Competitive Grant-Making: Lessons for Funders to Help Local Governments Increase Health Coverage
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Competitive Grant-Making: Lessons for Funders to Help Local Governments Increase Health Coverage

Published: May 20, 2015
Publisher: Princeton, NJ: Mathematica Policy Research
Health Medicaid and CHIP Advisory Services Technical Assistance Performance Management
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Key Findings

Key Findings:

  • The competitive nature of the design motivated cities to work to their full potential; the use of a cohort helped establish cross-city relationships to share ideas, challenges, and lessons learned; and the longer time line required cities to make lasting commitments that may enhance sustainability. At the same time, this design produced an inherent tension between the competitive nature of the grant and the desire for applicants to share ideas. Although some team members reported being reluctant to share their best ideas with competitors during the early grant phases, this reluctance dissipated over time. Two primary factors helped ease this tension: first, teams got together often enough to develop personal relationships with other city teams, and second, the National League of Cities assured the applicant teams that third-stage applications would be judged on how well their proposal fit the unique needs of their city, rather than the uniqueness of the approach.
  • The diverse cohort of cities that participated in the project proposed a variety of approaches to outreach and enrollment campaigns, but this diversity meant that the lessons learned were less transferable across cities. Also, although one goal of the project was to use competition to uncover and develop innovative strategies for finding and enrolling uninsured citizens, innovation was a minor factor in assessing grant applications. This was because the strategies that implementation teams used are typical of those that other groups that conduct health insurance outreach and enrollment assistance commonly use.
  • Even when using an intermediary organization to operationalize a project, funders should guide and oversee the project to ensure sound management of the grant award process.
  • Funders who wish to support local governments in increasing health coverage outreach and enrollment efforts would do well to help grantees identify essential partners, such as schools, health clinics, and other community-based organizations. Although personal connections can help forge these relationships initially, it is important to institutionalize outreach and enrollment assistance strategies and processes to sustain these investments despite staff turnover. Funders also can aid cities in their efforts to help uninsured citizens gain health care coverage by ensuring cities are connected to and educated about best practices in the field, including the importance of direct, one-on-one enrollment assistance.

To capitalize on the new health insurance options available to low-income children and families through the Affordable Care Act and increased attention on coverage issues, the Atlantic Philanthropies granted $3.25 million to the National League of Cities to conduct the Cities Expanding Health Access for Children and Families project. The goal of the three-year project was to engage cities on children’s coverage issues through a three-stage, competitive grant-making process. Atlantic contracted with Mathematica to explore the advantages and disadvantages of this strategy to achieve foundations’ grant-making objectives. To this end, we interviewed project stakeholders and reviewed key project documents. As the third-stage implementation grants were just awarded at the time this report was written, it was too early to assess the project’s effectiveness in increasing enrollment of children into public coverage in the eight cities that received these implementation grants. However, some lessons had already emerged regarding the benefits and drawbacks of the competitive grant-making strategy used to award these grants, and how philanthropic funders can best support municipal governments that wish to play a more active role in expanding health coverage. For example, certain aspects of the program design benefited cities, including inspiring them to work to their full potential, facilitating cross-city communication to share challenges and lessons, and enhancing the potential for sustainability. Other aspects of the multistage competition had mixed effects, such as the diversity of the cities, which meant some successful strategies were not easily replicable across sites. The evaluation found that cities are willing and able to be leaders in health benefits outreach, and the cities that have done so most effectively to date have adopted proven best practices, identified community partners with access to uninsured citizens, and made institutional changes so that outreach and enrollment become the new normal in how the cities operate.

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