Understanding churn: Predictors of reentry among families who leave the child care subsidy program in Maryland

Child care subsidies provide an important work support for low-income families, yet children often receive subsidies for only a short period of time and may cycle on and off the program. Much of the research to date on patterns of subsidy participation has focused on the duration of participation, and less attention has been paid to the dynamics of how often and how quickly children return to the program. This paper uses administrative data from Maryland to analyze the patterns of returns to the subsidy program after a break in subsidized care. We find that half of children who exited the program return to subsidy within five years, and most of those return within a few months. Returns to subsidized care are related to family circumstances, type of care, child age, and program policies related to eligibility redetermination. These factors have differential effects on the probability of returning to the same provider or a different provider, which may have important implications for the stability of children's care.     

Patterns of child care subsidy use and stability of subsidized care arrangements: Evidence from Illinois and New York

Given the prevalence of short child care subsidy spells and program churning documented in prior studies, researchers and policymakers have been concerned about the implications of discontinuity in subsidy receipt for the stability of children's care arrangements. Yet little research has studied the stability of subsidized arrangements or how subsidy discontinuity relates to changes in subsidized providers. Using child care subsidy program administrative records from a cohort of children in four diverse sites across Illinois and New York states, this study examines patterns of subsidy use and stability of subsidized care arrangements, as well as the relationship between the two. Results suggest that the length of states' eligibility periods is related to the duration of subsidy spells; however, significant variation in patterns of subsidy use within states suggests that local level factors are also important. Results show that subsidy discontinuity is related to children experiencing more total changes in subsidized providers. Focusing on provider changes across spells, we also find that the timing of subsidy exits, the length of gaps in subsidy receipt, and within spell provider instability are each related to whether or not children re-enter the program with a different subsidized provider after a break in subsidy receipt. We discuss these findings' implications for understanding how new program requirements established in the 2014 reauthorization of the Child Care and Development Block Grant may matter for subsidy continuity and care stability.     

Increasing access to quality child care for children from low-income families: Families' experiences

Identifying effective strategies for increasing access to quality care for children from low-income families has important implications for society. This study examined the effectiveness of expanding child care assistance for low-income families (capping expenses at 10% of income and raising eligibility to 200% of the federal poverty line) to purchase quality care. Mixed methods documented families' experiences (N = 181) and capitalized on a natural experiment when families lost assistance. Results pointed to improved access to quality care for children from low-income families by: 1) helping low-income families continue utilizing quality providers when incomes dropped, and 2) enabling others to begin utilizing quality providers. Perceived impacts were greatest for families with higher incomes (within the eligibility range), and for those with children ages five and younger. Additionally, parents were able to pay providers the full rate that they charge for care, which may help quality providers continue serving low-income families.     

Can we trust parental reports of child care subsidy receipt?

In recent years, research examining determinants and consequences of the means-tested child care subsidy program (the Child Care and Development Fund [CCDF]) has grown dramatically. To measure subsidy utilization, existing studies typically rely on parent-reported measures of subsidy receipt drawn from large surveys. As the research literature on child care subsidies has grown, however, so have concerns about the trustworthiness of parent-reported subsidy use. One way to assess the quality of parent-reported subsidy use is to examine its overlap with another subsidy receipt measure, drawn from a different source. The current paper uses the Fragile Families and Child Well-Being Study (FFCWS), the only existing survey data source that contains an alternate measure of subsidy receipt — based on child care provider report — which permits a comparison to parent-reported measures. We find evidence that increases our confidence in the trustworthiness of parents as accurate reporters of subsidy receipt. In recognition that neither data source reflects “true” subsidy receipt, however, we conclude with a discussion of limitations and steps for future research.     

A qualitative look at child care selection among rural welfare-to-work participants

The welfare reforms of 1996 changed the administration of public assistance to children and families. One of the key provisions, requiring parents to join the workforce, resulted in an expanded need for child care. Prior research demonstrates that welfare recipients, particularly in rural areas, utilize informal child care arrangements. Further, recipients in rural communities face greater challenges due to a lack of transportation, geographic spread, and less access to services. This qualitative study examined the child care selection experiences of 33 welfare recipients in six rural Northern California counties. More families selected home-based than center-based child care. During their search processes, welfare recipients utilized both formal and informal routes to locate child care providers. Parents took advantage of their connections with the social service system, but also accessed their social networks for recommendations. Rural families also reported that their choices were constrained by the available programs, transportation, and by the quality of the programs they were able to access. Given the high rate of utilization of home-based arrangements among families in welfare-to-work programs, quality of care in such programs should be improved. Recommendations for increasing quality and access, as well as supports for welfare to work participants, are discussed.     

Using Policy-Relevant Administrative Data in Mixed Methods: A Study of Employment Instability and Parents’ Use of Child Care Subsidies

In the United States, government subsidies help low-income families pay for child care when parents are working, yet policies that tie subsidy eligibility closely to employment may result in frequent disruptions in program participation for families. This paper uses a mixed methods research design that links administrative records on families and children to data collected through surveys and in-depth interviews to examine employment instability and job characteristics of parents using child care subsidies. The results suggest that parents experience substantial employment instability (employment loss and unpredictable schedules) and that exiting the subsidy program is frequently related to employment-related eligibility factors. Overall, the use of administrative data integrated with other methods provides substantial opportunities for researchers to explore complex social phenomenon and provide insights in the evaluation of social programs.     

The economics of child care and public policy

Child care denotes any arrangement used by a working parent for care of a child, including self-care. This article is concerned with the factors that influence the demand for market modes of child care by two parent families with working mothers. A unique aspect of the study is that it is able to assess the impact of a child care subsidy program. An implication of the analysis is that the demand for market care is price elastic and is therefore susceptible to considerable change through programs of increased subsidization.     

Time for a change? Predictors of child care changes by low-income families

Instability in child care arrangements can negatively affect children's development, especially in low-income families. However, few studies have examined what predicts changes over time in child care arrangements. This paper presents findings from a unique multiyear study tracking child care use in low-income families. We estimate rich quantitative models to analyze the relationships among child, household, and care provider characteristics and four different types of changes. We find turnover in child care arrangements to be common in this low-income population. Over a period of six months, half of the children changed primary provider. Child care changes were frequently related to job loss, changes in family composition, or the changing availability of caregivers. While concerns have been raised that short spells of child care subsidy receipt cause child care instability, we found that subsidy use was not associated with higher rates of change. In addition, we found that the lower a parent's assessment of the child's experience in a particular arrangement in the prior time period, the higher the likelihood of changing providers by the next survey wave. These results indicate that low-income parents recognize quality factors and change arrangements to improve the quality of care.     

Child care improvement on a shoestring: evaluating a low-cost approach to improving the availability of quality child care

The Philadelphia Early Childhood Collaborative (the Collaborative) was designed to improve the quality of child care by increasing coordination among organizations that locally deliver professional resources to child care providers. The evaluation examined the implementation of the Collaborative, utilization of its services, and the impact of service use on child care quality. Child care providers reported gains in their professional knowledge and behavior from using Collaborative resources and rated the resources highly. No long-term effects on provider behavior, knowledge, or attitudes were observed. Although the original organizations were able to function collaboratively and Collaborative services were widely used, more intensive interventions may be required to change the availability of quality child care.     

Controlling the supply of long-term care providers in thirteen states

Many states have responded to growing Medicaid long-term care expenditures by limiting the number of long-term care providers through certificate-of-need (CON) programs and moratoriums on new construction or certification for participation in the Medicaid program. This article focuses on the use of these policies in 13 states. Most of the 13 states control the supply of nursing home beds and hospital conversions with CONs or moratoriums, but they are struggling to adapt the role of supply policy to the growth of home health and residential care. As an increasing proportion of Medicaid long-term care spending goes to these nursing home alternatives, supply policy needs to keep pace with the changing provider market and the changing demographics of the consumer market if it hopes to ensure access to long-term care and control Medicaid expenditures.     

Needs-led child and youth care: Main characteristics and evidence on outcomes

Needs-led child and youth care has three main characteristics: a continuous focus on clients' needs, client participation in the care process (including decision making), and practitioners' displays of needs-led attitudes and skills. The primary aim of this review was to establish whether there is evidence for using a needs-led approach when working with children and families in need. We performed a literature search to find reviews and outcome studies of child and youth care for school-aged children and their families which included the core characteristics of needs-led care, and related them to outcome measures. Only a few studies attributed positive outcomes of care to the attention given to clients' needs and goals. Most studies referred to participation in terms of clients' involvement or engagement. Higher levels of participation were associated with positive changes in child behaviors and parenting stress, client satisfaction, higher completion rates, safety for children, feelings of well-being and empowerment, and better service coordination. Significant professional attitudes and skills included listening to clients and working in active partnership with them. There is some proof for the relevance of core characteristics of needs-led child and youth care, although that evidence is limited by the lack of rigorous studies. This study indicates that needs-led child and youth care can make a difference. Future research should pay attention to the intertwinement of the characteristics of the needs-led approach in care.     

Instability in patchworks of child care when moving from welfare to work

We use longitudinal, qualitative interview data collected from 38 initially welfare‐reliant women in Cleveland, Ohio to examine the factors driving instability in child‐care arrangements when women transitioned from welfare to work. Grounded theory analysis revealed that decisions about care were circumscribed by scarce social and economic resources, women went to extraordinary lengths to patch together arrangements that typically involved multiple providers, relative care was central to patchworks of care, and patchworks of child care were often highly unstable. These complex arrangements and their instability were influenced by mothers’ desires to find the most suitable arrangements for their children within resource and job constraints, dissatisfaction with providers, difficulties accessing subsidies, and changes in provider availability. Findings suggest that policymakers must consider instability in patchworks of multiple child‐care providers as they consider alternatives for meeting low‐wage working women's and children's needs for safe, affordable, accessible, and enriching nonmaternal child care.     

Child care subsidies and care arrangements of low-income parents

While enrollment into early education programs has increased significantly in the past two decades, many low-income children still do not attend these programs due to lack of funding and access. This study uses data from the 2005 National Household Education Survey to examine the effects of child care subsidies on the enrollment of low-income children in early childhood education programs. Multinomial regression results show that families that receive child care subsidies are more likely to place their child in center-based preschool programs. The analyses also show that subsidy receipt increases the probability of using center care for low-income households. These findings indicate that policies aimed at increasing funding and availability of early education for low-income families can help close the gap in enrollment.     

“We are merchandise on a conveyer belt”: How young adults in the public child protection system perceive their participation in decisions about their care

The aim of this study is to show young people's feelings about their experiences with participation in decision-making in public care. The study is based on semi-structured, in-depth interviews with eight young adults in the public child protection system in a northeastern state in the U.S. conducted between 2015 and 2016. All study participants had made both positive and negative experiences with participation. Most reported negative experiences at the point of their first entry into care, and most reported positive experiences when signing themselves back into the care of the child protection system when they turned 18. Further, we found barriers and pathways to participation at the individual child's or youth's level, including a child's or youth's ability to self-advocate, access to information, and age. Organizational-level factors that affected a child or young person's participation included the child protection agency's view of the child or youth; the agency's view of the parents; the quality of legal representation, and the type of rapport between social workers and children or young people in care. We discuss the implications of these findings on theory and policy.     

Vertical axes on the long-term care continuum: a comparison of board and care and assisted living

As the continuum of long-term care has expanded, public funding has not accompanied new care options. I detail access, provider profits and resources, and care quality in two types of residential care that fall in the center of the continuum, assisted living and board and care. These two options provide examples of how limited public funding leads to vertical axes, which represent access to services, the resources providers draw on to give care, and the quality of long-term care services, at each service point on the long-term care continuum.     

The labor supply effects of child care costs and wages in the presence of subsidies and the earned income tax credit

This paper uses CPS and SIPP data between 1990 and 2004 to examine the effects of child care expenditures and wages on the employment of single mothers. It adds to the literature in this area by incorporating explicit controls for child care subsidies and the EITC into the estimation. Doing so provides an opportunity to examine mothers’ sensitivity to prices and wages net of policies that influence these amounts. Results suggest that lower child care expenditures, higher wages, and more generous subsidy and EITC benefits increase the likelihood of employment. Allowing the impact of child care subsidies and the EITC to vary with expenditures and wages reveals substantial heterogeneity. In particular, the largest labor supply effects of child care subsidies are generated for mothers with higher child care costs, while the largest labor supply effects of the EITC are found for mothers with lower wages.     

Is stability always a good thing? Low-income mothers' experiences with child care transitions

Recent research has drawn attention to the deleterious effects of instability on child development. In particular, child care instability may make it hard for children to form secure attachments to their care providers which may have a negative impact on their development and school readiness. These effects seem to be heightened for low-income children and families. However, there remains a lack of clarity regarding how and why low-income mothers make changes to their child care arrangements. Using ethnographic data from Welfare, Children, and Families: A Three City Study, this study explored 36 low-income mothers' experiences of child care instability and stability and the factors that promoted each. We identified four kinds of child care transitions: planned, averted, failed, and forced. Financial resources, transportation and the availability of care during the hours that mothers work were important for helping mothers find and maintain preferred care arrangements. Our findings have implications for research on child care instability as well as the development of policy and programs to help low-income families secure high quality child care and maintain stable employment.     

Hospital pricing: cost shifting and competition

The issue of cost shifting has taken on enormous policy implications. It is estimated that unsponsored and undercompensated hospital costs--one measure of cost shifting--has totaled $21.5 billion in 1991. The health services research literature indicates that hospitals set different prices for different payers. However, the empirical evidence on hospitals' ability to raise prices to one payer to make up for unsponsored care or lower payments by other payers is mixed at best. No study has concluded that hospitals have raised prices to fully adjust for such actions. The extent of cost shifting is limited by the market. When a hospital has market power, it is able to set prices above marginal costs. However, when a buyer has enough patient/subscribers and a willingness to direct them to particular providers based on price considerations, hospitals have less flexibility in raising prices above costs. Thus, the extent of cost shifting is limited by the market. Cost shifting is not as easy as it may have been in the past because the nature of hospital and insurer competition has changed radically in the last decade. While hospital quality, services, and amenities still matter, some buyers are increasingly concerned about the price they pay. Evidence from studies of PPO and HMO negotiations with hospitals suggests that hospitals' market power is eroding, at least in some areas. In areas with relatively few hospital competitors and little PPO or HMO activity, Medicaid and Medicare price reductions and uncompensated care burdens will be partially absorbed by higher prices paid by private payers. In more price sensitive markets and in markets in which prices to private payers have risen to those commensurate with the market power of local hospitals, such cost shifting will not occur. A market-based approach in hospital pricing requires an explicit policy for the uninsured. In a competitive market, a hospital that traditionally cared for the uninsured by spending some of its profits on them will be unable to do so, at least to the same extent as it did in the past. Increased competition in health care without consideration of the uninsured will decrease the uninsured's access to care.     

An innovative child welfare pilot initiative: Results and outcomes

Successful family reunification is achieved only about 50% of the time when children are in foster care. Parents' ability to access and complete court ordered services are paramount in determining whether the family can achieve reunification. However, the research on how to best facilitate service access and utilization are sparse. A matched sample of 100 families with no prior child welfare involvement and at least one child in out of home care were selected from Department of Children and Family closed administrative case files. This study compared 48 families who received traditional child welfare services to 48 families who received a Family First model intervention (PFFP) from a large urban public child welfare agency. The independent variables were the elements that distinguished the Family First model from traditional child welfare services and included the number of caseworkers for the life of the case, caseload size, and service needs met through community partnerships. The dependent variables were the stability of the children's out of home placement, the time to reunification, the length of agency involvement, the stability of reunification at one year follow up, subsequent substantiated child maltreatment reports one year after the cases were closed, the distance a placement location was from the home of the family at intake, the match between identified needs and the timely access of services. Hierarchal regression and survival models were constructed to examine elements of the intervention for their impact on family outcomes. The results suggested that a community partnership model that incorporated family engagement, enhanced service provider accessibility, reduced caseloads, one caseworker for each family, are associated with successful reunification outcomes. Moreover, the intervention families were more likely to have their needs met with clinical or economic services, experienced fewer days in out-of-home placement, shorter involvement with the agency, reduced placement moves and were more likely to be reunified sooner compared to the group who received standard child welfare services. At one year follow up, the intervention families also had fewer substantiated child maltreatment reports and children were more likely to be living in the parental home. Implications for policy, research and practice are presented.