By Sarah Crow and Christina Altmayer
Revamping Medicaid policies to improve young children’s social and emotional health and address health care inequities is particularly critical in California, where over half of children ages 0 to 5 have Medicaid coverage (known as Medi-Cal, in California), and two-thirds are children of color. California ranks near the bottom of the nation on most standard measures of child well-being and access to care. For example, the American Academy of Pediatrics recommends all children be screened for developmental concerns three times before age three, yet only 26% of children in California receive such screenings. In 2019, as Governor Newsom took office after campaigning on the need to strengthen supports for parents and young children, we saw a unique moment in time to push forward.
Medi-Cal Breakthrough: Parity for Children’s Behavioral Health Care
Two major health care policy initiatives—CalAIM (California Advancing Innovation in Medi-Cal, the multi-year initiative to implement broad delivery system, program and payment reforms) and the anticipated reprocurement of Medi-Cal managed care contracts—have presented opportunities for reshaping how Medi-Cal is delivered to California’s children. If successful, First 5’s and our partners could contribute to lasting health care delivery system reforms for California’s youngest Medi-Cal members and their families.
A critical breakthrough came when the California Department of Health Care Services (DHCS) issued a new policy that allows children, along with their parents, to benefit from Family Therapy with no prerequisite mental health diagnosis. This policy acknowledges that children, especially very young children, can (and should) have access to preventive behavioral health care before any concerns or symptoms emerge or become severe enough to warrant a behavioral health diagnosis. At the same time, it also acknowledges the need to support and strengthen the child-parent relationship. California’s Medi-Cal agency (the Department of Health Care Services, DHCS) clarified that Medi-Cal covers family therapy for children who may have a mental health diagnosis, as well as children without a diagnosis but who may be at risk for later concerns. A broad range of risk factors described in the policy manual include both child-oriented variables, such as trauma exposure and maltreatment, as well as caregiver-oriented variables, such as substance use disorder and history of incarceration.
The recognition that a wide variety of risk factors could prompt the need for family therapy could not have come at a more important moment, as the COVID-19 pandemic, its resulting economic upheaval, and the strain of longstanding structural racism are compounding the health and financial stressors on children and families of color. Risk factors such as food insecurity, housing instability, and death of a parent/guardian, reflect this understanding. In addition, a risk factor acknowledging that “the experience of discrimination based on race, ethnicity, gender identity, sexual orientation, religion, learning differences, or disability” can also affect child development and health status later in life is a critically important step toward addressing health disparities and advancing health equity. California’s new policy demonstrates that parity can be achieved across physical and behavioral health care for children.
Opening the Door to More Sustainable Financing for Dyadic Care Models
Broadly speaking, dyadic care models address the needs of the infant or young child and caregiver together, holistically. While family therapy as treatment is an important dyadic service to help support young children’s health, it is only one among a range of supports young families may need. In keeping with the children’s health benefit required under the federal Medicaid statute—Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)—prevention, as well as any resulting treatment, is required and especially important for the youngest children. A broader set of dyadic models and services aimed at prevention and early intervention can serve infants and young children with their parents and caretakers in the context of pediatric well-child visits.
Promotive and preventive dyadic services can be anchored well-child visits, where the caregiver and child have the chance to experience more positive ways to interact with each other. Some also expand the care team by deploying “family specialists” or “peer navigators” to help prepare the parents for the well-child visit and to follow up on referrals to social supports and other community-based services. Several evidence-based, preventive dyadic care approaches (e.g., HealthySteps, DULCE) have been operating at the local level in California for years, funded primarily by philanthropy and/or by local First 5 commissions. Local First 5 commissions have also supported evidence-based dyadic treatment models, including Parent-Child Interaction Therapy (PCIT) and Child-Parent Psychotherapy (CPP).
When a California team was invited to join the Pediatrics Supporting Parents Medicaid and CHIP State Implementation Workgroup, a key objective was to learn more about how Medi-Cal financing strategies could help make dyadic care models more widely available and financially sustainable. The clarification of the family therapy benefit opened the door to exploring these questions. The PSP technical assistance team helped us by developing a detailed crosswalk that presents, for two of the dyadic care models, a side-by-side analysis showing how key Medi-Cal benefits (including the family therapy benefit and screenings that can help identify “risk factors”) align or do not. It will be a helpful tool for local early childhood partners to use to engage Medi-Cal managed care plans and providers, and hopefully help expand the use of the family therapy benefit as well as dyadic care more broadly.
About the Authors:
Sarah Crow is the Managing Director of the First 5 Center for Children’s Policy. Christina Altmayer is the Senior Vice President of the Center for Child and Family Impact First 5 LA.
About the Parents Supporting Parents Initiative:
In June 2019, as part of the Pediatrics Supporting Parents initiative, the Center for the Study of Social Policy, Donna Cohen Ross, and Manatt Health released Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change. Designed as a practical guide for policymakers, program administrators, managed care plans, pediatric care providers, advocates, and others, the Blueprint features key strategies and tools for optimizing the use of Medicaid and the Children’s Health Insurance Program (CHIP) to help ensure that the well-child pediatric health care delivered to young children promotes and strengthens early parent-caregiver relationships and healthy development that leads to school readiness and future success. Given that nearly half of young children in the U.S., and more than half of children of color, are covered under Medicaid and CHIP, these programs have a central role to play in promoting equitable outcomes for all young children; supporting children, families, and pediatric care providers; and in sparking innovation in the field.
Over the last 18 months, a workgroup of nine states—California, Kansas, Maine, Massachusetts, New York, Nevada, North Carolina, Virginia, and Wisconsin—used the Blueprint, their shared experience, and customized technical assistance to implement new Medicaid and CHIP policies and payment procedures. This blog series will share the successes and lessons from different states in the workgroup in hopes that more states will join them in leveraging Medicaid and CHIP financing to promote the social and emotional health of young children.
[This blog was originally published by the Center for the Study of Social Policy.]