Providing Universal Healthcare Access for Children (0-18): Children’s Health Initiatives

Why is health care access important during the first 36 months of life? The American Academy of Pediatrics and the Centers for Disease Control state that children need to be immunized against 15 different diseases during this period. Additionally, 9 of these vaccines are administered in multiple doses during this time period (CDC, 2009). Pediatricians are also an important source of early detection for developmental delays including cognitive, social/emotional and physical delays. Early Intervention Services can effectively remediate many types of developmental delays and have a demonstrated cost benefit of $13 in public savings for every $1 invested (Glascoe & Shapiro, 2007).

There is also a demonstrated connection between having insurance and consistent health care access. Uninsured children do receive health care services, but often they do not receive all of the care that they need when it is needed. This can be very expensive for them and the healthcare system since paying for chronic pre-existing conditions is significantly more expensive than providing preventive care (Stoll and Thorpe, 2005).

So who currently pays for care for uninsured children? A 2005 Families USA report revealed that roughly 1/3^rd is paid by uninsured children’s families, 1/3^rd is paid for through a combination of existing government programs and the final third is passed on to privately insured individuals and families in the form of higher health insurance premiums. The report estimated that the average privately insured family in Tennessee will be paying just over $1,299 extra in health insurance premiums each year by 2010 to cover the cost of providing health care for uninsured individuals (Stoll and Thorpe, 2005).

Increasingly, children whose families earn too much to qualify for publicly funded health insurance programs (Medicaid and SCHIP) lack insurance. California responded to this reality by creating the Children’s Health Initiative (CHI). The first Children’s Health Initiative was created in 2001 in Santa Clara County. Currently there are Children’s Health Initiatives in 30 counties and during their 8 years of existence, they have helped provide health insurance to 88,000 uninsured children (California Children’s Health Initiatives, 2009).

Children’s Health Initiatives work by enrolling eligible children in Medi-Cal, California’s Medicaid program, and Healthy Families, their SCHIP program. Children who are ineligible for either program are enrolled in locally funded and non-profit programs. The Initiative is primarily funded through the Foundation community of California, including the David and Lucille Packard Foundation, the California Endowment and the Tides Center. The programs which provide health insurance for children who do not qualify for Medi-Cal or Healthy Families include:

- Healthy Kids, a locally operated insurance program that does not have income eligibility limits. Families pay low premiums and co-pays for health, dental and vision coverage.

- CalKids, a non-profit program for children ages 2 through 18 whose families earn below 250% FPL, regardless of immigration status;

- Kaiser Permanente Child Health Plan, a state level program that provides low cost care for all children who do not qualify for state plans, regardless of family income.

There are also two federal and state funded programs that provide care for children with identified disabilities or medically necessary care.

To date, the CHI has demonstrated improved access to dental and medical care services, reduced child hospitalizations and improved health care status for many children statewide who would have lacked coverage otherwise (Cousineau et al, 2007; Howell and Trenholm, 2007; Phipps et al, 2008).

Sources

California Children’s Health Initiative (2009). History. Altadena, CA: The Tides Center. Accessed August 14, 2009. < http://www.cchi4kids.org/history.php>

California Children’s Health Initiative (2009). Vision and Mission. Altadena, CA: The Tides Center. Accessed August 14, 2009. < http://www.cchi4kids.org/vision&mission.php>

California Children’s Health Initiative (2009). Partners. Altadena, CA: The Tides Center. Accessed August 14, 2009. <>

Centers for Disease Control and Prevention (2009). Recommend Immunization Schedule for Persons Aged 0 through 6 Years. Washington D.C.: Author. Accessed August 14, 2009. <>

Cousineau, Michael R., Gregory D. Stevens and Trevor A. Pickering (December 2007). Children’s Health Initiatives Have Helped Prevent Over 1,000 Unnecessary Child Hospitalizations Annually. University of Southern California: Center for Community Health Studies. Accessed August 14, 2009. <>

Glascoe, F.P. & Shapiro, H.L.(2007). Introduction to developmental and behavioral screening.
Developmental Behavioral Pediatrics Online, www.dbpeds.org

Howell, Embry and Christopher Trenholm (March 2007). Santa Clara County Children’s Health Initiative Improves Children’s Health. Los Altos, CA: David and Lucille Packard Foundation. Accessed August 14, 2009. <>

Phipps, Kathy, Joel Diringer, T. Em Arpawong, Chris Feifer, Michael R. Cousineau, and Gregory D. Stevens (July 2008). Dental Utilization in California’s Children’s Health Initiatives’ Healthy Kids Programs. University of Southern California: Center for Community Health Studies. Accessed August 14, 2009. <>

Stoll, Kathleen and Kenneth Thorpe (June 2005). Paying a Premium: The Added Cost of Care for the Uninsured. Washington, D.C.: Families USA. Accessed August 14, 2009. <>

Tennessee Ranks Near Bottom In Child Well-Being: Child Poverty Especially High In Urban Shelby County

Last month, the Annie E. Casey Foundation published the 10th annual KIDS COUNT Databook, showcasing the welfare of our nation’s children on a state-by-state basis and grading states on 10 measures of child welfare*. According to the report, Tennessee has lots of room for improvement when it comes to children’s issues- our state ranks 46th nationally.

According to Linda O’Neal, Executive Director of the Tennessee Commission on Children and Youth, the majority of the factors examined by the Annie E. Casey Foundation are related to poverty. The percentage of Tennessee children residing in impoverished households in 2007 was 23 percent, up from 20 percent in 2000. “Tennessee and other Southern states have been plagued by a history of poverty, unemployment and low-paying jobs that worsen dropout rates, teen birth rates and other metrics the study considers” O’Neal suggested (Carey, The Tennessean, p.1).

Economic hardship is especially prevalent in our community. In Shelby County (2007), about 30 percent of children live in poverty, with half of these living in extreme poverty (approximately $10,000 in annual income for a family of four). Poverty is on the rise in the city of Memphis- from 2003 to 2007, the percentage of children in poverty rose from 35 to 42 percent (The Urban Child Institute [TUCI], 2009).

For our youngest citizens, residing in poverty is more than economic disadvantage- science suggests that poverty negatively impacts cognitive and social-emotional growth. Children raised in impoverished households lack access to critical resources needed for intellectual development, including high quality child care, medical care and reliable transportation.

How can we make sure that our infants and toddlers have a healthy start in life and guarantee that local families have access to the supports that will help them meet their young children’s basic needs?

Policy Suggestions (Zero To Three, 2009):
- Actualize family-friendly welfare-to-work programs that support the developmental requirements of very young children.
- Extend tax protocols for low-income families, including the Child Tax Credit and the Earned Income Tax Credit.

For more information on the well-being of children in Memphis and Shelby County, visit The Urban Child Institute at http://www.theurbanchildinstitute.org.

References

The Annie E. Casey Foundation. (2009). 2009 Kids Count DataBook. Baltimore, MD: The Annie E. Casey Foundation.

Carey, C. (2009, July 29). Tennessee is 46th in caring for kids: State worsens in poverty but
improves dropout rates. http://www.tennessean.com/article/20090729/NEWS01/907290393/Tennessee+is+46th+in+caring+for+kids

DiLauro, E. (2009). Getting back to basics: Building the foundation for infants, toddlers, and their families. Washington, DC: ZERO TO THREE Policy Center.

The Urban Child Institute. (2009). The State of Children in Memphis and Shelby County: DataBook. Memphis, TN: The Urban Child Institute.

*For a complete listing of variables examined by the Annie E. Casey Foundation, please visit http://www.aecf.org/.

Educare: An Early Child Care and Education Model that Bridges the Gap Between “What We Know” and “What We Do”

“Educare seeks to take the nation’s best early childhood research from the lab to the street” (Buffett Early Childhood Fund, 2009, 2).

Educare is a model for providing comprehensive full day, full year early child care and education services to at-risk families. Specifically, the program works with parents and children who are transitioning from welfare (Temporary Aid to Needy Families, or TANF) to work. The Educare Program model was designed by the Ounce of Prevention Fund and the first Educare center was opened in 2000 in Chicago. There are currently 9 Educare centers in the U.S. with another 3 in development.

In order to create an Educare center, local philanthropic and advocacy partners work together to obtain public dollars for Early Head Start, Head Start and child care. The funding is then combined to create a unified funding stream to provide comprehensive services for children from birth through age 5. Once a blended funding stream is established for the support of the center, local partners supply private dollars to design and build an Educare center and hire the support staff to run the programs.

Each Educare center is designed to serve between 140 and 200 at-risk children. Each classroom is led by a teacher with a Bachelor’s degree, and is also staffed by an assistant with an Associate’s degree along with a community volunteer. Each center has a supervisor with a Master’s degree in early childhood development. In addition to teaching staff, each center employs social workers to assist families in obtaining needed wrap around services, including health care. The program utilizes the most successful elements from nationally proven early childhood models such as Perry Pre-School and the Abecedarian project to design and implement their curriculum.

Providing services through an Educare Center begins with pre-natal care for children’s mothers. a third of the space at budget of each Educare Center is devoted to education and support to help parents establish strong relationships with their children and to help them balance the demands of work and family life. Parents are also expected to take an active role in the day to day operations and governance of the Educare center. Each Center is required to hire a Ph.D. level evaluator who regularly sends data on the center’s outcomes to the University of North Carolina where it is used to analyze how effectively services are being provided and children’s outcomes are being improved (Buffett Early Childhood Fund, 2009).

How large is the need for early care and education services among at-risk families in Memphis?

Currently, about 7,949 (30% of the eligible population) at-risk children (0-5) are being served by DHS child care funds. 95 (2% of the eligible population) children between birth and age 3 are served by Early Head Start; 2,296 (22% of eligible children) are served by Head Start and an additional 2,540 (24% of eligible children) are served by public pre-kindergarten (CUCP, 2009). All of these programs currently only reachat-risk families and their children. Additionally, with the exception of DHS child care, none of these programs provides full day, full year child care options. It is difficult to provide a complete estimate of eligible children who are not receiving services because there is overlap in the populations of children receiving different publicly funded care. For instance, many of the children who are participating in Early Head Start, Head Start, and public pre-K are also receiving before and after care from DHS funded child care providers. There are also many children in the population of families who are legally eligible for DHS child care, but only when there are funds available to cover them.

What would it mean to take the Educare model to scale in Shelby County?
In order to provide full day, full year care using the Educare model, we would need about 100 centers to provide care for all the children who are considered at-risk by virtue of their families being TANF recipients or transitioning off of TANF (CUCP estimate, 2009). From the ground up, the cost of an Educare center is daunting. The most inexpensive center in their system was created for $4 million dollars (Buffett, 2009). However, there is some potential for obtaining new funding dollars for an initiative of this type. Last month, the House of Representatives created the Early Learning Challenge Fund to provide a billion dollars a year for the next 8 years in order to provide grant money for states to undertake one or more of the following activities:

• Undertake activities to develop the components of an early learning system;

• Undertake such activities that will allow the state to become eligible and competitive for a Quality Pathways Grant;

• Prioritize the activities that improve the quality of early learning programs serving low income children.

The grants are designed to be dispersed for up to 3 years. In order to obtain funding, states must provide matching funds in each program year (Pre-K Now, July 2009). The grant funding is large enough that if we could coalesce public will around providing comprehensive full day, full year care for at-risk children in the city and convince the private foundation and business communities to provide matching funds to obtain the grants, we could obtain the funding to build an Educare system in Memphis. The most positive potential benefit is that we could have a vast improvement in the quality of early care and education services for at-risk children that could fundamentally improve our children’s brain development, school preparation and life successes.

Sources

Buffett Early Childhood Fund (2009). Educare. Omaha, NE: Author. Accessed 6th August, 2009. http://buffettearlychildhoodfund.org/downloads/EDUCARE.pdf

Center for Urban Child Policy (July 2009). Early Childhood Comprehensive Systems: Setting Our Children – And Our City – On a Path to Success. Memphis: The Urban Child Institute. http://www.theurbanchildinstitute.org/Download.php?fileId=4a672cd7c4e4c5.32385947

Pre-K Now (July 2009). Memorandum: Early Learning Challenge Fund. Washington D.C.: Author. Accessed 6th August, 2009. http://www.preknow.org/documents/ELCF_Post_Mark-up_Memo_7-24-09.pdf

The DC: 0-3: Enabling Healthcare Practitioners to Diagnose and Treat Infant Mental Health Disorders

Infants and toddlers establish their social/emotional foundational skills during their earliest years through interacting with their adult caregivers. Child development workers and psychiatrists refer to infant and toddler social/emotional development as infant mental health (Cohen et al, 2005). When a child’s earliest experiences are marked by poverty, family violence, child abuse and maternal depression, the physical regions of their brains that allow them to learn do not develop properly (National Scientific Council on the Developing Child, December 2008). Luckily, it is possible to assess and treat children’s mental health disorders early on in their lives so that they have the social/emotional skills they need before they enter kindergarten.

Babies need at least one stable adult relationship in order to develop the ability to form relationships with others and have the confidence to explore the world around them and learn. Adults also support babies in their social/emotional development by modeling and teaching them how to understand and manage their emotions, thoughts and actions. Developing social/emotional skills is necessary for a child’s successful transition into school because children are not capable of developing their cognitive skills in kindergarten if they do not know how to successfully engage in relationships and learning from the first day of school forward (Cohen et al, 2005).

The DC: 0-3 is the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. It was developed to supplement the DSM: V since many young children’s mental health disorders are not diagnosable using traditional instruments that focus on assessing the mental health of the individual. As one of the DC:0-3’s authors explains, “We say that much of the burden of mental and developmental disorder during infancy is primarily a disorder of the caregiver environment; it cannot even be described outside the context of the caregiving environment (Jancin 2001)”. In other words, the mental health of infants and toddlers is dependent upon and mediated through their relationships with their caregivers.

There are many children in Memphis who are at-risk for poor social/emotional development in their earliest years because of their exposure to poverty, family and neighborhood violence and child abuse. Currently, 47% of children in the city under 5 are growing up in poverty (ACS, 2007). One study of children in Early Head Start revealed that nearly half (48%) of the children participating had mothers who reported enough depressive symptoms to be considered clinically depressed (EHS Evaluation and Research Project, 2003). If these numbers hold true for Memphis, we would estimate that roughly a quarter of the children in the city under 5 have a mother suffering from clinical depression. Every year, roughly one third of the children who are victims of child abuse and neglect in Shelby County are between birth and age 3 (DCS Foster Care Data, 2008).

The key to effectively improving children’s social/emotional development in Memphis is to begin to identify young children who have mental health disorders and treat them before they enter kindergarten. Increasing the number of children who are assessed using the DC: 0-3 for disorders could improve our ability to target interventions to children and families who would benefit from them. These types of services could be targeted to the at-risk population via established DHS child care providers, Early Head Start and Head Start providers since they already care for the children who have the greatest exposure to risk factors.

Children’s social/emotional development could also be improved by increased screening and treatment for maternal depression. Many women seek mental health care services form their primary physician and so physicians need to be trained to perform maternal depression screenings. Physicians also need access to information on treatment programs for mothers who are depressed and reimbursement for screening and diagnosis.

In Illinois, multiple state agencies have worked together to create a funding stream for physicians to screen, diagnose and refer mothers for treatment for maternal depression. They have also provided training to physicians and access to psychiatrists to provide consultation on maternal depression for physicians as they see patients (Onunaku, July 2005). With these measures in place, depressed mothers have more resources for diagnosis and treatment. Effective treatment of depression enables mothers to provide nurturing, responsive care that supports their children social/emotional development.

In Shelby County, black churches have partnered with the mental health care system to create Emotional Fitness Centers. Through this partnership, peer advocates are being trained to do initial mental health screenings and then refer parishioners in need of care on to the mental health care system. Thus far, the program is being piloted in 6 Memphis churches with a budget of $250,000. They have a goal of serving 3,000 clients in their first several months of existence (Powers 2008). Hopefully, the Emotional Fitness Centers will provide more avenues for screening, diagnosis and treatment for mothers and children struggling with depression and other issues that hamper children’s social/emotional development.

Sources

American Factfinder (2007). Table B17001. POVERTY STATUS IN THE PAST 12 MONTHS BY SEX BY AGE. Washington D.C.: U.S. Census Bureau.

Cohen, Julie, Ngozi Onunaku, Steffanie Clothier and Julie Poppe (September 2005). Helping Young Children Succeed: Strategies to Promote Early Childhood Social and Emotional Development. Washington D.C.: Zero to Three and the National Conference of State Legislatures. Accessed 29th July 2009.

Early Head Start Evaluation and Research Project (January 2003). Research to Practice: Depression in the Lives of Early Head Start Families. Washington D.C.: U.S. Department of Health and Human Services, Administration for Children and Families.

National Scientific Council on the Developing Child (December 2008). Mental Health Problems in Early Childhood Can Impair Learning and Behavior for Life: Working Paper #6. Accessed 29th July 2009.

Jancin, Bruce (November 2001). "DC 0-3 Enhances Diagnosis of Mental Illness in Children: The Central Importance of the Parent-Child Relationship Needs to Be Recognized," Clinical Psychiatry News. Accessed May 21, 2009

Onunaku, Ngozi (July 2005). Improving Maternal and Infant Mental Health: Focus on Maternal Depression. Washington D.C.: Zero to Three. Accessed July 29, 2009.

Powers, Mary (13th March, 2008). "Six Churches Tapped for Emotional Fitness Campaign," The Commercial Appeal. Accessed 30 July, 2009. <http://www.commercialappeal.com/news/2008/mar/13/six-churches-tapped-for-emotional-fitness/>

Tennessee Department of Children's Services (2008). Child Abuse Data for Shelby County 2008. Available from TN: DCS. Estimates are the work of the author.