Rachel Yard, Center for Health Care Strategies

April 25, 2019


In most states, the connection between the health care and early childhood sectors is more tenuous than it should be, and the potential of these two systems working together to support early childhood and family services is largely untapped. Advancing greater alignment between Medicaid and early childhood-serving agencies is critical to identifying upstream opportunities that reduce or even avoid adverse childhood experiences. Intervening during the first 1,000 days of life can potentially generate long-term benefits for young children, as well as the social systems that may serve them into adolescence and adulthood.

Aligning Early Childhood and Medicaid, a new national initiative made possible by the Robert Wood Johnson Foundation, is seeking to enhance alignment across Medicaid and state agencies responsible for early childhood programs with the goal of improving the health and social outcomes of infants, young children, and families living on low incomes. This two-year multi-state learning group, which kicked off last week with its first face-to-face meeting of eight participating state teams, is led by the Center for Health Care Strategies (CHCS) in partnership with the National Association of Medicaid Directors and ZERO TO THREE.

CHCS recently spoke with the three project partners — Melissa Bailey, senior fellow at CHCS and former commissioner of the Vermont Department of Mental Health; Gretchen Hammer, senior strategic advisor at the National Association of Medicaid Directors and former Colorado Medicaid director; and Lindsay Usry, director of Infant and Early Childhood Mental Health Strategy for the Policy Center at ZERO TO THREE ­— to explore opportunities for strengthening partnerships between early childhood and Medicaid.

Q: What is the current landscape in states across the country for collaboration between Medicaid and early child-serving agencies?

A: G. Hammer: There are a lot of states with good working relationships between early childhood-serving state programs and the Medicaid program, particularly in areas like family planning, home visiting, and maternal and infant mortality-related task forces. Often a good relationship exists to address some of the crises we see with both maternal and infant mortality, or things that relate to pregnancy-related depression. A relatively few states have gone further to sharing higher level strategic initiatives that are being driven collaboratively by leadership at state agencies, even at the gubernatorial and/or legislative level. There is a lot of opportunity to encourage more states to elevate alignment of early childhood services and supports.

Q: What are the potential benefits to enhance collaborative relationships between Medicaid and early child-serving agencies?

The nature of early childhood requires that service provision be holistic and wrap around families, as caregivers are so vital to and inextricable from the child.

A: G. Hammer: The evidence is so abundantly clear that the early years of life, from the prenatal period through age three, are critical for building lifelong health within a child and a family — and not only at the basic level of brain and body organ development, but also social-emotional development. Ensuring that the parent or caregiver is building a sense of self-efficacy during this period (that when the baby needs something they can provide it for them) is so critical to get a family started on the right foot during those early years. That is why it is so critical to align state investments to ensure that the comprehensive supports that a young family needs are in place.

L. Usry: Alignment represents an opportunity for more efficient use of available resources. We are in danger of replication when we leave each child-serving system on its own to figure out how to confront the issues that children and families may be facing. The nature of early childhood requires that service provision be holistic and wrap around families, as caregivers are so vital to and inextricable from the child. We really need to think about how the family and relationship context influences the wellbeing of the child. Aligning systems with Medicaid can help with more efficient payment streams, and allow us to use resources efficiently.

Q: Realizing that state landscapes and cross-agency relationships vary widely, how might the ideal relationship look different from state to state? How would it look the same?

The ideal relationship begins with mutual respect and recognizing that each agency has a role to play, and that across agencies, they can come together and contribute to the overarching efforts that create good outcomes for young children.

A: M. Bailey: Structurally, there are differences across states, from the structure of state government, to programs, to delivery systems, but foundationally similarities exist — and they all have the same goals of serving children and families with the right services at the right time. How relationships develop may look different due to structural variations across states, but we all want to see children thrive, achieve positive social-emotional development, and be kindergarten ready. For me, the ideal relationship begins with mutual respect and recognizing that each agency has a role to play, and that across agencies, they can come together and contribute to overarching efforts to create positive outcomes for young children and their families.

G. Hammer: The ideal relationship is multi-tiered — partnerships that begin at the executive level and run parallel down throughout the agency. In Colorado, for example, Medicaid works closely with the public health department and department of human services on programs ranging from screening and treatment for perinatal depression to developmental early intervention. Through collaboration, Medicaid is able to ensure that the benefit and payment structure is aligned with the initiative’s goals. When questions or challenges arise, staff are able to elevate to leadership in agencies so they can work together to address the issues.

L. Usry: Encouraging agencies to formalize relationships through Memoranda of Understanding or other means can be helpful because it establishes a record of partnership. This is particularly useful when dealing with turnover across agencies. These agreements can be valuable for career staff under new leadership, as they provide proof of a partnership history and may allow the work to continue without interruption despite leadership change.

Q: What are the barriers impeding potential progress or opportunities to improve collaborative relationships between Medicaid and early childhood agency partners?

They are administering different programs, but when they come together there is huge opportunity — you just have to account for the differences among the agencies, and that those differences are purposeful.

A: L. Usry: We have to be careful about assumptions when working across agencies. On a daily basis, we are so immersed in our field and surrounded by others who speak the same language, with whom we share a frame of reference. When working in a cross-agency partnership you sometimes hit barriers when the other agency is conducting business in a way that does not feel like it is advancing mutual goals, and it is easy to make an assumption that they are making a deliberate decision to do so — that the person was presented with all the information surrounding the issue and made an informed decision. But oftentimes individuals have made decisions based on the limited information available to them, or are operating within previously constructed frameworks. This feels especially true when it comes to early childhood, as there are plenty of individuals who have not been brought up to speed on what we now understand about the science of how young children develop and the early childhood landscape. Facilitating conversations can help incorrect assumptions so that all sides can come together and start fresh to create solutions.

A: G. Hammer: The biggest barrier I have experienced is time. The realities of the daily calendar, especially when state agencies in big cities are located miles apart, can make meeting face to face for relationship building and collaboration more difficult. Also, Medicaid agencies can often feel like they are being perceived narrowly as just finance people and are therefore not tapped to participate as much in the policy department, which can be frustrating. That said, all of these agencies are separate for good reason. They are administering different programs, but when they come together there is huge opportunity — you just have to account for the differences among the agencies, and that those differences are purposeful but still ‘alignable’.

Q: Can you provide any examples of innovative cross-agency collaboration at the state level that is creating new opportunities to improve early childhood services?

A: G. Hammer: It is often a state public health crisis that drives state agency alignment. Right now, we are seeing a lot of efforts around maternal mortality and morbidity, as the data are more and more striking. Many states are using cross-agency collaborations to enhance maternal supports. The opioid epidemic is another example of a crisis prompting cross-agency collaboration. In West Virginia, the epidemic has spurred a child welfare crisis as the number of children removed from their homes has increased, causing other state agencies to help child welfare differently than they had in the past.

A: L. Usry: In Alaska, attention to the high rates of child maltreatment and other adverse childhood experiences for Alaskan children in combination with a fiscal crisis created an opening for this type of collaboration. Cross-agency partnership between key leadership in Medicaid and behavioral health resulted in their successfully incorporating elements to promote infant and early childhood mental health into the proposal for their recently approved Medicaid 1115 demonstration project. Very few 1115 waiver efforts have targeted mental health services for children under the age of five, so this represents an exciting development nationally.

A: M. Bailey: In addition to the work states are already doing, Aligning Early Childhood and Medicaid is going to be a great opportunity to identify other concrete areas to focus on and innovate around collaboratively with early childhood and Medicaid agencies.

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Ed Schor

Over a decade ago, with funding from The Commonwealth Fund, CHCS led a multi-state Medicaid project to improve developmental screening as part of EPSDT. You might want to review lessons from that project.

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