Medicaid and Early Learning: Complex Systems at Play in Washington State

Editor’s Note: Shannon Blood is the early learning and home visiting program manager in Washington’s Medicaid agency. We were excited to know of the state’s decision to dedicate a Medicaid staff to young children—even more exciting since Shannon came to the agency from the early learning sector. So we asked her to share her initial takeaways on learning to navigate and embrace Medicaid. (And, for more information on the 30+ states using Medicaid to support home visiting for pregnant women or children, see these resources from NASHP.)

Finding ways to use Medicaid funding to support home visiting takes patience with ambiguity and complex systems. It takes staff comfortable going between policy and program practice, and navigating the health and early learning sectors.

I often liken our state’s journey in Medicaid and early learning to my own experience with onions. As a child, my grandma would serve raw-onion-and-mayonnaise sandwiches on home-baked bread. Needless to say, I refused to try one bite. It was decades later before I was even willing to use an onion to flavor soups and casseroles. When you turn your mind off to a possibility—whether it’s onions or Medicaid funding for home visiting—it’s hard to turn it back on. Here in Washington State, we are working hard to peel the Medicaid onion together.

Anecdotal stories and health care research show how social, economic and environmental factors impact health and overall life success. While systems and organizations share many common goals for healthier communities, Washington State has tended to operate in public and private silos. The Affordable Care Act offered a unique opportunity to develop an innovative cross-sector framework to:

  • Increase access to whole-person care.
  • Integrate physical and behavioral health.  
  • Coordinate health care delivery with community services, education, social services, and public health.

Within that framework, home visiting was identified as a potential investment strategy in the health care system. Families typically qualify for services in both systems. But to what extent could Medicaid fund home visiting services? Were there other gaps or leverage points across health and early learning? To help answer these questions, the Washington State Health Care Authority (HCA) and the Department of Children, Youth and Families (DCYF) jointly funded a full-time staff position (that’s me!) in March 2016. By February 2018, HCA decided to fully fund my position, and DCYF brought an early childhood health systems coordinator on board. Our two positions complement one another nicely, further extending each agency’s capacity on health/early childhood intersections. While this shared work is still in early days, it’s worth noting a couple of lessons learned along the way:

  • Create a shared understanding of proprietary home visiting models and state-developed, Medicaid-funded programs.  From a financing perspective, this matters as some home visiting component services do not meet Medicaid requirements and must be supported through other state or local funds.  From an operational perspective, non-duplicative service coordination relies on understanding how programs complement and support each other.
  • Keep clients at the center of the health transformation vision, and providers at the center of implementation.  Rigorous coordination is the first step in improving population health, education and life outcomes. Over the years, competing policies, administrative mechanisms, and program requirements have been firmly established. A clear understanding of how each system works can help pinpoint gaps and leverage points to better support whole-person care across systems.
  • Entertain complexity but focus on simplicity. Home visiting is typically funded through public or private granting processes in amounts sufficient to cover their anticipated funded enrollment level. By comparison, Medicaid partially reimburses licensed or credentialed medical providers for federally approved health care services. It’s imperative to keep an eye on the end goal when navigating cross-system intricacies.     

And what’s next on this cross-sector journey? State legislation in 2018 supports the further development of Medicaid financing for home visiting.  Work is underway with home visiting providers to determine which financing strategies provide the most support and least disruption to current state and local administrative processes. The work of peeling the onion continues. Who knows? Maybe a raw onion will find its way between slices of home-baked bread yet!