Stephen A. Somers, PhD and Alexandra Maul, MPH

June 14, 2017

The first 1,000 days of a child’s life are a critical window for cognitive, physical, and social development. Exposure to adverse experiences during this period and beyond in early childhood dramatically increases the potential for lifelong poor health and social outcomes. This in turn can result in substantially increased health care costs across an individual’s life span. Adverse childhood experiences (ACEs) — including neglect, abuse, exposure to violence, family dysfunction, etc. — also drive negative social outcomes, such as poor school performance and involvement in the juvenile justice system, often leading to poor health consequences later in life.

Medicaid covers almost half of babies born in the United States and 40 percent of children. As such, intervening via Medicaid offers a prime opportunity to increase the odds that children (ages 0-3) get a good start in life. Indeed, before age three, the health care system is the social institution most likely to have regular contact with young children (e.g., a recommended schedule of 12 well-child visits before age three). Medicaid provides comprehensive benefits for children including guaranteed access to developmental screenings and treatment services. In short, Medicaid is uniquely positioned to serve as a platform for identifying problems and connecting at-risk infants, young children, and their families with needed health, developmental, and social services.

Capitalizing on the Window of Opportunity

Even though the pay-off for prevention is a long-term venture, more and more Medicaid stakeholders and policymakers are recognizing the importance of exploring Medicaid-driven strategies to generate system-wide investments in upstream prevention. These approaches will necessarily involve going beyond Medicaid and working with other state and local health and social service agencies. The financial incentives for such Medicaid investments will be clearest for stakeholders that will potentially bear the fiscal responsibilities as children grow into adulthood (e.g., states, regional health plans, accountable care organizations, etc.).

Through a planning grant from the David and Lucile Packard Foundation, the Center for Health Care Strategies (CHCS) convened Medicaid agencies and health plans in six states — Connecticut, Maryland, Minnesota, New York, Oregon, and Washington — to identify new strategies to support high-risk, low-income families, prevent ACEs, and improve the life chances, social determinants, and educational prospects of infants and young children. Through our conversations, a number of topics have emerged as key to this work:

  • Integrating cross-sector data;
  • Using data analytics and predictive modeling to target interventions to the highest risk infants, families, and neighborhoods;
  • Identifying assessment tools and shared metrics (e.g., kindergarten readiness);
  • Building state and community level cross-agency partnerships (e.g., across health, early childhood, child welfare, housing etc.); and
  • Creating new clinical models and community linkages to medical practices.

With additional support from the Robert Wood Johnson Foundation and the David and Lucile Packard Foundation, CHCS is launching the Medicaid Early Childhood Innovation Lab to continue its work within the identified early innovator states, and create new partnerships with other states and plans. A learning group will be formed to design, implement, and spread strategies for: (a) creating the conditions for optimal early childhood (ages 0-3) health and development of all children; (b) intervening with higher risk low-income families to prevent childhood trauma/ACEs, boost kindergarten readiness, and reduce long-term health and social services costs for federal, state, and local governments; and (c) generating connections between Medicaid stakeholders and innovators in early childhood development. Lessons from the participating teams will be shared broadly with stakeholders across the country.

Share Your Thoughts

19 Comment authors

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Karla D. Magie, RD, MPH

Count me in! What an inspiring and exciting journey to improve the lives of the most at risk, especially children. After 28+ years of work as a dietitian and health educator with WIC and a variety of public health department programs at the county and state level, I am ready to explore and document the value of new approaches that will expand our reach, resources, and most important, impact on the lives of the most vulnerable.

Julie Shuell, Nemours National Office

Interested in how you will select your states and when they will be chosen.

Janine Hron

So spot on and perfect timing for the national discussion that is to come regarding the structure of Medicaid. The importance of maintaining and tangibly leveraging this part of our health system to achieve improved population health among children and adults cannot be overstated. At Crittenton Children’s Center in Kansas City, over the last 10 years we have seen the benefits you cite among Head Start families participating in the Trauma Smart model, addressing adversity across systems and proactively building resilience within inidividusls and systems. Kudos to your essential work and smart approach.

Rachel Dodge

As a community pediatrician who sits on the Maryland Medicaid Advisory Committee- I am thrilled to see that MD is participating. I spend 8 years working in child welfare and so I am very in-tune with childhood trauma and the risk of slipping through the safety net for the 0-3 population. Medicaid and it’s heath delivery partners need to find a way to flag children who have missed well child care appointments and do appropriate intensive outreach. Outreach by community partners including Health Department programs and Department of Social Services must include verification of parents reasons/reports for lack of engagement.… Read more »

Carol McCormick

Using an “Upstream” approach, home visiting for pregnant women, especially new moms, but really all pregnant women is the most logical and effective place to put resources to address this and many other life long problems. Pregnancy is the single time in a woman’s life when she is wide open to information and change. I believe this life change has some effect on the dad as well and so much can be gained by using this pregnancy opportunity to reach the parents before more problems develop.

Rhonda Hertwig

I also commend you for these efforts. I am a Pediatric Nurse Practitioner, currently in a school nurse position. My search over the last few years on the ACE Study and its implications in the school system, already shows there are wonderful and proven (E-B) initiatives and programs in place. Enough of having to “create” new models or frameworks – Lets work on removing the barriers of why these programs are not being universally adopted. Lets go upstream and listen to our teachers and nurses who are with these students daily. We need universal screening for ACE, we need universal… Read more »

Murielle Romine, MPH

What a great partnership! Through the leadership of our Executive Director Sue Birch, The Colorado Department of Healthcare Policy & Financing has been working on a life stage, indicator based framework called the Colorado Opportunity Project.
I would love to connect our work and the findings from the Innovations Lab.

Rene Howitt

Intervening into the life of children in the first 1000 days to identify and then address the potenial for ACEs is good. However, I’m thinking about the 1000 days prior to conception. The parents are the root of the problem. When do we address the need to make parenting education a priority across the nation? The dysfunctional unhealthy family is public health issue number one in this nation. All teens should be getting education that is specific to the four factors all parents must have the ability to offer: 1. Provide 2. Protect 3. Love 4. Nurture Parenting is after… Read more »

Joclyn Reilly

I agree Rene that parents need the education. Check out

We are looking at this program to help all parents with prevention.


I totally agree with you Rene! Thanks for this informative post!

Peter A. Chiavetta

I would love to help but not sure how. I am a volunteer EMT integrating ACES awareness with most patient contact. I have a 6 page handout that I use to help patients connect the dots with adult health with childhood trauma. The population I cover has a school district with a 40% free lunch program and a Native American Territory.

Alexandra Maul, CHCS

Peter, it sounds like you’re already doing great work by raising awareness about ACEs through the handouts you are distributing. You may want to learn more about the work CHCS is doing through our Advancing Trauma-Informed Care project: Also, if you are not already familiar, ACEsConnection is a great resource:

Jenn Kaufman, Part C Coordinator, RI Executive Office of Health and Human Services

Is there a formal process/procedure to express interest in participating in this project?

Alexandra Maul, CHCS

Thank you for your inquiry Jenn. We are beginning to identify our initial next steps and will keep in touch as we move forward with this work.

Mimi Haley

I am the executive director of one of Oregon’s 16 coordinated care organizations (community governed integrated care Medicaid health plan) in three rural counties of the northwest coast. We have worked for over three years on addressing toxic stress and ACEs in our communities through a multifactorial community and clinical approach. Our partners include 11 school districts, early learning and childcare providers, law enforcement, community service agencies, social safety net providers, child welfare, primary care clinics and county leaders in all three counties. As a subsidiary company of the state’s largest Medicaid company, CareOregon, we have access to clinical and… Read more »

Alexandra Maul, CHCS

Thank you for your inquiry Mimi. We are excited to launch the Medicaid Early Childhood Innovation Lab and delighted to hear about your interest in participating in this project. We are beginning to identify our initial next steps and will keep in touch as we move forward with this work.

Betsy Campisi

Alliance for Better Health is a DSRIP PPS. This is one of our projects! We are starting a pilot study with a pediatrician in Troy NY, a hotspot – and 60% of his patients are Medicaid patients. It involves organizing providers, and doing education for both providers (including CBOs) and community members. I would love to be part of this learning collaborative. Also, the Center for Youth Wellness, founded by Dr. Nadine Burke Harris, is also starting one of these.

Alexandra Maul, CHCS

Thank you for your inquiry Betsy. We are delighted to hear about your interest in participating in this project. We are beginning to identify our initial next steps and will keep in touch as we move forward with this work.

Also, the Center for Youth Wellness is a participant in CHCS’ Advancing Trauma-Informed Care project:

Ed Schor

Terrific. I’m very happy to see attention to this issue. I would be happy to help.

Josh Greenberg, VP Government Relations, Boston Children's Hospital

I appreciate this emphasis, and the structure being put in place. I have some history with CHCS through early work on pediatric quality I did while running the Children’s Division at Health Care For All here in MA (and serving as MA Covering Kids Director). I am now deeply involved in standing up Boston Children’s Hospitals’ Medicaid ACO, which will be the only pediatric-focused ACO in the Commonwealth and will serve an estimated 1/4 of all MA Medicaid pediatric enrollees. I think it is a big mistake for you to assume the deep thinking, commitment, and likelihood of success is… Read more »

Lorie Martin

Thank you for your thoughtful response. Please rest assured that CHCS is not only working with states themselves, but also with leading-edge county health agencies and local health plans – often provider-based – to leverage existing programs. My colleagues at CHCS are familiar with the innovative pediatric-focused ACO work in Massachusetts based on their ACO work with the state. Stay tuned.

Celeste Putnam

I would like to be considered for the learning group. I serve as the Director of Service Integration for the Department of Children and Families, State of Florida

Alexandra Maul, CHCS

Thank you for your inquiry Celeste. We are excited to launch the Medicaid Early Childhood Innovation Lab and delighted to hear about your interest in participating in this project. We are beginning to identify our initial next steps and will keep in touch as we move forward with this work.

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