Young Children, Health Policy, and Health Reform

1. Young Children, Health Policy, and Health Reform Olivia Golden The Urban Institute

2. Plan • Why Medicaid/ CHIP Policy Choices Matter to Young Children’s Development • Four Priority Policy Areas • How Health Reform Expands the Opportunities – Planning for 2014 • Ideas for Getting Involved

3. Why Medicaid/ CHIP Policy Choices Matter to Young Children

4. Medicaid/ CHIP Today Medicaid/ CHIP have broad eligibility for children. Medicaid’s benefit package for children, EPSDT, has a developmental focus. Medicaid is where the resources are. Health Reform in 2014 Health reform will lead to big increases in coverage for adults. Parents’ health and access to health care matter to children. Why should early childhood leaders care about Medicaid/CHIP and health reform?

5. IL Children’s Eligibility for Medicaid/CHIP by Income, December 2009 NH VT WA ME MT ND MA MN OR NY SD WI ID RI MI CT WY PA NJ IA NE OH IN WV DE NV IL UT VA MD CO KS MO KY CA NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI < 200% FPL (4 states) *The Federal Poverty Line (FPL) for a family of three in 2009 is $18,310 per year. ***IL uses state funds to cover children above 200% FPL.; MA uses state funds to cover children above 300% FPL SOURCE: KCMU/CBPP annual survey of state eligibility and enrollment policies, 2009. 200-249% FPL (23 states) 250%+ FPL (23 states plus DC)

6. Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Benefit • Covers any service medically necessary to promote a child’s healthy physical, behavioral, and emotional development • By law, children in Medicaid should receive regular screenings and needed follow-up services

7. Medicaid ($74B) Child Tax Credit EITC Dependent Exemption Food Stamps Social Security Title I Grants Child Nutrition TANF Special Ed ($12.8B) The Ten Largest Federal Programs for Children (2009)

8. Sources for Children’s Budget Information • Julia Isaacs, Eugene Steuerle, Stephanie Rennane, Jennifer Macomber (2010). Kids Share 2010: Report on federal expenditures on children through 2009. http://www.urban.org/publications/412140.html • Jennifer Ehrle Macomber, Julia Isaacs, Tracy Vericker, Adam Kent (2010). Public Investment in Children’s Early and Elementary Years (Birth to Age 11). http://www.urban.org/publications/412061.html

9. Why Don’t Early Childhood Leaders Get Involved in Medicaid Policy?

10. Some Answers We’ve Heard • Medicaid policy is highly complex. • Health finance experts are intimidating. • Medicaid policy-makers don’t pay attention to children. • Early childhood leaders are too busy focusing on programs closer to home.

11. A Project To Address These Barriers Improving the Lives of Young Children Through Medicaid and CHIP • Olivia Golden, Genevieve Kenney, Jennifer Pelletier, Karina Fortuny, Michael Huntress, The Urban Institute • Partnerships with the BUILD Initiative and the National Academy of State Health Policy • Funded by the Birth to Five Alliance and the Mailman Family Foundation

12. Approach of the Project • Consult early childhood experts to pick priority topics. • Develop state policy papers credible to both health and early childhood experts. • Lead state meetings for both health and early childhood. • Work with federal officials to support good state policy choices.

13. Four Priority Policy Areas

14. Which Medicaid/CHIP Policy Choices Best Support…. Screening and early identification of children’s developmental needs? Access for young children to services that meet their needs? Case management and care coordination? Two-generational services?

15. Four Papers • Genevieve Kenney and Jennifer Pelletier (2010). Improving the Lives of Young Children: The Role of Developmental Screenings in Medicaid and CHIP. http://www.urban.org/publications/412275.html • Jennifer Pelletier and Genevieve Kenney (2010). Improving the Lives of Young Children: Increasing Referrals and Follow-up Treatment in Medicaid and CHIP. http://www.urban.org/publications/412291.html

16. Four Papers, continued • Carrie Hanlon (2010). Improving the Lives of Young Children: Opportunities for Care Coordination and Case Management for Children Receiving Services for Developmental Delay. http://www.urban.org/publications/412289.html • Olivia Golden and Karina Fortuny (2011). Improving the Lives of Young Children: Meeting Parents’ Health and Mental Health Needs Through Medicaid and CHIP So Children Can Thrive. http://www.urban.org/publications/412315.html

17. What Are the Take-Aways?Papers 1-3: Services for Children • Why don’t all children get the screenings, preventive services, treatments that the EPSDT benefit package is designed to ensure?

18. The Importance of Targeted Data • States need to invest in data systems that allow them to evaluate how rates of screenings, assessments, referrals, and treatment services are changing. • In the short run, they may need to assemble approximate data from many sources. • We should have a prototype for a quick data scan after our Iowa meeting.

19. What Are the Take-Aways?Paper 4: Parents • Medicaid is not well-designed to think about both children and parents (a two-generational framework). • Yet parents’ health and (especially) mental health matter a great deal to children. • States have some policy choices now. • They will have more choices after health reform.

20. Median Income Eligibility Levels for Medicaid/CHIP as Percent of Federal Poverty Level, December 2009

21. The Example of Maternal Depression Widespread depression, especially among low-income mothers of young children Maternal depression’s damage to children Effective treatment available Few depressed low-income mothers receive treatment Delivering what we know hugely benefits children’s development

22. Infants of Depressed Mothers Living in Poverty: Opportunities to Identify and Serve Tracy Vericker, Jennifer Ehrle Macomber, and Olivia Golden Supported by the Doris Duke Charitable Foundation http://www.urban.org/uploadedpdf/412199-infants-of-depressed.pdf

23. How Many Babies Have a Mother Experiencing Depression? Severe depression: 11 percent of infants living in poverty (and 7 percent of all infants) All levels of depression: More than half of infants in poverty (and 40 percent of all infants) Additional stresses: domestic violence, substance abuse, and worse maternal health

24. Do Parents Get Help? Few severely depressed mothers receive care for treatable depression Only 30% of the infants had mothers who sought a psychiatrist, doctor, or counselor

25. The Good News: Opportunities To Help Families 96 percent of infants in poverty with severely depressed mothers received WIC benefits 82 percent received Medicaid for some family member 70 percent received SNAP On average, these babies received six well baby visits after birth

26. Policy Approaches Available Today Increase Medicaid coverage among eligible parents Increase receipt of services (such as treatment for depression) among eligible parents Increase receipt of family-based services in families where young children are eligible but parents are not

27. How Health Reform Changes the Playing Field

28. Health Reform’s Dramatic Effects on Coverage of Adults All adults under 133 percent FPL who meet the citizenship requirements will be eligible for Medicaid in January 2014. Currently, more than 40 percent of poor parents and 33 percent of near-poor parents are uninsured.

29. Health Reform’s Dramatic Effects on Coverage of Adults (continued) 2.2 million parents and almost 10 million adult non-parents will be newly Medicaid eligible. The Medicaid benefit package under health reform will include mental health and substance abuse services.

30. Increases in Parental Coverage Will… Increase the likelihood that parents’ physical and mental health needs are met. Improve children’s likelihood of having insurance coverage and access to needed care. Improve children’s health and development.

31. Effects in North Carolina • Reduction in North Carolina’s nonelderly uninsured from 19% to 9%. • North Carolina will enroll in Medicaid an estimated 474,000 new eligibles and 118,000 current eligibles who are not now enrolled.

32. Other Opportunities in Health Reform • Health care reform will: • increase the number of children as well as parents covered under Medicaid • provide additional funding for community health centers, the promotion of a medical home model, and home visiting programs

33. Sources • Matthew Buettgens, John Holohan, Caitlin Carroll. (2011). Health Reform Across the States: Increased Insurance Coverage and Federal Spending on the Exchanges and Medicaid. http://www.urban.org/health_policy/url.cfm?ID=412310 • Genevieve Kenney and Jennifer Pelletier. (2010) How Will the Patient Protection and Affordable Care Act of 2010 Affect Children? http://www.urban.org/health_policy/url.cfm?ID=412129

34. State Planning for 2014 • States are planning for the eligibility systems required to enroll more adults in Medicaid. • They are also planning for many other features of health reform. • Could this be the time to figure out how Medicaid could be family-centered and work best for young children?

35. Ideas for Getting Involved

36. Opportunities to Consider • Gather information to tell the story of children’s health needs. • Join health partnerships in your community. • Pick health as a statewide focus.

37. Opportunities to Consider, continued • Get involved in North Carolina’s innovations, pilots, and planning. • Seize opportunities to tap into national expertise.