How Can Medicaid and CHIP Support Children’s Emotional Health?

Health Update
 

By Katie Beckmann, Program Officer, Children, Families and Communities Program, David and Lucile Packard Foundation | Jocelyn Guyer, Managing Director, Manatt Health | Donna Cohen Ross, Senior Advisor, Center for the Study of Social Policy

Editor’s Note: Nearly half of children under age three in the United States get their health insurance through Medicaid and the Children’s Health Insurance Program (CHIP).1 With such broad reach, these programs can play a powerful role in influencing the way pediatric care is delivered. Supporting pediatric approaches that help strengthen children’s social and emotional development is a critical place to begin, given that early social and emotional health have life-long consequences for physical and behavioral health, school success, and productivity.

How can states leverage Medicaid and CHIP to foster children’s healthy social and emotional development? How can Medicaid and CHIP fuel transformation in pediatric care? What strategies and tactics can state Medicaid agencies, managed care plans, pediatric providers and others put into action to optimize the healthy social and emotional development of children? The Pediatrics Supporting Parents Initiative turned to the Center for the Study of Social Policy (CSSP) and Manatt Health to develop a blueprint for fostering children’s social and emotional health. In a recent webinar, we revealed our findings and recommendations—and shared the blueprint for driving the transformation of pediatric care through Medicaid and CHIP. Part 1 of our article summarizing the webinar, below, reviews core practices, how Medicaid and CHIP can influence pediatric care, links to family well-being, and the five core strategies shared in the blueprint. Watch for part 2 of our summary in the August “Health Update,” providing a detailed look at each of the five strategies, including action steps for implementation and real-world examples.

Click here to view the webinar free on demand—and here to download a free copy of the presentation, as well as the full blueprint.

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Why Is Pediatrics So Critical?

The pediatric channel provides a unique opportunity to reach parents and their children during the first three years of life. Those years are a time when children’s brains are developing at an unparalleled rate and families are often attending well-child visits in pediatric and family care practices. The American Academy of Pediatrics recommends 15 well-child visits in the first five years of life. A national survey of children’s health in 2017 showed that approximately 90% of children attended a primary care visit in the previous year, making well-child visits a nearly universal access point. Unfortunately, according to the same survey, only about a third of parents completed a general developmental screening tool over the same time period. The American Academy of Pediatrics recommends that children be screened for developmental risks three times over the first five years of life.   

Clearly, something is not working. To understand the problem and identify solutions, the Pediatrics Supporting Parents Initiative turned to the Center for the Study of Social Policy (CSSP) to conduct an analysis of 65 evidence-based programs that were moving the needle on social and emotional development, parent-child relationships, and maternal depression. CSSP narrowed the 65 programs to 13 based on quality criteria and, partnering with the National Institute for Children’s Health Quality (NICHQ), Family Voices and a pediatric primary care advisory group, conducted site visits at primary care practices to get under the hood of these 13 target programs. The goal was to uncover common catalytic practices and interventions across evidence-based programs that actively promote positive social and emotional development in young children. 

Three Categories of Core Practices

The results of CSSP’s environmental scan and fieldwork revealed the core practices for supporting healthy social and emotional development in children. The core practices fall within three categories:

  1. Nurturing parenting competence and confidence
  2. Connecting families to supports to promote health and address stressors
  3. Developing the care team and clinical infrastructure

An essential foundation across the three categories is the creation of strengths-based, trusting and humble relationships among and between parents, the care team, and the community.

CSSP’s results are now being tested and refined through a NICHQ-led learning collaborative that includes 18 provider sites across 13 states. In addition, because the Pediatrics Supporting Parents Initiative is a “practice-to-policy” program, it funded CSSP and Manatt Health in creating a Medicaid and CHIP blueprint for state agencies, managed care plans, and pediatric providers to enable reimbursement and leverage financing to support the core practices that drive children’s healthy social and emotional development. (To download a free copy of the blueprint, click here.) 

What is social and emotional development? Social and emotional development is a child’s capacity to form secure relationships, experience and regulate emotions, explore, and learn. This capacity develops against a backdrop of family, community and culture. Responsive and nurturing relationships with adults—including parents, grandparents, other family members, childcare providers and pediatricians—are essential to children’s healthy social and emotional development. 

Why Focus on Medicaid and CHIP?

Nearly half of children under age three in this country are enrolled in Medicaid or CHIP. Therefore, Medicaid and CHIP are dominant players in driving how pediatric practice occurs. Parents of young children rely on pediatric practices for guidance, support and reassurance.

Medicaid and CHIP’s benefits packages are designed to support children’s health and development needs. Medicaid includes Early and Periodic Screening Diagnosis and Testing (EPSDT), a benefit that mandates children receive all medically necessary services—a perfect opening to include services that foster social and emotional development. Medicaid and CHIP also have significant built-in flexibility that makes them ideal tools for helping shape a greater focus on social and emotional health.

Children’s Social and Emotional Development Is Linked to Family Well-Being

Parents’ health and the economic and social factors that affect the family are central to children’s social and emotional development. The low- to modest-income children and families enrolled in Medicaid and CHIP face higher risk across several areas:

  1. Their parents may be uninsured. Twelve percent of parents with a child under age 3 did not have health insurance in 2016. The 14 states that have not expanded Medicaid pose the greatest challenge. Even in states that have expanded, however, Medicaid and CHIP tend to offer greater coverage for children than for their parents.
  2. Parental health status, such as maternal depression, can have a significant impact on children. In addition, a caregiver’s poor health can traumatically impact the child through adverse childhood experiences (e.g., toxic stress, interpersonal violence, neglect).
  3. Children in low- and modest-income families may be subject to external economic challenges that impact the family stability that is critical to healthy social and emotional development. For example, they may have to face food and housing insecurity, as well as the lack of affordable transportation to grocery stores, physicians’ offices and places of worship.

Our conversations around Medicaid and CHIP must address how these programs can support families with the full range of socioeconomic needs. At the end of the day, all of these factors that affect the entire family play a key role in children’s social and emotional development. 

Why Now?

We have reached a moment in time when there is an intensifying appreciation of the role that healthcare plays in supporting social and emotional development. Some of this appreciation is driven by the growing body of early brain research demonstrating what a critical period the first few years of life are for shaping social and emotional development.

In addition, from a Medicaid perspective, we are seeing a growing focus on the social determinants of health (SDOH). Many states are looking at SDOH and their effects with a broader lens, understanding that increasing access to affordable housing, food, and transportation while reducing toxic stress and protecting against violence all are central to fostering healthy social and emotional development in children. The interest in SDOH is wrapped up in the larger trend of value-based payment (VBP). There is growing recognition that providing parents with support is ultimately more cost effective than addressing the issues of a child who is failing to thrive. SDOH is part of a next generation of VBP that considers the larger picture of what families need socially and emotionally to optimize healthy outcomes.  

The negative news making headlines is also driving the increasing focus on children’s social and emotional health. There is growing recognition that the opioid epidemic and other substance abuse issues are wreaking havoc on families, and it is critical to do everything possible to mitigate the impact on children. Finally, the rising suicide rate and worsening mental health crisis are fueling the sense that more needs to be done to shape children’s social and emotional development in the early years of their lives.

Blueprint Provides Medicaid and CHIP Strategies and Tools

The blueprint that CSSP and Manatt developed is not just a white paper, but a new resource that presents a set of actionable strategies for using Medicaid to finance promoting social and emotional development in pediatric primary care. It includes:

  • Five core strategies, backed by statutory and regulatory authority
  • Action steps for implementing the strategies
  • Tools for implementation, such as federal guidance, as well as sample contract language and State Plan Amendment language
  • Real-world state examples of current policies and activities across the country

Five Core Strategies

In the blueprint, Manatt and CSSP consolidate and crystallize the research into five core strategies. They are not a “one size fits all recipe,” nor are they sequential steps. Each state can review them through the lens of its own challenges and objectives, and select those that best fit its needs and goals. The five core strategies are:

  1. Cover and support a full range of screening, assessment and treatment services for children and their parents.
  2. Leverage quality and performance improvement initiatives to spur changes in pediatric practice.
  3. Establish payment models that incentivize a focus on children’s social and emotional development.
  4. Facilitate investment in team-based care and training on children’s social and emotional development.
  5. Leverage a CHIP Health Services Initiative (HSI), which provides a mechanism for using CHIP administrative dollars to fund a range of activities beyond health insurance, such as early literacy programs or youth violence prevention. 

NOTE: Watch for part 2 of our summary in the August “Health Update,” providing a detailed look at each of the five strategies, including action steps for implementation and real-world examples.

1 Haley, J., Wang, R., Buettgens, M., Kenney, G. (2017). Health Insurance Coverage among Children Ages 3 and Younger and Their Parents: National and State Estimates. The Urban Institute. Retrieved from https://www.urban.org/research/publication/health-insurance-coverage-among-children-ages-3-and-younger-and-their-parents-national-and-state-estimates/view/full_report.