Long before I had children of my own, I knew the importance of health coverage for kids. Now, after dozens of pediatrician visits with my twin daughters, I've seen up close how critical good health care can be in getting children off to a good start. So it is gratifying to live and work in a state that takes children's health care seriously.
Today, nearly all children in New York have health coverage and begin seeing a provider early in life, thanks in part to the State's bold expansion of Child Health Plus eligibility to all uninsured children. The program's graduated, highly subsidized premiums and its inclusion of undocumented immigrant youth bring universal health coverage for New York's children tantalizingly near.
That coverage expansion, and others supported by the Affordable Care Act, have turned policy attention in New York to another critical health care challenge: addressing the high cost of care for complex, high-need patients—typically adults with multiple chronic conditions, often both physical and behavioral. Major state initiatives, like Medicaid's Delivery System Reform Incentive Payment program and the State Health Improvement Plan, focus most heavily on these high-need adults. Yet certain developments have set the stage for a renewed focus on children. The next few years will provide important opportunities to further advance their health; UHF will be working with a number of partners to move those improvements forward.
RECONSIDERING CHIP AND MEDICAID REFORM
With federal and state laws on Child Health Plus set to sunset in 2017, now is an ideal time to begin reevaluating State programs for children. Child Health Plus (CHP) was a huge step forward when initially designed, and again when expanded. But under the ACA, there is now a continuum of coverage available for most New Yorkers, including children, through the State's health insurance exchange, employer mandates, and Medicaid expansion. Whether a stand-alone program is the right design; whether the benefits, eligibility, and cost-sharing protections for children found in CHP can be exported to other programs; and whether current benefits and payment approaches are designed to maximally support child health are all important questions that policymakers could grapple with.
A second issue, under consideration since the outset of New York's Medicaid Redesign Team process, is the future of children's behavioral health care in Medicaid. It's a system that has historically been “siloed,” providing most care through six separate programs that, depending on a child's circumstances, may or may not provide the right mix of services. In most cases, there is little or no coordination with other health care services these children need. At UHF we've been examining key issues and recently brought together stakeholders for a productive discussion. The State has committed to taking a hard look at and addressing policy and implementation challenges, but many serious challenges remain.
NEW ROLE FOR PEDIATRIC PRIMARY CARE
The need to revisit existing programs isn't the only reason to bring children back into the spotlight. Recent research on brain development has revealed that children's experiences between birth and age 5 are critically influential, not only for long-term social and emotional well-being but also for physical health and cognitive abilities, from school readiness to executive functioning. In turn, intervention models have been designed to address the harms that can come from negative early experiences—exposure to severe maternal depression, violence, and poor parent-child interactions among them.
Some of those interventions can be initiated in pediatric primary care settings, where nearly all of the youngest New Yorkers see health care providers on a regular basis. That has profound implications—and promise—for the role of pediatric primary care in influencing long-term development. But how do we encourage the use of more of these interventions—screening for maternal depression, coaching for positive parenting, addressing social needs through linkages with social services, and more—in pediatric primary care? And how can they be incorporated or adapted in the small practices where many children are seen?
It's unlikely that these new approaches can be broadly scaled without new kinds of support and incentives. The structure of practices, payment policies, workforce and training—how these can be oriented to support key interventions is a critical question that UHF will be exploring.