The impact of program design on enrollment in state children's health insurance programs

The success of State Children's Health Insurance Programs (SCHIP) in expanding insurance coverage among low-income children varies considerably across states. Scholars have looked to different program characteristics to explain this variation, but have arrived at disparate conclusions regarding the impact of one of the most significant design choices-the decision to create a new program or to pursue increased child health insurance rates through an expansion of the existing Medicaid program. This study suggests that understanding the impact of programmatic choices requires a more careful consideration of the mechanisms through which these different program designs might influence enrollment than has been offered in previous research. Employing a multilevel governance framework, it suggests that there is a hitherto unexplored indirect impact, where design choices influence administrative behavior, which in turn influences enrollment success in SCHIP programs. It is important to understand the effect of administrative design choices because this is one of the key areas in which states exercise discretion in the implementation of many federal programs.