Abstract
Methods: This mixed methods study included Children’s HealthWatch survey responses from 39,321 caregivers of young children (2009-2019), and interviews and focus groups with 25 stakeholders. Administrative burden theory provided a conceptual basis for diagnosing participant-facing system barriers underlying multi-benefit under-enrollment and the Consolidated Framework for Implementation Research (CFIR) characterized contextual determinants of multi-benefit application (i.e., policy innovation) design, implementation, and uptake. Using multinomial and binary logistic regression, enrollment gaps (non-participation in >1 of four safety-net programs: Medicaid, SNAP, TANF, WIC) were analyzed by non-participation reasons (administrative burden costs) and state policy environments (State Safety-Net Generosity Index (SSGI)). Transcripts were analyzed thematically using a hybrid inductive-deductive approach grounded in CFIR.
Findings: Enrollment gaps were significantly higher among caregivers reporting compliance and learning costs. Higher SSGI scores (more generous) were associated with significantly lower odds of enrollment gaps. Four qualitative themes emerged: (1) Incentives that help or hurt application implementation and uptake, (2) Benefit implementers’ accountability – to and for whom [Subtheme 2.1: Lack of transparency leads to mistrust and 2.2: Governance structures streamline or complicate] (3) (Re)defining efficiency—whose time is valuable? and (4) Meaning of engagement in application design.
Conclusions: This study advances administrative burden theory by demonstrating how program applicants’ administrative burden costs compound across multiple programs, revealing implementation mechanisms that perpetuate barriers. States working to improve co-enrollment must pay attention to unspoken incentives, reboot efficiency’s definition, and deeply engage all stakeholders.