Provide Health Coverage and Access

Health coverage is essential to ensuring that children have access to the medical, dental, and behavioral supports and services required to meet their needs. However, in 2011, an estimated 7.5% of children were still uninsured.[1] Hispanic and American Indian children are significantly more likely to be uninsured than white or African American children; 40.4% of uninsured children are Hispanic, even though Hispanic children are only 23.6% of the child population.[2] Childhood health care plays a vital role in identifying developmental delays, preventing illness and connecting parents to needed information and resources. Ensuring equity of access to health coverage can help ensure that all children get the care they need to be healthy. Some strategies that can be used to improve health coverage and access include:

• Ensure Quality Prenatal Care (including preconception care).  Developing initiatives that ensure equity of access to preconception and prenatal care is important to reducing the risk of birth defects, miscarriage, low birth weight and premature delivery.[3] Quality preconception and prenatal care is especially important for low-income women, who may be in worse health and lack ongoing care before pregnancy and as a result be at higher risk for poor pregnancy outcomes.[4] Lack of insurance and other barriers including delayed awareness of pregnancy, lack of education regarding the importance of prenatal care, and language and cultural barriers make it more difficult for some women to access the care that could reduce these risks. Quality care before and during pregnancy helps to ensure the health and well-being of mothers and their babies. To address concerns about the rate of adverse birth outcomes in the state, the Tennessee state legislature created the Women’s Health in Under-served Areas Initiative[5] to improve access to prenatal and obstetric care in under-served areas of the state. The initiative has provided grants for a number of services to improve maternal and infant health, including the introduction of the evidence-based CenteringPregnancy program. CenteringPregnancy is a group prenatal care and education program model and has been implemented in a number of states. An evaluation found that participation in the program was associated with reduced odds of very low birth weight babies, increased gestational age (longer pregnancies), increased postpartum follow-up attendance and significantly higher rates of breastfeeding. The evaluation found that providers were more satisfied with delivering care in this format, which “adds little extra time burden for providers” while providing “much more exposure to prenatal care over the course of a pregnancy” and helping to build social networks for expectant mothers.[6] Another study of the CenteringPregnancy model found that it was cost-neutral in comparison with the traditional individual prenatal care model.[7]
• Support Well-child Care. Developmental health services positively affect children’s health and educational success. The American Academy of Pediatrics recommends multiple well-visits per year for children under three and an annual well-child visit for those ages 3-21.[8] Although Medicaid, SCHIP, and many commercial insurance plans cover well-child visits, such preventative care services are often underutilized.[9] A study of Medicaidenrolled children in nine states found that while 84% of children under 3 had received a well-child visit, only 63% of 3-6 year olds and 34% of children age 7-11 had received a well-child visit.[10] Effective policy can help families access such services in medically-underserved urban and rural areas, reduce barriers faced by immigrant families and ensure that children are able to utilize needed health services. The Patient-Centered Medical Home (PCMH) model being implemented by Colorado helps families build a partnership with a primary health care professional who coordinates all patient care with a team of health care providers and connects the family to supports and services. The Colorado Department of Health Care Policy and Financing has sponsored a PCMH program through Medicaid and SCHIP for children from low-income families. A 2009 study found that 72% of children receiving Medicaid and SCHIP who were enrolled in PCMH designated practices in Colorado had received well-child visits, compared with 27% of children not enrolled in PCMH practices.[11] The model was also associated with lower costs; the medial annual costs for children in the PCMH group were $785 while the median cost was $1000 annually for the comparison group due to reductions in hospitalizations and emergency room visits.[12] The Colorado Department of Public Health and the Environment is leading the Colorado Medical Home Initiative (CMHI) to build the infrastructure to support a Medical Home System for all families statewide.
• Promote Developmental Screening.  At least 10% of children experience developmental delays; however only about 2.3% of children under age three participate in early intervention programs. Research with primary care physicians suggests that many children with developmental delays are not identified for needed treatment because they are not receiving ongoing routine health care. Early treatment of developmental delays is important for achieving good treatment outcomes. States can promote children’s health by ensuring that developmental screenings become a systematic practice among health professionals that work with young children. The North Carolina Office of Rural Services introduced the Ages and Stages Questionnaire (ASQ), a standardized developmental screening shown to be effective in identifying developmental delays. The ASQ was implemented through local community care networks that serve low-income children and adults by introducing  easy-to-use screening tools, educating medical providers about resources in their communities and improving communication between medical providers and the referral agencies and organizations that provide services for children such as Early Intervention services to address developmental delays. Between 2004 and 2008, the number of developmental screenings conducted during Medicaid well-child visits quintupled and the number of referrals to Early Intervention services quadrupled.[13]
• Ensure the Accessibility and Provision of Nutritious Food. While childhood obesity rates have risen dramatically nationwide in the last 30 years,[14] 21% of households with children do not have a secure food supply throughout the year, putting children at risk of being undernourished.[15] Lack of proper nutrition often contributes to childhood obesity when families use cheap, starchy foods low in nutrients to stretch their food budgets, resulting in children who are both obese and undernourished. Lack of good nutrition poses serious risks to the developmental health of young children. Child care and preschool programs play an especially important role— both in the provision of healthy meals for children and in educating children and families about good nutrition. Effective state policies to ensure quality nutrition in child care and preschool settings are important for children’s health as they grow. In an effort to reduce the incidence of child obesity, Delaware created the first comprehensive state guidelines for both child care centers and family child care homes. The Delaware rules require that all meals and snacks served in child care centers and family child care homes meet the nutritional standards of the Child and Adult Care Food Program (CACFP) Meal Patterns.[16] Research has shown that CACFP is associated with better nutrition in child care.[17]