Daniela Lewy, EdLD, MPH* and Alexandra Maul, MPH

July 2, 2018


If a family has no means of transportation, consistent prenatal care becomes extremely difficult. If a mother is homeless, she is less likely to attend a child wellness visit. If a one-year-old is hungry, brain development is detrimentally impacted. And if a toddler is experiencing trauma at home, he or she cannot focus on learning. While there is significant evidence around the value of investing in early childhood to improve physical, social, and emotional development later in life, more attention needs to be paid to addressing social determinants of health (SDOH) to improve early childhood outcomes.

Since prenatal services and child wellness visits provide some of the earliest opportunities to intervene with at-risk families, Medicaid is uniquely positioned to identify potential problems and facilitate connections with needed social services. Through support from the Robert Wood Johnson Foundation and the David and Lucile Packard Foundation, the Center for Health Care Strategies’ Medicaid Early Childhood Innovation Lab (Innovation Lab) is exploring ways that Medicaid can align with other early childhood sectors to better address the SDOH needs of high-risk families. This blog post explores opportunities for Medicaid to support families through engaging in cross-sector efforts in education, supportive housing, child welfare, and home visiting.

Crossing the Cultures of Medicaid and Early Childhood Systems

Following are five key strategies for connecting Medicaid and early childhood system supports:

“When partnering with other sectors, we have found it helpful for all agencies involved to recognize that these are not your kids or my kids, but our kids.”

Kalin Scott, Director of Medicaid Redesign Team Project Management, New York State Department of Medicaid and member of the New York Innovation Lab team

1. Shift Mindsets

One common challenge with multi-sector partnerships is that each agency sees a given child through its own respective lens. For example, while many state education departments evaluate a child’s needs based on kindergarten readiness scores, Medicaid assesses that same child using developmental screenings. Taking a more holistic, interagency perspective can help departments collaborate to design intervention strategies that address the whole child. This scenario played out when New York’s state Medicaid agency partnered with the state education department to launch the First 1,000 Days on Medicaid, a statewide cross-sector initiative. The two agencies collaboratively led an effort to select 10 major policy and programmatic steps to improve outcomes for the 2.2 million children under the age of five in the Medicaid program. This type of partnership is similar to other national models that allow school districts to access Medicaid funding for mental health supports, as well as transportation and physical health needs.

2. Speak the Same Language

Every sector is notorious for jargon and cryptic acronyms, making out-of-sector practitioners often feel out-of-place. The health care system uses terms like “ACOs,” “MCOs,” and “waivers” while housing authorities speak about “Section 8,” “vouchers,” and “LIHTC.” Until these ambiguous terms are translated, there is a natural tendency to stay in one’s own lane. Similarly, agency-specific terms often refer to the exact same patients and clients. For example, a family of four in New York City is eligible for Medicaid if its household income is below $32,319, while a New York City family of four is eligible for Section 8 housing if its household income is below $31,300. This means that “Medicaid-eligible families” and “Section 8-eligible families” are often the same.

Interventions addressing both housing and health present opportunities for agencies to work together in innovative ways to meet a family’s needs. One such partnership is the Family Assertive Community Treatment (FACT) program in Chicago, which serves homeless and at-risk 18 – 25-year-old mothers with at least one child under age five. Financed through a public-private partnership that includes Medicaid investments, FACT provides integrated, family-focused treatment and support services. With support from this program, families found permanent housing, mean monthly income increased, mothers demonstrated improved mental health, and children received developmental screens and related supports.

3. Align Priorities

While civil servants join the public sector to positively impact communities, bureaucracy inadvertently can result in prescriptive grant deliverables, restricted funding, and extensive government reporting — obligations that can hinder their capacity to engage in collaborative activities. It is therefore essential to align agency priorities to enable innovative and creative partnerships that go beyond “business as usual.”

In Hennepin County, Minnesota, the Innovation Lab team is exploring cross-sector strategies to prevent out of home placement of children ages 0 – 5. The county has authority over local human service agencies, criminal justice programs, public health divisions, a safety net hospital, a health system, and a Medicaid managed care plan. All of these entities have a moral, financial, and value-based mission to keep children and families healthy and intact. The county plans to integrate data across sectors to illustrate a rich, quantitative, multisector pathway of families traveling through public programs. With its health system serving as the convener, Hennepin County is seeking to conduct a retrospective analysis of children under five experiencing out-of-home placements. The proposed analysis will explore the role of Medicaid and other predictors of child welfare placements in order to inform interagency solutions that break the intergenerational cycle of poverty and trauma.

4. Narrow the Scope

The key to a high-impact multisector partnership is to select a concrete challenge to tackle since the broad term “cross-sector collaboration” can feel nebulous. The Maryland Innovation Lab project demonstrates the value of a focused effort to distill a large question around collaboration between local home visiting programs and Medicaid managed care organizations (MCOs) into a focused exploration of referral responsibilities. Maryland is using a Section 1115 waiver authority to implement a Medicaid-funded, evidence-based, home-visiting services pilot for high-risk pregnant women and children up to age two. The state is leveraging the pilot to understand children and families’ access to, and utilization of, an array of services, including those covered by Medicaid and administered by MCOs. This will allow the team to develop a comprehensive understanding of the referral policies, practices, and partnerships to address issues related to SDOH, e.g., food insecurity, unemployment, housing instability, and lack of education.

5. Forge Cross-Sector Partnerships

A number of opportunities to foster cross-sector collaboration have emerged in recent years. For example, children’s cabinets, which often include Medicaid leaders, are diverse groups of state or local multi-sector agency leaders who collaborate to align funding, policies, programs, and practices around a broad set of outcomes and ages. Early childhood councils are similar groups with representatives from child-serving sectors, service providers, and philanthropies that usually focus on children up to the age of eight and their families. These coordinating bodies offer lessons and strategies for others looking to advance these types of partnerships.

In addition, philanthropy-funded learning groups bring together states across the country which are testing strategies for partnering Medicaid and early childhood-serving sectors to support healthy development and mitigate early adversity. Both Medicaid Early Childhood Innovation Lab and ZERO TO THREE’s Infant and Early Childhood Mental Health initiative, which has worked with 19 states and the District of Columbia, support states to bring sectors together to align, integrate, and collaborate.

Moving Forward

Starting children off on the right foot can improve physical, social, and emotional development later in life and save in the long-term through a healthier, more productive population. Since Medicaid covers almost half of the babies born in the United States and 40 percent of children, it is well-positioned to play a leading role in changing the trajectory for our youngest generation. Medicaid’s role in early childhood cannot be limited to a narrow window of prenatal health care and child wellness visits. There is a prime opportunity for Medicaid to work with early childhood sectors to address many other drivers that affect health outcomes, such as social and economic factors, health behaviors, and the physical environment.


*Blog post lead author Daniela Lewy, EdLD, MPH, serves as a consultant to the Medicaid Early Childhood Innovation Lab. Dr. Lewy is the former executive director of the Virginia Governor’s Children’s Cabinet, which worked across four secretariats, 19 state agencies, and over 150 programs, connecting local communities to state-level supports to address education inequities, health disparities, and poverty.

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Ruby Neville

I am a mental health specialist and have credentials in early childhood education. I would like to partner with programs in Maryland on the macro and micro level to provide strong learning foundations for young children.

Thank you for this great article and resource. It does feel like the “zero” piece isn’t quite discussed in the interventions you can mention. Here in Washington State, we are working to integrate MCH and Early learning components through Medicaid advocacy. I’d be happy to discuss. Feel free to reach out. PS Daniela, it would be great to connect again!

Janine Hron

You’re leading the way . . . thank you for such thoughtful and practical insights.

Chris Heiss

Great post! Another 1115 waiver example is in Illinois, where the state recently received approval for a pilot for evidence-based home visiting, focusing on children born with withdrawal symptoms. South Carolina also has a 1915(b) waiver that helps the state leverage federal financing for its pay-for-success initiative with Nurse-Family Partnership. I’m glad CHCS is focusing on this important area!

Marlenea Watkins

Like Frederick Douglas said ” It is easier to build strong children than to repair broken men”. We ought to make sure that this is done.

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