70. Strengthening Community Health Centers’ Role in Early Childhood Development: The New Biden Administration Initiative

Geiger Gibson Program in Community Health
Policy Issue Brief #70
February 2023

Sara Rosenbaum, JD
Rebecca Morris, MPP
Peter Shin, PhD, MPH
Feygele Jacobs, DrPH, MS, MPH

Background

 

Community health centers are an essential source of pediatric health care, whose modern place in child health  is an outgrowth of  seminal  child health and social welfare developments over a half century ago that established Medicaid, community health centers and Head Start, and expanded state maternal and child health programs.1  From the beginning, community health centers have worked closely with Head Start and other early care and education programs to improve care and services for underserved children who face serious risk for adverse health outcomes.

Building on this tradition of community health centers and child health improvement, the Biden administration has issued a $30 million funding opportunity announcement (FOA). Part of a national movement in health care transformation for young children, the aim of the FOA is to improve early child development and accelerate health care transformation, with a special emphasis on low-income children ages 0-5 insured by Medicaid.  The administration’s goal is to assist 150 community health centers—more than 1 in 10 grantees nationwide—to expand and improve early childhood development, a focus of child health for decades.   Child health helped propel Medicaid’s enactment and later, its expansion to tens of millions of additional low-income children.  It also explains the establishment of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) as a core Medicaid benefit that funds comprehensive well-child exams, preventive services, and comprehensive medical care beginning at birth and continuing through adolescence.2   Because such a high proportion of children served by health centers are insured through Medicaid, the FOA effectively enables health centers to strengthen their capacity in order to ensure that children under their care have access to high quality early childhood health and development services.

The FOA has one overarching goal: to increase the number of infants and young children served by health centers who receive age-appropriate developmental screenings and prompt follow-up services for conditions that could affect their development.  Within this overall goal, the FOA prioritizes efforts to recruit, retain and develop staff, improve the patient and caregiver experience, strengthen access and affordability, and integrate population and health-related social needs into child development services.  For the majority of children served, Medicaid will be the financial engine that enables health centers to sustain improvements over time; for near-poor children, additional support will come through CHIP and subsidized marketplace health plans.  Thus, although the FOA does not explicitly emphasize sustainability over time, health centers pursuing this FOA may wish to build sustainability into their plans by closely involving their Medicaid agencies, the managed care plans whose networks so heavily depend on health centers, and their state maternal and child health programs.  Health centers pursuing this opportunity would derive additional value from close collaboration with Head Start and other early care and education programs, IDEA Part C Early Intervention, nutrition programs, and social service agencies focused on child and family health and well-being. 

This initiative fits within an overall push across public and private sector efforts to accelerate transformation of primary care for low-income young children in ways that assure optimal development and equity.3   Over the past five years, federal and state governments, along with philanthropy, have made substantial investments in demonstration projects and technical assistance to advance such transformation and achieve this overarching goal. Many such initiatives are augmenting staff capacity to focus on child development, integrating evidence-based models of family-centered support, and adopting best practices for addressing social risks and needs.

Key Findings

 

Children’s Stake in Community Health Centers

Children have a high stake in efforts to invest in health center-located childhood development programs.   In 2021, community health centers served nearly 2.9 million children ages 5 and under, representing 1 in 10 children in this age group nationally and 1 in 4 young children living in poverty.4  Low-income health center patients ages 5 and under account for 9.5 percent or 1 in 10 of all CHC patients nationally.  The map (Figure 1) shows the varying state concentration of low-income children ages 5 and under (see Table 1 for state-by-state estimates).  In 6 states (FL, IL, IN, IA, NJ, TX) child patients represented more than 11 percent of total health center patients.  In terms of volume, 6 states (CA, FL, IL, NY, TX, WA) reported at least 1 million patients ages 5 and under. While other states may report a lower  volume or percentage of child health center patients,  in the wake of Dobbs v Jackson Women’s Health Care the demand for pediatric care is likely to increase in those and other states, as birth rates rise among medically underserved, low-income women and families, who are disproportionately likely to experience the decision’s impact.5

Because community health centers are a major source of maternal health care—serving 1 in 10 pregnant people nationwide—adding strong early childhood development capacity positions them to ensure patient care that spans the transition from birth into early childhood development.  With 619,000 infants under age 1 in their care in 2021,6  community health centers already have a deep connection to the target population.

Available evidence underscores the importance of a health center presence in child development. Among children cared for by health centers nationwide, more than 606,000 showed signs of developmental delay;7 this figure is likely a serious undercount, since it captures only those children who have been screened for physiological developmental conditions. A strengthened health center role in child development is of special importance to the most vulnerable children. By definition, their patients are poor or low-income and reside in medically underserved rural and urban communities.  Disproportionately, health center patients are Black, Indigenous, or Hispanic8  and live in households that face elevated cultural and language barriers.9

The need for early child developmental interventions is also great. Data from the 2020-2021 National Survey of Children’s Health show that compared to 56 percent of all privately insured children, just over half of privately insured children age 5 and under, and only 36 percent of children 0-18 covered by Medicaid and CHIP, received care that meets medical home criteria in its continuity, family centeredness, and comprehensiveness.10  Furthermore, despite the fact that all Medicaid-enrolled children are entitled to EPSDT – the most comprehensive pediatric insurance ever enacted in law – in many states, Medicaid-enrolled children still fail to have at least one well-child visit; although experts recommend four well-child visits for toddlers ages 1 to 2, only 78 percent of Medicaid-enrolled infants and toddlers in this age group received even one well-child visit in 2020.11

 

 

Too few children receive recommended developmental screening from ages of 9 to 36 months. The National Survey of Children’s Health, which measures the health of children over time, found that developmental screening was reported for only 29 percent of young children with Medicaid and CHIP coverage and 15 percent of uninsured children, compared to 40 percent of those with private insurance.12

 

What We Know About the Effectiveness of Child Development

Childhood development services consist of several basic components: ongoing assessments of physical and mental health and growth and development using well-validated tools for measuring health and social risk; rapid and early intervention with diagnostic and treatment services to address delays; access to health-related social and nutritional services; and strong supports to parents and caregivers, including improved access to care for their health needs. 

An enormous body of literature has shown the effectiveness of early childhood development.13 14  The American Academy of Pediatrics has called for a paradigm shift in primary care to partner with families and communities to promote optimal child development.15  Many have called for high performing medical homes for young children in Medicaid16  and whole child care.17  More team-based care, incorporating a greater role for community health workers and other staff, is widely recommended.  Studies also document the positive impact of efforts in select health centers across the country.18 19 20 21

 

Furthermore, health insurance for poor children is designed to ensure a financial basis for the full continuum of care as a result of EPSDT combined with such innovations as “in lieu of” and “value added” services that enable state Medicaid agencies, managed care plans, and network providers to expand the range of services offered as well as the settings in which care takes place.

 

Opportunities to Support Child Health & Development

 

Using the FOA to Build a Sustainable Child Health and Development System

The FOA provides community health centers with valuable resources to strengthen their child development capabilities through training, staffing enhancements,  and the creation  of strong partnerships with health plans in their service area and their state Medicaid agency, and to build and enhance their relationships with an array of other services and supports for families with young children, including Head Start and other early care and education programs, IDEA Part C Early Intervention programs, home visiting programs, nutrition and social services programs with which they partner.  It also provides an opportunity for health centers to integrate evidence-based models such as DULCE, HealthySteps, Reach Out and Read, VIP, and others that have been shown to increase early relational health, improve child development outcomes, and offset family stress (e.g., from poverty, racism, and discrimination).

Further, because Medicaid is such a dominant payer for health center pediatric care—covering half of all children and 6 in 10 Black, Hispanic, and Indigenous children, sustainability of the investment over time is highly feasible.   Children enrolled in Medicaid are entitled to the full range of clinical and health-related support services that go into good child development practice.  With the 2022 enactment of  annual Medicaid enrollment as a guarantee for children, along with a permanent state option to expand postpartum eligibility to a full 12 months, coverage stability  should improve, thereby also reinforcing  the opportunity to sustain this initiative over time. For children whose coverage is derived through  CHIP programs that operate separately from Medicaid (in many states, CHIP is administered in whole or in part as an expanded Medicaid program and thus is inclusive of EPSDT) or through marketplace health plans, coverage, even if not quite as comprehensive as EPSDT, encompasses a broad range of assessment, diagnostic, treatment, and care management services as a result of the HRSA Bright Futures pediatric coverage standards, which have become the coverage standard in both these insurance markets.

Finally, health centers pursuing the child development FOA may wish to expand their partnerships with state maternal and child health agencies, a major source of technical assistance and expertise on child health and development. 

1. Karen Davis and Cathy Schoen, Health and the War on Poverty (Brookings Institution Press, 1977)↩
2. Perrin, J. M., Kenney, G. M., & Rosenbaum, S. (2020). Medicaid and Child Health Equity. The New England journal of medicine, 383(27), 2595–2598. https://doi.org/10.1056/NEJMp2030646 ↩
3. Liljenquist, K., & Coker, T. R. (2021). Transforming Well-Child Care to Meet the Needs of Families at the Intersection of Racism and Poverty. Academic pediatrics, 21(8S), S102–S107. https://doi.org/10.1016/j.acap.2021.08.004. ↩
4. https://datacenter.kidscount.org/data/tables/43-children-in-poverty#det… ↩
5. Zephyrin, L and Blumenthal D. The Loss of Abortion rights Will Send Shockwaves Through the US Health Care System. June 2022 Commonwealth Fund. https://www.commonwealthfund.org/blog/2022/loss-abortion-rights-will-se… ↩
6. Health Resources and Services Administration (HRSA). 2021 Health Center Data, Table 3A.↩
7. Health Resources and Services Administration (HRSA). 2021 Health Center Data, Table 6A.↩
8. National Association of Community Health Center (2022) Community Health Center Chart Book. https://www.nachc.org/wp-content/uploads/2022/03/Chartbook-Final-2022-V… ↩
9. Health Resources and Services Administration (HRSA). 2021 Health Center Data, Table 3B.↩
10. Child and Adolescent Health Measurement Initiative. 2020-2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 02/20/2023 from www.childhealthdata.org.↩
11. Centers for Medicare and Medicaid Services. Annual EPSDT Form CMS-416 Reporting Data for FY 2020. https://www.medicaid.gov/medicaid/benefits/early-and-periodic-screening… ↩
12. National Survey of Children’s Health, Health Resources and Services Administration, Maternal and Child Health Bureau. https://mchb.hrsa.gov/data/national-surveys Child and Adolescent Health Measurement Initiative. 2020-2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 02-17-2023 from www.childhealthdata.org.↩
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16. Johnson, K., & Bruner, C. (2018). A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health. Child & Family Policy Center. https://www.inckmarks.org/docs/pdfs_for_Medicaid_and_EPSDT_page/Sourceb…. ↩
17. Gratale, D. J., Counts, N. Z., Hogan, L., Hewitt, A., Chang, D. I., Wong, C. A., Davis, M. B., Schoessow, G., McCabe, M. A., Johnson, K., Goldfinger, J., & Gionfriddo, P. (2020). Accountable Communities for Health for Children and Families: Approaches for Catalyzing and Accelerating Success. NAM Pperspectives, 2020, 10.31478/202001b. https://doi.org/10.31478/202001b. ↩
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19. Jeung, J., Hessler Jones, D., Frame, L., Gilgoff, R., Long, D., Thakur, N., Koita, K., Bucci, M., & Burke Harris, N. (2022). A Caregiver-Child Intervention for Mitigating Toxic Stress ("The Resiliency Clinic"): A Pilot Study. Maternal and Child Health Journal, 26(10), 1959–1966. https://doi.org/10.1007/s10995-022-03485-4. ↩
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