202 - Safety-net Program Enrollment Gaps, Administrative Burden and Public Policy Environment among US-born and Immigrant Families with Young Children

Publication Number: 202.6354

Stephanie Ettinger de Cuba, Boston University School of Public Health, Boston, MA, United States; Richard Sheward, Boston University Chobanian & Avedisian School of Medicine, Brookline, MA, United States; Sharon M. Coleman, Boston University School of Public Health, Boston, MA, United States; Kathryn Barger, Boston University, Boston, MA, United States; Diana B. Cutts, Hennepin Healthcare, EXCELSIOR, MN, MN, United States; Maureen M. Black, University of Maryland School of Medicine, Severna Park, MD, United States; Eduardo R. Ochoa, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Megan Sandel, Boston University School of Medicine, Boston, MA, United States; Félice Lê-Scherban, Drexel University Dornsife School of Public Health, Philadelphia, PA, United States

Background: Safety-net programs support child and family health by mitigating material hardships. Families with low incomes are often eligible for multiple safety-net programs, but complex and repetitive application processes hinder enrollment, retention, and benefit redemption, leading to enrollment gaps.

Objective: To examine how safety-net program (i.e. Temporary Assistance for Needy Families (TANF); Medicaid; Supplemental Nutrition Assistance Program; Special Supplemental Nutrition Program for Women, Infants, and Children) enrollment gaps (participation in < 4 programs) among a diverse multistate cohort of low-income families with young children vary by Administrative Burdens and state policy environments (as measured by the State Safety Net Generosity Index (SSGI)).

Design/Methods: Data are from repeat cross-sectional Children’s HealthWatch surveys (2009-2019; n=39,321) of racially and ethnically diverse caregivers of children < 4 years from five U.S. cities. We constructed samples of low-income households eligible for TANF of (1) US-born caregivers (n=15,982); and (2) US-born and immigrant caregivers living in the US for >5 years (n=19,158). Enrollment Gap defined as not receiving maximum benefits for which they were likely eligible. Using logistic regression, associations were analyzed between Enrollment Gap and 1) reasons for non-participation by Administrative Burden Cost type: (Learning (program/rules awareness), Compliance (following program rules), or Psychological (stress/stigma from bureaucracy)) and 2) SSGI score.

Results: Differences by race and ethnicity were evident in the US-born sample, with more white and fewer Latina mothers reporting Enrollment Gaps. Compared to caregivers who reported one Enrollment Gap, odds of larger Enrollment Gaps were significantly higher among those reporting Compliance and Learning Costs. The highest odds ratios were in the sample including immigrant caregivers. (Table 1) States with higher SSGI scores (more generous) had lower odds of families reporting Enrollment Gaps (Figure 1; Table 2).

Conclusion(s): Enrollment gaps in key safety-net programs were associated with Administrative Burden, especially learning about and complying with program rules. Relative generosity of state safety-net program policies also played a role in families’ participation in the maximum number of benefits for which they were eligible. Many states are working to improve health through multi-program enrollment. Addressing burdens and implementing supportive vs. restrictive policies can drive effective integrated public systems.

Table 1: Multi-program Enrollment Gap by Administrative Burden Among Families with Young Children (Outcome: progressive increase in Enrollment Gap)
Covariates: Children's HealthWatch site, caregiver race/ethnicity, educational attainment, current employment, marital status, child age, nativity* (*TANF-eligible +immigrant sample)

Table 2: Multi-program Enrollment Gap by Increase in State Safety-Net Generosity Index (SSGI) Score (Outcome: Enrollment Gap (y/n))
Reflects a 10 unit increase in SSGI
Covariates: Caregiver race/ethnicity, educational attainment, current employment, marital status, child age, nativity* (*TANF-eligible +immigrant sample)


Figure 1. SSGI by state over study period