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Health: Medicaid

To maintain health and well-being, people of all ages need access to quality health care that improves outcomes and reduces costs for the community. Colorado Medicaid is public health insurance for low-income Coloradans who qualify. The program is funded jointly by a federal-state partnership and is administered by the Colorado Department of Health Care Policy & Financing.

Benefits of the program include behavioral health, dental services, emergency care, family planning services, hospitalization, laboratory services, maternity care, newborn care, outpatient care, prescription drugs, preventive and wellness services, primary care and rehabilitative services.

In tandem with the Affordable Care Act, Colorado expanded Medicaid eligibility in 2013 – providing hundreds of thousands of Coloradans with health insurance for the first time and increasing the health and economic well-being of Colorado enrollees.

Most of the money for newly eligible Medicaid clients has been covered by the federal government, which will gradually decrease its contribution to 90% by 2020. Adults without dependent children can qualify for the program if they earn less than 133% FPL. Children and pregnant women qualify if their household income is under 260% FPL.

Some analyses indicate that Colorado’s investment in Medicaid will pay off in the long run by reducing spending on programs for the uninsured.

In developing analyses on Medicaid, the Colorado Alignment Project used estimates of Coloradans eligible for Medicaid but not enrolled from the Colorado Health Institute’s “Health Insurance of Coloradoans.” It also used enrollment data from 2014 provided by the Colorado Department of Health Care Policy and Financing.

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Food Security: SNAP

Hunger, though often invisible, affects everyone. It impacts people’s physical, mental and emotional health and can be a culprit of obesity, depression, acute and chronic illnesses and other preventable medical conditions. Hunger also hinders education and productivity, not only stunting a child’s overall well-being and academic achievement, but consuming an adult’s ability to be a focused, industrious member of society. Even those who have never worried about having enough food experience the ripple effects of hunger, which seeps into our communities and erodes our state’s economy.

Community resources like food stamps, formally known as the Supplemental Nutrition Assistance Program (SNAP) and the Food Assistance Program in Colorado, exist to ensure that families and individuals can purchase groceries, with the average benefit being about $1.40 per meal, per person.

Funding for SNAP comes from the USDA, but the administrative costs are split 50-50 between the state and federal governments. Yet, the lack of investment in a strong, effective food stamp program impedes Colorado’s progress in becoming the healthiest state in the nation and providing a better, brighter future for all. Indeed, Colorado ranks 45th in the nation for access to food stamps and lost out on more than $686 million in grocery sales due to a large access gap in SNAP enrollment.

In developing analyses on SNAP, the Colorado Alignment Project used average, point-in-time caseload data from July 2010-14 and the U.S. Census Bureau’s American Community Survey of the population under 125% FPL from 2010-14.

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Financial Security: Colorado Works

In building a foundation for self-sufficiency, some Colorado families need some extra tools to ensure they can weather challenging financial circumstances and obtain basic resources to help them and their communities reach their potential.

Colorado Works is Colorado's Temporary Assistance for Needy Families (TANF) program and provides public assistance to families in need. Colorado Works Program is designed to assist customers in becoming self-sufficient by strengthening the economic and social stability of families. The program provides monthly cash assistance and other support services to eligible Colorado families.

The program is funded by a federal block grant to the state.

In developing analyses on Colorado Works, the Colorado Alignment Project compiled average unduplicated basic cash assistance cases from 2010-14 and the U.S. Census Bureau’s survey of families living under 100 percent FPL from 2010-14.

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Early Learning: CCCAP

Child care is a must for working families. Along with ensuring that parents can work or obtain job-skills training to improve their families’ economic security, studies show that quality child care improves children’s academic performance, career development and health outcomes.

Yet despite these proven benefits, low-income families often struggle with the cost of child care. Colorado ranks among the top 10 most expensive states in the country for center-based child care. For families with an infant, full-time enrollment at a child-care center averages $12,736 a year—or two-thirds of the total income of a family of three living at the Federal Poverty Level (FPL).

The Colorado Child Care Assistance Program (CCCAP) provides child care assistance to families that are working, searching for employment or are in training, and families that are enrolled in the Colorado Works Program and need child care services to support their efforts toward self-sufficiency. Most of the money for CCCAP comes from the Child Care Development fund, which must be used on child care for those who earn up to 165% FPL and can’t serve those who exceed 85% of the area median income.

Unfortunately, while the need is growing, only an estimated one-quarter of all eligible children in the state are served by CCCAP. Inadequate funding has also resulted in fewer providers willing to accept CCCAP subsidies.

In developing analyses on CCCAP, the Colorado Alignment Project used Child Care Automated Tracking System (CHATS) payment data from fiscal year 2014, which (unlike other caseload data featured in this report) is not a measurement of actual active cases. Instead, CHATS measures the number of kids who were authorized by CCCAP at one point in fiscal year 2014. In addition, the Colorado Alignment Project also used the U.S. Census Bureau’s American Community Survey of the population age 12 and under with a household income under 165%FPL from 2010-14.

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Food Security: WIC

Every child deserves the nutritional resources needed to get a healthy start on life both inside and outside the mother’s womb. In particular, good nutrition and health care is critical for establishing a strong foundation that could affect a child’s future physical and mental health, academic achievement and economic productivity. Likewise, the inability to access good nutrition and health care endangers the very integrity of that foundation.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides federal grants to states for supplemental foods, health care referrals, and nutrition information for low-income pregnant, breastfeeding and non-breastfeeding postpartum women and to infants and children up to age five who are found to be at nutritional risk.

Research has shown that WIC has played an important role in improving birth outcomes and containing health care costs, resulting in longer pregnancies, fewer infant deaths, a greater likelihood of receiving prenatal care, improved infant-feeding practices and immunization rates.

In developing analyses on WIC, the Colorado Alignment Project compiled caseload data by WIC clinic in 2014, provided by the Colorado Department of Health and Environment. In addition, the project used data provided by the U.S. Census Bureau’s report: “Profile of WIC Modeled Eligibility and Participation in Colorado, 2014: Evidence from Administrative Records and the American Community Survey.”

Click a county below to begin

Top 16 Counties
Remaining Counties
Bottom 16 Counties
Geography Name

The composite rankings in the preceding map were generated by calculating each county’s average Eligible But Not Enrolled “gap” for five programs: Colorado Child Care Assistance Program (CCCAP), Colorado Works, Medicaid, Supplemental Nutrition Assistance Program (SNAP), and Women, Infants and Children (WIC). These five program averages were then ranked according to performance: counties with the lowest averages of percent Eligible But Not Enrolled hold the top spots.

Human-service programs ensure that Colorado communities have the building blocks for a prosperous future. Hover over the interactive map (above) for a county-by-county comparison of enrollment, allocations and costs for the following programs: 

  • Supplemental Nutrition Assistance Program (SNAP)
  • Women, Infants and Children (WIC)
  • Colorado Child Care Assistance Program (CCCAP)
  • Colorado Works
  • Medicaid

These programs are funded and supervised by the state and the federal government, but in Colorado, are allocated and administered by the counties. 

Not all residents who qualify for these basic necessities receive assistance. Without these community resources, Coloradans may lack the reinforcement needed to support and maintain a solid foundation throughout their lives. Improving access and administration of these programs will ensure Coloradans of all ages across the state can weather life’s storms and thrive, as well as boost our state’s economic health. 

Using fiscal, administrative and census data, the Human Services Gap Map, created by the Colorado Alignment Project, provides a window into how effectively Colorado counties are delivering the basic building blocks needed for lifelong health and well-being.

ESTIMATES OF LOW-INCOME POPULATION NOT ENROLLED IN MEDICAID AND SNAP

This interactive map provides an overlay of potentially eligible populations for Medicaid and SNAP. Simply toggle on the program to see concentrations of people financially eligible for Medicaid (by zip code) and SNAP (by census tract) but are not enrolled. The map also shows concentrations of Coloradans living in poverty. These concentrations are represented by a color gradient where lighter red means fewer people potentially eligible but not enrolled or living in poverty while darker shades of red mean a greater concentration of people eligible but not enrolled or living in poverty.

The true power of this map is the ability to overlay data to better understand the need for medical and food assistance and where to target outreach efforts at the neighborhood level.

  • By toggling on Medicaid, SNAP, and poverty level, the darkest areas represent the poorest areas of the state with the fewest eligible Coloradans enrolled in vital work support programs. These are the areas with the highest potential return on investment for enrollment outreach.
     
  • By toggling on the total number of unenrolled people, outreach organizations can determine where the highest number of low-income but not yet enrolled Coloradans reside.
     
  • By toggling on percent, the map shows the percent of the eligible population not enrolled which is helpful for comparing performance across different areas of the state. Communities with a lighter color are enrolling a higher percent of the estimated eligible population.
     
  • By toggling on SNAP and percent, the map provides a potent display of the invisibility of hunger. The darkest areas showing the highest percent of low-income people not enrolled in SNAP are in some of the most affluent parts of the state, such as Aspen, Cherry Hills Village, and Washington Park. This is a powerful reminder that need exists in all communities.
     
More low-income enrolled
Fewer in poverty
  Less low-income enrolled
More in poverty
Percent of the low-income population (185% federal poverty level) not enrolled in Medicaid
Percent of the low-income population (130% federal poverty level) not enrolled in SNAP
 
First check an option above,
then Search by Zip or Tract:
The total number of low-income people not enrolled in Medicaid, SNAP and/or living below the poverty line.
The percent of the low-income population not enrolled in Medicaid, SNAP, and/or living below the poverty line.

Human Services Gap No. 1:
Program Access

For many reasons, all counties experience some gap between the people eligible for basic needs programs and those who actually receive assistance. Some counties have a much larger gap than others. The size of a gap might signify a missed opportunity to meet residents’ needs or more efficiently use available resources.

This interactive graph shows the gap between the people enrolled in SNAP, WIC, CCCAP, Colorado Works and Medicaid and those who meet the eligibility criteria by county. Use the drop-down tools to select a county and a program. (Note: For CCCAP and Colorado Works, the “Max” line represents the maximum number of people that the program could serve based on its program allocation.) 

Select County:
Select Program:


Caseload vs Estimated Need

Scroll over the graph to see the number of those who are eligible but not enrolled vs. the county’s caseload.
For CCCAP and CO Works, the "Max" line is the maximum number of people that the program could serve based on its program allocation
Estimating Eligibility

Because the census does not ask the same questions as the eligibility applications, the comparison is not a perfect estimate of need. For example, CCCAP, SNAP and Colorado Works all have some type of work requirement. Likewise, eligibility for Medicaid and WIC are based on “countable income,” which does not match directly to what is captured by census data. Census data, however, is widely used to estimate eligibility because it does provide a helpful approximation of who is likely eligible for these programs.

The program “need" for CCCAP and Colorado Works is an estimate of income eligibility for these two programs by county population: The red bar indicates how many total Coloradans could still benefit from these programs. However, because these programs are funded by a federal block grant, participation space is capped. As a result, county allocations can only help a fixed amount of participants, indicated by the
‘max’ line, which clearly never reaches the estimated county ‘need’.

This is a powerful visual example as to why block-granted programs fall short in providing necessary services to help Americans build strong foundations: even if counties spend 100% of their program allocation, they seldom help even half of all eligible families in their communities.  

hUMAN SERVICES GAP MAP NO. 2:
PROGRAM ALLOCATIONS VS. ACTUAL SPENDING

The State of Colorado appropriates money for public benefit programs from a mix of general and cash funds that is divided up among the counties. Allocations are based on a formula that considers historical caseloads, poverty rates and population. Counties generally have a high degree of discretion in how funds are spent within state and federal laws applicable to each program. This interactive graph shows the gap between the program allocations for CCCAP and Colorado Works versus the actual spending by county. Use the drop-down tools to select a county, a time period and a program.

Select Year:
Select Program: 1
Select County:

Investing more in Colorado Works
Investing less in Colorado Works
Investing in more CCCAP Slots
Investing in fewer CCCAP Slots

Some counties overspend their allocation while other counties under-spend. Overspending may enable a county to more fully meet the community needs for assistance and may signal that the county needs additional state funds to support its residents.

Counties that under-spend their allocation might leave money on the table that could help their communities thrive. Under-spending suggests that a given county could do more to address the needs of their residents and stimulate the economy. For example, all Colorado counties under-spent their CCCAP allocations by $11.4 million in fiscal year 2015. Through a relatively complicated process, the state takes back unspent money from counties that did not spend their allocation and redistributes it to the counties that spent more money than they were allotted.
 
During fiscal year 2014-15, two “big 10” counties in Colorado overspent their allocations not covered by their county TANF reserve funds: Boulder County by $1.1 million and Denver County by $1.8 million.  The only other big 10 county to overspend its allocation was Mesa County by $425,284 (that over-expenditure was covered by their TANF reserves). These three counties either had an increase in their basic cash assistance caseload, an increased need for diversion funding, or invested increased funding in early intervention and community support programs for low-income TANF eligible families.  The remaining big 10 counties under-spent their allocations by $3.9 million. 

On the positive side, this can be caused by several factors including a decrease in need for basic cash assistance, decreased need for one-time diversion assistance, or decreased need for community investment in programs for low-income TANF-eligible programs.  On the negative side, this can be caused by unknown fluctuations in caseloads and the need to balance expenditures in order to not overspend or a lack of community providers to serve the population with job placement, education, internships, and case management. 
 
In total, 14 small- and medium-sized counties overspent their allocations.  This is most likely due to the TANF allocation not meeting the basic cash assistance and administration costs to run the program basics. This may indicate a slight unbalance in the TANF allocation methodology. 

Human Services Gap No. 3:
Cost Per Case/Return on Investment in $$$

Eligibility, allocation and spending may provide clues about how counties can align their enrollment efforts or better manage their human-service resources. But variability in administrative costs per case and return on investment might say more about a county’s efficiency (or inefficiency) than the overall expenditures of the state-supervised, county-administered system.

This interactive graph shows, for Medicaid, the cost for each county to enroll one client into the program. For SNAP and WIC it displays the county "return on investment," or how much one dollar spent on county administration returns as benefits to program participants. Use the drop-down tools to select a county, a time period and a program.

Select Year:
Select Program:
Select County:

Top Performing Counties
Average Performing Counties
Bottom Performing Counties

Gap Map Solutions

While the challenges of enrolling qualified Coloradans human-service programs and controlling administrative costs can be daunting, some recent breakthroughs in policy highlight how we can make a difference in closing the gaps so that more Coloradans can meet their basic needs.

SNAP

WIC

With enrollments in decline since 2009, Colorado WIC is focusing on identifying the potentially eligible population by census tract and county. This will enable prioritization of geographic areas with high levels of potentially eligible participants in order to strengthen outreach and referrals in specific areas.

Colorado WIC has partnered with the U.S. Census Bureau to receive detailed information on eligible but not enrolled (EBNE) by census tract. This data, while valuable, will be somewhat outdated.

To rectify the situation, Colorado WIC is partnering with Medicaid to get monthly counts of enrolled pregnant women and children who are 0-5 years old to compare with counts of WIC clients as a real-time proxy measure for participation.

CCCAP

CCCAP helps families build a foundation of self-sufficiency by providing childcare assistance to families who are working, searching for employment or in training. But not everyone who could benefit from the program has been able to use it.

Unfortunately, some families with the highest need for childcare assistance have been effectively barred from CCCAP because of a policy that requires recipients to identify both parents in order to qualify. For example, a teen mother might be unable to continue her education because she is unwilling to identify the father of her child. This refusal may be an effort to protect him or to protect their relationship. On the other hand, she or her family may want to protect the baby and the young mom by avoiding creating or continuing an unhealthy relationship. According to the National Campaign to Prevent Teen and Unplanned Pregnancy, one of the leading barriers that prevent teen mothers from graduating from high school is access to child care.

Fortunately, House Bill 1227 would lift the requirement for teenagers and victims of domestic violence to disclose the identity of the other parent when applying for childcare assistance. The legislation was passed by the Colorado House and Senate during the 2016 legislative session was signed by Gov. John Hickenlooper. The legislation will go into effect in the 2016-17 fiscal year.

Colorado Works

Single parents who receive Temporary Assistance for Needy Families (TANF) Basic Cash Assistance will no longer have to choose between receiving payments from the program and child support thanks to a new law approved by legislators and the governor in 2015. Currently, child support payments are “retained” by the state and used to help reimburse the federal, state and county governments for the cost of the Basic Cash Assistance program.

Developed by the Colorado Center on Law and Policy, Senate Bill 12 lets TANF recipients receive child support payments without reducing their benefits from the program. Furthermore, non-custodial parents are more likely to comply with child support orders when knowing that payments directly increase the financial support of their children.

The law is slated to go into effect in January 2017.

Medicaid

Medicaid recipients and administrators often face the challenge of “churn” – a word that describes the movement between health coverage programs due to fluctuations of income and household size. Unfortunately, churn results in sporadic loss of coverage when recipients’ statuses changes, but it also deteriorates health outcomes and raises administrative costs associated with enrolling and re-enrolling individuals into coverage programs.

To reduce churn and encourage better continuity of care, the Colorado Department of Health Care Policy and Financing, with the support of advocates, adopted a federal option that would allow recipients who are at risk of losing Medicaid due to seasonal, commission-based or self-employment income to annualize that income over the rest of the year.

For example, if a person is found ineligible for Medicaid based on monthly income due to seasonal work at a ski resort, that income can be spread out over the remainder of the year and prevent the person from losing coverage. This saves the system administrative costs and prevents a lapse of coverage that could potentially affect the individual’s health.

The new rule went into effect in Colorado on June 31, 2016.

Closing the Gaps

Recognizing that each Colorado county is unique, the Human Services Gap Map is intended to spark a dialogue among human service directors, their staff, advocacy organizations and community leaders for which policies and practices – on a statewide and local level – are most effective for closing gaps in enrollment vs. eligibility, allocation vs. spending, and overall effectiveness and efficiency of our limited resources.

Effectively addressing poverty requires the right mix of supportive services are provided and thereby maximizing the potential for all communities. For example, because of the large access gap in SNAP, Colorado missed out on more than $686 million in grocery sales in 2013. Gaps in Medicaid mean that medical providers absorb the costs of uninsured care. Clearly, there are consequences for the individual not receiving the benefits as well. Forgoing meals, incurring medical debt or not being able to work because child care needs are unmet.

To support thriving communities and individuals, we need to promote and align key human-service programs to support the health and well-being of all Coloradans.

The following maps display Eligible But Not Enrolled data for Colorado’s two largest programs: Medicaid and SNAP. The data for Medicaid can go as far down to zip code level (when available), and the data for SNAP data is by census tract.

The available data performs two important functions: first, they show human-service program staff and community stakeholders where gaps in these two larger programs are most likely to exist. As a result, targeted strategies can be designed and implemented to enroll more individuals in these locales, as they will likely represent the most concentrated pockets of Coloradans who are eligible for these services.

In addition, the data can be overlaid to draw a detailed picture of where enrollment in one program may be strong but is deficient in the other. These communities may use this information to analyze potential program barriers for eligible clients and create strategies for enrollment based on the best practices identified in the more successful program.

Human-Service Programs

Health: Medicaid
Food Security: SNAP
Food Security: WIC
Financial Security: Colorado Works
Early Learning: CCCAP

About the Gap Map

The Human Services Gap Map project was led by the Colorado Center on Law and Policy with support from Hunger Free Colorado, the Bell Policy Center, Covering Kids and Families and the Colorado Consumer Health Initiative.

The Human Services Gap Map aims to increase accountability, transparency and planning to build public and political will, in order to improve access, effectiveness and integration of core health and work-support programs. The coalition includes Hunger Free Colorado, the Colorado Center on Law and Policy, Bell Policy Center, Covering Kids and Families and the Colorado Consumer Health Initiative. It is funded by the Center for Law and Social Policy.