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By Charles Bruner and Kay Johnson

Our country and the world are eager to move toward the coming new year. In 2020, the triple crises of the COVID-19 pandemic, economic downturn, and reckoning on racism have elevated attention to social injustice in both the health care system and our country as a whole. Because of COVID-19, the public and policy leaders have heightened awareness of the importance of physicians, nurses, community health workers, child care providers, teachers, and others who support the health and well-being of young children and their families. While COVID-19 has had its major medical impacts upon older Americans and Americans with disabilities, it has disrupted the lives of children and their families and, without concerted and intentional responses, threatens to have its greatest long-term impacts upon children – in their physical, mental, social, and behavioral health and development.

This comes even as, before COVID-19, too many U.S. children—through the poverty, racism, isolation, stress, discrimination, or marginalization of their families and communities—do not receive the services and supports they need to succeed. This results in profound disparities in opportunity unfairly based upon a child’s socio-economic status, zip code, and/or race/ethnicity. Currently, none of the systems serving  children—health care, economic assistance, early care and education, and family support—has sufficient resources to provide high-quality, effective services to all. The federal government has a critical leadership opportunity to invest in these systems, in partnership with states and communities, and to equip the child- serving fields to move toward a new and better standard of practice.

A major shift toward strengths-based and relational approaches that support children and their families is needed. While Adverse Childhood Experiences (ACEs) endanger mental and physical health in childhood and throughout the lifespan, emerging science helps us understand how Positive Childhood Experiences (PCEs) promote optimal health and well-being.  Integrating the Healthy Outcomes from Positive Experiences (HOPE) framework into pediatric medical homes and other child service systems will help build upon child, family, and community strengths and resilience.

Child health transformation, beginning with Medicaid and young children, must be one goal as we shift approaches. New leadership and investment from the federal government can be the stimulus needed to accelerate such transformation and to diffuse exemplary practices and evidenced-based models that embody high performing medical homes. This includes team-based care that uses more family-centered, strengths-based, preventive, holistic, and relational approaches, as well as links to other community services and supports.  Health care must address social determinants of health, as well as bio-medical health care needs.  This requires a more diverse workforce, including community health workers, family specialists, and others whose role is to promote family strengths and advance HOPE.

Through discussions with a National Advisory Team and a network of partner organizations, the InCK Marks Initiative has defined a set of key actions the federal government can take to improve the health and development of children and their families. Some are specific to young children, but many apply to older children.  All aim to improve health equity and child health transformation to support optimal health and development for all children.

  1. Guarantee health coverage
    • Health coverage guaranteed for all newborns until at least their third birthday, including automatic and continuous enrollment in Medicaid/CHIP for those without identified private health coverage.
    • Continuous Medicaid postpartum enrollment of mothers for a year following the end of pregnancy, through the child’s first birthday.
  2. Provide incentives to states
    • Enhanced federal financial participation under Medicaid for well-child visit reimbursements for practices that meet standards as advanced, high performing medical homes.
    • Enhanced federal financial participation under Medicaid for care coordination/ case management services for children which address social as well as medical determinants of health, including staffing that is diverse and responsive to and representative of the communities served.
  3. Invest in innovation and quality improvement
    • Provisions (and reauthorization) for the Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation (CMMI), that focus on advancing innovation and diffusion of advanced, high performing medical homes for children in Medicaid, including a federal funding opportunity announcement (FOA) for young children and State Innovations in Medicaid (SIM) grants to states specifically for child health.
  4. Build a community-based workforce
    • Additional funding (through the Title V Maternal and Child Health Services Block Grant or other flexible block grant funds) for a community-based child health workforce (e.g., community health workers, family specialists, relational health workers, doulas, family navigators, and others) to build the capacity to provide family-centered, culturally congruent, and strengths-based services.
    • Additional funding through Medicaid and other federal programs such as IDEA Part C to expand early intervention services for children with developmental risks and delays related to medical or social complexity,  providing appropriate child-specific responses and supporting families in their roles.
  5. Advance equity
    • Incorporation of expectations and supports within all actions taken above to advance and promote accountability among payers for equity, with a particular and specified role for child health providers to contribute to eliminating bias and being explicitly anti-racist.
    • Specific financing for equity training, guidance, and continuous improvement as part of Medicaid and other health care contracting and administrative support, including workforce diversification to reflect the populations being served.
    • Focused attention to monitoring quality and equity in Medicaid, with data collected and oversight provided to ensure accountability for health expenditures so that all children receive continuous coverage, equitable treatment, and quality care responding to their needs and circumstances.

Our nation must take steps to build back better, smarter, and fairer from the 2020 crises. Health care has an essential role to play. This requires helping pediatric primary care providers become high performing medical homes, growing a diverse community-based workforce, and making investments in equity training and improvements.  Medicaid/CHIP cover more than half of Black, Hispanic, and Native American infants and more than 40 percent of young children. We cannot ensure health equity without using this program leverage for change. The future of our children and society depends upon it.

NOTE: The InCK Marks Initiative has submitted a set of key actions to the transition effort for President-Elect Biden and Vice-President-Elect Harris, with over 100 child health leaders signing on. InCK Marks is continuing to accept sign-ons here:

Photo by Rui Xu on Unsplash

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