Economic 

Research 

Service

Electronic Publications from the Food Assistance & Nutrition Research Program

Linking WIC Program Data to

Medicaid and Vital Records Data

Phase II Report, Data Development

Initiatives for Research on Food

Assistance and Nutrition Programs—

Final Report

By Loren Bell, Health Systems Research, Inc.

ERS project representatives: Parke Wilde and Alex Majchrowicz

Abstract

This report is a followup to a proposal to create a national database that links State data from

the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with

Medicaid and vital records data. The linked information would create new opportunities for

Federal and State program administrators, as well as independent researchers, to examine a

number of factors related to program participation and dynamics. The report provides an

implementation plan for creating a national database, including potential costs, benefits, and

alternatives. The initiative is one of three that have the potential to improve the usefulness and

cost-effectiveness of research on Federal food assistance and nutrition programs. The other

initiatives are addressed in the reports, Linking the Current Population Survey to State Food

Stamp Program Administrative Data (E-FAN-04-005-1) and Establishing a Web-Based Data

Collection System for National School Lunch and National School Breakfast Program Data

(E-FAN-04-005-3).

E-FAN-04-005-2

June 2004

This report was prepared by the Health System Research, Inc., under a

research contract from the Economic Research Service. The views

expressed are those of the authors and not necessarily those of ERS or

USDA.
Acknowledgements 

This document has benefited substantially from the input of several researchers and 

program administrators. Parke Wilde (Economic Research Service) provided excellent 

technical input on the methodological approach and policy questions throughout the 

entire project. Several State WIC Directors, including Karen Sell of the Inter-Tribal

Council of Arizona, Victoria Warren from the Missouri Department of Health, and Alice 

Lenihan of the North Carolina Department of Health provide valuable input and 

information for inclusion in this report. In addition, advise was provide by Kaye Earl and 

Patricia Starzick of the Washington State Division of Vital Records on issues related to 

linking WIC records with vital records, and on confidentiality agreements. Additional 

information regarding interagency agreements and issues related to privacy was provided 

by the Iowa and Massachusetts WIC and Medicaid programs. Finally, several staff at 

Health Systems Research, Inc. provided advise, support and review, including Vivian 

Gabor, Renee Schwalberg, and Christopher Miller. 

The opinions expressed and conclusions drawn in this report are the responsibility of the 

author, and do not represent the official views of Economic Research Service other 

government agencies, Health Systems Research, Inc. or The Urban Institute, which acted 

as the prime contractor for this effort with ERS. 
Table of Contents 

Section I Overview.............................................................................................................. 1 

Section II. Background.......................................................................................................... 3

Section III. Initiative Summary............................................................................................... 5

A. Structure and Content. ......................................................................................... 5 

B. Importance for Research and Administrative Purposes....................................... 6 

Section IV Overview of Implementation Plan..................................................................... 11 

A. Description of Key Actors ................................................................................ 11 

B. Overview of Activities....................................................................................... 14 

C. Potential Barriers to Implementation................................................................. 15 

Section V Description of Specific Tasks............................................................................ 19 

Task 1. ........................................................................................................................... 19 

Task 2 ........................................................................................................................... 20 

Task 3 .......................................................................................................................... 21 

Task 4 .......................................................................................................................... 22 

Task 5 .......................................................................................................................... 23 

Task 6 .......................................................................................................................... 24 

Task 7 .......................................................................................................................... 25 

Task 8 .......................................................................................................................... 26 

Task 9 .......................................................................................................................... 26 

Task 10 .......................................................................................................................... 26 

Section VI Summary of Costs and Schedule ....................................................................... 28 

Section VII Summary of Initiative Alternatives.................................................................... 30 

Section VIII References.......................................................................................................... 31 

Appendix A-Detailed Cost Assumptions 

Appendix B- Sample Missouri Reports Using Linked Data 

Appendix C-Data Elements Contained in WIC and Vital Records Files 

Appendix D- 1997 Missouri Report “WIC Coverage and Targeting High-Risk Infants” 

I. Overview 

The purpose of this initiative is to create a national database containing 

information regarding WIC participant health outcomes and participation in the Medicaid 

program by encouraging State WIC agencies to link WIC, Medicaid, and vital records 

data. The initiative proposes to take advantage of advances made by States in conducting 

and using linked WIC, Medicaid, and vital record data for program planning and 

evaluation. This initiative is designed to identify potential experts in record linkage, 

create models by which record linkages can take place, and provide technical assistance 

and support to interested States to facilitate the process of linking these data sets. The 

long-term goal is to have in place a nationally representative database of linked WIC, 

Medicaid, and vital record data that can be accessed by both researchers and program

administrators. 

This report is a follow-up to Wittenburg, et al. (2001), which included a summary 

of ten data collection/enhancement initiatives that have the potential to improve the utility 

and cost-effectiveness of research on federal food assistance and nutrition programs. 

Economic Research Service (ERS) selected three initiatives from that report for further 

development. This report, along with Wittenberg, et. al (2002) and Kenyon, et al. (2002), 

provide a specific implementation plan, including potential costs, benefits, and alternative 

options, for the three initiatives selected by ERS. 

 Data currently collected by WIC, Medicaid and vital records would be linked and 

aggregated to create a nationally representative database containing information on the 

demographic characteristics, services provided to, and health outcomes of WIC 

participants. State-level merged data sets of this sort would be combined into a single 

federal-level database enabling both state program administrators and program

researchers to do a much better job of monitoring outcomes for WIC clients, identifying 

gaps in program participation and services, and helping to better direct resources to 

improve health outcomes. 

USDA places a high priority on well-designed outcome studies for the WIC 

program, focusing on the program’s health outcomes. In the past, the Food and Nutrition 

Service (FNS) has funded several important studies using linked WIC and health records 

at the individual level, and FNS officials continue to regard well-designed outcome

studies using this approach as an important evaluation tool. In addition, individual States

have increasingly recognized the importance of conducting outcome studies of WIC 

participants linking WIC data with Medicaid and vital records data, both to identify 

health outcomes related to WIC participation, and to assess program participation

dynamics and targeting of high-risk clients. 

In the past, the costs of producing a new record linkage from scratch for each 

evaluation effort have been substantial. To overcome this shortcoming, this initiative 

proposes to begin regular and more widespread development of a type of data resource 

whose value has been well demonstrated. This initiative is consistent with information 

obtained through key informant interviews with State WIC officials and FNS staff, both 

Health Systems Research, Inc. Final Report Page 1 
of which indicated that future WIC research will need to focus on developing appropriate 

outcome measures that describe the effectiveness of WIC program participation. 

The initiative proposes to create a nationally representative database composed of 

WIC client demographic, nutritional risk, birth outcome, and health services data 

obtained from the States’ WIC program files; vital records data obtained through state 

birth registries; and data on Medicaid participation accessed through the state’s Medicaid 

agency. By linking WIC and vital records data, one can establish a database containing 

pregnancy and birth outcome information not available on the WIC record alone (such as 

APGAR, complications of delivery, etc). In addition, by linking the WIC record with 

vital records, the database can then be used to link the mother’s record with the child’s. 

Because the WIC program enrolls children separately from their mom, this link cannot 

often be established from the WIC record alone. Linking WIC and vital records data has 

become easier as State vital records programs begin implementing the new national 

model birth certificate, which has a field for capturing WIC participation. By adding 

Medicaid participation to the database, the potential exists to examine both WIC 

participant access to health care and health status information of children through data 

obtained from Medicaid services files, such as those contained in the Early and Periodic 

Screening, Diagnosis, and Treatment (EPSDT) program. 

These data can be used by program administrators at the federal and state level, as 

well as independent researchers, to examine a number of factors related to program

participation and dynamics. For example, the proposed database could be used to 

examine trends in birth outcomes of WIC mothers, assessments of the impact of WIC 

participation on Medicaid births, and to identify target populations that are likely to be 

eligible for WIC services but not being reached by the WIC program. 

Health Systems Research, Inc. Final Report Page 2 
II. Background 

Since its inception, the WIC program has been viewed as a nutritional program

designed to be an adjunct to the health care delivery system. The WIC program is the 

only food assistance program administered by State health departments. Over the years, 

local WIC programs have been encouraged (and in some cases, required) to refer lowincome women and children to health care services. Among the types of services to 

which WIC clients have been historically referred are prenatal care, well baby checks, the 

Medicaid program, and immunization services. 

Data from the WIC program have been linked to data from the Medicaid program

in the past. For example, in 1986 the State of Missouri became one of the first States to 

examine the effect of WIC participation on the Medicaid costs related to the delivery and 

care of newborns by matching Medicaid claims records with WIC administrative records 

(Schramm, 1986). In addition, the Missouri WIC Program has continued to use linked 

WIC, Medicaid, and vital records data to produce annual reports on the status of WIC 

participants participation in Medicaid, examine prenatal pregnancy outcomes of WIC 

participants, and examine the extent to which WIC has provided coverage to high-risk 

infants (Stockbauer, 1996). The linkage of WIC program data with Medicaid and vital 

records information has proven so valuable to Missouri officials, they continue to link 

these records to produce annual reports from these linked data. Sample reports provided 

to HSR by Missouri officials reflecting data analyzed from 1997-2000 are included in 

Appendix B. 

Additional research conducted in 1999 by the North Carolina Department of 

Health, examined how WIC and Medicaid data could be linked to examine birth 

outcomes of Medicaid clients on WIC as compared to those not enrolled in WIC (Center 

for Infomatics and Health Statistics, 1999). In another use of this type of linkage, data 

have been linked between the WIC program and vital records in Washington State to 

check for the possibility of dual participation by WIC clients (Bell, et. al. 2001) 

A variety of other researchers have used WIC, Medicaid, and vital records data to 

conduct both state-level research and research in local WIC programs in order to examine 

outcomes. Researchers have found that by linking WIC records with vital records data, 

mothers can be linked with their children to examine birth outcomes based on such 

variables as number of prenatal care visits, demographic data, income data, and 

pregnancy weight gain. For example, the 1987 national WIC evaluation linked WIC 

records with birth outcomes in order to determine the impact of WIC participation on 

birth outcomes (U.S. Department of Agriculture, Food and Nutrition Service, 1987). 

However, in each case, individual researchers were required to negotiate with individual 

state programs to access data from these three sources. These researchers were then

responsible for linking the files, and creating a usable database. Currently, there is no 

single representative database that researchers can access to conduct research on WIC 

outcomes, program participation, and program dynamics using data from these three 

sources. 

Health Systems Research, Inc. Final Report Page 3 
Additional research conducted using linked WIC, Medicaid, and vital records data 

include: 

• Utilizing WIC, Medicaid, and vital records data from 1985 to 1997, the Illinois 

Department of Human Services conducted a study of the effect of multiple 

program participation on birth outcomes (Durkee, 1999) 

• In 2000, the South Carolina Department of Health and Environment conducted a 

study of immunization coverage using linked WIC, Medicaid, and vital records 

data (South Carolina Department of Health and Environment, 2000) 

• A study published in the March 2002 American Journal of Public Health used 

linked WIC, Medicaid, and vital records data to examine improved health of 

children at Medicaid managed care sites with WIC providers on location (Kendal, 

et.al. 2002) 

Because all three files are rich in client-level data, such a database would allow 

for better descriptions of WIC participants and provide an ongoing capability to evaluate 

WIC in relation to various prenatal, post-partum, and child health program objectives. 

By developing and updating a database that is readily available to researchers, USDA can 

create a data file that can be used to examine client demographic contributions (age of 

mother, weight gain, use of prenatal care, breastfeeding status, race and ethnicity, etc.) to 

a number of health outcomes, such as mother’s weight gain, birth weight of children, 

pregnancy complications, APGAR scores, and nutritional risks of the pregnant woman 

and child. In addition, participation in the Medicaid program will help to examine such 

issues as access to preventative health services, immunization status, and ongoing 

utilization of health care services. Further, since nutrition and health services are 

complementary services that work together to improve health outcomes for infants and 

children, these linked data will be very useful in better understanding the relationships

between maternal and child health and nutrition services, food assistance, and health 

outcomes. 

Health Systems Research, Inc. Final Report Page 4 
III. Initiative Summary

A. Structure and Content 

This initiative proposes to create a national database of linked WIC, Medicaid, 

and vital records data. The database will be created by asking States to link a single 

month WIC participation data with data from the States’ Medicaid program, and for 

infants and children, with the States birth registry. To ease the reporting burden for 

States, it is proposed that the WIC data used for the linkage be the same data that are 

reported for the required WIC program characteristics data set. 

The database itself will contain information from all three data sources. While the 

exact structure and number of variables included in the database will need to be 

developed as a part of this initiative, the number and type of variables available are 

impressive. Some of the potential variables available from each data set are described 

below. A detailed listing of variables contained in the WIC and vital records files are 

contained in Appendix C. 

• Client Demographic Information. Information regarding client 

demographics are numerous. From all three files, data can include date of 

birth, race/ethnicity, and sex. The WIC files contain such demographic 

information as migrant status, family income, and certification category. 

From the vital records data, additional demographic data are available, 

including mother and father’s education level, number of live births, and 

parents birthplace. In addition information in the vital records system

includes the status of such risk factors as tobacco use during pregnancy and 

alcohol use during pregnancy. 

• Client Services Information. The database will provide information 

regarding the client’s access to health care service through information 

regarding the geographic location of service providers and the number of 

visits to the providers. From the WIC record, information is available 

regarding the location of the WIC service site. From the vital records data,

information is available on the county of residence, the location of the 

delivery, the type of services provided the mother (including amniocentesis, 

ultrasound, etc) and the number of pre-natal visits. From the Medicaid 

records, information is available regarding the location of the Medicaid 

service provider, and the number and types of EPSDT visits for children. 

• Client Health Outcome Information. The WIC record will provide 

information regarding the WIC priority level, nutritional risk(s) present at

certification, anemia status, weight, height, and breastfeeding status. The vital 

records data will provide such basic information as the weight and length of

the infant and the APGAR score, as well as information such as complications 

of labor and delivery, method of delivery, medical risk factors for the mother, 

abnormal conditions of the newborn. Through the Medicaid EPSDT records, 

Health Systems Research, Inc. Final Report Page 5 
information is available about the immunization status of the child, the 

number and type of screenings, information regarding lead poisoning, and 

information regarding hearing loss. 

 

While this is not intended to be a complete list of all the variables available, nor is 

it a set of specific variable recommendations, it does show the type of database that can 

be created from the linked records. The variables included in the final database will 

likely need to be prioritized in order to capture data of most interest to federal and State 

researchers. 

The basic procedure for the initiative will have five steps, which will be detailed 

in section V. These steps will include: 

 Using the experience of those States that have linked WIC, Medicaid, 

and vital record data, the initiative proposes to Develop Federal 

guidelines for data sharing, data abstraction, and data linkages. This 

will include the development of a model data linkage file, a 

hierarchical database, and protocols for linking the data. 

 Developing the format and structure of the national database, including 

the list of variables, reporting methods, sampling techniques, access 

protocols, and data file updating and storage. 

 Recruit States and provide assistance with creating the linked data set . 

This would be accomplished by having the State first linking the WIC 

records with vital records, and then linking the combined file to the 

State’s Medicaid records. This will also involve having the States 

strip individual client identifying information from the files. 

 Extracting a nationally representative sample from the linked statelevel data, and entering it into a national database. 

 Storing the national database in an accessible file that will be made 

available to Federal and State officials, as well as program researchers. 

B. Importance for Research and Administrative Purposes 

As was noted above, linking WIC, Medicaid and vital records data will provide a 

significant source of information on WIC program outcomes, program participation and 

program dynamics. In addition, by linking data from the national database with files 

containing health outcomes of individuals not participating in the WIC program, 

researchers will be able to compare the outcomes of WIC clients with those who did not 

participate in the program. Also, because the State agency will be creating the initial 

links, each State will have its own database that can be used to evaluate program

participation and outcome objectives. A discussion of these advantages is presented 

below. 

Health Systems Research, Inc. Final Report Page 6 
1. Advantages of the single federal database. 

By having the single federal database containing linked information about WIC clients, 

federal officials and researchers will be able to examine the health outcomes of WIC 

clients, examine program participation dynamics related to joint WIC/Medicaid 

enrollment, and conduct trend analyses of WIC health outcomes over time. Each of these 

advantages is discussed below. 

A, Development of a single data source that can be used to track the health

outcomes of WIC participants. The creation of a single data set 

containing the linked information can be used to track a number of health 

outcomes of WIC clients. Researchers will have access to a national 

database to examine trends in program outcomes and conduct very 

specific research studies. For example, if a researcher wanted to conduct a 

study of the birth outcomes of overweight women participating in the WIC 

program, the linked data set would contain this information. 

This is a significant improvement over the current system. Under the 

current system, the only national data set available on WIC clients is the 

minimum data set required by FNS for the program characteristics study. 

These data only provide access to an individual participant’s basic 

program data, and the data can not link the mother to the child to evaluate 

outcomes. 

Under the proposed initiative, the data that will be available for each WIC 

client will be significantly larger than the current minimum data set. More

importantly, the proposed national database. will contain information 

about both the mother to the child, thus allowing researchers to examine 

pregnancy factors as they might related to birth outcomes. In addition, the 

linked data will allow researchers to not only examine national trends, but 

compare outcomes between States and regions as well. 

Having the national database of linked WIC /Medicaid/Vital Records data 

avoids the pitfall of the current system for conducting research studies, 

which must rely on multiple data collection efforts that are geared to the 

specific research or program management objectives. The initiative 

provides a far more cost-effective approach to conducting research and 

program administrative activities than currently exists. 

B. The ability to track the health outcomes of WIC participants. As noted 

above, by linking the WIC participant’s record to the birth record and 

Medicaid file, information about the mother and child is created. One can 

then use the proposed database to examine contributing factors of the 

mother’s health status on the birth outcome of the child. For example, 

Health Systems Research, Inc. Final Report Page 7 
once could examine the birth outcomes of women with various nutritional 

risks to possibly identify those risks for which WIC participation seem to 

have little impact on positive birth outcomes. 

In addition, information is available to assess the impact of Medicaid 

participation on WIC birth outcomes as compared to those not 

participating. For example, if one wanted to compare the impact of 

Medicaid participation on birth outcomes of WIC children, the database 

would contain information about WIC infants and moms who participated 

in Medicaid, and those who did not. 

C. The ability to conduct trend analysis. The national database will allow for 

researchers to conduct trend analysis of the WIC population over time. By 

updating the file every two years, any trends in program participation and 

health outcomes can be examined by comparing data from prior years, and 

by updating prior files. 

In addition, the national database would allow researchers to compare 

trends between States. This may be useful in examining the impact of 

outreach campaigns or other targeted efforts that may occur in one state, 

but not in another. In addition, trend analysis can be conducted based 

upon the priority status of the WIC participant, which would then allow an 

examination of the WIC program’s impact on various risk groups. 

2. Advantages of having a database that can be linked to data regarding persons 

not participating in the WIC program. 

One of the key research questions regarding the WIC program has been the 

question related to whether or not program participation makes a difference in health 

outcomes. The national database of linked WIC/Medicaid/vital records data is a major 

step in creating a research database that will allow some of these questions to be 

addressed. While data regarding persons who do not participate in the WIC program will 

not be available in the national database, the initiative makes it much easier to obtain 

information about non-participants. This is done by making it simpler for researchers and 

State officials to create a database of non-WIC participants for comparison purposes. 

For example, because each state will link their own data, it will be easy for a 

researcher to have access at the same time to and individual State’s vital records data 

with WIC participants already extracted. A researcher could simply request these data 

from either the WIC State Agency or the State Vital Records office one the linkage was 

complete. The researcher could then compare the health outcomes of individuals who did 

not participate in WIC with those in the national database. 

In addition, by creating a single, data-rich file, the newly created database can 

potentially be linked to data from other national surveys, other data files maintained by 

Health Systems Research, Inc. Final Report Page 8 
state and local governments (food stamp administrative files, TANF files, etc.), or data 

files maintained by Federal agencies such as the Centers for Disease Control and 

Prevention (nutrition surveillance files). Data from these files could be used to track 

outcomes beyond those reported in the WIC/Medicaid/vital records files. For example, 

through linkages with the CDC pediatric and maternal nutrition surveillance systems, 

additional information about the nutritional status of clients can be obtained. However, 

because only 44 states participate in the nutrition surveillance system, data would be 

limited in scope. 

3. Advantages to State WIC Agencies in using the Database to identify gaps in 

program practices. 

Since the individual States will be linking the three data sets, they will be able to 

maintain a complete data set of their own linked data for use at the State level. There are 

major benefits that can accrue to State WIC agencies by having a linked database of their 

own WIC clients available for research and program evaluation purposes. For example, 

by linking the data from the three files, issues related to the relative health outcomes of 

persons of color, persons living in rural areas, or adolescents can be assessed and new 

program interventions can be devised to better serve these clients. Data on these 

demographic factors can then be used to target specific outreach efforts. In addition, the 

data can be used to expose gaps in program coverage by identifying Medicaid births in 

geographic areas where mothers did not receive WIC services, or the extent to which 

WIC children may be eligible for Medicaid coverage, but are not enrolled. An example 

of how the State of Missouri used these linked data to examine whether the WIC program

was reaching the highest risk clients is provided in Appendix D. 

As can be seen, there are a number of advantages to a national linked 

WIC/Medicaid/vital records database. In addition to having a significant advantages over 

the existing system of collecting WIC data for research purposes, a number of potential 

research questions can be addressed by this initiative. These include: 

 Because the database will contain information that allows the infant to be linked 

to the mother, one can examine the extent to which various maternal health and 

demographic factors contribute to the health outcome of the infant. For example, 

one can ask “ Is there any association of various nutritional risk factors (such as 

obesity) of the mother that may influence birth outcomes of WIC participants?”

 By linking Medicaid enrollment data with WIC participation data, one can

address the question “How does participation in both WIC and Medicaid impact 

birth outcomes as compared to participation in only one of the two programs?” 

• By linking WIC data with data available in the Medicaid files (such as EPSDT 

data) one can answer the question “What are some of the health outcomes of 

WIC participation on children as compared to children participating in the 

EPSDT program, but not participating in the WIC program?”

Health Systems Research, Inc. Final Report Page 9 
 With the combined WIC/Medicaid data in a single database, one can examine the 

extent to which WIC clients are served by the Medicaid program. This has been 

an important issue for State health departments that have been conducting strong 

outreach programs to reach children without health insurance. 

 By having data available on the risk status of the mother and infant, and 

combining these data with vital records data, one can examine the extent to which 

low-income mothers of high-risk infants participated in the WIC program. 

These are just some of the research questions that can be answered at the national level 

by utilizing the database proposed in this initiative. As was noted earlier, States can use 

the information that will be available to examine program participation dynamics, 

conduct demographic analysis of various groupings of WIC clients, and compare 

outcomes across states. 

Health Systems Research, Inc. Final Report Page 10 
IV. Overview of the Implementation Plan 

This section introduces the proposed methodology for developing the initiative to 

create a national research database linking WIC, Medicaid and vital records data. 

Specifically, it provides information about the key individuals that will need to be 

involved in the initiative, an overview of the activities that must take place, and potential 

implementation barriers.

It is very important to note that the success of this initiative is dependent on a 

significant amount of “up-front” work on the part of federal and State officials. By 

bringing together experts in the area of data linkages, persons with experience using 

linked WIC data for research purposes, and experts in maternal and child health, a 

number of difficult factors can be dealt with in advance of presenting the initiative to the 

States. Specific challenges that can be mitigated by such up-front cooperation and 

deliberation are discussed in Section C. 

A. Description of Key Actors 

When designing an initiative that involves programs administered through two 

Federal Departments and three separate state-level agencies, it is critical to identify key 

players for both the design and oversight of the initiative as will as the implementation 

phase. This initiative is designed to bring together experts from the key federal and state 

agencies, as well as national organizations representing State agencies, for the design and 

oversight portion of the project. Once the implementation phase begins, additional actors 

will become involved, as State WIC programs work with their Medicaid and Vital 

Records directors to coordinate data merging and submission. Specific actors and their 

roles include: 

1. USDA Staff 

Staff from USDA will be responsible for coordinating this initiative and providing 

guidance to other key players. Specifically, staff from USDA will be responsible for:

 Identifying key Federal and State officials to participate in the planning and 

oversight of the initiative;

 Conducting meetings with key constituent and oversight groups in order to 

develop and implement the initiative;

 Developing, in conjunction with HHS officials, the model data sharing 

agreement by which the individual programs in each state (WIC, Medicaid, 

Vital Records) can share their data with one-another. 

 Develop the sampling plan for data collection; 

Health Systems Research, Inc. Final Report Page 11 
 Identifying the key data elements that will be included in the database, and 

developing the database structure; 

 Identifying appropriate methods by which data can be linked and submitted to 

USDA or other appropriate Federal agency; 

 Testing the linkage methodologies, data base development, and data 

submission protocols; 

 Obtaining OMB clearance, if necessary; 

 Providing technical assistance to States during the implementation phase of 

the project; 

 Making the database accessible to researchers and State agency officials; and 

 Overseeing quality control and storage of the data. 

2. Officials from the Department of Health and Human Services. 

Because this initiative utilizes data from three different sources, it will be 

important for officials located within the Department of Health and Human Services to be 

involved in this project. Specifically, it will be important to have representatives from

the National Center for Health Statistics and the Health Care Financing Administration 

involved in the project. In addition, USDA may wish to involve officials from the 

Maternal and Child Health Bureau, as they have experience with using Medicaid and 

vital records data for evaluation purposes. The specific activities in which these federal 

officials will be involved include: 

 Assisting USDA officials with providing overall guidance to State agencies; 

 Helping to draft a model data sharing agreement for use by State programs; 

 Participating in oversight committee meetings during the development and 

implementation phase; and 

 Providing support and assistance to USDA and State agencies in order to 

resolve issues that may arise during the testing and implementation phases. 

It is important to note that funding issues will likely arise from these meetings. It 

is anticipated that their will be interest on the part of HHS officials in being able to utilize 

this database to promote research into achieving such departmental objectives as the 

Healthy People 2010 goals. In addition, during the 2000 federal fiscal year, the Maternal 

and Child Health Bureau funded grants to State health departments and research 

institutions to examine methods by which public health programs could overcome 

racial/ethnic disparities in access to health care. A number of these grantees proposed 

Health Systems Research, Inc. Final Report Page 12 
developing links between WIC program data and vital records/Medicaid data (MCH 

Bureau grant announcements, 2001). It therefore will likely be prudent to include in the 

discussions between HHS and USDA the notion of joint funding of this initiative. 

3. Representatives from State Associations of Program Directors. 

In order to gain the cooperation of State officials, it will be critical to involve 

representatives from each of the three programs in the early developmental stages of this 

initiative. Each of the three programs involved have associations composed of State 

program directors. Asking each of these three associations to participate in the 

developmental stages will be key to gaining state support during the testing and 

implementation phases. Specific responsibilities of the State association representatives 

will include: 

 Providing advice and technical consultation to Federal officials during the 

developmental stages of the initiative;

 Attending meetings of the developmental and oversight committees in order to 

represent the interests of State officials; 

 Provide feedback to State officials through the normal channels used by the 

associations for communicating with their membership; and 

 Providing support to the federal agencies during the testing and 

implementation phases of the initiative. 

4. State Program Directors

Much of the testing and implementation of this initiative will be the responsibility 

of the State WIC directors and their counterparts in the Medicaid and Vital Records 

programs. It is assumed that the State WIC programs will take the lead in coordinating

state-level activities, including developing data sharing agreements, arranging for 

obtaining data from the other two programs, conducting the data merge, and submitting 

data to USDA. Specific responsibilities include: 

 Developing data sharing agreements with State Medicaid programs and 

offices administering the State’s vital records ; 

 Implementing the database structure to be compatible with the State’s WIC 

data system so data can be merged; 

 Conduct the data merge and create the datafiles for submission; 

 Obtain State-level clearances required by State human subjects review 

committees; 

Health Systems Research, Inc. Final Report Page 13 
 Conduct data quality edits and updates prior to submission of data; and 

 Submission of data to USDA 

B. Overview of Activities 

On the surface, this initiative seems feasible because it requires no new data 

collection on the part of State agencies. However, because this initiative requires the 

cooperation of so many agencies and officials, it will require a significant amount of 

preliminary activities, planning, and testing prior to implementation. This initiative will 

likely take from two to two and one-half years to implement. Detailed tasks involved in 

the planning and implementation of this initiative are contained in Section V. 

It is envisioned that the initiative will be developed and implemented in three 

phases. These phases include: 

 A preliminary phase the will bring together all of the major players in the 

initiative and develop a shared vision of the project, its goals, and its 

methodology. The preliminary phases will require that officials both agree to 

cooperate with the initiative and commit to providing their time and expertise 

in the developmental and implementation phases.

 A developmental phase, in which after all parties agree to the value of

pursuing the initiative, the basic logistical and technical issues will be 

developed. This phase will include the development of model data sharing 

agreements, identification of data elements and development of the basic 

database that will be created for the merged data set, development of the data 

merging protocols and the programs necessary to implement the data merge, 

and development of quality control, data access, and data storage protocols. 

Activities will need to occur at both the State and Federal level during this 

phase, and by its end the mechanisms should be in place to begin testing and 

implementation of the initiative. 

 An implementation schedule, which will begin with testing the developed data 

merging protocols, database integrity, and the data submission protocols. 

Refinements will need to be made once the initial testing is complete, and a 

second round of testing will be likely. Once the testing phase is complete, and 

implementation schedule will need to be developed and submitted to the 

States. 

 Much of the time-consuming work will be involved in the developmental phase, 

and will involve obtaining agreement and cooperation from the multitude of Federal and 

State officials involved. In addition it will be important to provide States WIC officials 

with assurances that this initiative will not be a significant added burden to their 

workload. 

Health Systems Research, Inc. Final Report Page 14 
In order to properly implement this initiative, a steering committee will need to be 

organized to oversee each of the phases of the initiative, and, at times, may involve 

different individuals depending upon the task being undertaken. For example, while a 

State WIC director may wish to participate in the preliminary and planning phases, they 

may wish to have a technical person participate in activities involving the development of 

the database structure and data merging activities. Therefore, it is envisioned that a 

steering committed to oversee the phases will be developed, some of the players may 

change as the initiative progresses. 

C. Potential Barriers to Implementation 

Some limitations and potential difficulties in developing this initiative also need 

to be considered before deciding to proceed. 

1. The Complexity of the Data Links. While it has been noted previously 

that several States have been successful in linking WIC, Medicaid, and 

vital records data, this is still a complex process when expanded across all 

States. This initiative proposes to use the expertise of numerous 

individuals who have had experience in linking data files to both develop 

the content and structure of the database as well as develop the protocols 

for linking the data. Because data can not be linked through a single 

identifier, an algorithm utilizing demographic information will be used to 

create the links. The algorithm will need to be tested and refined prior to 

utilizing it as the method by which files will be linked in each State. Once 

in place, however, the future data links should be much easier to 

accomplish. 

One other factor must also be considered, which is the technical feasibility

of State systems to link the records. It is important to note that States are 

consistently refining their State WIC program data systems, and, in many 

cases, have included systems by which linking WIC with Medicaid and 

vital records data will be easier. For example, North Carolina, South 

Carolina, California, Massachusetts. and Illinois identify Medicaid 

participation in their WIC files. Recent RFPs for North Dakota, Iowa and

Maryland propose to capture data to improve linkages. We believe that 

improvements in State data systems, including the movement to Internetbased systems, will make the feasibility of data linkages easier. 

2. Obtaining the Cooperation of State Agencies. State agency’s initial 

reaction to this initiative may be to express concerns regarding the 

perceived burden they will incur to make the initiative successful. 

However, it must be noted that given the interest expressed by State 

officials regarding the importance and need for outcome information 

regarding WIC program participation and program dynamics, the existing 

system places a far greater burden on States than would a structure 

approach proposed in this initiative. The number of States that currently 

Health Systems Research, Inc. Final Report Page 15 
link data further supports this. Under the existing system, data are 

collected and used for a single individual study. This means that any time

additional information is needed, or additional research projects are 

funded, States must undergo the burdensome process of cooperating with 

the new study. By conducting a data linkage every two years, as proposed 

in this initiative, multiple research projects can be undertaken by federal 

and state officials, without requiring state cooperation and involvement in 

each individual research effort. 

3. Overcoming Administrative Barriers. One of the key implementation 

parameter to consider in terms of project time and effort needed to enact 

this initiative is the fact that there are both technical and administrative 

pieces requiring time and effort on the part of those involved. In most 

cases, the technical components will likely be less difficult to design and 

implement in comparison to the time-consuming administrative process 

that will be necessary to obtain cooperation and approval from all of the 

key players. As was noted earlier, the up-front efforts to develop this 

initiative are critical to its acceptance and success. It is anticipated that 

there will need to be a review of the initiative’s progress at different stages 

to decide if full implementation is still possible, or if alternatives will need

to be considered 

4. Limitations of Vital Records Data. Vital records data reflect only the 

births within a given State, so some WIC and Medicaid data will not be

able to be linked to these data. In the studies cited earlier in the States of 

Missouri and North Carolina, the main reason cited for non-matching 

records was the fact that some WIC infants were born out-of-state, and 

therefore were not included in the vital records database. While both 

North Carolina and Missouri showed relatively high match rates (over 

95%), this may be more problematic in States with more migrant 

populations. 

5. Creating Data Sharing Agreements. One of the key issues identified by 

State WIC agencies in trying to link data records is the need to develop 

data sharing agreements. This is particularly important since the passage 

of the Health Insurance Portability and Accountability Act of 1996 

(HIPAA), which enhances privacy, rights of individuals receiving health 

care. The custodians of the WIC, Medicaid, and vital records data all face

limitations as to how their data can be used, and by whom. However, 

States are addressing this issue through the modification of existing data 

sharing agreements. For example, the Massachusetts WIC and Medicaid 

programs recently worked with their Attorney General’s office to revise 

their data sharing agreement to address HIPAA concerns. Both Missouri 

and Iowa are currently working on revising data sharing agreements and 

Health Systems Research, Inc. Final Report Page 16 
consent forms to allow for the continued linkage of WIC, Medicaid and 

vital records data. 

It would be very helpful to States for USDA to take the lead in working 

with States who successfully addressed the HIPAA issues to develop 

model data sharing agreements. This initiative envisions USDA working 

with selected States, along with several divisions of the Department of 

Health and Human Services on this initiative. These players would 

including the National Center for Health Statistics, the Health Care 

Financing Administration, and the Maternal and Child Health Bureau. 

While the idea of cooperation between the two departments is reasonable, 

the resulting need to coordinate may slow the process down. 

6. Use of Managed Care Plans by State Medicaid Agencies. Because some

State Medicaid programs use managed care plans for delivering health 

services, there will be limited encounter data available on individual client 

medical visits. Traditional Medicaid encounter data includes information 

on the type of services provided to the client. However, because managed 

care plans are not required to bill for individual visits, the specific 

encounter data is usually not available in the State’s Medicaid data file. 

Researchers would still be able to use Medicaid enrollment data to 

examine program participation and dynamics issues. In addition, most 

states required managed care plans to report on certain basic health 

services, such as EPSDT services, pre-natal care information, and the 

immunization status of children enrolled in the plan. This information 

would be useful in examining some of the program outcomes of interest to 

USDA. Finally, as was demonstrated in the Detroit study, linkage of 

managed care data and WIC data with birth records can also examine birth 

outcomes in managed care settings as compared to traditional primary care 

providers. 

7. Client Confidentiality Issues. There may be concerns expressed by 

individual State WIC Directors with regard to client confidentiality. This 

is likely to be a result of traditional concerns combined with HIPAA 

regulations. It is important to note that this initiative proposes to strip off 

any client identifying information prior to making the data available for 

research purposes. This issues must be addressed when the data sharing 

agreements noted above are developed by the individual states. In 

addition, we propose to develop model data sharing agreements and 

consent forms that can address HIPAA issues, which will help States to

overcome administrative barriers associated with client confidentiality. It 

is important to note that the data being asked for from the WIC program is 

data that is already collected and submitted to USDA for the WIC 

Program Participant Characteristics database. While the linkages with 

vital records and Medicaid may result in additional concerns, the fact that 

Health Systems Research, Inc. Final Report Page 17 
several states currently or in the recent past have overcome privacy issues 

should be considered encouraging and not insurmountable. 

Health Systems Research, Inc. Final Report Page 18 
V. Description of Specific Tasks 

While the technology that would be used for linking the records from these three 

programs has been proven to be effective in a number of prior studies, there are a number 

of tasks that must take place that will require the cooperation of both Federal and State 

agencies. Below is an overview of each of the tasks, including a listing of proposed 

subtasks. In addition, at the end of each task is a summary of the cost information for 

that task. In order to be consistent with Kenyon, et. al (2001) and Wittenburg and 

Alderson (2001) we assume that each agency has three labor categories; Senior Manager, 

Senior Analyst, and Research Assistant. The Senior Manager category includes experts 

who have at least ten years of research and /or program experience. The Senior Analyst 

category includes researchers and technical staff that have between three to nine years of 

experience. The Research Assistant category includes individuals with limited 

experience. 

Estimates for labor hours were derived from examining prior efforts to conduct 

data merges at the State level, prior experience of the principle investigator in 

implementing the WIC minimum dataset, and experience from other federal agencies 

conducting research with data merging. In particular, information provided by the 

Maternal and Child Health Information Resource Center, which is funded by the Bureau 

of Maternal and Child Health (HHS) and administered by HSR, was very helpful in 

estimating labor hours. 

The following tasks are proposed for creating the database. 

Task 1. Conduct Initial Meeting Among Federal Agencies 

One of the key issues that will need to be addressed by Federal and State officials 

is the need to develop data sharing agreements between the WIC Program, the State 

Office of Vital records, and the State Medicaid program. In order to facilitate this 

process, it is proposed that an initial meeting be conducted between representatives from 

USDA and those from offices within the Department of Health and Human Services 

responsible for the state-level programs included in this initiative. The meeting should 

include representatives from the National Center for Health Statistics (vital records), the 

Medicaid program, and possibly representatives from the Maternal and Child Health 

Bureau. 

The purpose of this initial meeting would be to brief the representatives from

these agencies on the proposed initiative and request their involvement and cooperation. 

A number of products could come from this meeting, including a joint letter of agreement 

supporting the initiative that could be shared with State agencies, a working “steering 

committee” to help oversee the implementation, and a sample data sharing agreement that 

could be used by States to meet both federal and state data confidentiality requirements.

Subtasks: 

Health Systems Research, Inc. Final Report Page 19 
 Identify potential participants to be included in initial meeting. 

 Prepare summary of project and distribute to invited participants. 

 Conduct meeting. 

 Identify committee to prepare model data sharing agreement. 

 Prepare and distribute model data sharing agreement 

Federal Costs: $12,056 

State Costs: 0 

Total Task Cost: $12,056 

Task 2. Conduct a Series of Meetings with State Program Representatives and 

steering committee members.

Once there is agreement among the Federal Agencies, the next task would be for 

USDA to conduct a meeting with representatives from each of the three State programs 

involved in this initiative. This meeting would be with representatives from the National 

Association of WIC Directors, The National Association of State Registrars, and the 

National Association of State Medicaid Directors. The purpose of the meeting would be 

to provide information about the initiative, gain their support and cooperation with the 

initiative, and develop a workgroup to help oversee the implementation process and solve 

problems as they occur. It will be critical to have support and input from these agencies 

as the initiative progresses. 

At this meeting, it will be important to identify a core group of State and Federal staff 

who can serve as a steering committee for the project. The committee should represent 

all of the major players in the initiative. This committee will have responsibility to 

oversee both the developmental and testing phase of the project, as well as the 

implementation of the national database. 

 Subtasks: 

 Identify and invite participants to initial meeting. 

 Prepare and distribute background materials to meeting participants. 

 Conduct meeting and develop Steering Committee for ongoing oversight of 

the initiative.

Health Systems Research, Inc. Final Report Page 20 
 Prepare joint letter to State Health Departments and Medicaid Agencies from

committee describing the initiative and requesting State agency support. 

 Conduct additional Steering Committee meetings as the project progresses.

Federal Costs: $39,772 

State Costs: $17,627 

Total Task Cost: $57,399 

Task 3. Develop a Nationally Representative Sample Plan 

Deciding on how to construct the sample frame for the database will require 

considerable thought on the part of USDA and other federal officials. While developing 

sample frames for national studies are not new, the fact that the ultimate goal is to link

the data with other participant databases may provide for opportunities not commonly 

considered in developing samples. In the case of this initiative, the sample will be 

designed to allow for both state-level analysis of data as well as national research. This 

means that a larger number of WIC participants will be included in the sample than if the 

purposed was to examine national issues alone. 

Another key issue that will need to be decided is at what point during WIC 

participation the record should be entered into the database. While the database should 

be representative of women, infants and children enrolled in WIC, there may need to be 

some consideration given to the age of the child and length of participation prior to 

inclusion. For example, if a four-year old is added to the file, and then data are linked, 

there will be more data available for that child than a two-year old. However, if the fouryear old is only recently enrolled in WIC, then there will be less WIC data available than 

for a two-year old that has participated since birth. This may mean that the sample may 

need to be controlled for the child’s age and length of participation. 

Once these decisions are made, the sample can be drawn. The sample frame will 

need to be constructed using data currently available in the participant characteristics 

study, but actual data to complete the sample will need to be obtained from the State WIC 

program participant database. 

Subtasks: 

 Identify model and structure for national sample that includes the ability to 

examine state-level data.

 Develop sampling plan for national data collection. 

Health Systems Research, Inc. Final Report Page 21 
 Develop State-by-State sample requirements to assure validity of State-level 

data. 

 Prepare and submit sampling plan to oversight committee for review. 

Federal Costs: $7,599 

State Costs: $2,820 

Total Task Cost: $10,419 

Task 4. Create the Database Structure for Data to be Linked. 

This next step will require that the specific data elements to be contained in the 

database be identified, and a database be constructed in a form that allows for analysis. 

The database structure would be hierarchical, creating a header record that links all data 

back to a family unit tied to the mother. Then separate detail records are created 

containing information about the mother and child, including the health status of the 

mother and pregnancy information, birth outcome data, and information about the child. 

The database should be large enough to capture the essential demographic components of 

the WIC participant, as well as health outcome information contained in the records. For 

example, the WIC record for a pregnant woman will contain both demographic 

information as well as health outcome information such as weight gain during pregnancy 

and nutritional risk factors. The birth certificate information will also contain numerous 

demographic data for the baby’s parents, as well as information about the pregnancy. 

The Medicaid record will also contain information about health care utilization, such as 

prenatal care visits. 

As a result, the database structure will need to be carefully constructed in order to 

recognize duplicate information that will be available from each of the three files. For 

example, in the case of a pregnant woman, it is likely that all three files will contain 

information regarding her age, racial or ethnic identification, weight gain during 

pregnancy, and other demographic and service-related factors. The database will need to 

be structured in such a way that duplications can be recognized and inconsistencies 

resolved. 

Additional consideration will need to be made when linking the child’s file to the 

mother’s. The database will need to be structured in such a way that individual 

information about the parent and child can be extracted for research purposes. At the 

same time the data file must be able to create associations between the mother’s 

pregnancy, the birth outcome, medical participation and ongoing WIC participation. 

In implementing this task, it would be advisable to develop a participatory process 

that would include representatives from the federal and state agencies involved, as well as 

independent researchers. Having this type of input may make it easier to construct a 

workable database as well as avoid pitfalls that other researchers may have experienced. 

Health Systems Research, Inc. Final Report Page 22 
 Subtasks: 

 Identify key data elements to be included in the merged database, including 

the development of consistent data definitions and acceptable ranges of 

values; 

 Identify potential duplications of data that will need to be resolved through 

edits; 

 Identify an appropriate structure for the database, including the structure of 

the hieracterical database, how to display family data within the hieracterical 

structure, and how the overall structure of the database can be made userfriendly 

 Develop security and access protocols for the database; and 

 Develop methods by which client identifiers are stripped from the records 

prior to submission to USDA. 

 

Federal Costs: $19,514 

State Costs: $0 

Total Task Cost: $19,514 

Task 5. Create the Protocols for Linking the Three Databases. 

Once the sampling method is developed, the next step is to develop the protocols 

that will be used to link the WIC record with the Medicaid and vital record information. 

This can be done using a number of methods. Because the data files contain a significant 

amount of demographic data about the clients, matches can be created by identifying 

common demographic characteristics. As has been noted, matching WIC records with 

birth records has been successfully accomplished in the past, and would likely be the first 

two databases to be linked. For example, the WIC, Medicaid, vital records links that 

occurred in the Missouri studies accomplished a 93.6% linkage in 1994 and a 95% 

linkage rate in 1997. In some cases, records can be linked if the mother’s social security 

number is available. However, in most cases, WIC programs do not collect social 

security numbers, so matching will need to take place using demographic data such as 

name, birthday, date of delivery, and other client demographic data.

After a combined WIC/birth record match has been established, the next step is to 

determine whether or not the individual WIC participant also is enrolled in Medicaid. 

This can be done by matching the newly linked database to the state’s Medicaid 

enrollment file. The newly created database will then have information as to whether the 

participant was enrolled in Medicaid or not. This will allow for outcome comparisons of

WIC clients who are enrolled in Medicaid as compared to those who are not. In addition, 

Health Systems Research, Inc. Final Report Page 23 
some States will have information on services provided through the Medicaid program, 

such as the immunization status of children or the prenatal visits of the mother, can be 

captured and analyzed. 

 Subtasks: 

 Examine prior efforts to link the three databases and develop a range of 

specific protocols and algorithms that will be considered for developing model 

methods for data linkages; 

 Develop a technical panel to review the prior efforts and make 

recommendations as to the best protocols to recommend and implement; and 

 Prepare a document that provides guidance to State agencies on the best

methods by which data can be linked. 

Federal Costs: $16,667 

State Costs: $17,627 

Total Task Cost: $34,294 

Task 6. Develop Access Protocols and Guidelines for Removing Client 

Identifying Information 

The next step will be to develop recommended protocols for remove identifying 

information about the client and develop methods by which researchers will be able to 

gain access to the database. In addition, decisions will need to be made about how often 

to update the database. To provide quality information, it is recommended that the 

database be updated at least every two years with new data. The updating procedure 

should be able to be linked with the prior database in order to update client records, and 

allow for tracking of certain clients over time. By using the birth record number as an 

identifier, information about the delivery of pregnant women included in the prior 

database can be updated. The resulting file will then be available for research purposes. 

It is recommended that the database be maintained by and made available through 

USDA. 

 Subtasks: 

 Identify key client identifiers that must be removed from the database in order 

to ensure client confidentiality; 

Health Systems Research, Inc. Final Report Page 24 
 Review methodologies used in prior studies linking data from these sources to 

develop the best method by which to remove client identification information; 

and 

 Develop a method by which dummy client identifiers can be inserted so 

comparisons can be run once the data are linked. 

Federal Costs: $5,558 

State Costs: $4,230 

Total Task Cost: $9,789 

Task 7. Test the Protocols for Data Linkage Integrity and Database 

Functionality. 

One of the key elements of this initiative will be to test the protocols that have 

been developed by asking a limited number of States to create a linked database using the 

developed protocols. In order to avoid having to obtain clearance from the Office of 

Management and Budget during this test phase, it is recommended that fewer than nine 

states be selected to test the protocols. The States selected for the test should be ones that 

have had experience linking their WIC files with Medicaid and vital records data. Each 

State would be asked to develop their data sharing agreements and then follow the 

linkage protocols developed by USDA. These data would be submitted to USDA 

electronically and placed into the newly designed database. One the data were in place, 

tests should be run on the data to assess the functionality of the database and query 

software. 

 Subtasks: 

 Identify testing methods and protocols; 

 Identify States that have linked records in the past, and would be willing to 

test the data merge protocols; 

 Develop and implement data sharing agreements in the selected States; 

 Run test data linkages in each State and submit data to trial database; 

 Develop and test query software on the sample database; and 

 Review results of the testing and make appropriate adjustments to the data

collection and merger protocols and/or query software. 

Federal Costs: $32,861 

State Costs: $48,448 

Health Systems Research, Inc. Final Report Page 25 
Total Task Cost: $81,309 

Task 8. Revise Protocols Based Upon Test Results. 

After completion of the testing, the protocols may need to be revised to 

incorporate lessons learned. Once the protocols are revised, it is recommended that 

representatives from the nine test states review the protocols to be sure they are still 

functional and have not created any new problems. 

Federal Costs: $8,521 

State Costs: $4,230 

Total Task Cost: $12,715 

Task 9. Prepare OMB Clearance Package. 

It is not known whether or not this initiative will require clearance from the Office 

of Management and Budget (OMB), but because data are being merged from different 

Federal programs, it is assumed that such clearance will be required. Upon completion of

the testing phase, the next step will be to request clearance from OMB to collect data 

from all the States that will be included in the sample. This package should emphasize 

that these data are already being collected by State agencies, and the linking of these 

existing database will lessen State-level burdens when conducting future research on 

WIC outcomes. 

 Subtasks: 

 Prepare Federal Register notice of data collection;

 Prepare and submit OMB clearance package; and 

 Make revisions to clearance package as required by OMB. 

Federal Costs: $6,742 

State Costs: $0 

Total Task Cost: $6,742 

Task 10. Implement the Initiative on a National Level. 

Once OMB clearance is granted, the next step will be to implement the initiative 

on the national level. It will be important for there to be technical assistance available to 

States during the first year in order to help them with implementing the protocols. Each 

Health Systems Research, Inc. Final Report Page 26 
State would complete the data linkage, and then submit the sample data to USDA. Once 

the file is complete, USDA will need to clean and edit the file, and then can prepare a

public access file for use by researchers. 

 

Subtasks: 

 Develop time table for full implementation of the initiative;

 Notify States of timetable and submission requirements; 

 Ensure that proper data sharing agreements are in place within each State; 

 Ensure that appropriate data collection and merge protocols are in place; 

 States WIC program obtain Medicaid and Vital Record data and complete 

data merge; 

 Run State-level edits to remove duplicate information and clean data; 

 Submit Data to USDA; 

 Edit and clean data at Federal level; and 

 Implement query software and make data available to researchers 

Federal Costs: $44338 

State Costs: $175,552 

Total Task Cost: $219,860 

Health Systems Research, Inc. Final Report Page 27 
VI Summary of Costs and Schedule 

Table 1 below summarizes the cost of the initiative to the government. Costs 

include both Federal and State loaded labor costs and estimates of other direct costs. 

Table 1. Summary of Costs of Base Initiative by Government Agency

Agency Total Cost 

Federal $193,628

States $270,204

Total $463,832

Table 2 summarizes the schedule and estimated cost for each of the proposed 

tasks described in Section V. A detailed itemization of the estimated costs for each task 

in the Base Initiative is presented in Appendix A. A detailed itemization of the estimated 

costs for each alternative task is presented. 

Health Systems Research, Inc. Final Report Page 28 
Table 2. Summary by Proposed Task of Schedule and Estimated Cost 

Task Description 

Duration of 

Activity

Estimated 

Cost

Estimated 

Cost of 

Alternative 

Task 1

Conduct Initial Meeting 

among Federal agencies 

Identify officials and HHS and 

invite them to initial meeting Month 1 $12,506 N/A 

Task 2

Conduct Meetings with 

State program 

representatives 

Identify representatives from 

State program directors 

associations and invite them to 

participate in initiative 

Months 2-3 $57,399 N/A 

Task 3

Develop the sampling plan 

Develop the plan by which the 

number of WIC participants will 

be selected for inclusion in the 

database 

Months 3-6 $10,419 N/A 

Task 4

Create the database 

structure 

Develop the overall structure for 

the national database Months 3-7 $19,514 N/A 

Task 5

Create data linkage 

protocols 

Develop methods for States to 

use in order to ensure quality 

protocols for linking data. 

Months 7-10 $34,294 N/A 

Task 6

Develop access protocols 

and guidelines for removing 

client identifying information 

Develop methods by which 

researchers will be able to access

data and client identification 

information will be removed 

Months 7-10 $ 9,789 N/A 

Task 7

Test protocols for data 

linkage integrity and 

database functionality 

Conduct tests of the data linkage

protocols and the database 

functionality in no more than 9 

States 

Months 8-12 $81,309 N/A 

Task 8

Revise protocols based 

upon test results 

Make revisions to protocols based

upon problems or issues 

identified in the test phase 

Months 13-15 $12,751 N/A 

Task 9

Prepare OMB clearance 

package

Prepare any required clearances Months 16-18 $6,742 N/A 

Task 10

Implement Initiative on 

national level 

Schedule and implement initiative

at the national level Months 20-24 $157,965 N/A 

Health Systems Research, Inc. Final Report Page 29 
VII. SUMMARY OF INITIATIVE ALTERNATIVES 

In order to accomplish development of a national research database that can be used to 

measure WIC program outcomes and participation dynamics at both the Federal and the 

State level, there are very little in the way of alternatives. The obvious alternative would 

be to maintain the present system, where each individual State may chose to link records 

to measure program outcomes, or the Federal government can conduct a national study 

using linked records as was done in the national WIC program evaluation. 

The only real alternative that might accomplish some or all of the goals of this initiative 

would be to limit the data linkage to just WIC and Vital Records, and not including 

Medicaid. The justification for this might be that Vital Record database often contain 

sources of payment for pre-natal care and delivery, which would include Medicaid. If 

these data were available, one could compare WIC clients who claimed to be on 

Medicaid with those that did not report Medicaid as a source of payment. 

There are two major problems with this approach. First, not all States require local 

hospitals to report source of payment, and those that do may not always know at the time 

of delivery that Medicaid is paying for the services. It is unknown how often this field is 

left blank by hospital staff, but discussions with two State registrars indicated that both 

find source of payment data in the vital records system to be unreliable. By cross-linking 

the WIC and vital records data with the Medicaid data, a more accurate picture of 

Medicaid participation can be developed. 

The second problem with this approach is that there would be a missed opportunity to 

obtain data that would be valuable in measuring WIC program outcomes and/or 

participation dynamics. States that still use fee-for-service billing can provide both 

encounter data and service data in order to determine which services WIC participants are 

seeking, and often can provide data on the outcome of those services. Even with States 

that are using managed care plans, and not collecting encounter data, there are still 

opportunities to capture data on such services as EPSDT, pre-natal care and 

immunizations. It would seem valuable to have this third source of data on WIC 

participants to accurately compare outcomes and program dynamics of participants that 

use Medicaid as compared to those who do not. 

As a result, this initiative has not provided a cost estimate for this alternative. 

Health Systems Research, Inc. Final Report Page 30 
VIII References 

Loren Bell and Christopher Miller: Washington WIC Program Management Plan; Final 

Report; Washington State WIC Program, 2001 

Buescher, P., Horton,.S., Devaney, B., Roholt, S., Lenihan, A., Whitmire, T., and Kotch, 

J. The Relationship of Child WIC Participation to the Use of Health Care Services and 

Medicaid Costs. Center for Health Informatics and Statistics, North Carolina Division of 

Public Health, 1999 

Durkee, Jo Anne, The effect of Participation in Multiple Maternal and child Health 

Programs on Birth Outcomes, Illinois Department of Human Services, 1999, 

www.nawrs.org/cleveland.pdf/durkee.pdf

Kendal, A., Peterson, A., Manning, C., Xu, F., Neville, L., and Houge, C., Improving the 

Health of Infants on Medicaid by Collocating Special Supplemental Nutrition clinics with 

Managed Care Provider Sites American Journal of Public Health, March 2002 

Kenyon, A., Heinrich, T., Zullo, D., Bell, L. (2002) Initiative To Establish A Web Based

Data Collection System for National School Lunch (NSL) and National School Breakfast 

(NSB) program data 

Schramm, W., Prenatal Participation and its Relationship to Medicaid Cost for Missouri 

Newborns, 1982 Update, Public Health Reports, 101:607-615, November-December 

1986

South Carolina Department of Health and Environmental Control, Two-year Old 

Immunization Coverage Survey of South Carolina Children, 2002, 

www.scdhec.net/hs/diseasecont/immunization/doc/00survey.pdf 

Stockbauer, J. W.: Coverage and Targeting of High Risk Infants by the Missouri WIC 

Program; Missouri Department of Health Document, July 1998 

U.S. Department of Agriculture, Food and Nutrition Service, The National WIC 

Evaluation, and Evaluation of the Supplemental Food Program for Women, Infants, and 

Children, Vol. 1, Alexandria, Virginia, 1997 

Wittenburg, D. and Alderson, D; Developing a Link Between the Current Population 

Survey (CPS) and State Food Stamp Program (FSP) Administrative Data. 2002 

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Appendix A: Detailed Cost Assumptions
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Appendix B: Sample Missouri Reports Using Linked Data

(Source—Missouri WIC Program)
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Appendix C: Data Elements Contained in WIC and Vital Records Files

(Source—USDA PC 98 Instructions and National Center for Health Statistics)
Birth Certificate Data Elements
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WIC PC Data Elements
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Appendix D: 1997 Missouri Report

“WIC Coverage and Targeting High-Risk Infants”

(Source—Missouri WIC Program)
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