Posts About Children's Health

The rise in opioid misuse has continued to receive attention across the country, and only more urgently in recent months as Republicans continue to press forward toward a repeal of the ACA with a disastrous replacement bill that makes deep cuts to the Medicaid program and would reduce or eliminate care for many people with substance use disorders. Often, the majority of this attention is on adults, who are the primary users of opioids. Less attention has been directed toward infants exposed to substances during pregnancy and who, as a result, may be born with an opioid use disorder. This condition in newborns is termed neonatal abstinence syndrome (NAS). 

Opioid misuse is a multi-generational issue that requires supports along the lifespan. Massachusetts is disproportionately affected, placing it second in the nation for prenatal exposure (13.7 per 1,000) after the East/South Central region of the U.S. Nationally, the rate is about five babies out of every 1,000 births. The average duration of inpatient treatment for NAS is 19 days with an average cost of $30,000, placing severe strain on health systems to support affected infants and their families. Through this lens, the Massachusetts Interagency Task Force on Newborns with Neonatal Abstinence Syndrome published a highly anticipated report that provides key recommendations about how to address the current gaps in care and more deliberately address the needs of infants and parents through collaboration and coordination across health and human services.

It is worth noting that this Task Force is the product of robust advocacy by a Community Catalyst-led workgroup on NAS that included a broad array of members ranging from early intervention providers, legal advocates, child welfare advocates and children’s mental health advocates to physicians –pediatricians, obstetricians/gynecologists and medical residents. The lead children’s health advocacy partner, Children’s Health Access Coalition (CHAC), helped develop and champion legislative language in the last hours of the state’s budget deliberations in 2016 to include the revenue-neutral task force.

We are pleased with the report, although we note the need to address how all substance use disorders affect newborns, not just opioids. We also note that this response is much more productive than society’s response to the “crack baby” epidemic of the 1980s, when the babies at risk were born to women of color.

What did the Taskforce find?         

There are 12 key findings in the taskforce report. It is worth a close review. We highlight some key themes that are important for advocates as they seek to influence state policy and practice:

A multi-generational approach that embraces trauma-informed practices across the lifespan is necessary for a robust blueprint to address NAS and substance use newborn (SEN) exposure.

  • The Taskforce leverages a Five-Point Intervention Framework developed by National Center on Substance Abuse and Child Welfare (NCSACW) that is a multi-generational, trauma-informed approach and embraces a life-course approach to services and supports. In other words, substance use programming should be universally included at all stages of life – from adolescent prevention and pre-pregnancy through pregnancy, birth, neonatal and post-natal stages.

Evolving state-level health system transformation (HST) efforts are a lever to advance NAS/SEN priorities and best practices.

  • The Taskforce recommends insurance reimbursement for care-coordination across provider types and a mechanism for provider accountability for warm handoffs to different levels of care. We would add that any patient care team be culturally/linguistically competent and include peer support through a family member, caregiver or trained peer support coach.
  • Another set of recommendations highlights strategies to increase connections between the health system and community-based supports. We would also recommend cross-sector training so that different agency disciplines build trust across human service sectors.

Public health awareness campaigns around opioids continue to be important but could integrate more explicit messages about substance use and pregnancy. We suggest that they also include discussion of other substances, particularly alcohol, that do even graver damage to newborns.

Coverage is key. Many of the recommendations rely on affordable access to contraception, substance use treatment, mental health services and preventive services across the care continuum.

Data remains a barrier to coordinating care and tracking and monitoring quality and outcomes.

  • Notably, the Taskforce calls for the creation of a statewide “dashboard” of key metrics to monitor progress on aspects of care for families impacted by perinatal substance use. See the report for a visual of the dashboard and its proposed elements. We recommend inclusion of analyses of race/ethnicity data to document health inequities and to develop targeted programs and improvements to advance health equity.

As you dig into this report – there are clear areas of policy and program improvement that advocates might consider in their states. For example:

  • Extending early intervention eligibility for all babies exposed to substances (not just opioids) to a full three years;
  • Increasing the number of inpatient mother-child treatment beds and requiring universal mother-child bonding protocols in hospital settings;
  • Developing of a coaching track for specialized training in supporting families across the intervention points;
  • Developing incentives for providers to develop post-partum support programming; and
  • Developing and expanding recovery coaching for foster care involved families.

What’s Next?

As advocates mobilize to protect our care through ACA and Medicaid defense – this Taskforce report highlights the important role that coverage and expanded SUD benefits play in providing a crucial doorway to recovery for adults and opioid exposure reduction for infants. We must highlight that this improves care for our youngest and most fragile consumers. The Taskforce report also provides advocates a set of actionable priorities to set in motion in their states. Our infants and families cannot wait.

A special thank you to Gabrielle Orbaek White for her leadership on the NAS workgroup and to Mark Friedman for his participation in the Advisory Council. Finally, a thank you to Maryanne Mulligan for her tireless advocacy on behalf of Early Intervention providers and Suzanne Curry for her legislative advocacy.

This month, in celebration of the Department of Health and Human Services Office of Minority Health’s National Minority Health Month, advocates, providers, communities and other key stakeholders are working to raise awareness about racial and ethnic health disparities across the country and the role that social determinants play in advancing a health equity agenda for vulnerable populations. Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age.” They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care.

Getting Local: Partnering for Community Health

In step with this broader understanding of how social determinants influence health equity, Community Catalyst’s Children’s Health Initiative recently launched a new project, Partnering for Community Health. The project works in multiple states focusing on building the capacity of local community efforts while connecting them with state health advocates to improve health equity outcomes through community collaborations. Through these collaborations, the community organizations can inform state advocates on Medicaid and social services policy needs, including Medicaid defense. In March, Community Catalyst staff visited Shelby, North Carolina, one of the project sites, to meet with the local leadership partners Benchmarks and NC Child and other organizations engaged in this work. The experience reminded us of the richness of local work and that advancing health equity is about consumer engagement at every level—starting with the individual up to the system.

Shelby, NC: A Snap Shot

In Shelby, Sun Drop is the local soda - a high octane version of Mountain Dew with a hint of pulpy orange juice - and it personifies Shelby. Shelby is not unlike many small towns in the South - it has a warm familiarity with an extra jolt of something special. In Shelby, folks know each other and, if they don’t, they’ll ask your family name and try to find the connections quickly. The Shelby community feels like family. For instance, one of our hosts, Chris, (the project’s “community quarterback”) could barely sit down for lunch because family and old coworkers were constantly pulling him aside to catch up at the restaurant where we were eating.

In Shelby, the impacts of social determinants of health are ever-present at Graham Elementary School. According to the Robert Wood Johnson Foundation’s Country Health Rankings & Roadmaps, Cleveland County, where Shelby and Graham Elementary reside, ranks 89th out of 100 in the state for health outcomes.  As evidenced by the school’s attendance zone, Graham Elementary School includes most of Shelby’s low-income housing communities and these class and racial differences could be impacts of student health outcomes. Social determinants of health research show the greater one’s income, the lower one’s likelihood of disease and premature death. Race, racial prejudice, and race discrimination also impact health outcomes.

These determinants have jump-started this school into being a hub of change as a community school, where it serves an integrated focus on academics, health and social services, and youth and community development and engagement. This charge started with the school’s principal, who can easily identify where the fixes need to happen, and then makes them happen. Even her efforts to turn a pile of dirt into a welcoming grassy entrance have made a world of difference. And she hasn’t stopped there. In fact, she was late meeting up with us during our site visit because she was helping a student’s mother get to a counseling appointment. It’s this natural ability to see opportunity to address the things that impact student health outcomes that makes Graham Elementary a prime location for aligning services and supports to address social determinants of health. For our state partner, NC Child, their engagement with the community informs their Medicaid defense advocacy, understanding that Medicaid services are of primary importance to people in communities like Shelby.

Outside of Graham Elementary, the Shelby community is fueled by positive energy that will make the community school project successful in further advancing health equity outcomes in the next three years. It’s this energy that allows the community to recognize and realize health equity every single day.

Communities as Change Agents

From our short tour of the community work in Shelby, it is a clear reminder that communities have a key role to play in reducing health inequities for vulnerable populations and in paving the way for innovative approaches that connect children and families to the health and social services they need to be healthy. State advocates will be instrumental in deepening their engagement with communities, too – learning from their work and advocating for the tools that they need to be successful. We are excited to support this collaboration each step of the way.

In the middle of the night, in an effort to save their flawed health care bill, Republicans released a number of amendments to the American Health Care Act (AHCA) that would dramatically impact the ability of low-income children, including millions of children with disabilities, to access health care. AHCA’s original language changed Medicaid financing to a per capita cap financing scheme that would harm children and families and burden state budgets. The bill would also eliminate coverage for certain low-income school aged children and deny them access to important preventive services including vision, hearing and dental. The amendments House Republicans released last night add insult to injury by offering states the option of a block grant (an option that includes a financial incentive for states) and permitting states to impose a work requirement that could apply to some parents – even those with young children.

Medicaid is a multi-generational program set up to protect our most vulnerable consumers at any stage in their lives including infants, toddlers and school-aged children. Roughly half of the 73 million enrolled in Medicaid around the country are kids and almost 60 percent of children with disabilities rely on Medicaid for coverage and access to necessary health services. Under the current Medicaid program, children have special protections to make sure they have access to the health care they need. These protections include no cost-sharing and access to a comprehensive benefit package known as Early Periodic Screening, Diagnosis and Treatment (EPSDT), which provides the full range of services children need to help them develop and grow.

The original language in AHCA would roll back eligibility for children ages six to 18 from 133 percent of the Federal Poverty Level (FPL) to 100 percent of FPL. The amendments would exacerbate this eligibility rollback by allowing states to implement a block grant. A block grant, like the one House Republicans are proposing, would significantly decrease the amount of funding available to states and would not keep pace with increases in medical spending or eligibility needs. Because of this massive cut in federal funding, states would be forced to cut benefits, roll back eligibility, increase cost sharing, and deny children comprehensive preventive care they need to stay healthy. This bill gives states permission to make such changes, reversing the Medicaid program’s longstanding commitment to protecting low-income children. Children with special health care needs will be at particular risk for benefit cuts and cost sharing increases. Their more complex health care needs make them a target as states look for places to make cuts and find savings in the new capped funding environment. 

These changes would have significant negative long-term impacts on kids health outcomes. Studies show that children who have access to continuous health services lead healthier, more productive lives over the long term. For example, EPSDT helps very young children (0-3 years) access screenings and treatment they need during these critical years for brain development. The House Republican proposal does not require states that choose a block grant to cover EPSDT, putting access to these critical services at risk.

The combination of the eligibility rollback and state’s ability to reduce benefits will also negatively impact school-aged children. Children of color will disproportionately be hurt. For black children whoare six times more likely to attend a high-poverty school than their white peers, Medicaid is a lifeline that can help students access eligible health services inside school walls. These services include, but are not limited to, mental health services, substance use disorder screening and chronic care management (such as diabetes and asthma care). For children with disabilities, the risk, too, is great. Many school-aged children with disabilities require health services in school in order to participate and thrive.

AHCA was already a huge step backwards for children's health and these amendments do nothing to increase access to health care or improve the health of children. In fact, they will only lead to further coverage losses and reverse the progress made since the passage of the Affordable Care Act. They are merely political ploys to try and win over the votes of members of Congress who are on the fence about passing this deeply flawed bill that would strip coverage from millions of Americans.

1. The per capita cap financing scheme burdens state budgets and harms children and families.

The House bill dramatically alters Medicaid’s financing structure. This restructuring would reduce federal funding, shifting the majority of the cost burden to states. As a result, states would be forced to ration important benefits for low-income children and families, placing their health and wellness at risk. These benefits include important access to preventive screenings to keep kids healthy. Roughly half of the 72 million enrolled in Medicaid around the country are children and almost 60 percent of children with disabilities rely on Medicaid for coverage and access to necessary health services.

Medicaid is a key tool to advance health equity. A Medicaid per capita cap would exacerbate disparities in health outcomes between white children and children of color. Capping Medicaid funding will result in lower provider rates, reduced access to care predominately in communities of color and low-income communities and separate and unequal health care systems.

2. The bill eliminates coverage for certain low-income school aged children and denies them access to important preventive services including vision, hearing and dental.

Children ages 6-19 are at risk of losing Medicaid coverage. The House bill reverses a requirement to cover all children under 19 up to 138 percent of the federal poverty level and allows states to roll back eligibility for school-aged children from 6-19 to pre-ACA levels. This would translate into higher costs for families and fewer benefits for school-aged children—namely, Early Periodic Screening, Diagnosis and Treatment (EPSDT)—an important set of benefits that ensures that children and adolescents receive appropriate preventive, dental, mental health, vision and developmental services. 

Children of color will disproportionately be hurt. For black children who are 6 times more likely to attend a high poverty school than their white peers, Medicaid is a lifeline that can help students access eligible health services inside school walls. These services include, but are not limited to, mental health services, substance use disorder screening and chronic care management (such as diabetes and asthma care). For children with disabilities, the risk, too, is great. Many school-aged children with disabilities require health services in school in order to participate and thrive. Rolling back access to Medicaid coverage threatens children’s health and long-term success.


3. Higher out-of-pocket costs combined with reduced tax credits bar families from accessing affordable coverage.

Higher cost-sharing and premiums force families to make difficult decisions about accessing care and making ends meet at home. For moderate-income families, the reduction in tax credits would make coverage out of reach. Over 1 million children rely on health coverage through Marketplaces and a cut to tax credits will impose an additional financial strain on parents. If the bill were enacted today, estimates show that families’ costs would increase by over $2,000. For families with income below 250 percent of poverty, costs would increase by over $6,000 on average. By 2020, when many provisions of the bill kick in, costs would increase by over $4,000 and over $9,000 for those living below 250 percent of poverty. These hikes in costs would be unsustainable for families.


4. Parents cannot access needed benefits to stay healthy and care for their children.

Healthy parents are able to care for their children, helping ensure that they thrive and become healthy adults. Winding down the Medicaid expansion would punish adult caregivers by limiting their access to needed care. The House bill would phase out the ACA’s Medicaid expansion by restricting current federal reimbursement to only continuously covered individuals. If Medicaid expansion enrollees experience a gap in coverage, the federal contribution reverts to pre-ACA levels. In addition to financially starving the program, the House bill strips down the benefit package by sunsetting the essential health benefits package for the Medicaid expansion population only.

The Medicaid expansion benefit package currently provides mental health and substance use disorder services as a core benefit. Eliminating these needed services puts families at risk, denying parents a pathway to good health and family unity. It is well-documented that when parents are healthy and have access to coverage their children are also more likely to be covered.


5. Cuts to Medicaid will have a ripple effect on state budgets and stunt innovation.

Healthy communities rely on more than just access to health coverage but also equitable access to safe neighborhoods, robust public schools and affordable housing. States work to balance the needs of their residents to ensure they can leverage multiple programs and resources to raise healthy families. Forcing states to shoulder the financial cost of Medicaid means that other important budget items would need to be reduced. These could range from public school budgets to public safety priorities. According to Center on Budget and Policy Priorities, per capita caps would shift $370 billion in costs to states over ten years. The House bill would also eliminate funding for the Prevention and Public Health Fund which would result in detrimental cuts to core public health programs including disease tracking, access to immunizations for low-income individuals and the prevention of and response to lead poisoning.

With a rise in cost burden, states would not have any funds to invest in innovative models of care that lead to smart program savings across the health care system. Medicaid coverage and adequate funding are the foundation for innovation, including testing methods that reward value instead of volume and address social determinants of health. The House bill’s per capita cap proposal would slash total federal Medicaid funding. Rather than increasing innovation, funding cuts due to per capita caps would hinder innovation and may even prevent it altogether.

Amidst the noise of the national political landscape, it is important to remind ourselves that February is Black History Month. While this month serves to celebrate the accomplishments of black people in America, it is also a reminder of how inequality has, and continues to, plague many black communities. Health inequity constitutes one of the many systemic forces that perpetuate the marginalization of the same community we celebrate for its undeniable contributions to American society. In the words of civil rights playwright and activist James Baldwin, “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

The challenge: Why must we act? Disparities persist.  2017 marks 53 years since the passage of the Civil Rights Act of 1964, key legislation that outlawed de jure discrimination based on race, color, religion, sex or national origin. And yet, half a century later, we still suffer the consequences of de facto discrimination across all axes in health such as disparate health outcomes, and/or access to affordable quality care. In fact, according to a Kaiser Family Foundation brief “disparities in quality of care are not getting smaller. Over time, the health disparities between Whites and African Americans, Hispanics, Asians, and American Indians/Alaska Natives has either remained unchanged or worsened for most of the core qualities measures of health.” The longstanding weight and trauma of racism has long-term consequences across the lifespan for people of color.

Adverse Childhood Events: A metric for trauma.  One health disparity among children garnering growing concern and attention is prolonged adversity (or trauma) in the absence of positive adult caregiver support. Researchers have used Adverse Childhood Experiences (“ACEs”) to categorize the many forms of early trauma. Not surprisingly, Black and Hispanic children – even at the highest income levels – are more likely than their white peers to experience adversity. Work led by Harvard University’s Jack Shonkoff illustrates how exposure to trauma and stress negatively affects brain development before the age of three. Further, research shows that trauma can have long-term psychological and physiological health impacts that exacerbate health disparities over generations if left untreated. This is a stunning reminder of the urgency surrounding health care coverage and access for children and parents throughout the life cycle – from preconception to a child’s transition into adulthood.

Despite this substantiated research, it is not standard practice for medical providers to inquire about the trauma history of their patients. Moreover, there are not enough financial incentives put forth by insurance payers to do so. A first step is to focus on parents, assessing their exposure to stress and trauma and providing tools and resources as they develop as parents and caregivers of young children.

But what can ACEs screening tool do?  There is reason to keep hope. We know that resilience – the ability to overcome hardship – can attenuate some of the impacts of significant adversity. Kids who have a supportive relationship with an adult caregiver are better able to build resilience. And while historically, African-Americans/Black people have found ways to build such resilience by employing faith, hope and community, these supports are simply not enough for many of our most vulnerable families and children who face persistent adversity.

These disparities emphasize the importance of implementing more targeted programmatic intergenerational policies and programs that focus on addressing the needs of both vulnerable parents and their children together in order to create cycles of opportunities for more families.

A validated ACEs screening tool would serve the dual purpose of employing a more strategic approach that properly identifies and provides social service resources to at-risk families in order to build supportive caregiver relationships.

Concrete pathways to action:  This is a difficult political environment, but it is more imperative than ever to focus on the health and wellness of our communities. If we know that our communities shape the conditions families face, and that families shape the conditions children grow up in, then we must urgently support families in strengthening their capacity for resilience so they can build that capacity amongst our children. In that vein, the children’s health team at Community Catalyst has developed an issue brief to support a shared understanding of ACEs, trauma and stress and the multi-generation policy approaches that support healthy families.

Over the next few months the children’s health team will be conducting a review of ACE’s legislation and programs across the country. This will include investigating initiatives that are Community-, Provider- and legislative- led to inform an issue brief for consumer health advocates and provider communities. We hope the resulting issue brief will serve as a call to action with the dual purpose of reminding us all why health equity work matters, and what vehicles providers, consumers and legislators can use to advance the ACE agenda.

Nana Yaa Misa, Children’s Health Initiative Intern

73 million.

73 million. This is the number of people who rely on Medicaid for their health coverage - and almost half of them are children. It’s the number that stands out on the screen as we read Kaiser Health News’s assessment of how a shift in Medicaid policy would impact consumers. As we near the end of one administration and ready for a new one, it is important to reflect on the reach of Medicaid and the Children’s Health Insurance Program (CHIP) and their impact and role as a lifeline for families to access needed health care.

And while uncertainty may surround what the next administration might do, one thing is certain: Medicaid and CHIP work.

My Medicaid Matters

Medicaid and CHIP are the cornerstones of coverage for low-income families.

Medicaid is a multi-generational program set up to protect our most vulnerable consumers at any stage in their lives. Under the ACA, Medicaid has expanded in many states to cover people in the coverage gap – those earning too much for traditional Medicaid but too little to qualify for tax credits in the Marketplace. Alongside Medicaid, CHIP has provided coverage to the almost eight million children whose families currently or once lived in this gap.

Healthy families lead productive lives: healthy parents contribute to their workplace and their community and healthy children come to school ready to learn.

Medicaid and CHIP work to increase access to timely and needed care. Studies show that children who have access to continuous health services lead healthier, more productive lives over the long term. We know that restricting access to these vital programs harms children and their families and can limit their opportunity to lead healthy lives.

Medicaid and CHIP play an important role in advancing health equity for children.

According to the Kaiser Family Foundation, Medicaid and CHIP cover more than half of all Hispanic children (52 percent) and Black children (56 percent) compared to a little over a quarter of white (26 percent) and Asian children (25 percent). As the Kaiser report shows, Medicaid and CHIP, in partnership with the ACA, are important initiatives to reduce health disparities and increase access for children of color. Coverage is the first step in securing better health outcomes for all children. And for children from racially and ethnically diverse backgrounds, Medicaid and CHIP open a door to needed health services.

Let’s start collecting and sharing the stories of the low-income families that have benefited from Medicaid and CHIP.

More than 73 million. That is how many stories are out there about the success of Medicaid and CHIP. Let’s get started on collecting those stories, like advocates in Pennsylvania have done through their new InsurePA website, so we can ensure that Medicaid and CHIP will continue to support children and families for years to come. Stay tuned for helpful messages and other tools from Community Catalyst to assist in your story collection efforts.

While school nurses have long been recognized for their vital role in supporting children’s educational success through better health, there is increasing recognition that school nurses are integral to reforming our health care delivery system. School nurses are the eyes and ears of the school community; being physically present throughout the school day makes them uniquely positioned to be a child’s health care touch point across multiple settings, from the classroom to the physician’s office. 

This past month, American Academy of Pediatrics (AAP) released a policy statement highlighting the important role school nurses play across a child’s continuum of care. In particular, the AAP statement recommends that every school should have at least one nurse. In instances with larger student populations and/or greater need, more than one nurse may be necessary. This is important on a number of fronts but most notably because many schools currently go without this important resource. In 2014, more than half of all elementary schools did not have a registered nurse working at least 30 hours a week.

Why is having a nurse in every school so important?

School nurses can play pivotal roles in improving and maintaining children’s health—particularly for children with special health care needs and low-income children who face challenges outside of school that negatively impact their health. Such challenges may range from food and housing insecurity to safety at home. A school nurse can observe children’s needs, screen for factors beyond health care such as income and housing that impact health (social determinants of health) in addition to medical concerns and connect children and their families to needed support services. A nurse’s role spans the full spectrum of care, from prevention to treatment; they manage upstream factors through surveillance and address downstream health challenges through coordination and collaboration with a child’s medical home and other support services. Specifically, school nurses are able to:

  • Educate and promote health and safety, including what makes a healthy living environment
  • Identify and intervene in potential health and wellness issues—including addressing social determinants of health that impact children
  • Collaborate with physicians and health teams by jointly developing and implementing medical action plans for a vast array of conditions
  • Provide case-management services
  • Provide on-site care for illness or injury emergencies
  • Identify behavioral health risks, while providing support to the student in school and referral to appropriate resources
  • Build capacity for health learning, self-advocacy and literacy

In addition to the diverse roles that nurses can play in supporting children’s overall health, the most obvious reason for a school nurse on each school campus is that they are able to address children’s needs during the school day. For parents and caregivers, taking time off of work for multiple or ongoing medical appointments can be difficult and stressful. Nurses can support families’ economic security by simply collaborating with pediatricians and other providers to address the ongoing care needs of children during the school day. This reduces student absenteeism and parent/caregiver stress.

How can states support one school, one nurse?

A first step states can take is to validate the important role that school nurses play in the securing the health our children, their families and our communities. The second step is to translate this into action through increased investment in a school nurse workforce. Two options include added revenue for a school nurse workforce through changes in Medicaid and dedicated inclusion of a school nurse workforce in health system transformation efforts underway.

One clear way to support school nursing is for states to take the required steps to change their Medicaid policy and allow for reimbursement of all services provided to Medicaid-eligible children in school settings—otherwise known as the revision of the Municipal Medicaid free care rule (learn more about the free care rule here). This new opportunity can potentially bring additional resources to schools, enabling school systems to invest in the school nurse workforce and expand their reach and role in children’s health and wellness.

A second parallel strategy is to include the school nurse infrastructure in delivery system reform planning such as Accountable Care Organizations (ACOs), State Innovation Models (SIM) and other ongoing initiatives aimed at reinventing health care delivery systems. Currently, reforms to improve the pediatric delivery system include the incorporation of social and economic supports for children and families—all with the goal of improving community health. Who better to advance community health goals than the front-line workforce that is already in place, working with children every day?

We know that a healthy child is ready and able to learn. State health stakeholders need to heed the advice of the American Academy of Pediatrics and take the next step in securing a minimum of one nurse in every school.



We know that as the energy in the health care world turns to reinventing health care delivery systems, social and economic determinants of health and the role they play in community health are front and center. Studies have uniformly shown that social, economic, environmental and behavioral factors play a larger role in determining health than genetics and health care combined (as illustrated by the County Health Rankings and Roadmaps program infographic below). 

However, we know that addressing any of the social and economic determinants of health requires robust partnerships between health care systems and providers, as well as numerous others in the community, many of whom may have never worked together in a formal way. The intersection between health and human services and housing is well-documented by the Kresge Foundation and Policy Link in their Healthy Communities of Opportunity: An Equity Blueprint to Address America’s Housing Challenges.

Over the past year, I had the opportunity to contribute to one such effort here in Boston related to the intersection of health and housing. These initiatives offer some good insights into how these partnerships might work to support vulnerable families accessing the health care system to gain access to secure, safe and affordable housing that is essential to their overall health.

The Boston Foundation (TBF), in collaboration with the Kresge Foundation, the John D. and Catherine D. MacArthur Foundation, the Blue Cross Blue Shield of Massachusetts Foundation, and Partners HealthCare, is funding opportunities to create and sustain health and housing partnerships in greater Boston. This program, the Health Starts at Home initiative, seeks to improve health outcomes for children and their families by ensuring families’ housing needs are addressed in conjunction with their health and other social service needs. Each project is approaching the intersection of health and housing differently, each with a variety of partners, including hospital/health centers, social services agencies, housing providers, legal services, and/or homeless programs.

As diverse partners come together, there is incredible synergy and opportunity—yet there are challenges and important lessons for others as they plan and collaborate to address safe, secure, affordable housing as one of the individual needs necessary to maintain and/or improve health for children and families.

Tracking Families Is at the Center of the Work.

When working with three different agencies in three different, yet connected, domains, tracking families is vital. The families in the Health Starts at Home program are housing insecure – they may be in and out of shelter, placed in shelters far outside the Boston area, and/or difficult to contact. Combine that with the variety of challenges they face—from food insecurity to employment volatility—and the number of agencies providing services, and you have a difficult time getting a clear picture of where they are in the housing process.

Establishing a workflow and a tracking process means families receive robust services, everyone is on the same page, and families don’t slip through the cracks or get lost in the process. This is a complex undertaking.

All Partners Have a Role.

In each of these projects, there are a diverse set of partners, each with a distinctive role as it relates to health and housing. For example, the hospital can conduct assessments and make referrals for needs, including housing, through a coordinated case management program. Legal services can provide legal representation to housing-insecure families, or provide education to families living in homeless shelters. Homeless shelters can help families navigate early education and child care subsidies as well as host training and educational programs that help residents understand the resources available to them. While everyone has a role, those roles overlap and intersect, demanding a high level of communication among partners and a shared mission and set of values.

Understand Capacity and Bandwidth.

An unfortunate reality of partnerships is that many organizations lack staff capacity and resources—especially social service agencies, as outlined in a recent article in Health Affairs. Collaboration among agencies, like that in the Health Starts at Home Initiative, can result in greater efficiencies. However, there are several challenges to forming strong partnerships across agencies such as finding a regular time to meet, identifying roles within the group and how they fit into the culture of the agencies. Cultural shifts require commitment and leadership to improve how different partners work together across health and human services to support consumers.

How Do You Know it Worked?

The Boston Foundation, in partnership with Health Resources in Action (HRiA) and outside evaluators, established an evaluation process to measure the efficacy of the proposed interventions. An additional $200,000 in funds is dedicated annually to evaluate the partnerships and the work the organizations are doing together, with the goal of understanding what works and share that with others who want to try these kinds of collaborations.

These are challenging yet important conversations. Advocates are increasingly engaged in discussions about how to move the needle on population health; they have a valuable contribution to make as health and human services stakeholders and decision makers design and implement pilots and initiatives that attempt to embed deeper connections across social determinants and health outcomes. Vehicles for this work span the full continuum of care from screening to treatment to maintenance as evidenced in forward thinking accountable care communities. We look forward to supporting advocates in these ongoing conversations with new partners.

Stay tuned for another blog about the development of a key position in this new work aligning health and housing —the community health worker.

Katherine Fukumoto
Intern with the Community Catalyst Alliance for Children’s Health

Recently, Community Catalyst hosted a national learning community webinar called Health and Housing 101: Understanding the Intersections.  We will be continuing this webinar series in the coming months with additional webinars and calls featuring national, state and local partners who are engaging in work to address health and housing issues. To be included in future emails to learn more about this work, please contact Michele Craig.

The third in our National Minority Health Month blog series.

In 2014, Tennessee became the first state in the country to pass a law making it a criminal offense to use drugs while pregnant. Now, two years later, the state is reversing its position by allowing the law to sunset. We applaud the closing of this chapter – allowing the law to sunset, particularly at the height of an opioid epidemic, sends a clear message of the flawed logic leading to the passage of the law in the first place.

While this is good news, Tennessee is not the only state in the nation to impose punitive action on pregnant women with a substance use disorder. Since 2005, 800 women have been jailed nationwide for drug use during pregnancy. Based on their respective state Supreme Court rulings, both South Carolina and Alabama have been able to prosecute women under similar statutes. In three other states, substance use during pregnancy is considered grounds for civil commitment - either involuntary commitment of a pregnant person to treatment or involuntary placement of a pregnant person in protective custody of the State. Civil commitment looks different in each of these states, but in Wisconsin, for instance, a woman can be detained against her will for the duration of her pregnancy. And in 18 states, substance use during pregnancy is considered child abuse, which sets as-yet unborn children on a course to be separated from their parent(s).

It is well documented that punitive approaches to substance use during pregnancy are harmful to both parents and their children. The threat of punishment discourages pregnant people from seeking vital prenatal care and of equal importance to the growing babytreatment for their substance use disorders. People across the country have gone without care altogether throughout their pregnancies, out of fear of possible consequences related to their substance use. After babies are born, we know that best practice, including for those with neonatal abstinence syndrome, is to keep them with their mothers and provide robust care for the pair.

Rules that guide the care of mother and child during pregnancy when there is a substance use involved, such as the laws mentioned above, can disproportionately impact moms of color. Despite the fact that multiple studies have found no significant differences in maternal substance use by race, black women and their babies are more than 1.5 times more likely to be drug tested in a hospital setting than non-black women, and ten times more likely to be reported to public health officials.

What can we do to protect pregnant people and their children, and ensure the best outcomes for both? Halting the criminalization and disproportionate action against women of color can be addressed on multiple fronts, including:

  • Changing harmful state laws. ProPublica has compiled an interactive map of how states handle drug use during pregnancy; learn more here. Advocates, public health and medical associations from across the country have unanimously agreed - we should dismantle laws that punish pregnant people for their substance use disorder.
  • Reducing explicit and implicit bias in the health care system. Implicit bias training for health care providers has been shown to help reduce racial disparities in provision of care.
  • Clarifying screening and reporting rules. Providers need more clarity and transparency from state government about mandatory reporting rules to ensure that pregnant people are screened and referred to appropriate services, based on best practices for patients.
  • Expanding access to prevention and treatment. It is critical that we expand use of preventive screenings, like SBIRT (Screening, Brief Intervention, and Referral to Treatment), for all consumers, and especially for pregnant people, as a public health measure.
  • Intensive case management. Case management can help ensure mothers get access to treatment and other supportive services, and has been shown to be an effective strategy for reducing future substance exposure during pregnancy. 

Earlier this month, Florida joined 29 other states that offer Medicaid and CHIP coverage to children and pregnant women who legally reside in this country under five years. We, in Ohio, celebrate this monumental step with our friends in Florida. In Ohio, our “lifting” of the five-year bar – or adoption of the Immigrant Children’s Health and Improvement Act (ICHIA) option – came with much less fanfare.

For us, our work on immigrant coverage emerged from partnerships within Ohio’s ethnic and minority communities. As a result of that community connected work, we published a report, Reaching Ohio’s Ethnic Minority Children, which outlined key strategies for reaching more ethnic minority children and pregnant mothers the health coverage they need.  The change in policy for legal immigrant families in Ohio living here less than five years allowed the opportunity to amplify these key strategies and deepen our work, ensuring that the option was fully implemented. 

After deliberate investigation, Children’s Defense Fund-Ohio found that many healthcare provider systems and immigrant populations were unaware of the option for immediate coverage.  To remedy this, Children’s Defense Fund-Ohio employed a variety of strategies that other states could pursue. We focused our work on three primary ethnic minority populations in Ohio—Asian American and Pacific Islander, African, and Latino children—and worked with four community-based organizations to help gather data and analyze findings.

Our strategy entailed:

  • Advertising campaign: We published culturally competent advertisements about ICHIA and Medicaid eligibility, in targeted community-based newspapers, on public buses and on neighborhood benches within immigrant communities.
  • Marketing materials: We developed culturally competent one-page brochures and compelling posters and distributed the posters along with educational materials in targeted population community centers, grocery stores and daycare centers.
  • Targeted outreach in the community: We presented directly to respective county job and family service offices and qualified entities across the state with the highest concentrations of immigrant populations (on-going).
  • Multimedia channels: We are working to produce an online instructional video to be published on our website and distributed directly to community-based groups via email and social media.

Because of the state’s current focus on the high infant mortality rate—6.8 deaths per 1,000 live births overall, and a rate of 14.3 per 1,000 for black babies—we have the opportunity to reach audiences who are eager to find another strategy to better birth outcomes.  Knowing that connecting vulnerable pregnant women to prenatal care is a sure way to begin to save our babies, we are leveraging the statewide focus on maternal and infant health by underscoring the benefits of ICHIA in contributing to our state’s efforts to combat infant mortality. As we support community-based efforts to reverse negative infant mortality trends, we are educating community based partners about the opportunity to enroll women and children thanks to the ICHIA option.

This work will continue to be an important part of achieving health equity in Ohio and allowing more of Ohio’s children to celebrate their first birthday.  

Renuka Mayadev, Executive Director
Children’s Defense Fund-Ohio

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