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1 Introduction The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal grant program to states that provides food and nutrition services to pregnant and postpartum women, infants, and young children who meet income eligibility criteria or who are enrolled in other federal public assistance programs (who are called adjunctively eligible) and who meet at least one approved criterion for nutritional risk. WIC empha- sizes prevention. Its purpose is "to provide supplemental nutritious food as an adjunct to good health care during such critical times of growth and development in order to prevent the occurrence of health problems" (Pub- lic Law 94-105) and "improve the health status of these persons" (Public Law 95-6271. In 2001, WIC served 7.3 million women, infants, and chil- dren and distributed just over $3 billion of food to participants. WIC is not an entitlement program that is, the number of eligible people who can enroll may be limited by the amount of funds appropriated to the program. Each year the United States Department of Agriculture (USDA) esti- mates the number of people eligible for WIC and the number of eligible people who are expected to participate in the program if funds are avail- able. These estimates serve as a basis for making budget requests for the upcoming year. Inaccuracies in these projections can have detrimental con- sequences. If the projections are too low, eligible people may not be able to receive WIC benefits. If the projections are too high, then other valuable programs may not receive appropriate levels of funding. In recent years, 13

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14 ESTIMATING ELIGIBILITYAND PAR TICIPATION FOR THE ~CPROGR~ funding for WIC has been sufficient to serve all applicants seeking assis- tance. To monitor the reasonableness of their estimates and how much of the eligible population the program serves, USDA computes coverage rates each year. Coverage rates are computed as the average monthly number of WIC participants in an eligibility category as reported in administrative records divided by estimates of the number of eligible people in that category for a given year. USDA estimates of the number of participants have come un- der critical scrutiny, in part because the number of infants and postpartum women who actually enrolled in the program has exceeded the number projected to be eligible by as much as 20 to 30 percent in recent years. These high coverage rates have led some members of Congress to conclude that some participants are truly ineligible, and that funding could be re- duced somewhat and still meet the needs oftruly eligible people who would participate under full funding (see U.S. House of Representatives, 19981. In contrast, some advocates and state WIC agencies believe that the esti- mates of the number of eligible persons are too low and that there are additional people who are eligible and would choose to participate, given their eligibility. PANEL CHARGE With these concerns in mind, USDA asked the Committee on Na- tional Statistics of the National Research Council to convene a panel of experts to review the methods used to estimate the national number of people eligible and likely to participate in the WIC program. The panel is charged with reviewing data and methods for estimating categorical eligi- bility, income eligibility, adjunctive eligibility from participation in other public assistance programs, and nutritional risk among the income eligible population, as well as for estimating participation if the program is fully funded. The panel was also asked to consider alternative methods and data for making these estimates. As previously noted, the WIC program is intended to provide nutri- tious food supplements and services to help women, infants, and children to prevent future health problems and to promote healthy growth and de- velopment. There is no guarantee that the full complement of eligibility requirements will identify the individuals Congress truly intended to serve with the WIC program. Nor is it guaranteed that the benefits provided to

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INTRODUCTION 15 recipients are effective in alleviating the nutritional deficits envisioned. While both of these questions are important and deserve to be addressed, the charge to this panel was to review and suggest potential improvements to the methodology of the Food and Nutrition Service for estimating the number of eligible individuals who wish to participate given the existing rules, regulations, and practices of the WIC program. It was not the charge of the panel to examine the efficacy of the current eligibility rules and regulations or the states' implementation of them. Nor was it in the panel's charge to examine the efficacy of the WIC program in reducing the nutri- tional deficits of pregnant and postpartum women, infants, and children. TIMELINE OF PANEL WORK The panel's work has been conducted in two phases. The first phase of the study focused on the estimation issues that we determined would have the biggest impact on the final estimates. During the first phase, the panel met twice, including a meeting to convene a workshop on the estimation methodology. The panel's publication Estimating Eligibility and Participa- tion for the WIC Program: Phase I Report (National Research Council, 2001) presents several major conclusions and recommendations for USDA: Current methods used to estimate eligibility for WIC result in a sizable underestimate of the number of people eligible for WIC. Not fully accounting for those who are adjunctively eligible for WIC is a key reason for the underestimation. Estimates of the prevalence of nutritional risk need to be reexam- ined with more recent data and with improved methods. Using participation rates for the Food Stamp Program as a proxy for participation in WIC is inappropriate, and a new method for esti- mating the percentage of eligible persons who are likely to partici- pate should be developed. Phase II of the study began in September 2001, during which time the panel has met twice. Our mission in Phase II was to more fully examine some of the issues covered in Phase I of the study and to investigate meth- ods that could be used to estimate eligibility for and participation in WIC. Specifically, we conducted additional data analysis to assess whether our conclusions about adjunctive eligibility and the use of monthly income

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16 ESTIMATING ELIGIBILITYAND PAR TICIPATION FOR THE ~CPROGR~ instead of annual income could hold across multiple years.1 In addition to the analysis of methods used to determine income and adjunctive eligibil- ity, the panel considered weighting adjustments to correct for the undercount of infants in the data currently used to estimate eligibility, the Current Population Survey (CPS). The panel also explored methods for estimating the prevalence of nutritional risk among income-eligible popu- lations. An extensive analysis of bends and determinants of WIC participa- tion among eligible people was also undertaken by the panel. Several components of the estimation methodology that the panel did not have time to take up in Phase I were explored in Phase II. We examined current assumptions used to estimate the number of eligible postpartum and breastSeeding women. BreastSeeding postpartum women are a separate eligibility category than nonbreastEeeding postpartum women and are given different food packages, have different certification periods, and are treated differently in the priority waiting system. The panel commissioned a paper to review the literature on breastSeeding rates among WIC-eligible popula- tions, data sets for estimating breastSeeding prevalence among postpartum women, and methods for estimating the prevalence of breastSeeding. We also examined the assumptions currently made to infer the number of eli- gible pregnant women from the number of infants. A second commissioned paper examined family income variability around the time a child is born to assess the validity of the assumption that the income of an infant is similar to the income of the mother before the infant was born. We also reviewed current assumptions made to infer the number of eligible post- partum women. Finally, we examined use of the Survey of Income and Program Participation (SIPP) to estimate eligibility and participation for WIC. PLAN OF THE REPORT . . . The remainder of this report describes the panel's findings regarding each of these components of the estimation methodology. In Chapter 2, we tin further analyzing data used in the Phase I report, the panel discovered a problem with estimates of adjunctive eligibility. It did not affect the conclusion that current methods underestimate the number adjunctively eligible for WIC, but it did affect the size of the underestimation. The panel explained the problem and changes in estimates in a letter report issued to USDA on May 16, 2002.

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INTRODUCTION 17 describe the reasons that USDA makes eligibility and participation esti- mates each year and review the current methods for doing so. Chapter 3 considers the accuracy of the estimates resulting from the current method- ology and outlines possible sources of error in these estimates. Chapters 4-7 examine different aspects of the methods for estimating eligibility for WIC. The order in which issues are addressed follows the steps in the current methodology for estimating WIC eligibility. Chapter 4 reviews the methods for estimating the number of infants and children who are categorically eligible for WIC. Chapter 5 reviews current and alter- native methods for estimating the number of income-eligible infants and children. This chapter discusses two major problems with the current meth- odology that the panel found in its Phase I report: the use of an annual measure of income and the lack of an adequate estimate of the number of people adjunctively eligible for WIC. The estimates of the number of in- come-eligible infants are especially important for the current methodology because they are used to infer the number of pregnant and postpartum women who are eligible. Chapter 6 discusses methods for inferring the number of income-eligible pregnant and postpartum women from the number of income-eligible infants. Methods to estimate how many of the income-eligible population are at nutritional risk are reviewed in Chap- ter 7. Chapter 8 considers estimates of the number of eligible people who choose to participate in WIC. Chapter 9 outlines alternative methods for estimating eligibility and participation. Finally, in Chapter 10, we summa- rize our major findings and conclusions.