Oregon’s Waiver Proposal: Continuous Eligibility for Young Children as a School Readiness Tool, But Why Not EPSDT?

As my colleagues blogged last week, Oregon released its 1115 waiver proposal for state public comment, which included precedent-setting concerns and innovations. We were pleased to see multi-year continuous eligibility included—up to five years for children under age 6, and two years for ages 6 and older. While a few states are in various stages of requesting or pursuing multi-year continuous eligibility, Oregon is first out of the gate to request the change as part of a 1115 waiver proposal—a welcome use of waiver authority to test a new approach to increase access to care.

CCF has long promoted multi-year continuous eligibility because it’s a concrete step for states to keep more people covered, reduce administrative burden on families and state staff, and minimize delays in needed care. Oregon also rightly holds continuous eligibility up as one of several strategies designed to reduce barriers to care that can contribute to health inequities. As Tricia Brooks and Allie Gardner detailed in a brief earlier this year, this policy offers many prospects for children, especially young children.

Less paperwork and administrative burden on families. Stable coverage for young children is especially promising given the period of rapid development for the child alongside uncertainties or worries new parents often face. Continuous eligibility for young children under 6 takes additional paperwork off the table for families with newborns or toddlers. One less mental stressor can only help families trying to juggle work, caregiving, bills and other responsibilities further challenged by pervasive income inequality and discrimination. 

Better access to regular check-ups before Kindergarten (and improved measurement ability!). Continuous eligibility also takes away a barrier to preventive health care. AAP recommends 16 check-ups for young children through age 6, more heavily concentrated in the earliest months and years. These well-child visits are essential to regularly track children’s development through a range of screenings and—most importantly – connect families with any needed follow-up evaluations or other referrals if a hearing, language or mental health screen suggests a medical need. Continuous eligibility can also offer a better population-level look at whether children are getting their required screens and services. Churning in Medicaid can exclude children from quality measurement if they are not continuously enrolled, which can overestimate system performance—a critical feature for a state like Oregon, which has strong metrics guiding payments for its Coordinated Care Organization (CCOs).

Part of a broader state strategy to improve school readiness. Oregon is clear that in this proposal is part of the state’s commitment to improving school readiness (p. 166), giving a welcome reference to the Raise Up Oregon statewide early learning plan, which calls for improved access to prevention and promotion of physical and mental health, as well as better identification and support for young children with social-emotional, developmental, and health care needs.

The frequency of check-ups for young children makes the health system a critical access point to reach most low-income children before they reach Kindergarten, where missed delays can undermine their opportunity to succeed in school.

Why school readiness? A child’s brain develops most rapidly in the early months and years of life, when preventive care and early intervention can be the most impactful. The application highlights not only physical health, but also social-emotional health, which are both important for learning. Key to this in the child’s earliest years is not merely serving the child’s health, but also the relationship between a child and their parents or caregivers. This early relational health underpins positive development for children by engaging and supporting families whose nurturing and interactions help infants and toddlers make sense of their new worlds.

It’s no coincidence that Oregon is working to improve early social-emotional health through a new Medicaid measurement initiative of the state’s Health Aspects of Kindergarten Measurement Technical Workgroup. Starting in January, the state’s 16 CCOs can receive additional incentive payments for taking concrete system-level steps to develop social-emotional health services for young children and their families—an area often overlooked and under-resourced despite clear and growing evidence on the importance of early childhood mental health. It’s a great step toward placing more systemic, upstream attention and resources on young children, and one that other states could mirror in their state MCO contract requirements.

Can Oregon successfully impact school readiness while also waiving EPSDT?

Oregon’s priority on young children is exciting to see in the context of Medicaid, which serves the vast majority of low-income young children nationally. The state’s stated objective to improve access to preventive care and early interventions for children—especially those that support social-emotional health— is truly innovating amidst a disease-oriented system designed to spend most resources on older adults. Given this important progress, it remains truly puzzling why state leaders, as part of the same application, also seek to waive Medicaid’s foundational pediatric benefit, EPSDT, for all children over age 1. Limiting the range or depth of services that EPSDT protects for children would not only undercut the professional judgment of children’s medical providers—it also stands to undermine the state’s overall efforts to improve school readiness. We will be watching this one closely.

Elisabeth Wright Burak is a Senior Fellow at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.