Examines how grantees of RWJF's project to increase enrollment in Medicaid and State Children's Health Insurance Programs formed coalitions of community groups, government agencies, and others; what types of policy change they achieved; and for how long

Judith Wooldridge

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© Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfAdvocates and funders seek effective ways to modify statepolicies and procedures. Findings from the Covering Kids &Families® (CKF) program, sponsored by the Robert WoodJohnson Foundation (RWJF), indicate that coalitions ofcommunity-based organizations, government agencies,health plans, providers and advocates can be developed bygrantees to support and shape policy and procedural changes in state Medicaidprograms and the State Children’s Health Insurance Program (SCHIP), evenafter grant funding ends. This brief summarizes the following types of findingsrelating to state CKF coalitions: 1. Ways in which state grantees built coalitions that achieved policy changes;2. The types of changes coalitions supported; and 3. The sustainability of capacity and change after the grant period.BACKGROUNDRWJF developed the Covering Kids® program in 1999 to increase enrollmentand retention in Medicaid and the recently formed SCHIP program(Wooldridge 2007). In 2002 RWJF expanded Covering Kids to include families,renaming it Covering Kids & Families (CKF) (see insert on page 2). In all, RWJF funded 46 state CKF grantees; advocacy groups, health care and socialservice agencies, government agencies, academic institutions and health careproviders housed these grantees.1 The 46 state grantees in turn funded 152 localgrantees. RWJF required each grantee to form and work through a coalition, inorder to achieve desired changes as well as build “lasting capacity in states andcommunities to continue progress toward the initiative’s objectives even afterthe funding period” (RWJF 2001).2Contents1 Background2 Building Coalitions toAchieve Policy Change4 Creating Policy Change6 Sustaining Capacityand Change6 Conclusions7 Endnotes7 ReferencesCKF Coalitions Propel Policy and Procedural Changes Assessing theImpact of CoveringKids & Families®A national program ofthe Robert WoodJohnson Foundation®Mathematica PolicyResearch, Inc.P.O. Box 2393Princeton, N.J. 08543-2393This issue brief was written byMathematica Policy Research,Inc. Support for this publicationwas provided by the Robert WoodJohnson Foundation in Princeton,New Jersey.Issue Brief | November 2007Sheila Hoag, researcher, and Judith Wooldridge, senior vice president,Mathematica Policy Research, Inc. © Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfF I G U R E  1Types of State Coalition Members Issue Brief | CKF Coalitions Propel Policy and Procedural Changes2BUILDING COALITIONS TO ACHIEVE POLICY CHANGEState CKF grantees built diversified coalitions; this diversity gave coalitionsadvantages in pursuing CKF goals. State CKF coalitions are diverse: the most common type of members arecommunity–based organizations, such as children’s health and other healthadvocacy groups. Other members include health plans and providers,government officials, educators, business people and others (Figure 1).3Source: Lavin et al. 2004. Data extracted on October 7, 2003.Note: Government includes TANF, Medicaid, SCHIP and other government agency officials.34% Community-based Organization 1% Community Resident 3% Other Business5% Education  15% Other or Uncoded 20% Health Plans and Providers 22% Government CKF had two goals:• To increase Medicaid and SCHIP enrollment among eligible butuninsured children and families;• To retain Medicaid and SCHIP coverage for eligible enrollees.CKF specified three strategies to achieve these goals:• Outreach to those uninsured but eligible for the programs toencourage enrollment;• Simplification of SCHIP and Medicaid policies and procedures tomake it easier for families to enroll and stay enrolled in programs; and• Coordination between SCHIP and Medicaid to ensure that familiestransition easily between programs if they apply for the wrongprogram or if their eligibility changes. © Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfIssue Brief | CKF Coalitions Propel Policy and Procedural Changes3Different types of coalition members played different types of roles. For example, providers and school officials interacted with uninsuredindividuals through their work, and so became important sources for outreachwork. Organizations representing ethnic communities, as well as other advocacyorganizations, identified language or translation barriers to enrollment that might otherwise be unknown to state officials, leading to language simplificationsin applications, renewal forms and other state notices.State coalitions provided a place for working with Medicaid and SCHIP officials to change policies and procedures. As a condition of funding, RWJF required grantees to include state Medicaidand SCHIP officials as participants in the state coalitions. State CKF granteesnamed state Medicaid and SCHIP officials their most important collaborators,because of officials’ control over and ability to change Medicaid and SCHIPpolicies and procedures (Hoag and Stevens 2005). Moreover, coalitions had the greatest success implementing the CKF strategies if they included amongtheir members those SCHIP and Medicaid officials who had the authority to make program changes (Wooldridge 2007). State Medicaid and SCHIPofficials likewise valued the coalitions, noting that CKF coalitions created a communication network and a forum for policy dialogue, both importantlegacies of the program (Duchon, Ellis and Gifford, forthcoming 2008).Coalition membership remained stable over time. Throughout the four-year CKF grant, turnover among individuals and organiza-tions participating in most state CKF coalitions was low, allowing the coalitionsto focus on goals without the distraction of constant recruiting (Figure 2). Lowturnover suggests that members had a high level of commitment to CKF issues.F I G U R E  2Turnover Among State CKF Coalition Members Source: 2007 CKF Online Survey of Project Directors, Coordinators and Coalition Leaders, in response to the question “During the course of your four-year CKF grant, approximately how much turnover among members (either organizations or individuals) did you have in your coalition?” Preliminary data as of July 30, 2007.0 100PERCENT38 40 6 10 627 32 17 2 22n CKF coalition turnover was less than 10% over four yearsn CKF coalition turnover was between10% and 25% over four years n CKF coalition turnover was between25% and 50% over four years n CKF coalition turnover was more than 50% over four years n Don’t knowCKF Grantee Project Director or CoordinatorN=32CKF Coalition LeadersN=162© Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfIssue Brief | CKF Coalitions Propel Policy and Procedural Changes4CREATING POLICY CHANGEState coalitions pursued CKF strategies to increase coverage, resulting inpolicy and procedural changes. In the last year the coalitions operated under the RWJF grant, 63 percent ofcoalition leaders said outreach was their coalition’s highest priority, 26 percentsaid simplification was the highest priority and 28 percent said coordinationwas the highest priority.4 CKF grantees noted numerous ways their coalitionssupported their achievements on each of these fronts. For example:• Many coalitions pursued outreach. For example, after members of the Massachusetts coalition helped eliminate and enrollment freeze,coalition members conducted intensive outreach to eliminate the waitinglist of 15,000 within two months. In Maine, coalition members helpedsecure an eligibility expansion to childless adults, and then, workingindependently and with the state, initiated outreach to this group,resulting in 24,000 fewer uninsured individuals in Maine. • CKF coalitions often supported simplification activities. The OregonCKF coalition, for example, included attorneys with Medicaid expertisewho helped state officials understand how the state’s existing Medicaidapplication could be simplified and still meet federal requirements. Other coalitions focused on simplification of renewal policies andprocesses. For example, members of the Connecticut coalition collecteddata to support their interest in simplifying renewals, such as by using pre-populated and shorter renewal forms, which the state thenimplemented. In Washington, the coalition won reinstatement of 12 months’ continuous eligibility by showing the state the higher costs of churning associated with six-month eligibility rules, as well as bydocumenting the numerous administrative barriers resulting from themore restrictive policy.• Thirty CKF grantees said their most promising coordination activity was to identify or eliminate barriers that were interfering with coordination of policies; coalition members helped to identify these coordination gaps.© Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfIssue Brief | CKF Coalitions Propel Policy and Procedural Changes5For example, the Florida grantee and state coalition developed anorganizational flow chart showing the gaps in coordination among the four state agencies that administer Florida Medicaid and SCHIPeligibility, benefits and programs, helping the state to identify areas in which coordination improvements were needed. Coalitions inPennsylvania and Wyoming worked on aligning Medicaid and SCHIPpolicies to make it easier for beneficiaries to understand the two programsand to move from one to the other when their circumstances changed.• Coalitions in Maryland, Massachusetts, Louisiana and California, amongothers, worked to expand coverage policies in SCHIP to include additionalgroups of children, parents and pregnant women.CKF coalitions helped grantees confront barriers they faced. RWJF implemented CKF to overcome barriers to enrollment and retention.Forty percent of CKF grantees interviewed in 2006 reported that their coalitionhelped them overcome the greatest overall barrier they faced to achieving CFK goals, while 75 percent said their coalitions were helping them overcomethe greatest current barrier they were facing. Coalitions provided help throughtheir expertise and their contacts in the state, and by providing direct outreach,communicating accurate information to constituents when policy changesoccurred and identifying resources when needed. For example, when theDeficit Reduction Act (DRA) citizenship and identity documentationrequirement was implemented in 2006, several grantees reported that theircoalitions were an important source of information for state officials. The coalitions provided stories about barriers their clients encountered underthe new rules, such as conflicting instructions about the documentation thatapplicants needed to provide, or whether new rules applied only to Medicaidor also to SCHIP. The coalitions were also an important conduit for sharingand clarifying information about new state policies. © Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfIssue Brief | CKF Coalitions Propel Policy and Procedural Changes6SUSTAINING CAPACITY AND CHANGECoalitions can outlive initial funding and continue to work on increasinginsurance coverage. Before RWJF funding ended, more than half of grantees and state coalitionleaders interviewed expected that their state coalitions would be sustained after the funding ended, even though funding constraints would limit theiractivities (Stevens and Hoag 2005). An early look at an ongoing survey of CKF project directors and coordinators whose CKF grants ended between sixand 14 months before the survey was fielded, along with findings from asurvey of state Medicaid and SCHIP officials in December 2006 and January2007, suggests that most coalitions are continuing their roles as agents ofchange even though grant funding ended. Despite resource limitations,coalition members have found ways to continue pursuing CKF goals, whetherby taking on an activity themselves or as a group, or by promoting policies that support CKF goals through continued coalition meetings. Their successesin CKF—creating awareness of the number of uninsured children and adults,facilitating enrollment, simplifying processes, coordinating coverage andresisting reductions in coverage—demonstrate the relevance of coalitions forsustaining projects after funding ends.CONCLUSIONS Through their coalitions, CKF grantees brought interested and influentialparties together to help bring about desired change. State officials and othercoalition participants initially valued the coalitions because they established aforum for dialogue among these parties, in many cases for the first time. Overtime, coalition members used this new platform to advocate for policies thatsupport CKF goals. They particularly benefited from their members’ expertiseand experience about how various policies and procedures function in doctors’offices, emergency rooms, schools and workplaces throughout their states. A new survey of coalition members conducted in mid-2007 will provideupdated findings on sustainability. An early look at this data, together withfindings from a survey of state Medicaid and SCHIP officials in December2006 and January 2007, suggests that most coalitions are continuing their rolesas agents of change; how long this work can continue without an identified,sustainable source of funding remains unknown. In a world of ongoing policychanges, from the 2006 implementation of the DRA to the continuinguncertainty of SCHIP reauthorization, the coalitions’ work remains critical. © Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfIssue Brief | CKF Coalitions Propel Policy and Procedural Changes7Endnotes1. In addition to the 46 state grants, RWJF funded small liaison grants in theremaining five states (Wooldridge 2007).2. Each state had at least two local grantees, each of which formed a localcoalition. RWJF specified that “…local coalitions should serve as learninglaboratories for the statewide CKF coalitions.” (RWJF 2001). Local coalitionsthus provided information to state coalitions on effective outreach strategiesand barriers to enrollment.3. Local coalitions are similarly diverse, with most members coming fromcommunity-based organizations (38 percent), health plans and providers (22 percent), government agencies (13 percent) and educators (11 percent),among others (Lavin et al. 2004).4. From an ongoing survey of CKF coalition leaders, as of July 30, 2007. Sample size of coalition leaders was 162. Leaders could rank more than one objective as “first;” thus, the numbers sum to more than 100 percent.ReferencesDuchon L, Ellis E and Gifford K. Sustaining the Effects of Covering Kids & Families:Results of a Follow-up Telephone Survey of Medicaid and SCHIP Officials in 46 States. Forthcoming 2008.Hoag S and Stevens B. CKF Activities: A Collaborative Effort. Covering Kids &Families Evaluation Highlight Memo 13. Princeton, NJ: Mathematica PolicyResearch, Inc., May 2005. Available at www.rwjf.org/files/research/Highlight%20Memo%2013.pdf.Lavin B, Wooldridge J, Ellis E, et al. Covering Kids & Families Evaluation: AnAnalysis of CKF Coalitions. Princeton, NJ: Mathematica Policy Research, Inc., July 2004. Available at www.rwjf.org/files/research/Coalitions%20Synthesis.pdf.Robert Wood Johnson Foundation. Call for Proposals. Covering Kids & Families,May 2001.References continue on page 8.Stevens B and Hoag SD. Expectations of Sustainability: What Do CKF Granteesand State Officials Predict Will Happen Once RWJF Funding Ends? Covering Kids & Families Evaluation Highlight Memo 21. Princeton, NJ: Mathematica PolicyResearch, Inc., December 29, 2005. Available at www.rwjf.org/files/research/Highlight_Memo_21.pdf.Wooldridge J. Making Health Care A Reality for Low-income Children and Families.Issue Brief No. 2. Princeton, NJ: Robert Wood Johnson Foundation, February 2007.Available at www.rwjf.org/files/publications/other/CKFissueBrief2.pdf.Our Commitment to EvaluationThe Robert Wood Johnson Foundation is committed to rigorous, independentevaluations like this one. Evaluation is the cornerstone of our work and is part of the Foundation’s culture and practice. Our evaluation efforts often include variedapproaches to gather both qualitative and quantitative data. These evaluations arestructured to provide insight, test hypotheses, build a knowledge base for the field,and offer lessons learned to others interested in taking on similar efforts.Route 1 and College Road East P.O. Box 2316Princeton, New Jersey 08543-2316www.rwjf.org© Robert Wood Johnson Foundation | November 2007 | www.rwj f .org/pdf /CKFissuebr ie f5 .pdfIssue Brief | CKF Coalitions Propel Policy and Procedural Changes8

CKF Coalitions Propel Policy and Procedural Changes

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CKF Coalitions Propel Policy and Procedural Changes

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