insurance and nutrition assistance programs primarily among low-income children , using recent historical data to look both at statewide patterns and county -level factors that influence enrollments . As California increases efforts to achieve full participation for those qualified, examining these patterns can help inform plans to expand program integration. It can also hel p illuminate the role local administration plays so that policymakers can develop strategies that support counties coping with rising enrollments during times of economic stress. More than half of all California children and about 85 percent of low -income children participate in one or more public health insurance and nutrition assistance programs —Medi-Cal, which provides no -cost and low -cost health insurance, monthly CalFresh benefits, school meals, and specified foods from WIC. The state supervises these programs, and local entities —including county government, local WIC agencies, and school districts —administer them . Because all of these programs require low family income to qualify for benefits, worsening job opportunities during and after the recent recession resulted in higher program participation across the state. In deed, at the state level increases in participation outstripped the growth in need. Across all programs, increased county resources to administer programs helped to boost enrollments amo ng low-income children . At the same time, we find that the sharply weaker economy tended to offset these gains . As of 2012, nearly all low -income California children age s 0–4 and about four in five older children were enrolled in at least one health or nutrition program. From the point of view of attaining full enrollment in these programs, this is good news. Still, some children enrolled in one or more of the nutrition assistance program s lack ed health insurance , indicating that there is still room for improvement. T o build on t he positive momentum brought about by the ACA and to move toward full enrollment across counties, state policymakers can make use of our findings in several ways. They can aim to have funding allocations for program administratio n keep pace with changes in the low -income population. They can consider increasing resources for counties with relatively low program enrollments. They can take advantage of ACA funding for information technology (IT) investments through 2015 in order to implement a higher degree o f program integration. This latter step can, in turn , help to identify and enroll uninsured family members who may be eligible, and could be especially critical for counties during times of economic downturn, when eligibility may outpace administrative capacity. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 2 Contents Summary 2 Figures 4 Tables 4 Abbreviations 5 Introduction 6 The Scope of California’s Health and Nutrition Safety Net for Children 8 Why do eligible people not enroll? 9 Enrollments grew during the recent recession 10 Factors That Drive Differences in Program Enrollment among Low -Income Children 14 Enrollment opportunities and outreach 15 Local administration 16 Local economic opportunities 17 Horizontal Integration— a Gateway to Greater Access 19 How often are low-income children enrolled in multiple health and nutrition programs? 19 Opportunities to connect low-income adults to insurance coverage 21 Conclusion 22 References 23 About the Authors 25 Acknowledgments 25 Technical appendices to this paper are available on the PPIC website: www.ppic.org/content/pubs/other/215LBR_appendix.pdf http://www.ppic.org/main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 4 Figures 1. Health and nutrition safety net programs served a larger share of all California children as the economy worsened 11 2. Caseloads increased as the economy worsened and child poverty rates climbed 12 3. The share of low-income children enrolled also increased during recent recession 13 4. Program use among low-income children varied across counties and programs in 2012 14 5. Nearly all low-income young children make use of at least one program but fewer school-aged, low-income children do 20 6. Many uninsured adults lived with a child participating in at least one health or nutrition safety net program 21 Tables 1. Major public health and nutrition assistance programs that serve children 8 Abbreviations ACA Affordable Care Act CalWORKs California Work Opportunity and Responsibility to Kids CDE California Department of Education DHCS California Department of Health Care Services DPH California Department of Public Health DSS California Department of Social Services LEA Local Education Agency MRMIB Managed Risk Medical Insurance Board NSLP National School Lunch Program SNAP Supplemental Nutrition Assistance Program TANF Temporary Assistance for Needy Families WIC Supplemental Nutrition Assistance Program for Women, Infants, and Children http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 5 Introduction In this report, we focus on enrollment in public health insurance and nutrition assistance programs among low -income children —a particular population of concern, and one for which high enrollment in health and nutrition programs has been a longstanding priority. 1 One quart er of children in California —about 2.3 million —are estimated to live in poverty. If not for social safety net program assistance, an additional 1.28 million would live in families without the resources to meet basic needs (Bohn e t al. , 2013; Wimer et al. , 2013). Despite the importance of safety net programs , there is evidence of under enrollment in Medi -Cal and CalFresh relative to the size of California’s eligible population. 2 Further more, the percenta ge of children not in poverty due to their families’ participation in social safety net programs appears to vary regionally (Bohn and Danielson, 2014). Finally, there is evidence nationally that children are not always enrolled in the combination of safety net programs for which they are eligible (Todd, Newman, and Ver Ploeg, 2011) , which may also be the case in California. The expansion of health insurance under the Affordable Care Act (ACA) has as its goal maximizing coverage for all legal residents . This has catalyzed broader efforts at both the state and federal level s to further integrate health and human service s program administration in order to improve participation in programs and to increase government efficiency ( Legislative Analyst 's Office , 2014; Do rn et al., 2013, Dorn and Peters, 2014 ). Recognizing the role administration plays in improving program access, the ACA included provisions to streamline the enrollment process —standardizing income eligibility and investing in information technology (IT) s ystems to make enrolling in subsidized insurance coverage more straightforward. California took advantage of this funding and created new streamlined systems to process enrollment . However, policymakers also retained the longstanding delegation of authori ty to counties to administer eligibility and enrollment for the Medi -Cal program. L ocal administration allows for greater flexibility and control to serve the needs of different communities , but it does raise questions of efficiency and equity. Ultimately, these are federally supported programs with uniform eligibility guidelines across the state, even the nation (Belshé and McConville, 2013; Danielson, 2013). Fostering equity throughout California is an important policy goal . Even before policy changes ushered in by the ACA, c hildren have had the broadest access to public health insurance, nutrition , and cash assistance. O ver the past decade, public insurance expansions for children — coupled with outreach and policy efforts to connect all children to insurance and other safety net supports — became a policy goal. 3 Now that the ACA has made maximized health insurance enrollment and program integration a policy priority, we can benefit by examining historical patterns of children’s participation . 1 The creation of the federal State Children’s Health Insurance Program (S -CHIP) and other state and local efforts throughout California over the past decade have been focused on expanding insurance cov erage opportunities for children. Federal law mandates automatic enrollment of school children in NSLP if they receive CalFresh, CalWORKs, or have certain other characteristics. Federal law allows states to enroll children in WIC if they fall within higher income eligibility guidelines for Medi- Cal. All of these efforts were accompanied by targeted strategies to maximize enrollment in available programs. 2 In particular, in 2011 about 84% of California’s eligible children and 63% of eligible adults are enro lled in Medi-Cal and just over half of eligible residents enroll in CalFresh. This places California in the middle range relative to other states for Medi-Cal participation and near the bottom for CalFresh (Cunnyngham, Sukasih, and Castner, 2014; Kenney e t al ,. 2012). 3 Availability of public health insurance programs for children expanded well before the economic downturn with the creation of the federal Children’s Health Insurance Program (CHIP) in 1998 and additional county -level efforts (Healthy Kids) in California that began early this decade. Although both CHIP and Healthy Kids programs were already established, targeted outreach and enrollment campaigns, in cluding the availability of electronic, web -based enrollment tools, increased access over the pa st decade for all children’s health insurance programs. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 6 What we discover by doing so can help inform efforts to integrate programs moving forward—not just for children, but for families as well . It can also provide context to help us understand the role local administration may play in differential enrollment levels across the state . That understanding can inform strategies to support enrollment goals across the state, particularly when the number eligible is changing rapidly . 4 In this report, we first provide an overview of the programs available to California children and describe statewide trends in enrollment over the past decade, in cluding during the recent recession. We focus primarily on Medi -Cal and CalFresh , large -scale programs that enroll mill ions of low-income children, although they are not limited to children. We also make some comparisons to participation in two other programs focused solely on children : the Natio nal School Lunch Program (NSLP) and the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC). 5 Next , we examin e differences in enrollmen t levels for low-income children across counties to better understand how changes in economic need, administrative capacity, and enrollment opportunities a ffect program participation . Finally, we look at patterns of low -income children using multiple health and nutrition programs and discuss how “ horizontal integration ”—the pursuit of connections across safety net programs —might help maximize enrollment in health insurance affordability programs among other family members. 4 With the expansion of Medi -Cal, the state role in funding county administrative costs for enrollment has been in flux. The governor’s 2015 –16 budget proposal notes the state’s intention to review th e budgeting methodology once the new eligibility system is fully functional. 5 The technical appendices also provide comparative analysis of two other programs. The first is CalWORK s, California’s cash assistance program for low -income families with children. The second is the predecessor program to the Targeted Low -Income Children’s Program, which was known as Healthy Families, and which served children with incomes below 250% of FP L who did not meet the income criteria for Medi-Cal. This program was centrally administered, but beginning in 2013 children enrolled in Healthy Families were transitioned to the Targeted Low - Income Children’s Program, which is county -administered as part of Medi-Cal. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 7 The Scope of California’s Health and N utrition Safety Net for Children Although diverse, the f o ur health and nutrition assistance programs described in Table 1 share overlapping goals and eligibility criteria. All require family incomes to be below a defined percentage of the federal poverty line to qualify for benefits . All are intended to improve outcomes for low -income children — and often low -income adults—by providing them with access to health care and adequate nutrition . Statewide, these programs serve millions of children . D epending on the program, between 1.14 million and 3.78 million children were enrolled as of July 2012. TABLE 1 Major public health and nutrition assistance programs that serve children Program name Number of children statewide (2012) Eligibility thresholds (2012) Limited to children? Age of children served Local administration Medi-Cal 3.78 million 100%–200% (depending on age of child) No, but non-disabled adult beneficiaries are custodial parents (expanded in 2014) 0–18 Counties CalFresh 2.23 million 130% FPL No 0–17 Counties National School Lunch Program (NSLP) 3.33 million 185% FPL Yes 5–17 * Local education agencies/school districts Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 1.14 million 185% FPL No, but adult beneficiaries are pregnant, postpartum, or breastfeeding mothers 0 –4 Local WIC agencies NOTES: Eligibility thresholds for the Medi -Cal program have changed since 2012 . As of January 2014, children up to 150% FPL are eligible for no -cost , Medi -Cal coverage. As of 2013, children with incomes up to 250% of FPL are eligible for the Targeted Low -Income Children’s Program. Until 2013, children with income levels higher than the age -specific Medi -Cal thresholds were eligible for the Healthy Families, the state’s Children Health Insurance Program. T ypical age range s of children served are show n, but persons older than 18 may be enrolled under special circumstances. For example, the NSLP is available to some pre- school aged children. Differing income thresholds, age qualifications, and immigration st atus are three major reasons for varying program size . Although a ll programs target low -income children , income eligibility thresholds vary across programs . 6 At the low end, to qualify for no -cost health insurance through Medi -Cal, o lder children must have family incomes under 100% of the federal poverty level (FPL) —about $1,650 per month for a family of three. 7 CalFresh serves families with income s up to 130% of FPL.8 NSLP provides free school lunch (and often other meals) to school -aged children in families living under 130% of FPL and low -cost meals to those between 130% and 185% of FPL. In addition, c hildren who receive CalFresh are automatically eligible for free school meals. 9 Finally, WIC provides vouchers for specific foods, along with nutri tion education. It serves 6 Definitions of countable income and assets, along with family units, vary across programs. Across all programs families are allowed certain deductions from their gross income amount. Major categories of deductions include a portion of earnings, child support payments, expenses for child care and housing . 7 The eligibility thresholds for Medi- Cal increased on January 1, 2014 when the state expanded the Medi -Cal program under the ACA. The eligibility threshold for no -cost Medi-Cal coverage for older children is now 150% of the FPL. 8 Eligibility for CalFresh is not restricted by age. 9 Children enrolled in CalWORKs, California’s main cash assistance program, children who are in foster care, homeless, migrant, and runaway children are also all categorically eligible for free meals. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 8 children ages 0–4 and in general employs a higher income eligibility cut -off (185% of FPL). WIC also uses the Medi -Cal income cut -off when the latter is higher. 10 Beyond income and age, another important aspect of eligibility is immigration status. In order to qualify for Medi -Cal and CalFresh, children must generally be documented as legal residents or citizens. 11 WIC and school lunch do not require such documentati on. Although we do not have precise information on undocumented status, available estimates suggest the vast majority of children of undocumented immigrants are citizens and thus likely eligible for safety net programs if income qualified (Passel and Taylo r, 2010). Another defining aspect of all of these programs is that they are locally administered . This mean s local entities have primary responsibility for pr ocessing enrollment. California’s 58 counties enroll Medi-Cal and CalFresh recipients, 84 local a gencies administer the WIC program , and the more than 1 ,000 school districts across the state manage school meals enrollment . Why do eligible people not enroll? A number of factors could contribute to under enrollment in safety net programs. They include familiarity with the programs and their benefits, the costs of applying and keeping eligibility current ( both the time involved and potentially other costs, such as taking time off from work or finding child care ), and the degree to which a program is perceived positively. 12 Although constrained by state and federal regulations, there may be opportunities for local entities that administer these programs to increase enrollment among low - income populations by reducing the se barriers. Context shapes these factors substantially. For example, regions with higher immigrant populations may need to address informational barriers, while areas exposed to fluctuating economic conditions may need to find ways to adapt to relatively large caseload changes within a single year. When we examine the impact of some of these factors to explain different enrollment levels across counties, we find some interesting results. 10 Until 2013, infants under 200% of FPL were eligible f or Medi-Cal, a higher income threshold than for WIC. Children 5 and under were eligible if family incomes are under 133% of FPL. When the Targeted Low-Income Children's Program was begun within the Medi -Cal program (replacing the standalone Healthy Families program), t hese income thresholds rose to 250% of FPL for all children. Pregnant, post -partum, and breastfeeding women who meet the other program criteria are also eligible for WIC. 11 There are a few exceptions to this. Medi -Cal pays for emergency services for undoc umented immigrants and also includes a PRUCOL eligibility category for full-scope Medi -Cal benefits. Certain refugee groups are also eligible. 12 A review of the academic literature focused on examining participation rates in social safety net programs provides evidence about the role of three factors generally offered to explain low take -up among eligible populations -- stigma, transaction costs and administrative burden, and lack of information. The research evidence suggests that the level of administrative burden lowers program “take -up,” while automatic or default enrollment procedures increase participation. The review finds little support for the proposition that stigma influences participation, but acknowledges the difficulty of adequately testing stigma (Currie, 2004). http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 9 Enrollments grew during the recent recession The share of California’s children enrolled in safety net programs grew over the past decade. As of July 2012, nearly 40 percent of all children ages 0 –18 in the state were enrolled in the Medi -Cal program , compared to 33 percent in 2005 (Figure 1). CalFresh s erves a smaller proportion of California’s children, but participation increased the most dramatically during the recent recession, growing from 13 percent to 23 percent of all children. School lunch enrollment grew by 7 percentage points to half of all ag e-eligible children between 2005 and 2012. Participation in WIC was also substantial (about 45 percent of all children ages 0 –4) and also grew over the period. Defining the eligible population In this paper, we report both shares of all children participating in health and nutrition programs and shares of low -income children enrolled in these programs. Neither approach provides a precise estimate of the share of eligible children who receive benefits from one or several program s. The share of eligible children enrolled (of ten referred to as the take-up or participation rate) is a ratio of the actual caseload —as measured in administrative records —to the pool of all eligible children. Producing a reliable estimate depends on accur ately estimating the denominator of the ratio. This task is accomplished using survey, not administrative, data. Multiple differences between the concepts measured in large- scale, high-quality survey data and administrative data make such a calculation com plex. Principal differences include annual rather than monthly income reporting, insufficient information on sources of income and assets, and imperfect detail about family relationships, immigration status, and precise age. Estimates of the share of low -income children receiving benefits from health or nutrition program do provide an approximate sense of the reach of the program relative to the intended target population. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 10 FIGURE 1 Health and nutrition safety net programs served a larger share of all California children as the economy worsened SOURCE: California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services, MEDS database; California Department of Education ; California Department of Public Health; National Cancer Institute SEER population data. NOTE: Program enrollment is based on enrollment totals for the month of July in the given year. The denominator used for enrollment rates for Medi -Cal and CalFreshis the total number of children aged 0 to 18 even if program eligibility based on age may be more or less restrictive. Denominator s used for NSLP is school -aged children ages 5 –18. Denominat or used for WIC is children ages 0 –4. Variation in eligibility is t he primary factor we expect to see driving chang es in enrollment. During the Great Recession and after, California saw a massive deterioration in economic opportunities. The unemployment rate rose from an average of 5.4 percent in 2007 to a high of 12.4 percent in 2010 and continued to be above 10 percent through 2012 (Figure 2) . Concurrent with worsening employment prospects, child poverty rates also rose over this period. In 2007 Califor nia’s child poverty rate had reached a decade low of slightly more than 17 percent, but by 2012 it had increased by more than 6 percentage points to more than 23 percent. 13 Child participation in health and nutrition safety net programs increased statewide a s worsening economic conditions enlarged the number of potentially eligible children . 13 Here and below the estimates refer to official rather than supplemental poverty rates. 0% 20% 40% 60% 80% 100% Medi-Cal CalFresh NSLPWIC Program participation among all children 2005 2012 http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 11 FIGURE 2 Caseloads increased as the economy worsened and child poverty rates climbed SOURCE: California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services, MEDS database; US Census Bureau, Small Area Income and Poverty Estimates; California Employment Development Department. NOTE: Annual caseloads are for children under age 19 and based on total enrollment as of July of the given year. Unemployment rates are also based on July. The c hild poverty rate is an annual measure. Empirical models suggest that for every percentage point increase in the unemployment rate, counties saw a 0.6 percentage point increase in the share of children enrolled in Medi -Cal and a 1.1 percentage point increase in the share of children receiving benefits from CalFresh. 14 To put this in context, half of counties experienced an increase in their unemployment rates of 5.8 percentage points or greater between 2005 and 2012. The quantitative models imply that such a change drives up the share of all children participatin g in Medi -Cal by 3.2 percentage points and the share enrolled in CalFresh by 6.4 percentage points —or the majority of the actual change that occurred. 15 At the same time, Figure 3 indicates that between 2005 and 2012 both the share of all children and the share of low -income children participating in Medi- Cal and CalFresh increased. 16 This suggests that statewi de the increase in participation outstripped the increase in need—good news from the point of view of attaining full enrollment. In the next section, we shift our focus to the county level, examining factors that may play a role in the varying enrollment levels of low -income children across the state. 14 These models hold constant a broad range of other factors at the county level, including child poverty, the race -ethnic and age composition of the child population, and characteristics of county administration. See Technical Appendices A through C for a detailed description of the modeling strategy, data sources, and empirical estimates. 15 Other research that examines program caseloads nationally has established that they do respond strongly to economic expansions and recessions. See, for example, Bitler and Hoynes (2013), Danielson and Klerman (2013), and Klerman and Danielson (2011). 16 The share of low -income children participation in WIC and NSLP also increased over the time period. 0% 5% 10% 15% 20% 25% 0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 2003200420052006200720082009201020112012 Medi-Cal Child CaseloadCalFresh Child Caseload Child poverty rateUnemployment rate http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 12 FIGURE 3 The share of low -income children enrolled also increased during recent recession SOURCE: California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services, MEDS database; U.S. Census Bureau, Small Area Health Insurance Estimates. NOTE: The denominator for low -income participation rates is the child population age 19 and under with family income below 200% of the FPL. 0% 20% 40% 60% 80% 100% Medi-Cal CalFresh Medi-CalCalFresh Program participation among children 2005 2012 Participation rate — all children Participation rate — low -income children http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 13 Factors That Drive Differences in P rogram E nrollment among Low-I ncome Children The share of low -income children e nrolled in safety net programs differs widely from county to county in California . Figure 4 shows th is full range across all 58 counties . 17 Medi -Cal enrollment ranges from a low of 52 percent to about 100 percent . The spread is similarly broad for CalFresh, and slightly narrower for WIC and scho ol lunch . These variations reflect a multitude of factors that differ across counties . To complicate matters even more, these factors are all evolving at once. This is particularly true of the past decade, during which California experienced a severe recession and deep budget cuts . FIGURE 4 Program use among low -income children varied across counties and programs in 2012 SOURCE : California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services , MEDS database; California Department of Education ; Califor nia Department of Public Health ; US Census Bureau, Small Area Health Insurance Estimates. NOTE: The denominator for low -income participation rates is the child population age 19 and under with family income below 200% of the FPL , regardless of the specific age or income eligibility thresholds for the different programs. As discussed in the text, programs actually differ in their age and income eligib ility thresholds. In order to clarify what may be affecting pro gram enrollments, we examine three sets of specific factors that were changing within counties over the past decade and assess whether they have the potential to narrow differences across count ies in the share of low -income children enrolled. Two groups of factors that contain elements that may be amenable to policy intervention include county administrative resources and opportunities for program enrollment that exist outside of county offices. A third critical factor that we consider is the changing economic climate . 18 We analyze program caseload data reported by the different 17 This figure uses a "box and whiskers plot.” The lower edge o f the box denotes the relatively low enrollment (25th percentile) county, the upper edge of the box indicates the relatively high enrollment (75th percentile) county, and the line in the middle, the median cou nty. The whiskers denote the full range from lo west to highest. Each 25 percentage points demarcates approximately 15 counties out of California’s 58 counties. 18 In this section, we rely on a standard empirical strategy to isolate the roles of different types of factors that may affect program enrollm ent. This regression-based strategy , however, is not fool -proof. We discuss threats to the validity of our findings in Technical Appendix B. We do not 0 20 40 60 80 100 Medi-Cal CalFreshSchool Lunch WIC Percent of low-income children enrolled http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 14 state departments that oversee each program. 19 We combine t hese caseload data in quantitative models with information on county demographic s, economic conditions, administrative capacity, and other county -level resources obtained from federal survey and federal and state administrative data sources. Nearly 98 percent of California's children reside in 35 of the state's 58 c ounties. 20 For methodological reasons we focus on these 35 larger counties. Although the specific findings in this section of the report apply just to these counties , we believe the information has value for thinking about how to improve enrollment across all counties . For a detailed discussion of our data and methodological approach, see the technical a ppendices that accompany this report. In the following subsections, we wil l discuss first the factors that appear to have no effect on enrollments, and then move to those that do. Enrollment opportunities and outreach When we examine factors having to do with changes in outreach activities and enrollment opportunities within counties, we discover that these do not seem to affect levels of enrollment. Access to programs var ies across counties based on the extent of opportunities for enrollment , including the number of visits children make to community health clinics and hospitals , and the prevalence and outreach of community -based organizations . 21 Although the measures of enrollment opportunities we incorporate in our quantitative models do vary considerably across the 35 largest counties, we find no systematic associations between enrollment and observed changes in this group of factors. We also look at information collected by the Department of Social Services for the CalFresh program to determine whether adoption of certain county outreach practices are associated with changes in program enrollments among low -income children. Again , we do not find that the specific changes we measure are systematically associated with increased enrollments. 22 focus on differences across counties that a re largely unalterable in the short run (for example, their degree of urbanization).We also do not examine statewide or national changes —for instance the 2009 American Recovery and Reinvestment Act, or “stimulus bill” —that may have played a role in changin g program participation. 19 Note that the concepts of “participation” vary across programs, but generally represent enrollment. For Medi -Cal, counts represent certified eligibles as of July of each year, regardless of whether they used health care. For WIC, counts include those who were certified in the program and who were issued a food voucher as of July of each year (most, but not all, redeem v ouchers received). For CalFresh, counts represent those who were issued benefits on an EBT card as of July of ea ch year. Finally, school lunch counts include those enrolled in free or reduced -price meals as of October of each year (regardless of whether they decided to eat school meals). 20 We list all 58 counties and their share of the child population in 2012 in A ppendix A. 21 We quantify opportunities for enrollment using measures of child patients at community health clinics and hospitals, given th at health care providers often facilitate enrollment in Medi-Cal and are also one of the most common sites for CalFres h materials and application forms. Additionally, for public health insurance and, to a lesser degree, nutritional programs, enrollment could be related to the h ealth status and need for services among children within the county. The availability of other c ommunity-based resources, including organizations providing individual and family social services, could also enhance the ability of people to become aware of and enroll in safety net p rograms. Finally, knowledge about program availability and eligibility criteria is another important component of access and could vary based on the language abilities of potentially eligible populations, but we do not find that changes in the percentage of the population that is no n-English speaking are associated with progr am enrollments. 22 Specifically, we measure whether a county employs one or more of four practices: use of eligibility workers stationed outside of welfare offices (for example, in health clinics or employment offices), availability of outreach materials g eared towards non-citizens, use of local media public service announcements, and whether or not counties enabled enrollment at ten or more different types of locations. Counties have broad discretion as to the level and types of outreach strategies they em ploy, and these outreach practices plausibly capture differences in county culture. Other research has found that differing outreach strategies employed for public health insurance programs do have an impact on enrollment levels (Aizer, 2007; Cousineau et al., 2011). We modeled outreach strategies both as a single index (number of outreach strategies employed) and as five separate factors. In neither case did we obtain significant estimates. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 15 Local administration The U .S . Department of Hea lth and Human Services classifies California as “state supervised and county administered.” This means that s tate-level departments respond to federal requests and supervise county approaches to program administration, but California’s 58 counties engage in outreach to inform residents of their potential eligibility, process applications, and provide case management assistance. C ounty welfare departments are the primary enrollment entity for both Medi -Cal and CalFresh. School districts administer the school lunch program and local WIC agencies are responsible for the administration of that program . We find statistically significant and positive relationships for both these measures . We consider two aspects of county administrative capacity: full -time equivalent (FTE) county employees assigned to public welfare administration and the combined dollar amount of Medi -Cal , CalFresh, and CalWORKs funding the state provide s for county administration . 23 Even though state funding allocations for Medi -Cal, CalFresh, and CalWORKs county administration does capture factors other than personnel, these two measures are related: c ounties make decisions about employment levels based at lea st in part on available resources. Perhaps more important , these allocations are an annual signal of the level of resources available to support program enrollments, while staffing levels are a longer- term county decision. To capture the impact these county resources may have on enrollment levels and account for varying sizes of counties, we divide both measures by the low -income population . 24 In other words, holding a range of other factors constant , when county administrative resources relative to the size of the low -income population increased, the share of low -income children enrolled in CalFresh and Medi -Cal grew . For example, our research indicates that for every additional public welfare employee relative to every thousand low -income county residents, we estimate an increase of 0.7 percentage points in CalFresh enrollment and an increase of 1.0 percentage point in Medi -Cal enrollment. For every additional $10 in funding for administration relative to each low-income county resident , we estimate an increase of 0.6 percentage points in CalFresh enrollment and an increase of 2.0 percentage points in Medi -Cal enrollmen t. 25 In reality, three quarters of counties saw declines in per capita county public welfare employees over the period 2005 -2012. This was due both to generally declining numbers of county employees and to increasing numbers of low -income county residents . We find that a typical county decline in per capita welfare 23 There is evidence that counties tend to pool funds across safety net programs to cover shared administrative costs (Logan and Klerman, 2008; Rosenstein, et al., 2012). Medi -Cal allocations made up over half of total state administrative allocations for CalFresh, CalWORKs, and Medi-Cal in every year between 2005 and 201 2. We use the initial allocations made at the beginning of the fiscal year rather than adjusted allocations that are determined toward the end of the fiscal year. While it could be the case that counties expect to be reimbursed for documented expenditures according to funding formulas, there is evidence that this has not been always the case in recent years (Rosenstein, et al., 2012). In other words, it is reasonable to suppose that counties acted in accordance with the level of state funding initially allo cated for their administrative costs. 24 We note that the current approach to allocating state funds for county administration of Medi -Cal is currently based on projected caseloads rather than low -income population. See Appendix C for a further discussion. In our analysis, w e divide both FTE counts and total administrative funding by the number of county residents estimated to have incomes below 150 percent of FPL, an estimate of the low -income population potentially eligible for these programs . Low -income, unauthorized immigrants are of necessity included in these estimates of county low -income populations. Our empirical strategy does adjust for unchanging county differences in factors such as the size of their unauthorized populations. However, there is un avoidable mis-measurement in our estimate of changing county resources given that unauthorized populations are more affected by labor market fluctuations and that the unauthorized population was dropping during this time period. 25 Note that the administrative funding variables shown in Appendix C are scaled to be an additional $100 per low -income resident. If the denominator of the funding allocation variable is specified as the entire population instead of the low -income population or as the anticipated caseload, the coefficient turns negative. We interpret these differences to mean that the estimates are sensitive to the defin ition of the population potentially eligible for the programs. See Appendix Tables C8 and C9 and the accompanying discussion for mo re details and additional robustness checks. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 16 employees is linked to a 1.2 percentage point drop in the share of low -income children en rolled in CalFresh and a 1.7 percentage point decline in the share of low -income children enrolled in Medi -Cal. 26 As a share of low -income county residents, state allocations for administration of these programs grew over the period, but peaked in most counties before 2012. Still, 32 of the 35 largest counties saw overall increases between 2005 and 2012. We find that a t ypical increase in administrative funding is associated with a 4. 2 percentage point increase in the share of low-income children e nrolled in CalFres h, and a 12. 4 percentage point growth in the share of low -income children enrolled in Medi -Cal . 27 These are im pressive increases. Yet as we show next, they were offset by reductions in enrollments engendered by the economic downturn. Local economic opportunities As noted above, half of the 35 largest counties saw increases in their unemployment rates of a t least 5.8 percentage points between 2005 and 2012. Such a change is associated with a 1 3.7 percentage point decrease in enrollment in Medi -Cal and a 5.6 percentage point decrease in CalFresh participation among low -income children. 28 In other words, the e xtraordinary change in the economy during and after the Great Recession appears to have retarded progress towards full enrollment in these programs among children. This is not 26 The median change in the number of public welfare employees per 1,000 county residents under 150 percent of FPL was -0.0025 over the period 2007 to 2012. Increases in per capita county employees is associated with a statistically significant increase in NSLP enrollments, but is not associated with statistically significant changes in Healthy Families or WIC participation. The relationship between welfare employees and NSLP enrollment is consistent with an inter pretation of counties directly enrolling CalFresh and CalWORKs students in NSLP using administrative data matches. 27 The median change in state administrative allocations per every 1,000 county residents under 150 percent of FPL was $617 over the period 2 005 to 2012. Increases in per capita administrative allocations are also associated with statistically significant increases in W IC and NSLP participation among low -income children, but a decrease in Healthy Families participation. 28 For NSLP, enrollments among low -income children are also negatively associated with the unemployment rate. We do not find a statistically significant relationship between the unemployment rate and either WIC or Healthy Families participation. The Role of Policies Does research find generally that policies drive social safety net program enrollment ? Yes, but the evidence is mixed: some, but not all, measured policy changes show a statistically significant relationship with the size of the caseload. SNAP (the federal name for CalFresh) is a program that has experienced considerable policy change over the late 1990s and int o the 2000s. Studies focusing on specific state -to -state policy changes find evidence that policies intended to reduce the burden of applying for and remaining enrolled in SNAP do increase caseloads ( Kornfeld, 2002; Kabbani and Wilde, 2003; Hanratty, 2006; Ratcliffe, McKernan, and Finegold, 2008; Mabli, Martin, and Castner, 2009; Klerman and Danielson, 2011). However, the policy changes can account for only a relatively small share (around one sixth) of the actual caseload increase that occurred over the 2000s (Klerman and Danielson, 2011). While these nationwide studies are not directly applicable to the context of county -administered programs, they do suggest that factors both within and outside of county control likely play a role in program enrollments and that effective strategies to maximize enrollment among those eligible are not necessarily obvious. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 17 because program enrollments shrank—we have seen that both Medi -Cal and CalFresh grew robustly —but rather because the number of those eligible grew faster than the number enrolled. There are several reasons why this might be the case. First, those newly eligible for a safety net program due to job loss might not have been aware of th eir eligibility, or not have realize d it in a timely way. Or they might not have taken the steps to apply because they did not expect to remain eligible for a lengthy period of time . Even though the precise mechanism is unclear, the evidence does suggest t hat when eligibility is changing rapidly , program enrollments may not keep pace . This dynamic underscores the need to step up enrollment ef forts when eligibility expands. Altogether, our models show that the combined effects of the weakening economy and the changes in county administrative capacity are important in determining health and nutrition program enrollments among low - income children. C ounties and the state can make use of this information now, to target the low-income population and aim to keep pace with, or even outpace, changes in this population in order to support enrollments . And even though state and county resource allocation decisions are complex, these findings demonstrate that increasing resources for counties with relatively low program enrollments is a promising strategy for boosting enrollments. In the next section of this report, we will explore how integrating administration of programs that serve overlapping populations might also be part of th e solution, not just for individual counties, but also helping to maximize enrollments statewide. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 18 Horizontal Integration — a Gateway to G reater Access California’s health and nutrition safety net programs are designed to serve families, individuals, and ch ildren of overlapping populations . The ACA is expanding opportunities to make enrollment in one program a gateway for accessing others. This “h orizontal inte gration”—eligibility determination and enrollment across multiple safety net programs —can increase participation, improve the client experience, and lower administrative costs. All these benefits can in turn help to alleviate what we have seen in the previous section —how enrollments can lag when the economy is in trouble and eligibility outpaces the administrative capacity of counties to keep up . Program integration for children was a priority in California even before the ACA . For example, t he state used a federal op tion to pilot a project aimed at simplifying Medi -Cal enrollment for school lunch program participants . Likewise, school districts are using administrative data matching to automatically certify students in CalFresh for school lunch. As we will show below, even with these pre- ACA efforts, there is room for improvement in integrating programs and increasing enrollment, particularly among school -aged children. T he ACA could also facilitate even greater integration across health and human services progr ams for low - income families and individuals , and invites further consideration o f the vision of integration in California ( Legislative Analyst ’s Office, 2014). Expanded health insurance options make it possible to connect more people to programs f or which they may be eligible. Likewise, current program enrollment s make it possible to identify people who may be newly eligible for Medi -Cal or subsidized coverage in Covered California. For example , the state’s Express Lane Enrollment Project uses CalFresh enrollment to qualify people for Medi - Cal without the need for an application or determination for 12 months . More than a quarter of a million Californians —233,000 adults and more than 48,000 children—have been enrolled in Medi -Cal that way . 29 The success of this program underscores the potential of horizontal integration to enroll people in available health insurance options. How often are low-income children enrolled in multiple health and nutrition programs? Despite the interest in horizon tal int egration , available data makes it difficult to assess the degree to which families and children participate in multiple safety net programs. Administrative enrollment data generally provide a highly accurate picture ( and are the source we rely on earlier i n this report). But they are collected and typically reported program -by -program . Moreover, although there are state efforts underway to provide more information on crossover enrollment , d ata on multiple program use are not routinely made available or examined. Administrative data also lack information on unenrolled family members who may be eligible. However, l arge-scale household survey data do offer the opportunity to examine usage of multiple safety net programs, albeit with some limitations. 30 We use a combination of information from the American 29 Enrollmen t reported as of December 5, 2014 by the California Department of Health Care Services. 30 Inaccurate reporting of program participation —due to misunderstanding, forgetting, or stigma —is a concern, as is the documented under- reporting of safety net program usage in major household surveys (Meyer et al., 2009; Davern et al. 200 9.) http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 19 Community Survey with aggregated administrative data on nutrition programs to provide a more complete picture ( see Bohn et al., 2013 , and Appendix D for more information ). This picture shows us that California’s low-income children make considerable use of safety net programs — particularly infa nts and young children (Figure 5 ). Regardless of age, four in ten participate in all available programs —public health insurance, CalFresh, and either WIC or the sc hool lunch program. About 95 percent under age 5 and 80 percent age s 5–18 make use of at least one program. Bundling of public health insurance with only one nutrition program is much more prevalent am ong children under five than older children. FIGURE 5 Nearly all low -income young children make use of at least one program but fewer school -aged, low -income children do SOURCE : American Community Survey, 2012 . NOTE: Low-income children are those with family incomes under 200 percent of FPL. Public health program participation includes Medi -Cal, Healthy Families, or other public insurance and refe rs to enrollment by the child. Nutrition programs include CalFresh, NSLP, and WIC. P articipation in CalFresh is based on someone in the household rec eiving benefits, while NSLP and WIC is based on child participation . For more information, refer to Appendix D. D espite the relatively high level of combining health and nutrition programs among low -income children, 25 percent of young children and 33 perc ent of school -aged children are enrolled in either public health insurance only or nutrition programs only . There are reasons why children may not need certain program benefits for which they may be eligible. The most obvious example is low -income children not enrolled in public health insurance may already have coverage through another source. However, when we look at children who do not participate in any programs or participate in only nutrition programs –about 40 percent of school -aged children and 30 percent of young children are uninsured. Income thresholds for CalFresh may limit the eligibility of some children , but it is less clear why children would not make use of the school lunch or WIC programs , given th ose programs’ higher income thresholds and 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Age 0 to 4 Age 5 to 18 All programs Health and one nutrition program Nutrition programs only Health insurance only Age 0–4 Age 5– 18 http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 20 relative ease of applying. Nevertheless, as we have shown, there is room for improvement in enrollment and in integrating programs, particularly among school -aged children. Opportunities to connect low -income adults to insurance coverage Increasing program integration could capitalize on low -income children’s relatively high rates of participation , in order to reach parents or other adults in their families who may be newly eligible under the ACA for Medi -Cal or subsidized health insurance coverage through Covered California. Near ly 2.5 million adults live in families with low -income children who participate in at least one health or nutrition program – and prior to the ACA coverage expansions , about 45 percent of those adults lacked health insurance (Figure 6 ). 31 Even beyond this g roup, the 21 percent with employer -based coverage —depending on the employee cost -sharing and affordability of the employer plan —may find subsidized or no-cost coverage through Covered California or Medi -Cal to be a viable alternative . Enhanced horizontal integration could facilitate the identification of those adults to help them obtain coverage. FIGURE 6 Many uninsured adults lived with a child participating in at least one health or nutrition safety net program SOURCE: American Community Survey, 2012 NOTE: Includes non -elderly adults age 19 to 64 who are in family units with at least one child that is participating in a public health insurance or nutrition program. Because we are looking at historical data, the figures we use are based on information that pre-dates the ACA coverage expansions. The proportion of uninsured Californians has undoubtedly declined g iven the larger- than-expected enrollment s in Medi -Cal and Covered California during the first year of the ACA. Still , millions remain uninsured . U sing family connections to other safety net programs could help to change that for the better. 31 An unknown share of these adults are likely undocumented immigrants and are not eligible for subsidized health insurance cove rage under the ACA coverage expansions. Uninsured 44% Public health insurance 32% Employer -based coverage 21% Other source 3% http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 21 Conclusion Maximizing enrollment in health insurance is a new policy goal under the ACA, one that affects not just those who became newly eligible for coverage as of January 2014, but also those who were previously eligible but not enrolled. During the first year of ACA implementation, t he increase in Medi -Cal enrollment was sizable —much larger than expected— and involved delays in processing new enrollees . T his experience underscores the need to understand the drivers of enrollment, potential sources for local -level differences, and the opportunities more integrated systems could offer. Throughout the state, enrollment in health and nutrition safety net progr ams among low-income children—a group for whom eligibility has not changed substantially because of the ACA —is quite high and did expand over the recent economic downturn. However, there are differences in enrollment levels among children across counties. What drives these differences depends in large part on how we define the target population. When we focus on the share of all children enrolled, changes in economic conditions such as local area unemployment rates and child poverty rates account for the li on’s share of observed differences. However, when we focus on the enrollments among low -income children, we see that county public welfare personnel and state funding allocations for program administration are systematically associated with enrollments in both CalFresh and Medi -Cal . Since administrative resources play a role in differential enrollment levels among low -income populations, it is important to use them strategically to maximize enrollment. Horizontal integration is one way to streamline enrollment processes and ease the administrative burden on both those applying for benefits and the government entities responsible for enrollment. Because safety net programs target overlapping populations, integrating them has the potential not only to maximize enr ollments for children, but also to expand participation by reaching uninsured adults newly eligible for subsidized health insurance. Broadening integration beyond programs administered by counties —specifically WIC and the school lunch program —could assist in increasing their reach. Among low -income children, particularly infants and young children, we see a relatively high level of bundling health and nutrition programs. About 70 percent of low -income children under age five benefit from both, and about h alf of low -income school -aged children are recipients of public health insurance and at least one nutrition program. Even so, particularly among school -aged children, it appears that improvements can be made , some of which are already underway. The changes brought about by the ACA, including requirements for more streamlined enrollment processes for public health insurance programs and large federal investments for IT eligibility and enrollment systems, clearly offer opportunities to improve the enrollment process for health insurance programs. In addition, state policymakers have coupled California's Medi -Cal expansion with special efforts to streamline access to additional safety net programs 32 and there have been calls for state legislators to s et out a vision for future integration of health and social safety net programs. Moving forward, it will be important to monitor enrollment levels in conjunction with changing administrative pro cesses and resource allocations. It will also be important to take advantage of available IT resources to facilitate increased integration across safety net programs, particularly before the window on federal investments closes at the end of 2015. 33 32 Recent legi slation includes Strengthening the Connection between CalFresh and Medi -Cal (AB 191) and Aligning Opportunities for Health (SB 1002). 33 The governor’s recently released budget proposal acknowledges the need for increased county resources to administer the Medi -Cal program and indicates continued monitoring to assess additional funding needs. A new Medi -Cal county administration budgeting methodology is planned for once the impacts of changes in eligibility systems and enr ollment processes brought about the ACA are better known. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 22 References Aizer, Anna. 2007. “Public Health Insurance, Program Take -up and Child Health” Review of Economics and Statistics , 89 (3):400 -415. Belshé, Kim and Shannon McConville. 2013. Rethinking the State -Local Relationship: Health Care. Public Policy Institute of California. Available at www.ppic.org/main/publication.asp?i=1045 . Bitler, Marianne and Hilary Hoynes. 2013. “The More Things Change, the More They Stay the Same: The Safety Net, Living Arrangements, and P overty in the Great Recession.” NBER Working Paper 19449. Available at www.nber.org/papers . Bitler, Marianne, Janet Currie, and John Karl Scholz. 2003. “WIC Participation and Eligibility.” Journal of Human Resources. 38 (S): 1139- 79. Bohn, Sarah and Caroline Danielson. 2014. Child Poverty and the Social Safety Net in California. Public Policy Institute of California. Available at http://www.ppic.org/main/publication_quick.asp?i=1114 Bohn, Sarah, Caroline Da nielson, Matt Levin, Marybeth Mattingly, and Christopher Wimer. 2013. The California Poverty Measure: A New Look at the Safety Net. Public Policy Institute of California. Available at w ww.ppic.org/main/publication.asp?i=1070 . Cousineau, Michael R., Gregory D. Stevens, and Albert Farias. 2011. “Measuring the Impact of Outreach and Enrollment Strategies for Public Health Insurance in California.” Health Services Research 46: 319- 335. Cunnyngham, Karen, Amang Sukasih, and Laura C astner. 2014. Empirical Bayes Shrinkage Estimates of State Supplemental Nutrition Assistance Program Participation Rates in 2009 -2011 for All Eligible People and the Working Poor. Mathematica Policy Research. Available at www.fns.usda.gov/sites/default/files/techpartrate2009 -2011.pdf. Currie, Janet. 2004.”The Take -Up of Social Benefits.” NBER Working Paper No. 10488. Danielson, Caroline and Jacob Alex Klerman. 2013 . “The Responsiveness of SNAP, NSLP, and WIC to Economic Conditions.” Unpublished conference paper presented at the Association for Public Policy and Management annual meeting, Washington, DC. Danielson, Caroline. 2013. Rethinking the State -Local Relationship: Social Services . Public Policy Institute of California. Available at www.ppic.org/main/publication.asp?i=1046 . Danielson, Caroline. 2012. “California’s Welfare Caseload.” Just the Facts . Public Policy Institute of California. Available at www.ppic.org/main/publication_show.asp?i=888 . Davern, Michael, Jacob Alex Klerman, David K Baugh, Kathleen Thiede Call, a nd George D Greenberg. 2009. “An Examination of the Medicaid Undercount in the Current Population Survey: Preliminary Results from Record Linking.” Health Services Research 44(3): 965-987. Dorn, Stan, Julia Isaacs, Sarah Minton, Erika Huber, Paul Johnson, Matthew Buettgens, and Laura Wheaton. 2013. Overlapping Eligibility and Enrollment: Human Services and Health Programs u nder the Affordable Care Act. Urban Institute. Available at http://aspe.hhs.gov/hsp/14/IntegrationProject/rpt_integrationproject.pdf Dor n, Stan and Rebecca Peters. 2014. Opportunities under the Affordable Care Act for Human Services Programs to Modernize Eligibility Systems and Expedite Eligibility Determination . Urban Institute. Available at http://aspe.hhs.gov/hsp/14/IntegrationProject/i b_ModernizeEligibilitySystems.pdf Hanratty, M. J. 2006. “Has the Food Stamp Program B ecome More Accessible? Impacts of R ecent Changes in R eporting R equirements and A sset Eligibility Limits. ” Journal of Policy Analysis and Management 25 : 603– 621. Kabbani, N. S., and Wilde, P. E. 2003 . “Short Recertification Periods in the U.S. Food Stamp Prog ram.” Journal of Human Resources. 38: 1112 –1138. Kenney, Genevieve, Victoria Lynch, Michael Huntress, Jennifer Hayley, and Nathaniel Anderson. 2012. Medicaid/CHIP Partic ipation Among Children and Parents . Urban Institute. Available at www.urban.org/health_policy/url.cfm?ID=412719. Klerman, Jacob Alex and Caroline Danielson. 2011. “The Transformat ion of the Supplemental Nutrition Assistance Program.” Journal of Policy Analysis and Management. 30 (4): 863– 888. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 23 Kornfeld, R. 2002. Explaining Recent Trends in Food Stamp Program Caseloads: Final Report U.S. Department of Agriculture, Economic Research Service. Retrieved April 21, 2011, from www.ers.usda.gov/Publications/efan02008/ . Legi slative Analyst’s Office. 2014. Integrating Health and Human Services Eligibility and Enrollment P rocesses. Available at www.lao.ca.gov/reports/2014/hhs/integrating -hhs-eligibility/integrating -hhs-eligibility -103014.pdf . Logan , Christopher and Jacob Alex Klerman. 2008. Feasibility of Assessing Causes of State Variation in Food Stamp Program Administrative Costs: Final Report. U.S. Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis. Available at www.fns.usda.gov/sites/default/files/sae.pdf . Mabli, J., E. S. Martin, and L. Castner. 2009. Effects of E conomic Conditions and P rogram Policy on State Food Stamp Program Caselo ads, 2000 to 2006. U.S. Department of Agriculture, Economic Research Service. Available at http://ddr.nal.usda.gov/bitstream/10113/35893/1/CAT31037490.pdf . Meyer, Bruce D., Wa llace K.C. Mok, and James X. Sullivan. 2009. “The Underreporting of Transfers in Household Surveys: Its Nature and Consequences.” NBER Working Paper No. 15181. Passel, Jeffrey and Paul Taylor. 2010. “Unauthorized Immigrants and their U.S. Born Children.” P ew Hispanic Center. Available at www.pewhispanic.org/2010/08/11/unauthorized -immigrants-and -their -us-born -children/ . Ratcliffe, C., S. McKernan and K. Finegold. 2008. “Effects of Food Stamp and TANF P olicies on Food Stamp Receipt.” Social Service Review 82: 291 -334. Rosenstein, Stan, Caroline Davis, and David Fosdick. 2012. Financing County Medi -Cal Eligibility and Enrollment in California. Califo rnia HealthCare Foundation. Available at http://www.chcf.org/publications/2012/07/financing - county -medical . Todd, Jessica E., Constance Newman, and Michelle Ver Ploeg. 2011. “Children’s Participation in Multiple Food Assistance Programs: Changes from 1990 to 2009.” Social Service Review 85 (1): 535-564. Wimer, Christopher, Marybeth Mattingly, Matt Levin, Caroline Danielson, and Sarah Bohn. 2013. “A Portrait of Poverty within California Counties and Demographic Groups. ” The Stanford Center on Poverty and Inequality. Available at http://web.stanford.edu/group/scspi/poverty/cpm/CPMBrief_CPI.pdf . http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 24 About the Author s Laurel Beck is a research fellow at the Public Policy Institute of California . She focuses on health policy, including program evaluation, insurance markets, and issues among aging populations. She has also researched the physical and men tal health of working mothers. Before joining PPIC, she was a research associate at the Federal Reserve Board of Governors and participated in doctoral trainee programs with the National Institute of Mental Health and the National Institute on Aging. She h olds a Ph.D. in economics from the University of Wisconsin –Madison. Caroline Danielson is a senior fellow at the Public Policy Institute of California. Her research focuses on multiple dimensions of the social safety net, including its role in mitigating poverty, program access and enrollment, and the integration and governance of programs. Her research has been supported by the Blue Shield of California Foundation, the California HealthCare Foundation, The Wal ter S. Johnson Foundation, the Stuart Foundation, and the U.S. Department of Agriculture. Before coming to PPIC she was a principal analyst at the University of California's Welfare Policy Research Project and a faculty member in the Department of Politics at the State University of New York, Potsdam. She holds a PhD in political science from the University of Michigan and a master’s in policy analysis from the Pardee RAND graduate school . Shannon McConville is a research associate at the Public Policy Institute of California . Before joining PPIC, she was a research training fellow in the Health Services and Policy Analy sis program at the University of California, Berkeley; a senior research associate at the Department of Health Research and Policy at Stanford University; and a project manager at the Lewis Center for Regional Policy Studies at the University of California , Los Angeles. Her research interests include health care access, utilization, and outcomes among vulnerable populations. She holds an M.P.P. degree from the University of California, Los Angeles. Acknowledgments The authors thank Frederic Blavin , Mia Bird, Kelly Brooks-Lindsey, and Lynette Ubois for their careful reviews and insightful comments on earlier drafts of this work. We also thank Chansonette Buck for excellent editorial support. Any errors or misinterpretations in this work are the auth ors’ alone. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 25 PUBLIC POLICY INSTITUTE OF CALIFORNIA Board of Directors Donna Lucas, Chair Chief Executive Officer Lucas Public Affairs Mark Baldassare President and CEO Public Policy Institute of California Ruben Barrales President and CEO GROW Elect María Blanco Executive Director Undocumented Student Legal Services Center University of California Office of the President Brigitte Bren Attorney Louise Henry Bryson Chair Emerita, Board of Trustees J. Paul Getty Trust Walter B. Hewlett Member, Board of Directors The William and Flora Hewlett Foundation Phil Isenberg Vice Chair, Delta Stewardship Council Mas Masumoto Author and Farmer Steven A. Merksamer Senior Partner Nielsen, Merksamer, Parrinello, Gross & Leoni, LLP Kim Polese Chairman ClearStreet, Inc. Thomas C. Sutton Retired Chairman and CEO Pacific Life Insurance Company The Public Policy Institute of Californi a is dedicated to informing and improvin g public policy in California through independent, objective, nonpartisan research on major eco nomic, social, and political issues. The institute’s goal is to raise public awareness and to give elected represen tatives and other decisionmakers a more informed basis for developing policies and programs. PPIC is a public charity. It does not take or support positions on any ballot measures or on any local, state, or federal legislation, nor does it endors e, support, or oppose any political pa rties or candidates for public office. PPIC was established in 1994 with an en dowment from William R. Hewlett. Mark Baldassare is President and Chief Executive Officer of PPIC. Donna Lucas is Chair of the Board of Directors. Short sections of text, not to exceed three paragraphs, ma y be quoted without written permission provided that full attribution is given to the source. Research publications reflect the views of the authors and do not necessarily reflect the views of the staff, officers, or Board of Directors of the Public Policy Institute of California. Copyright © 2015 Public Policy Institute of California All rights reserved. San Francisco, CA PUBLIC POLICY INSTITUTE OF CALIFORNIA 500 Washington Street, Suite 600 San Francisco, California 94111 phone: 415.291.4400 fax: 415.291.4401 www.ppic.org PPIC SACRAMENTO CENTER Senator Office Building 1121 L Street, Suite 801 Sacramento, California 95814 phone: 916.440.1120 fax: 916.440.1121" } ["___content":protected]=> string(102) "

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" ["_permalink":protected]=> string(124) "https://www.ppic.org/publication/enrollment-in-health-and-nutrition-safety-net-programs-among-californias-children/r_215lbr/" ["_next":protected]=> array(0) { } ["_prev":protected]=> array(0) { } ["_css_class":protected]=> NULL ["id"]=> int(8940) ["ID"]=> int(8940) ["post_author"]=> string(1) "1" ["post_content"]=> string(0) "" ["post_date"]=> string(19) "2017-05-20 02:42:19" ["post_excerpt"]=> string(0) "" ["post_parent"]=> int(4413) ["post_status"]=> string(7) "inherit" ["post_title"]=> string(8) "R 215LBR" ["post_type"]=> string(10) "attachment" ["slug"]=> string(8) "r_215lbr" ["__type":protected]=> NULL ["_wp_attached_file"]=> string(12) "R_215LBR.pdf" ["wpmf_size"]=> string(6) "405789" ["wpmf_filetype"]=> string(3) "pdf" ["wpmf_order"]=> string(1) "0" ["searchwp_content"]=> string(72458) "Enrollment in Health and Nutrition Safety Net Programs among California’s Children February 2015 Laurel Beck, Caroline Danielson, and Shannon McConville with research support from Marisol Cuellar and Landon Gibson Supported with funding from the Blue Shield of California Foundation Summary High enrollment in safety net programs for low -income children has long been a priority in California. In January 2014, majo r expansions in health insurance coverage programs under the Affordable Care Act (ACA) catalyzed efforts to better integrate safety net program s. Because these programs serve overlapping populations, integrating administration across them can increase part icipation, improve the client experience, and lower administrative costs. This report focuses on enrollment in public health insurance and nutrition assistance programs primarily among low-income children , using recent historical data to look both at statewide patterns and county -level factors that influence enrollments . As California increases efforts to achieve full participation for those qualified, examining these patterns can help inform plans to expand program integration. It can also hel p illuminate the role local administration plays so that policymakers can develop strategies that support counties coping with rising enrollments during times of economic stress. More than half of all California children and about 85 percent of low -income children participate in one or more public health insurance and nutrition assistance programs —Medi-Cal, which provides no -cost and low -cost health insurance, monthly CalFresh benefits, school meals, and specified foods from WIC. The state supervises these programs, and local entities —including county government, local WIC agencies, and school districts —administer them . Because all of these programs require low family income to qualify for benefits, worsening job opportunities during and after the recent recession resulted in higher program participation across the state. In deed, at the state level increases in participation outstripped the growth in need. Across all programs, increased county resources to administer programs helped to boost enrollments amo ng low-income children . At the same time, we find that the sharply weaker economy tended to offset these gains . As of 2012, nearly all low -income California children age s 0–4 and about four in five older children were enrolled in at least one health or nutrition program. From the point of view of attaining full enrollment in these programs, this is good news. Still, some children enrolled in one or more of the nutrition assistance program s lack ed health insurance , indicating that there is still room for improvement. T o build on t he positive momentum brought about by the ACA and to move toward full enrollment across counties, state policymakers can make use of our findings in several ways. They can aim to have funding allocations for program administratio n keep pace with changes in the low -income population. They can consider increasing resources for counties with relatively low program enrollments. They can take advantage of ACA funding for information technology (IT) investments through 2015 in order to implement a higher degree o f program integration. This latter step can, in turn , help to identify and enroll uninsured family members who may be eligible, and could be especially critical for counties during times of economic downturn, when eligibility may outpace administrative capacity. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 2 Contents Summary 2 Figures 4 Tables 4 Abbreviations 5 Introduction 6 The Scope of California’s Health and Nutrition Safety Net for Children 8 Why do eligible people not enroll? 9 Enrollments grew during the recent recession 10 Factors That Drive Differences in Program Enrollment among Low -Income Children 14 Enrollment opportunities and outreach 15 Local administration 16 Local economic opportunities 17 Horizontal Integration— a Gateway to Greater Access 19 How often are low-income children enrolled in multiple health and nutrition programs? 19 Opportunities to connect low-income adults to insurance coverage 21 Conclusion 22 References 23 About the Authors 25 Acknowledgments 25 Technical appendices to this paper are available on the PPIC website: www.ppic.org/content/pubs/other/215LBR_appendix.pdf http://www.ppic.org/main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 4 Figures 1. Health and nutrition safety net programs served a larger share of all California children as the economy worsened 11 2. Caseloads increased as the economy worsened and child poverty rates climbed 12 3. The share of low-income children enrolled also increased during recent recession 13 4. Program use among low-income children varied across counties and programs in 2012 14 5. Nearly all low-income young children make use of at least one program but fewer school-aged, low-income children do 20 6. Many uninsured adults lived with a child participating in at least one health or nutrition safety net program 21 Tables 1. Major public health and nutrition assistance programs that serve children 8 Abbreviations ACA Affordable Care Act CalWORKs California Work Opportunity and Responsibility to Kids CDE California Department of Education DHCS California Department of Health Care Services DPH California Department of Public Health DSS California Department of Social Services LEA Local Education Agency MRMIB Managed Risk Medical Insurance Board NSLP National School Lunch Program SNAP Supplemental Nutrition Assistance Program TANF Temporary Assistance for Needy Families WIC Supplemental Nutrition Assistance Program for Women, Infants, and Children http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 5 Introduction In this report, we focus on enrollment in public health insurance and nutrition assistance programs among low -income children —a particular population of concern, and one for which high enrollment in health and nutrition programs has been a longstanding priority. 1 One quart er of children in California —about 2.3 million —are estimated to live in poverty. If not for social safety net program assistance, an additional 1.28 million would live in families without the resources to meet basic needs (Bohn e t al. , 2013; Wimer et al. , 2013). Despite the importance of safety net programs , there is evidence of under enrollment in Medi -Cal and CalFresh relative to the size of California’s eligible population. 2 Further more, the percenta ge of children not in poverty due to their families’ participation in social safety net programs appears to vary regionally (Bohn and Danielson, 2014). Finally, there is evidence nationally that children are not always enrolled in the combination of safety net programs for which they are eligible (Todd, Newman, and Ver Ploeg, 2011) , which may also be the case in California. The expansion of health insurance under the Affordable Care Act (ACA) has as its goal maximizing coverage for all legal residents . This has catalyzed broader efforts at both the state and federal level s to further integrate health and human service s program administration in order to improve participation in programs and to increase government efficiency ( Legislative Analyst 's Office , 2014; Do rn et al., 2013, Dorn and Peters, 2014 ). Recognizing the role administration plays in improving program access, the ACA included provisions to streamline the enrollment process —standardizing income eligibility and investing in information technology (IT) s ystems to make enrolling in subsidized insurance coverage more straightforward. California took advantage of this funding and created new streamlined systems to process enrollment . However, policymakers also retained the longstanding delegation of authori ty to counties to administer eligibility and enrollment for the Medi -Cal program. L ocal administration allows for greater flexibility and control to serve the needs of different communities , but it does raise questions of efficiency and equity. Ultimately, these are federally supported programs with uniform eligibility guidelines across the state, even the nation (Belshé and McConville, 2013; Danielson, 2013). Fostering equity throughout California is an important policy goal . Even before policy changes ushered in by the ACA, c hildren have had the broadest access to public health insurance, nutrition , and cash assistance. O ver the past decade, public insurance expansions for children — coupled with outreach and policy efforts to connect all children to insurance and other safety net supports — became a policy goal. 3 Now that the ACA has made maximized health insurance enrollment and program integration a policy priority, we can benefit by examining historical patterns of children’s participation . 1 The creation of the federal State Children’s Health Insurance Program (S -CHIP) and other state and local efforts throughout California over the past decade have been focused on expanding insurance cov erage opportunities for children. Federal law mandates automatic enrollment of school children in NSLP if they receive CalFresh, CalWORKs, or have certain other characteristics. Federal law allows states to enroll children in WIC if they fall within higher income eligibility guidelines for Medi- Cal. All of these efforts were accompanied by targeted strategies to maximize enrollment in available programs. 2 In particular, in 2011 about 84% of California’s eligible children and 63% of eligible adults are enro lled in Medi-Cal and just over half of eligible residents enroll in CalFresh. This places California in the middle range relative to other states for Medi-Cal participation and near the bottom for CalFresh (Cunnyngham, Sukasih, and Castner, 2014; Kenney e t al ,. 2012). 3 Availability of public health insurance programs for children expanded well before the economic downturn with the creation of the federal Children’s Health Insurance Program (CHIP) in 1998 and additional county -level efforts (Healthy Kids) in California that began early this decade. Although both CHIP and Healthy Kids programs were already established, targeted outreach and enrollment campaigns, in cluding the availability of electronic, web -based enrollment tools, increased access over the pa st decade for all children’s health insurance programs. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 6 What we discover by doing so can help inform efforts to integrate programs moving forward—not just for children, but for families as well . It can also provide context to help us understand the role local administration may play in differential enrollment levels across the state . That understanding can inform strategies to support enrollment goals across the state, particularly when the number eligible is changing rapidly . 4 In this report, we first provide an overview of the programs available to California children and describe statewide trends in enrollment over the past decade, in cluding during the recent recession. We focus primarily on Medi -Cal and CalFresh , large -scale programs that enroll mill ions of low-income children, although they are not limited to children. We also make some comparisons to participation in two other programs focused solely on children : the Natio nal School Lunch Program (NSLP) and the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC). 5 Next , we examin e differences in enrollmen t levels for low-income children across counties to better understand how changes in economic need, administrative capacity, and enrollment opportunities a ffect program participation . Finally, we look at patterns of low -income children using multiple health and nutrition programs and discuss how “ horizontal integration ”—the pursuit of connections across safety net programs —might help maximize enrollment in health insurance affordability programs among other family members. 4 With the expansion of Medi -Cal, the state role in funding county administrative costs for enrollment has been in flux. The governor’s 2015 –16 budget proposal notes the state’s intention to review th e budgeting methodology once the new eligibility system is fully functional. 5 The technical appendices also provide comparative analysis of two other programs. The first is CalWORK s, California’s cash assistance program for low -income families with children. The second is the predecessor program to the Targeted Low -Income Children’s Program, which was known as Healthy Families, and which served children with incomes below 250% of FP L who did not meet the income criteria for Medi-Cal. This program was centrally administered, but beginning in 2013 children enrolled in Healthy Families were transitioned to the Targeted Low - Income Children’s Program, which is county -administered as part of Medi-Cal. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 7 The Scope of California’s Health and N utrition Safety Net for Children Although diverse, the f o ur health and nutrition assistance programs described in Table 1 share overlapping goals and eligibility criteria. All require family incomes to be below a defined percentage of the federal poverty line to qualify for benefits . All are intended to improve outcomes for low -income children — and often low -income adults—by providing them with access to health care and adequate nutrition . Statewide, these programs serve millions of children . D epending on the program, between 1.14 million and 3.78 million children were enrolled as of July 2012. TABLE 1 Major public health and nutrition assistance programs that serve children Program name Number of children statewide (2012) Eligibility thresholds (2012) Limited to children? Age of children served Local administration Medi-Cal 3.78 million 100%–200% (depending on age of child) No, but non-disabled adult beneficiaries are custodial parents (expanded in 2014) 0–18 Counties CalFresh 2.23 million 130% FPL No 0–17 Counties National School Lunch Program (NSLP) 3.33 million 185% FPL Yes 5–17 * Local education agencies/school districts Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 1.14 million 185% FPL No, but adult beneficiaries are pregnant, postpartum, or breastfeeding mothers 0 –4 Local WIC agencies NOTES: Eligibility thresholds for the Medi -Cal program have changed since 2012 . As of January 2014, children up to 150% FPL are eligible for no -cost , Medi -Cal coverage. As of 2013, children with incomes up to 250% of FPL are eligible for the Targeted Low -Income Children’s Program. Until 2013, children with income levels higher than the age -specific Medi -Cal thresholds were eligible for the Healthy Families, the state’s Children Health Insurance Program. T ypical age range s of children served are show n, but persons older than 18 may be enrolled under special circumstances. For example, the NSLP is available to some pre- school aged children. Differing income thresholds, age qualifications, and immigration st atus are three major reasons for varying program size . Although a ll programs target low -income children , income eligibility thresholds vary across programs . 6 At the low end, to qualify for no -cost health insurance through Medi -Cal, o lder children must have family incomes under 100% of the federal poverty level (FPL) —about $1,650 per month for a family of three. 7 CalFresh serves families with income s up to 130% of FPL.8 NSLP provides free school lunch (and often other meals) to school -aged children in families living under 130% of FPL and low -cost meals to those between 130% and 185% of FPL. In addition, c hildren who receive CalFresh are automatically eligible for free school meals. 9 Finally, WIC provides vouchers for specific foods, along with nutri tion education. It serves 6 Definitions of countable income and assets, along with family units, vary across programs. Across all programs families are allowed certain deductions from their gross income amount. Major categories of deductions include a portion of earnings, child support payments, expenses for child care and housing . 7 The eligibility thresholds for Medi- Cal increased on January 1, 2014 when the state expanded the Medi -Cal program under the ACA. The eligibility threshold for no -cost Medi-Cal coverage for older children is now 150% of the FPL. 8 Eligibility for CalFresh is not restricted by age. 9 Children enrolled in CalWORKs, California’s main cash assistance program, children who are in foster care, homeless, migrant, and runaway children are also all categorically eligible for free meals. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 8 children ages 0–4 and in general employs a higher income eligibility cut -off (185% of FPL). WIC also uses the Medi -Cal income cut -off when the latter is higher. 10 Beyond income and age, another important aspect of eligibility is immigration status. In order to qualify for Medi -Cal and CalFresh, children must generally be documented as legal residents or citizens. 11 WIC and school lunch do not require such documentati on. Although we do not have precise information on undocumented status, available estimates suggest the vast majority of children of undocumented immigrants are citizens and thus likely eligible for safety net programs if income qualified (Passel and Taylo r, 2010). Another defining aspect of all of these programs is that they are locally administered . This mean s local entities have primary responsibility for pr ocessing enrollment. California’s 58 counties enroll Medi-Cal and CalFresh recipients, 84 local a gencies administer the WIC program , and the more than 1 ,000 school districts across the state manage school meals enrollment . Why do eligible people not enroll? A number of factors could contribute to under enrollment in safety net programs. They include familiarity with the programs and their benefits, the costs of applying and keeping eligibility current ( both the time involved and potentially other costs, such as taking time off from work or finding child care ), and the degree to which a program is perceived positively. 12 Although constrained by state and federal regulations, there may be opportunities for local entities that administer these programs to increase enrollment among low - income populations by reducing the se barriers. Context shapes these factors substantially. For example, regions with higher immigrant populations may need to address informational barriers, while areas exposed to fluctuating economic conditions may need to find ways to adapt to relatively large caseload changes within a single year. When we examine the impact of some of these factors to explain different enrollment levels across counties, we find some interesting results. 10 Until 2013, infants under 200% of FPL were eligible f or Medi-Cal, a higher income threshold than for WIC. Children 5 and under were eligible if family incomes are under 133% of FPL. When the Targeted Low-Income Children's Program was begun within the Medi -Cal program (replacing the standalone Healthy Families program), t hese income thresholds rose to 250% of FPL for all children. Pregnant, post -partum, and breastfeeding women who meet the other program criteria are also eligible for WIC. 11 There are a few exceptions to this. Medi -Cal pays for emergency services for undoc umented immigrants and also includes a PRUCOL eligibility category for full-scope Medi -Cal benefits. Certain refugee groups are also eligible. 12 A review of the academic literature focused on examining participation rates in social safety net programs provides evidence about the role of three factors generally offered to explain low take -up among eligible populations -- stigma, transaction costs and administrative burden, and lack of information. The research evidence suggests that the level of administrative burden lowers program “take -up,” while automatic or default enrollment procedures increase participation. The review finds little support for the proposition that stigma influences participation, but acknowledges the difficulty of adequately testing stigma (Currie, 2004). http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 9 Enrollments grew during the recent recession The share of California’s children enrolled in safety net programs grew over the past decade. As of July 2012, nearly 40 percent of all children ages 0 –18 in the state were enrolled in the Medi -Cal program , compared to 33 percent in 2005 (Figure 1). CalFresh s erves a smaller proportion of California’s children, but participation increased the most dramatically during the recent recession, growing from 13 percent to 23 percent of all children. School lunch enrollment grew by 7 percentage points to half of all ag e-eligible children between 2005 and 2012. Participation in WIC was also substantial (about 45 percent of all children ages 0 –4) and also grew over the period. Defining the eligible population In this paper, we report both shares of all children participating in health and nutrition programs and shares of low -income children enrolled in these programs. Neither approach provides a precise estimate of the share of eligible children who receive benefits from one or several program s. The share of eligible children enrolled (of ten referred to as the take-up or participation rate) is a ratio of the actual caseload —as measured in administrative records —to the pool of all eligible children. Producing a reliable estimate depends on accur ately estimating the denominator of the ratio. This task is accomplished using survey, not administrative, data. Multiple differences between the concepts measured in large- scale, high-quality survey data and administrative data make such a calculation com plex. Principal differences include annual rather than monthly income reporting, insufficient information on sources of income and assets, and imperfect detail about family relationships, immigration status, and precise age. Estimates of the share of low -income children receiving benefits from health or nutrition program do provide an approximate sense of the reach of the program relative to the intended target population. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 10 FIGURE 1 Health and nutrition safety net programs served a larger share of all California children as the economy worsened SOURCE: California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services, MEDS database; California Department of Education ; California Department of Public Health; National Cancer Institute SEER population data. NOTE: Program enrollment is based on enrollment totals for the month of July in the given year. The denominator used for enrollment rates for Medi -Cal and CalFreshis the total number of children aged 0 to 18 even if program eligibility based on age may be more or less restrictive. Denominator s used for NSLP is school -aged children ages 5 –18. Denominat or used for WIC is children ages 0 –4. Variation in eligibility is t he primary factor we expect to see driving chang es in enrollment. During the Great Recession and after, California saw a massive deterioration in economic opportunities. The unemployment rate rose from an average of 5.4 percent in 2007 to a high of 12.4 percent in 2010 and continued to be above 10 percent through 2012 (Figure 2) . Concurrent with worsening employment prospects, child poverty rates also rose over this period. In 2007 Califor nia’s child poverty rate had reached a decade low of slightly more than 17 percent, but by 2012 it had increased by more than 6 percentage points to more than 23 percent. 13 Child participation in health and nutrition safety net programs increased statewide a s worsening economic conditions enlarged the number of potentially eligible children . 13 Here and below the estimates refer to official rather than supplemental poverty rates. 0% 20% 40% 60% 80% 100% Medi-Cal CalFresh NSLPWIC Program participation among all children 2005 2012 http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 11 FIGURE 2 Caseloads increased as the economy worsened and child poverty rates climbed SOURCE: California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services, MEDS database; US Census Bureau, Small Area Income and Poverty Estimates; California Employment Development Department. NOTE: Annual caseloads are for children under age 19 and based on total enrollment as of July of the given year. Unemployment rates are also based on July. The c hild poverty rate is an annual measure. Empirical models suggest that for every percentage point increase in the unemployment rate, counties saw a 0.6 percentage point increase in the share of children enrolled in Medi -Cal and a 1.1 percentage point increase in the share of children receiving benefits from CalFresh. 14 To put this in context, half of counties experienced an increase in their unemployment rates of 5.8 percentage points or greater between 2005 and 2012. The quantitative models imply that such a change drives up the share of all children participatin g in Medi -Cal by 3.2 percentage points and the share enrolled in CalFresh by 6.4 percentage points —or the majority of the actual change that occurred. 15 At the same time, Figure 3 indicates that between 2005 and 2012 both the share of all children and the share of low -income children participating in Medi- Cal and CalFresh increased. 16 This suggests that statewi de the increase in participation outstripped the increase in need—good news from the point of view of attaining full enrollment. In the next section, we shift our focus to the county level, examining factors that may play a role in the varying enrollment levels of low -income children across the state. 14 These models hold constant a broad range of other factors at the county level, including child poverty, the race -ethnic and age composition of the child population, and characteristics of county administration. See Technical Appendices A through C for a detailed description of the modeling strategy, data sources, and empirical estimates. 15 Other research that examines program caseloads nationally has established that they do respond strongly to economic expansions and recessions. See, for example, Bitler and Hoynes (2013), Danielson and Klerman (2013), and Klerman and Danielson (2011). 16 The share of low -income children participation in WIC and NSLP also increased over the time period. 0% 5% 10% 15% 20% 25% 0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 2003200420052006200720082009201020112012 Medi-Cal Child CaseloadCalFresh Child Caseload Child poverty rateUnemployment rate http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 12 FIGURE 3 The share of low -income children enrolled also increased during recent recession SOURCE: California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services, MEDS database; U.S. Census Bureau, Small Area Health Insurance Estimates. NOTE: The denominator for low -income participation rates is the child population age 19 and under with family income below 200% of the FPL. 0% 20% 40% 60% 80% 100% Medi-Cal CalFresh Medi-CalCalFresh Program participation among children 2005 2012 Participation rate — all children Participation rate — low -income children http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 13 Factors That Drive Differences in P rogram E nrollment among Low-I ncome Children The share of low -income children e nrolled in safety net programs differs widely from county to county in California . Figure 4 shows th is full range across all 58 counties . 17 Medi -Cal enrollment ranges from a low of 52 percent to about 100 percent . The spread is similarly broad for CalFresh, and slightly narrower for WIC and scho ol lunch . These variations reflect a multitude of factors that differ across counties . To complicate matters even more, these factors are all evolving at once. This is particularly true of the past decade, during which California experienced a severe recession and deep budget cuts . FIGURE 4 Program use among low -income children varied across counties and programs in 2012 SOURCE : California Department of Health Care Services, Medi -Cal annual enrollment reports; California Department of Social Services , MEDS database; California Department of Education ; Califor nia Department of Public Health ; US Census Bureau, Small Area Health Insurance Estimates. NOTE: The denominator for low -income participation rates is the child population age 19 and under with family income below 200% of the FPL , regardless of the specific age or income eligibility thresholds for the different programs. As discussed in the text, programs actually differ in their age and income eligib ility thresholds. In order to clarify what may be affecting pro gram enrollments, we examine three sets of specific factors that were changing within counties over the past decade and assess whether they have the potential to narrow differences across count ies in the share of low -income children enrolled. Two groups of factors that contain elements that may be amenable to policy intervention include county administrative resources and opportunities for program enrollment that exist outside of county offices. A third critical factor that we consider is the changing economic climate . 18 We analyze program caseload data reported by the different 17 This figure uses a "box and whiskers plot.” The lower edge o f the box denotes the relatively low enrollment (25th percentile) county, the upper edge of the box indicates the relatively high enrollment (75th percentile) county, and the line in the middle, the median cou nty. The whiskers denote the full range from lo west to highest. Each 25 percentage points demarcates approximately 15 counties out of California’s 58 counties. 18 In this section, we rely on a standard empirical strategy to isolate the roles of different types of factors that may affect program enrollm ent. This regression-based strategy , however, is not fool -proof. We discuss threats to the validity of our findings in Technical Appendix B. We do not 0 20 40 60 80 100 Medi-Cal CalFreshSchool Lunch WIC Percent of low-income children enrolled http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 14 state departments that oversee each program. 19 We combine t hese caseload data in quantitative models with information on county demographic s, economic conditions, administrative capacity, and other county -level resources obtained from federal survey and federal and state administrative data sources. Nearly 98 percent of California's children reside in 35 of the state's 58 c ounties. 20 For methodological reasons we focus on these 35 larger counties. Although the specific findings in this section of the report apply just to these counties , we believe the information has value for thinking about how to improve enrollment across all counties . For a detailed discussion of our data and methodological approach, see the technical a ppendices that accompany this report. In the following subsections, we wil l discuss first the factors that appear to have no effect on enrollments, and then move to those that do. Enrollment opportunities and outreach When we examine factors having to do with changes in outreach activities and enrollment opportunities within counties, we discover that these do not seem to affect levels of enrollment. Access to programs var ies across counties based on the extent of opportunities for enrollment , including the number of visits children make to community health clinics and hospitals , and the prevalence and outreach of community -based organizations . 21 Although the measures of enrollment opportunities we incorporate in our quantitative models do vary considerably across the 35 largest counties, we find no systematic associations between enrollment and observed changes in this group of factors. We also look at information collected by the Department of Social Services for the CalFresh program to determine whether adoption of certain county outreach practices are associated with changes in program enrollments among low -income children. Again , we do not find that the specific changes we measure are systematically associated with increased enrollments. 22 focus on differences across counties that a re largely unalterable in the short run (for example, their degree of urbanization).We also do not examine statewide or national changes —for instance the 2009 American Recovery and Reinvestment Act, or “stimulus bill” —that may have played a role in changin g program participation. 19 Note that the concepts of “participation” vary across programs, but generally represent enrollment. For Medi -Cal, counts represent certified eligibles as of July of each year, regardless of whether they used health care. For WIC, counts include those who were certified in the program and who were issued a food voucher as of July of each year (most, but not all, redeem v ouchers received). For CalFresh, counts represent those who were issued benefits on an EBT card as of July of ea ch year. Finally, school lunch counts include those enrolled in free or reduced -price meals as of October of each year (regardless of whether they decided to eat school meals). 20 We list all 58 counties and their share of the child population in 2012 in A ppendix A. 21 We quantify opportunities for enrollment using measures of child patients at community health clinics and hospitals, given th at health care providers often facilitate enrollment in Medi-Cal and are also one of the most common sites for CalFres h materials and application forms. Additionally, for public health insurance and, to a lesser degree, nutritional programs, enrollment could be related to the h ealth status and need for services among children within the county. The availability of other c ommunity-based resources, including organizations providing individual and family social services, could also enhance the ability of people to become aware of and enroll in safety net p rograms. Finally, knowledge about program availability and eligibility criteria is another important component of access and could vary based on the language abilities of potentially eligible populations, but we do not find that changes in the percentage of the population that is no n-English speaking are associated with progr am enrollments. 22 Specifically, we measure whether a county employs one or more of four practices: use of eligibility workers stationed outside of welfare offices (for example, in health clinics or employment offices), availability of outreach materials g eared towards non-citizens, use of local media public service announcements, and whether or not counties enabled enrollment at ten or more different types of locations. Counties have broad discretion as to the level and types of outreach strategies they em ploy, and these outreach practices plausibly capture differences in county culture. Other research has found that differing outreach strategies employed for public health insurance programs do have an impact on enrollment levels (Aizer, 2007; Cousineau et al., 2011). We modeled outreach strategies both as a single index (number of outreach strategies employed) and as five separate factors. In neither case did we obtain significant estimates. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 15 Local administration The U .S . Department of Hea lth and Human Services classifies California as “state supervised and county administered.” This means that s tate-level departments respond to federal requests and supervise county approaches to program administration, but California’s 58 counties engage in outreach to inform residents of their potential eligibility, process applications, and provide case management assistance. C ounty welfare departments are the primary enrollment entity for both Medi -Cal and CalFresh. School districts administer the school lunch program and local WIC agencies are responsible for the administration of that program . We find statistically significant and positive relationships for both these measures . We consider two aspects of county administrative capacity: full -time equivalent (FTE) county employees assigned to public welfare administration and the combined dollar amount of Medi -Cal , CalFresh, and CalWORKs funding the state provide s for county administration . 23 Even though state funding allocations for Medi -Cal, CalFresh, and CalWORKs county administration does capture factors other than personnel, these two measures are related: c ounties make decisions about employment levels based at lea st in part on available resources. Perhaps more important , these allocations are an annual signal of the level of resources available to support program enrollments, while staffing levels are a longer- term county decision. To capture the impact these county resources may have on enrollment levels and account for varying sizes of counties, we divide both measures by the low -income population . 24 In other words, holding a range of other factors constant , when county administrative resources relative to the size of the low -income population increased, the share of low -income children enrolled in CalFresh and Medi -Cal grew . For example, our research indicates that for every additional public welfare employee relative to every thousand low -income county residents, we estimate an increase of 0.7 percentage points in CalFresh enrollment and an increase of 1.0 percentage point in Medi -Cal enrollment. For every additional $10 in funding for administration relative to each low-income county resident , we estimate an increase of 0.6 percentage points in CalFresh enrollment and an increase of 2.0 percentage points in Medi -Cal enrollmen t. 25 In reality, three quarters of counties saw declines in per capita county public welfare employees over the period 2005 -2012. This was due both to generally declining numbers of county employees and to increasing numbers of low -income county residents . We find that a typical county decline in per capita welfare 23 There is evidence that counties tend to pool funds across safety net programs to cover shared administrative costs (Logan and Klerman, 2008; Rosenstein, et al., 2012). Medi -Cal allocations made up over half of total state administrative allocations for CalFresh, CalWORKs, and Medi-Cal in every year between 2005 and 201 2. We use the initial allocations made at the beginning of the fiscal year rather than adjusted allocations that are determined toward the end of the fiscal year. While it could be the case that counties expect to be reimbursed for documented expenditures according to funding formulas, there is evidence that this has not been always the case in recent years (Rosenstein, et al., 2012). In other words, it is reasonable to suppose that counties acted in accordance with the level of state funding initially allo cated for their administrative costs. 24 We note that the current approach to allocating state funds for county administration of Medi -Cal is currently based on projected caseloads rather than low -income population. See Appendix C for a further discussion. In our analysis, w e divide both FTE counts and total administrative funding by the number of county residents estimated to have incomes below 150 percent of FPL, an estimate of the low -income population potentially eligible for these programs . Low -income, unauthorized immigrants are of necessity included in these estimates of county low -income populations. Our empirical strategy does adjust for unchanging county differences in factors such as the size of their unauthorized populations. However, there is un avoidable mis-measurement in our estimate of changing county resources given that unauthorized populations are more affected by labor market fluctuations and that the unauthorized population was dropping during this time period. 25 Note that the administrative funding variables shown in Appendix C are scaled to be an additional $100 per low -income resident. If the denominator of the funding allocation variable is specified as the entire population instead of the low -income population or as the anticipated caseload, the coefficient turns negative. We interpret these differences to mean that the estimates are sensitive to the defin ition of the population potentially eligible for the programs. See Appendix Tables C8 and C9 and the accompanying discussion for mo re details and additional robustness checks. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 16 employees is linked to a 1.2 percentage point drop in the share of low -income children en rolled in CalFresh and a 1.7 percentage point decline in the share of low -income children enrolled in Medi -Cal. 26 As a share of low -income county residents, state allocations for administration of these programs grew over the period, but peaked in most counties before 2012. Still, 32 of the 35 largest counties saw overall increases between 2005 and 2012. We find that a t ypical increase in administrative funding is associated with a 4. 2 percentage point increase in the share of low-income children e nrolled in CalFres h, and a 12. 4 percentage point growth in the share of low -income children enrolled in Medi -Cal . 27 These are im pressive increases. Yet as we show next, they were offset by reductions in enrollments engendered by the economic downturn. Local economic opportunities As noted above, half of the 35 largest counties saw increases in their unemployment rates of a t least 5.8 percentage points between 2005 and 2012. Such a change is associated with a 1 3.7 percentage point decrease in enrollment in Medi -Cal and a 5.6 percentage point decrease in CalFresh participation among low -income children. 28 In other words, the e xtraordinary change in the economy during and after the Great Recession appears to have retarded progress towards full enrollment in these programs among children. This is not 26 The median change in the number of public welfare employees per 1,000 county residents under 150 percent of FPL was -0.0025 over the period 2007 to 2012. Increases in per capita county employees is associated with a statistically significant increase in NSLP enrollments, but is not associated with statistically significant changes in Healthy Families or WIC participation. The relationship between welfare employees and NSLP enrollment is consistent with an inter pretation of counties directly enrolling CalFresh and CalWORKs students in NSLP using administrative data matches. 27 The median change in state administrative allocations per every 1,000 county residents under 150 percent of FPL was $617 over the period 2 005 to 2012. Increases in per capita administrative allocations are also associated with statistically significant increases in W IC and NSLP participation among low -income children, but a decrease in Healthy Families participation. 28 For NSLP, enrollments among low -income children are also negatively associated with the unemployment rate. We do not find a statistically significant relationship between the unemployment rate and either WIC or Healthy Families participation. The Role of Policies Does research find generally that policies drive social safety net program enrollment ? Yes, but the evidence is mixed: some, but not all, measured policy changes show a statistically significant relationship with the size of the caseload. SNAP (the federal name for CalFresh) is a program that has experienced considerable policy change over the late 1990s and int o the 2000s. Studies focusing on specific state -to -state policy changes find evidence that policies intended to reduce the burden of applying for and remaining enrolled in SNAP do increase caseloads ( Kornfeld, 2002; Kabbani and Wilde, 2003; Hanratty, 2006; Ratcliffe, McKernan, and Finegold, 2008; Mabli, Martin, and Castner, 2009; Klerman and Danielson, 2011). However, the policy changes can account for only a relatively small share (around one sixth) of the actual caseload increase that occurred over the 2000s (Klerman and Danielson, 2011). While these nationwide studies are not directly applicable to the context of county -administered programs, they do suggest that factors both within and outside of county control likely play a role in program enrollments and that effective strategies to maximize enrollment among those eligible are not necessarily obvious. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 17 because program enrollments shrank—we have seen that both Medi -Cal and CalFresh grew robustly —but rather because the number of those eligible grew faster than the number enrolled. There are several reasons why this might be the case. First, those newly eligible for a safety net program due to job loss might not have been aware of th eir eligibility, or not have realize d it in a timely way. Or they might not have taken the steps to apply because they did not expect to remain eligible for a lengthy period of time . Even though the precise mechanism is unclear, the evidence does suggest t hat when eligibility is changing rapidly , program enrollments may not keep pace . This dynamic underscores the need to step up enrollment ef forts when eligibility expands. Altogether, our models show that the combined effects of the weakening economy and the changes in county administrative capacity are important in determining health and nutrition program enrollments among low - income children. C ounties and the state can make use of this information now, to target the low-income population and aim to keep pace with, or even outpace, changes in this population in order to support enrollments . And even though state and county resource allocation decisions are complex, these findings demonstrate that increasing resources for counties with relatively low program enrollments is a promising strategy for boosting enrollments. In the next section of this report, we will explore how integrating administration of programs that serve overlapping populations might also be part of th e solution, not just for individual counties, but also helping to maximize enrollments statewide. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 18 Horizontal Integration — a Gateway to G reater Access California’s health and nutrition safety net programs are designed to serve families, individuals, and ch ildren of overlapping populations . The ACA is expanding opportunities to make enrollment in one program a gateway for accessing others. This “h orizontal inte gration”—eligibility determination and enrollment across multiple safety net programs —can increase participation, improve the client experience, and lower administrative costs. All these benefits can in turn help to alleviate what we have seen in the previous section —how enrollments can lag when the economy is in trouble and eligibility outpaces the administrative capacity of counties to keep up . Program integration for children was a priority in California even before the ACA . For example, t he state used a federal op tion to pilot a project aimed at simplifying Medi -Cal enrollment for school lunch program participants . Likewise, school districts are using administrative data matching to automatically certify students in CalFresh for school lunch. As we will show below, even with these pre- ACA efforts, there is room for improvement in integrating programs and increasing enrollment, particularly among school -aged children. T he ACA could also facilitate even greater integration across health and human services progr ams for low - income families and individuals , and invites further consideration o f the vision of integration in California ( Legislative Analyst ’s Office, 2014). Expanded health insurance options make it possible to connect more people to programs f or which they may be eligible. Likewise, current program enrollment s make it possible to identify people who may be newly eligible for Medi -Cal or subsidized coverage in Covered California. For example , the state’s Express Lane Enrollment Project uses CalFresh enrollment to qualify people for Medi - Cal without the need for an application or determination for 12 months . More than a quarter of a million Californians —233,000 adults and more than 48,000 children—have been enrolled in Medi -Cal that way . 29 The success of this program underscores the potential of horizontal integration to enroll people in available health insurance options. How often are low-income children enrolled in multiple health and nutrition programs? Despite the interest in horizon tal int egration , available data makes it difficult to assess the degree to which families and children participate in multiple safety net programs. Administrative enrollment data generally provide a highly accurate picture ( and are the source we rely on earlier i n this report). But they are collected and typically reported program -by -program . Moreover, although there are state efforts underway to provide more information on crossover enrollment , d ata on multiple program use are not routinely made available or examined. Administrative data also lack information on unenrolled family members who may be eligible. However, l arge-scale household survey data do offer the opportunity to examine usage of multiple safety net programs, albeit with some limitations. 30 We use a combination of information from the American 29 Enrollmen t reported as of December 5, 2014 by the California Department of Health Care Services. 30 Inaccurate reporting of program participation —due to misunderstanding, forgetting, or stigma —is a concern, as is the documented under- reporting of safety net program usage in major household surveys (Meyer et al., 2009; Davern et al. 200 9.) http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 19 Community Survey with aggregated administrative data on nutrition programs to provide a more complete picture ( see Bohn et al., 2013 , and Appendix D for more information ). This picture shows us that California’s low-income children make considerable use of safety net programs — particularly infa nts and young children (Figure 5 ). Regardless of age, four in ten participate in all available programs —public health insurance, CalFresh, and either WIC or the sc hool lunch program. About 95 percent under age 5 and 80 percent age s 5–18 make use of at least one program. Bundling of public health insurance with only one nutrition program is much more prevalent am ong children under five than older children. FIGURE 5 Nearly all low -income young children make use of at least one program but fewer school -aged, low -income children do SOURCE : American Community Survey, 2012 . NOTE: Low-income children are those with family incomes under 200 percent of FPL. Public health program participation includes Medi -Cal, Healthy Families, or other public insurance and refe rs to enrollment by the child. Nutrition programs include CalFresh, NSLP, and WIC. P articipation in CalFresh is based on someone in the household rec eiving benefits, while NSLP and WIC is based on child participation . For more information, refer to Appendix D. D espite the relatively high level of combining health and nutrition programs among low -income children, 25 percent of young children and 33 perc ent of school -aged children are enrolled in either public health insurance only or nutrition programs only . There are reasons why children may not need certain program benefits for which they may be eligible. The most obvious example is low -income children not enrolled in public health insurance may already have coverage through another source. However, when we look at children who do not participate in any programs or participate in only nutrition programs –about 40 percent of school -aged children and 30 percent of young children are uninsured. Income thresholds for CalFresh may limit the eligibility of some children , but it is less clear why children would not make use of the school lunch or WIC programs , given th ose programs’ higher income thresholds and 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Age 0 to 4 Age 5 to 18 All programs Health and one nutrition program Nutrition programs only Health insurance only Age 0–4 Age 5– 18 http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 20 relative ease of applying. Nevertheless, as we have shown, there is room for improvement in enrollment and in integrating programs, particularly among school -aged children. Opportunities to connect low -income adults to insurance coverage Increasing program integration could capitalize on low -income children’s relatively high rates of participation , in order to reach parents or other adults in their families who may be newly eligible under the ACA for Medi -Cal or subsidized health insurance coverage through Covered California. Near ly 2.5 million adults live in families with low -income children who participate in at least one health or nutrition program – and prior to the ACA coverage expansions , about 45 percent of those adults lacked health insurance (Figure 6 ). 31 Even beyond this g roup, the 21 percent with employer -based coverage —depending on the employee cost -sharing and affordability of the employer plan —may find subsidized or no-cost coverage through Covered California or Medi -Cal to be a viable alternative . Enhanced horizontal integration could facilitate the identification of those adults to help them obtain coverage. FIGURE 6 Many uninsured adults lived with a child participating in at least one health or nutrition safety net program SOURCE: American Community Survey, 2012 NOTE: Includes non -elderly adults age 19 to 64 who are in family units with at least one child that is participating in a public health insurance or nutrition program. Because we are looking at historical data, the figures we use are based on information that pre-dates the ACA coverage expansions. The proportion of uninsured Californians has undoubtedly declined g iven the larger- than-expected enrollment s in Medi -Cal and Covered California during the first year of the ACA. Still , millions remain uninsured . U sing family connections to other safety net programs could help to change that for the better. 31 An unknown share of these adults are likely undocumented immigrants and are not eligible for subsidized health insurance cove rage under the ACA coverage expansions. Uninsured 44% Public health insurance 32% Employer -based coverage 21% Other source 3% http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 21 Conclusion Maximizing enrollment in health insurance is a new policy goal under the ACA, one that affects not just those who became newly eligible for coverage as of January 2014, but also those who were previously eligible but not enrolled. During the first year of ACA implementation, t he increase in Medi -Cal enrollment was sizable —much larger than expected— and involved delays in processing new enrollees . T his experience underscores the need to understand the drivers of enrollment, potential sources for local -level differences, and the opportunities more integrated systems could offer. Throughout the state, enrollment in health and nutrition safety net progr ams among low-income children—a group for whom eligibility has not changed substantially because of the ACA —is quite high and did expand over the recent economic downturn. However, there are differences in enrollment levels among children across counties. What drives these differences depends in large part on how we define the target population. When we focus on the share of all children enrolled, changes in economic conditions such as local area unemployment rates and child poverty rates account for the li on’s share of observed differences. However, when we focus on the enrollments among low -income children, we see that county public welfare personnel and state funding allocations for program administration are systematically associated with enrollments in both CalFresh and Medi -Cal . Since administrative resources play a role in differential enrollment levels among low -income populations, it is important to use them strategically to maximize enrollment. Horizontal integration is one way to streamline enrollment processes and ease the administrative burden on both those applying for benefits and the government entities responsible for enrollment. Because safety net programs target overlapping populations, integrating them has the potential not only to maximize enr ollments for children, but also to expand participation by reaching uninsured adults newly eligible for subsidized health insurance. Broadening integration beyond programs administered by counties —specifically WIC and the school lunch program —could assist in increasing their reach. Among low -income children, particularly infants and young children, we see a relatively high level of bundling health and nutrition programs. About 70 percent of low -income children under age five benefit from both, and about h alf of low -income school -aged children are recipients of public health insurance and at least one nutrition program. Even so, particularly among school -aged children, it appears that improvements can be made , some of which are already underway. The changes brought about by the ACA, including requirements for more streamlined enrollment processes for public health insurance programs and large federal investments for IT eligibility and enrollment systems, clearly offer opportunities to improve the enrollment process for health insurance programs. In addition, state policymakers have coupled California's Medi -Cal expansion with special efforts to streamline access to additional safety net programs 32 and there have been calls for state legislators to s et out a vision for future integration of health and social safety net programs. Moving forward, it will be important to monitor enrollment levels in conjunction with changing administrative pro cesses and resource allocations. It will also be important to take advantage of available IT resources to facilitate increased integration across safety net programs, particularly before the window on federal investments closes at the end of 2015. 33 32 Recent legi slation includes Strengthening the Connection between CalFresh and Medi -Cal (AB 191) and Aligning Opportunities for Health (SB 1002). 33 The governor’s recently released budget proposal acknowledges the need for increased county resources to administer the Medi -Cal program and indicates continued monitoring to assess additional funding needs. A new Medi -Cal county administration budgeting methodology is planned for once the impacts of changes in eligibility systems and enr ollment processes brought about the ACA are better known. http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 22 References Aizer, Anna. 2007. “Public Health Insurance, Program Take -up and Child Health” Review of Economics and Statistics , 89 (3):400 -415. Belshé, Kim and Shannon McConville. 2013. Rethinking the State -Local Relationship: Health Care. Public Policy Institute of California. Available at www.ppic.org/main/publication.asp?i=1045 . Bitler, Marianne and Hilary Hoynes. 2013. “The More Things Change, the More They Stay the Same: The Safety Net, Living Arrangements, and P overty in the Great Recession.” NBER Working Paper 19449. Available at www.nber.org/papers . Bitler, Marianne, Janet Currie, and John Karl Scholz. 2003. “WIC Participation and Eligibility.” Journal of Human Resources. 38 (S): 1139- 79. Bohn, Sarah and Caroline Danielson. 2014. Child Poverty and the Social Safety Net in California. Public Policy Institute of California. Available at http://www.ppic.org/main/publication_quick.asp?i=1114 Bohn, Sarah, Caroline Da nielson, Matt Levin, Marybeth Mattingly, and Christopher Wimer. 2013. The California Poverty Measure: A New Look at the Safety Net. Public Policy Institute of California. Available at w ww.ppic.org/main/publication.asp?i=1070 . Cousineau, Michael R., Gregory D. Stevens, and Albert Farias. 2011. “Measuring the Impact of Outreach and Enrollment Strategies for Public Health Insurance in California.” Health Services Research 46: 319- 335. Cunnyngham, Karen, Amang Sukasih, and Laura C astner. 2014. Empirical Bayes Shrinkage Estimates of State Supplemental Nutrition Assistance Program Participation Rates in 2009 -2011 for All Eligible People and the Working Poor. Mathematica Policy Research. Available at www.fns.usda.gov/sites/default/files/techpartrate2009 -2011.pdf. Currie, Janet. 2004.”The Take -Up of Social Benefits.” NBER Working Paper No. 10488. Danielson, Caroline and Jacob Alex Klerman. 2013 . “The Responsiveness of SNAP, NSLP, and WIC to Economic Conditions.” Unpublished conference paper presented at the Association for Public Policy and Management annual meeting, Washington, DC. Danielson, Caroline. 2013. Rethinking the State -Local Relationship: Social Services . Public Policy Institute of California. Available at www.ppic.org/main/publication.asp?i=1046 . Danielson, Caroline. 2012. “California’s Welfare Caseload.” Just the Facts . Public Policy Institute of California. Available at www.ppic.org/main/publication_show.asp?i=888 . Davern, Michael, Jacob Alex Klerman, David K Baugh, Kathleen Thiede Call, a nd George D Greenberg. 2009. “An Examination of the Medicaid Undercount in the Current Population Survey: Preliminary Results from Record Linking.” Health Services Research 44(3): 965-987. Dorn, Stan, Julia Isaacs, Sarah Minton, Erika Huber, Paul Johnson, Matthew Buettgens, and Laura Wheaton. 2013. Overlapping Eligibility and Enrollment: Human Services and Health Programs u nder the Affordable Care Act. Urban Institute. Available at http://aspe.hhs.gov/hsp/14/IntegrationProject/rpt_integrationproject.pdf Dor n, Stan and Rebecca Peters. 2014. Opportunities under the Affordable Care Act for Human Services Programs to Modernize Eligibility Systems and Expedite Eligibility Determination . Urban Institute. Available at http://aspe.hhs.gov/hsp/14/IntegrationProject/i b_ModernizeEligibilitySystems.pdf Hanratty, M. J. 2006. “Has the Food Stamp Program B ecome More Accessible? Impacts of R ecent Changes in R eporting R equirements and A sset Eligibility Limits. ” Journal of Policy Analysis and Management 25 : 603– 621. Kabbani, N. S., and Wilde, P. E. 2003 . “Short Recertification Periods in the U.S. Food Stamp Prog ram.” Journal of Human Resources. 38: 1112 –1138. Kenney, Genevieve, Victoria Lynch, Michael Huntress, Jennifer Hayley, and Nathaniel Anderson. 2012. Medicaid/CHIP Partic ipation Among Children and Parents . Urban Institute. Available at www.urban.org/health_policy/url.cfm?ID=412719. Klerman, Jacob Alex and Caroline Danielson. 2011. “The Transformat ion of the Supplemental Nutrition Assistance Program.” Journal of Policy Analysis and Management. 30 (4): 863– 888. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 23 Kornfeld, R. 2002. Explaining Recent Trends in Food Stamp Program Caseloads: Final Report U.S. Department of Agriculture, Economic Research Service. Retrieved April 21, 2011, from www.ers.usda.gov/Publications/efan02008/ . Legi slative Analyst’s Office. 2014. Integrating Health and Human Services Eligibility and Enrollment P rocesses. Available at www.lao.ca.gov/reports/2014/hhs/integrating -hhs-eligibility/integrating -hhs-eligibility -103014.pdf . Logan , Christopher and Jacob Alex Klerman. 2008. Feasibility of Assessing Causes of State Variation in Food Stamp Program Administrative Costs: Final Report. U.S. Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis. Available at www.fns.usda.gov/sites/default/files/sae.pdf . Mabli, J., E. S. Martin, and L. Castner. 2009. Effects of E conomic Conditions and P rogram Policy on State Food Stamp Program Caselo ads, 2000 to 2006. U.S. Department of Agriculture, Economic Research Service. Available at http://ddr.nal.usda.gov/bitstream/10113/35893/1/CAT31037490.pdf . Meyer, Bruce D., Wa llace K.C. Mok, and James X. Sullivan. 2009. “The Underreporting of Transfers in Household Surveys: Its Nature and Consequences.” NBER Working Paper No. 15181. Passel, Jeffrey and Paul Taylor. 2010. “Unauthorized Immigrants and their U.S. Born Children.” P ew Hispanic Center. Available at www.pewhispanic.org/2010/08/11/unauthorized -immigrants-and -their -us-born -children/ . Ratcliffe, C., S. McKernan and K. Finegold. 2008. “Effects of Food Stamp and TANF P olicies on Food Stamp Receipt.” Social Service Review 82: 291 -334. Rosenstein, Stan, Caroline Davis, and David Fosdick. 2012. Financing County Medi -Cal Eligibility and Enrollment in California. Califo rnia HealthCare Foundation. Available at http://www.chcf.org/publications/2012/07/financing - county -medical . Todd, Jessica E., Constance Newman, and Michelle Ver Ploeg. 2011. “Children’s Participation in Multiple Food Assistance Programs: Changes from 1990 to 2009.” Social Service Review 85 (1): 535-564. Wimer, Christopher, Marybeth Mattingly, Matt Levin, Caroline Danielson, and Sarah Bohn. 2013. “A Portrait of Poverty within California Counties and Demographic Groups. ” The Stanford Center on Poverty and Inequality. Available at http://web.stanford.edu/group/scspi/poverty/cpm/CPMBrief_CPI.pdf . http://www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 24 About the Author s Laurel Beck is a research fellow at the Public Policy Institute of California . She focuses on health policy, including program evaluation, insurance markets, and issues among aging populations. She has also researched the physical and men tal health of working mothers. Before joining PPIC, she was a research associate at the Federal Reserve Board of Governors and participated in doctoral trainee programs with the National Institute of Mental Health and the National Institute on Aging. She h olds a Ph.D. in economics from the University of Wisconsin –Madison. Caroline Danielson is a senior fellow at the Public Policy Institute of California. Her research focuses on multiple dimensions of the social safety net, including its role in mitigating poverty, program access and enrollment, and the integration and governance of programs. Her research has been supported by the Blue Shield of California Foundation, the California HealthCare Foundation, The Wal ter S. Johnson Foundation, the Stuart Foundation, and the U.S. Department of Agriculture. Before coming to PPIC she was a principal analyst at the University of California's Welfare Policy Research Project and a faculty member in the Department of Politics at the State University of New York, Potsdam. She holds a PhD in political science from the University of Michigan and a master’s in policy analysis from the Pardee RAND graduate school . Shannon McConville is a research associate at the Public Policy Institute of California . Before joining PPIC, she was a research training fellow in the Health Services and Policy Analy sis program at the University of California, Berkeley; a senior research associate at the Department of Health Research and Policy at Stanford University; and a project manager at the Lewis Center for Regional Policy Studies at the University of California , Los Angeles. Her research interests include health care access, utilization, and outcomes among vulnerable populations. She holds an M.P.P. degree from the University of California, Los Angeles. Acknowledgments The authors thank Frederic Blavin , Mia Bird, Kelly Brooks-Lindsey, and Lynette Ubois for their careful reviews and insightful comments on earlier drafts of this work. We also thank Chansonette Buck for excellent editorial support. Any errors or misinterpretations in this work are the auth ors’ alone. http:// www.ppic.org /main/home.asp Enrollment in Health and Nutrition Safety Net Programs among California’s Children 25 PUBLIC POLICY INSTITUTE OF CALIFORNIA Board of Directors Donna Lucas, Chair Chief Executive Officer Lucas Public Affairs Mark Baldassare President and CEO Public Policy Institute of California Ruben Barrales President and CEO GROW Elect María Blanco Executive Director Undocumented Student Legal Services Center University of California Office of the President Brigitte Bren Attorney Louise Henry Bryson Chair Emerita, Board of Trustees J. Paul Getty Trust Walter B. Hewlett Member, Board of Directors The William and Flora Hewlett Foundation Phil Isenberg Vice Chair, Delta Stewardship Council Mas Masumoto Author and Farmer Steven A. Merksamer Senior Partner Nielsen, Merksamer, Parrinello, Gross & Leoni, LLP Kim Polese Chairman ClearStreet, Inc. Thomas C. Sutton Retired Chairman and CEO Pacific Life Insurance Company The Public Policy Institute of Californi a is dedicated to informing and improvin g public policy in California through independent, objective, nonpartisan research on major eco nomic, social, and political issues. The institute’s goal is to raise public awareness and to give elected represen tatives and other decisionmakers a more informed basis for developing policies and programs. PPIC is a public charity. It does not take or support positions on any ballot measures or on any local, state, or federal legislation, nor does it endors e, support, or oppose any political pa rties or candidates for public office. PPIC was established in 1994 with an en dowment from William R. Hewlett. Mark Baldassare is President and Chief Executive Officer of PPIC. Donna Lucas is Chair of the Board of Directors. 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