Co-Enrollment in Safety-Net Programs Among Families with Young Children: A Multistate Analysis of Enrollment Gaps, Design and Implementation

Abstract Context: Development and implementation of multiprogram applications remain understudied. This study estimated enrollment gaps due to administrative burden and state policy environments, and explored state, nonprofit, policy, and caregiver stakeholders' perspectives on application design and implementation. 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.