October 9, 2020 | Policy Cheat Sheet


By Stefanie Polacheck and Hannah Gears

A recent Centers for Medicare & Medicaid Services (CMS) report shows worrisome downtrends in health care utilization during the COVID-19 pandemic for the nearly 40 million children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). Data reflect a sharp decline in children’s engagement in both primary and preventive care, driven by stay-at-home orders in states across the nation. For children, particularly those from low-income households, the lack of primary and preventive health services can potentially impact physical health, as well as mental health, social-emotional development, and academic outcomes.

  • What are the numbers? From January to May 2020, the number of Medicaid and CHIP-enrolled children under age two receiving vaccinations declined by more than 30 percent. From March to May 2020, there were sharp declines in key health services for Medicaid and CHIP beneficiaries age 18 and under, including an over 40 percent decrease in health screenings, 44 percent fewer outpatient mental health services, and an almost 75 percent reduction in dental services. While child health services utilization has begun to increase as states relax “lockdown” guidelines, use of these essential child health services have not yet returned to pre-pandemic levels.
  • Why does this matter? Failure to receive routine health care can have long-term implications for child health, development, and overall wellness. When children fall behind on immunizations, they run the risk of developing vaccine-preventable diseases. Without access to regular screenings recommended under Early and Periodic Screening, Diagnosis and Treatment (EPSDT) guidelines, children may miss a critical opportunity for their provider to identify potential physical and/or cognitive delays.
    Beyond potential negative health and developmental outcomes, missing opportunities for timely referrals to early intervention or other necessary therapies is often associated with poorer health outcomes and higher costs in the future. Failure to identify emerging social-emotional needs and mental health conditions in childhood or adolescence may result in exacerbation of symptoms over time, potentially leading to increased distress for the child, as well as the need for high-cost inpatient or residential care. With most schools at least partly closed, children and adolescents who previously depended on in-person, school-based mental health care — including a disproportionate number from racial/ethnic minority groups and low-income households — no longer have access to those services.
  • What are other potential impacts? In the current pandemic environment, not only are families feeling the effects of isolation from friends and extended family, they are also isolated from providers who often give an important form of social support. Without regular contact with primary or specialty care providers, many families are experiencing gaps in their support system. For Medicaid and CHIP beneficiaries especially, providers may support a child’s well-being by referring families to resources that directly affect health, such as food and housing supports. With many families out of work and facing economic challenges, these services are critical to ensuring that families can meet their basic needs. As food insecurity rises amid the pandemic, the American Academy of Pediatrics is urging pediatricians to be staunch advocates for child health and well-being. Providers regularly interact with children and their families, allowing them to identify family stress and social risk and needs. Providers often also recognize concerns related to child safety and help families connect with supports, as well as notify child protection agencies and other social services about safety concerns related to child abuse, neglect, or intimate partner violence in the home.
  • How can states promote well-child care during the pandemic? Following are policy and programmatic options that states can explore to increase preventive care for children and families.
    • Continue or expand telehealth flexibilities. While all states expanded Medicaid coverage for telehealth services during the pandemic, behavioral health coverage varies, and not all states have issued guidance on EPSDT and well-child visits. States may explore allowing telehealth flexibility for behavioral health services, and states that have already made allowances may consider continuation of those flexibilities as safety restrictions ease.
    • Consider the role of community health workers. Community health workers (CHWs) can conduct outreach to socially isolated families through telehealth, home-based, or office visits. As of 2014, CMS offers provisions for the reimbursement of CHW services under Medicaid and CHIP. CHWs can serve as health educators, encourage use of preventive services, and connect families to needed social supports.
    • Explore the use of healthy behavior incentives. States may use Section 1115 waiver authorities to provide financial incentives to beneficiaries for engaging in healthy behavior, such as participation in preventive care visits.
    • Managed care organizations can employ new engagement strategies. Medicaid managed care organizations (MCOs) can provide transportation to in-person child health appointments, connect families to needed social services, and use technology to support patient interaction — such as text messages for appointment and medication reminders.
    • Establish cross-agency strategies to close the utilization gap. States may consider looking to Rhode Island, which implemented a number of strategies to boost immunization rates and increase pediatric primary care engagement.* Rhode Island’s cross-agency efforts to boost immunization rates included: (1) Governor Gina Raimondo’s establishment of a COVID-19 Pediatric Advisory Council to encourage stakeholder engagement and create shared priorities across the state; (2) a requirement that the state’s MCOs submit plans for improving immunization rates and biweekly data reports; and (3) an immunization learning collaborative, offered by the Care Transformation Collaborative of Rhode Island and financed by the Rhode Island Coronavirus Relief Fund and Blue Cross and Blue Shield of Rhode Island.
      Colorado has similarly looked to collaborative efforts to boost Medicaid and CHIP utilization among children and families during the pandemic. The state’s Office of Early Childhood partnered with the Department of Health Care Policy and Financing to provide access to food, child care, and early intervention services to close the gap in services that children and families were receiving pre-pandemic to now. They also removed access barriers, such as requiring a signature on benefit documents, and allowed home visiting and early intervention services to be delivered via telehealth. These flexibilities allowed Colorado to increase its number of certified telehealth providers, as well as families’ use of home visiting services.
  • What’s the bottom line?  The road to recovery from the impacts of COVID-19 may be a long and arduous one with unique implications for child health, development, and well-being. While participation in well-child care has begun to improve in recent months, it is difficult to say if and when numbers will return to pre-pandemic levels. States should consider both policy and programmatic solutions to promote pediatric patient engagement and a renewed focus on the importance of preventive care to children.

*Email to authors from Libby Bunzli, Senior Medicaid Policy Advisor, State of Rhode Island, Executive Office of Health and Human Services. October 2020.