AAP’s Bright Futures Takes Step Forward to Incorporate Social Determinants of Health

A child’s healthy development is influenced by access to health care but also by the social and physical environment in which the child lives. There is clear scientific evidence that children who live in safe, stable, and nurturing environments are more likely to thrive. And now pediatrician-developed preventive care guidelines for children have caught up with the scientific evidence by incorporating recommended screenings for poverty and the social determinants of health.

Bright Futures is a national health promotion and prevention initiative led by the American Academy of Pediatrics. The guidelines—which include a recommended schedule for specific screenings, immunizations, and procedures such as testing for blood lead levels—provide theory-based and evidence-driven guidance for all preventive and well-child visits. The standards were adopted by CMS to guide pediatric preventive care in private insurance as part of the Essential Health Benefits (EHB) package in the Affordable Care Act (ACA).

Bright Futures is periodically reviewed to ensure that the standards are keeping pace with the latest in evidence-based preventive and well-child care. The most recent update was released a few weeks ago and one change, in particular, stood out. Now, as part of psychosocial/behavioral screenings, which should be conducted at every preventive health check from birth until age 21, Bright Futures recommends that health providers conduct a family-centered assessment that includes child social-emotional health, caregiver depression, and other social determinants of health.

What does this mean for Medicaid and EPSDT? While all state Medicaid programs are required to provide child-centered comprehensive services through EPSDT (Early and Periodic Screening, Diagnostic, and Treatment services), states are allowed to establish their own periodicity schedules for screenings. Unfortunately, it’s difficult to find a current list of states that have adopted Bright Futures for this purpose. While there would be merit in universally adopting Bright Futures across states, that’s not likely to happen given a current federal health policy environment that favors state control. Still we can celebrate the fact that many states do follow the AAP’s recommendations and will continue to champion its adoption in states that aren’t yet aligned.

How do the new guidelines apply to managed care? Let’s start with private insurance. The ACA requires qualified health plans (QHPs) in the marketplaces, as well as private individual and small group insurance, to provide preventive care without cost-sharing. For children, Bright Futures establishes the periodicity schedule and required screenings. But just as pediatrician-recommended screenings were taking a step forward, Congress was weighing an 11th hour amendment to the ACA repeal and replacement plan that would have eliminated the EHB, leaving it to politicians not pediatricians to make decisions about children’s health care. For now, the EHB and Bright Futures standards remain intact.

The answer to what the Bright Futures standards mean for Medicaid managed care isn’t as clear cut, even in states that have adopted Bright Futures as the periodicity schedule for Medicaid. In fact, when CMS initially adopted the new Medicaid managed care regulations, there was ambiguity in the application of EPSDT standards for managed care, which CMS subsequently corrected. The agency also put out helpful guidance to clarify how EPSDT should work in a managed care setting.

But the reality is that it’s incumbent on states to ensure that their contracts with managed care plans clearly articulate EPSDT requirements and whether Bright Futures or some other periodicity schedule must be followed. States should also have external quality review processes to validate compliance with Bright Futures and include provisions in their managed care contracts that articulate the consequences of non-compliance.

What might child health advocates do to advance the inclusion of the social determinants of health in Medicaid? In states that have adopted Bright Futures (or something that looks like Bright Futures), advocates should double check to make sure that EPSDT educational and outreach materials, as well as policy and provider manuals, are updated as needed. States should also be encouraged to think about how to incorporate oversight and reporting on the new provisions in their quality strategies, such as reporting on the developmental screening measure in the child core set of health quality measures.

In states that have not adopted Bright Futures, advocates should encourage their states to do so. While a state could incorporate screenings for the social determinants of health in their periodicity schedules, full adoption of Bright Futures provides a universal and proven approach to supporting children’s healthy development recommended by pediatricians.

Addressing the social determinants of health is one way to improve children’s health and reduce future health care spending. The updated version of Bright Futures gets us a step closer by recognizing the importance of screening for poverty, caregiver depression and other social determinants.

The burning question, though, is what impact current efforts to cap Medicaid funding and repeal the ACA will have. In particular, child health champions should be concerned about proposals – like the block grant option in the AHCA – that would eliminate EPSDT as a foundational requirement in Medicaid. Inadequate funding for Medicaid can also impact innovative state-level efforts to take a more holistic approach to health care and the social determinants of health like New York’s Medicaid program. When it comes to children’s health, we should invest more not less to ensure that all children get the healthy start they need to succeed in school and life.

For more information on Bright Futures inclusion of screenings for the social determinants of health, see “Promoting Optimal Development: Screening for Behavioral and Emotional Problems” and “Poverty and Child Health in the United States.”

Tricia Brooks is a Research Professor at the Center for Children and Families (CCF), part of the McCourt School of Public Policy at Georgetown University.