Aligning, Leveraging Medicaid Across Sectors to Improve Early Childhood

An infant is born into poverty, and then later, as a young child, may interact with multiple different government agencies and systems—not only Medicaid, but also perinatal health care, early intervention, child care, preschool education, and more.

Recognizing that intervening early in life can improve the trajectory of adulthood by reducing adverse childhood experiences and improving the factors that contribute to poor social determinants of health (such as inadequate housing, food insecurity, or income), 8 states are participating in a project from the Center for Health Care Strategies (CHCS) that aims to break down the silos and the barriers that exist among different agencies and better connect Medicaid to early childhood programs.

“Unless you start way upstream, you’re not going to prevent this stuff. You’re just going to be treating it,” said Stephen A. Somers, PhD, CHCS’ president, chief executive officer, and founder.

However, intervening early to address the factors that can affect health later, even into adulthood, as one 2010 landmark study examining the relationship between childhood poverty and adult outcomes found, is not a strategy of Medicaid, despite its prevalence in the lives of American children.

The focus on prevention and intervention came after earlier work showed that so-called “super utilizers” of health services like emergency department visits and inpatient services had challenging backgrounds.

It’s an issue that has been the focus of professionals in this field for a while now.

“How did they land in that situation? What had happened in their life to get them there? What we learned, not surprisingly, was that people had really challenging lives, challenging childhoods, challenges finishing school, challenges with drug and alcohol and mental health, criminal justice involvement,” said Christine Bernsten, director of strategic initiatives of Health Share of Oregon, the largest coordinated care organization (CCO) in the state, with about 315,000 Oregon Health Plan (OHP) members. Oregon’s CCOs are unique; they were approved by the state legislature and a Section 1115 Medicaid demonstration waiver from CMS. Health Share said 40% of their members are under age 18.

Across the country, Medicaid covers nearly half of all births and in some states, far more. In New Mexico, for example, Medicaid pays for 72% of all births.

Medicaid’s main focus in early childhood health is contained in its Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provision, which requires all states to cover comprehensive health services. However, the extent of what each state might cover may vary.

Despite the fact that Medicaid (along with the Children’s Health Insurance Program) provides health coverage to more than 46 million children, including almost half of all children under the age of 6, it has not previously worked directly with early education programs.

With that in mind, CHCS is working with the National Association of Medicaid Directors and ZERO TO THREE on an initiative called Aligning Early Childhood and Medicaid.

Three of the states—Connecticut, Maryland, and New York—participated in what could be considered the first part of the program, which also included Oregon’s Health Share and Minnesota’s Hennepin Health. The 2017 Medicaid Early Childhood Innovation Lab, funded by the Robert Wood Johnson Foundation (RWJF) and the Packard Foundation, created a way for state agencies and health organizations to plan how Medicaid could be used to drive improvements in prenatal and early childhood health and development as well as interventions for at-risk families to prevent trauma.

In the next phase, state Medicaid agencies and human service departments in Colorado, Minnesota, New Jersey, New York, Oregon, Rhode Island, Washington, and Vermont will build on the earlier work, Somers said.

“There will be progression and continuity between the 2 projects,” he said.

Over the next 20 months, the states will focus on aligning state programs and investments between Medicaid and other early childhood systems to drive more strategic, evidence-based investments in this low-income population, and show the value of early childhood cross-sector alignment, for improving near- and long-term health and social outcomes. The $2 million project is also funded by RWJF.

CHCS will provide technical assistance and it plans to share what was learned, as well as best practices, nationally.

When CHCS first began looking into parts of Medicaid that could be open to innovative projects, Somers said the areas that came up had to do with

measurement, metrics, kindergarten readiness, and financing and incentives for health systems and providers.

One of the what he called “tension areas” that arose was whether to create targeted interventions for specific groups at risk, such as child protective services, or work with the entire pediatric population.

New York, for example, is moving forward with its entire Medicaid 0 to 3 population in what it calls the First 1000 Days Initiative, a value-based payment, cross-sector effort that was planned during the 2017 innovation lab.

In Oregon, Health Share, which serves the Portland-metro area in 3 counties, began one part of this work with screenings in maternity clinics, including screening for social risk, such as maternal depression, domestic violence, food insecurity, and other factors that affect a baby­—and a family’s—well-being.

The screening tool, called the Oregon Family Well Being Assessment, was already in place, but getting it implemented and spreading it to other practices is part of Health Share’s work, said Bernsten.

In addition, for years Oregon has been working towards the goal of improving kindergarten readiness, a marker for later success in life; Health Share is building cross-sector partnerships, said Peg King, MPH, MA, who manages the CCO’s early life health initiatives.

After Health Share’s board learned and understood more about the challenges of patients who are high-need, high-cost users of medical services, Bernsten said, they made a decision to invest in early childhood, recognizing that “if we want to get ahead of creating the next generation of utilizers, we need to go back and focus more on prevention and supporting early childhood and families in those early years because we know that has such an impact on the rest of their life.

As a CCO, Health Share is accountable for health outcomes through 17 quality incentive measures set by the Oregon Health Authority. Stephanie Vandehey, the organization's communications manager, said Health Share earned 100% of its quality incentive funding in 2017, a total of $43 million. "These are the funds that allow us to get creative and invest in unique programs, like kindergarten readiness," she said.

Challenges with cross-sector players

There are multiple challenges when multiple agencies are brought together, no matter which state is involved.

“The systems are completely siloed,” said King, adding that Health Share is convening some 60 different organizations “to redesign the systems so that race, poverty, disability status are no longer predictors of kindergarten readiness.”

Turf wars can erupt when funders are reluctant to fund something differently, or are afraid of doing things differently. As part of this process, states and organizations are conducting fiscal mapping, to trace each line of funding that touches the life of a young child, whether it be from Medicaid or somewhere else.

King described it as a process of understanding the different funding streams, seeing where there is flexibility, and then overlaying priority populations, which in Health Share’s case are families of color, families in poverty, and families with children with disabilities. An analysis can show who is and who is not being funded, and find opportunities and gaps in order to make the biggest impact.

“Keeping the focus on the child and the family—that’s really what’s driving us to do all this work,” she said.