Charles BrunerBUILD Initiative and Child and Family Policy Center

February 2014

Health Equity and Young Children:The Imperative and Opportunity to Achieve the

“Triple Aim”

Of all the forms of inequality, injustice inhealth care is the most shocking andinhumane.

-- Martin Luther King

We cannot allow the color of a child’s skinor zip code determine the child’s health.

-- Maxine Hayes

THE IMPERATIVE

A mother brings her one-year-old in for a check-up and it’sclear that the mom is stressed, if not depressed, and showslittle sign of responding to the child’s cues for attention.While the child isn’t “diagnosable” today, if things proceedas the primary health practitioner expects, in two yearsthere will be significant indicators of development delay andlikely social and emotional problems, including a DSM-IVdiagnosis. The primary health practitioner does not want towait two years to take action and the mom seems receptiveto receiving help. At the same time, pointing out problemswithout offering help couldbe considered malpractice.

The Opportunity

1. Our youngest are our most diverse and mostin need

2. The first years are the most critical to lifelong

health (but where we invest the least)

3. Child health is in jeopardy

4. Health disparities are profound andpreventable

5. Health practitioners are key to early and

timely response.

What We Know About Health Equityand Young Children

1. Affecting the health trajectory is essential tofuture health

2. There are exemplary programs upon which to

build

3. These exemplary practices can become theroutine standard

4. Neighborhoods matter too

5. Investments pay off– and must be

financed for the long-term

What We Can Do About HealthEquity and Young Children

1a. Our Youngest Are Our MostDiverse

Source: United States Census Bureau, Population Division 2013

1b. Our Youngest Are Our Mostin Need

Source: U.S. Census Bureau, Public Use Microdata Sample, 2011-2013

1c. Our Most Diverse YoungestAre Our Most in Need

Source: U.S. Census Bureau, Public Use Microdata Sample, 2011-2013

2a. The First Years Are MostCritical …

• Brain development and toxic stress• Early childhood adversity/ACEs and future chronic health

conditions• Epigenetics• The impact of social determinants

on health– social gradient, early life, stress, social exclusion and social support – all related to health equity

Harry T. Chugani, MD, PET Center Director, Chief of PediatricNeurology and Developmental Pediatrics, Children’s Hospital of

Michigan

2b. … But Where We Invest theLeast

BUILD Initiative. Early Learning Left Out (2013).

For every dollar invested in the educationand development of a school –aged child,only 7 cents is invested in aninfant/toddler and 25 cents in apreschooler.

For the first time in our country’s history, childrenface the prospect of growing up less healthy and

living less long lives than their parents– notbecause of medical care but due to demographics,social determinants, and exercise, nutrition, and

obesity.

3a. Child Health is inJeopardy

3b. This Jeopardy Affects aLarge Proportion of Children

4a.Health Disparities are Profound …

Select Child Health Disparities by Race/Ethnicity and Income from NationalSurvey of Children’s Health Health Indicators: Infant mortality; low birthweight; prevalence of lead poisoning and asthma;developmental disability or delay; food insecurity, malnutrition, obesity; mental/behavioral health disorder Health Response in Relation to Need: • Children with one or more parent-reported concerns about physical, behavioralor social development •Children with no preventive dental care during the past 12 months/since (his/her)birth •Children who do NOT have a usual source for care • Maternal mental health status of children living with mothers in the householdis fair or poor

4b. … and Reflected in Family Demographics

Race/EthnicityChild

Poverty1

25-34 year-oldswith Associates

Degree orHigher2

Children inSingle Parent

Families3Teen Birth Rate

(per 1,000)4

Hispanic 34% 18% 42% 49

White, non-Hispanic 14% 46% 25% 22

Black, non-Hispanic 40% 26% 67% 47

Family Demographics

* = estimates based on sample sizes too small to meet standards for reliability or precisionS = estimates suppressed when the confidence interval around the percentage is greater than or equal to 10% points

1. http://www.childrensdefense.org/child-research-data-publications/state-of-americas-children/

2. http://dashboard.ed.gov/statecomparison.aspx?i=o&id=0&wt=40

4b. … and Reflected in Family Concerns andStressors

Race/Ethnicity

Live in anUnsupportiveNeighborhood

Fair/PoorMaternal

Mental Health

Parents areUsually or

Always Stressedabout Parenting

Hispanic 25% 10% 16%

White, non-Hispanic 12% 6% 8%

Black, non-Hispanic 28% 11% 16%

Family Concerns and Stressors

http://www.childhealthdata.org/browse/survey

4b. … and Reflected in Child Outcomes

Race/Ethnicity

Concerns AboutChild’s

Development1Low –

Birthweight2

Percent Proficientor above on 4thGrade Reading

NAEPAssessment3

Hispanic 47% 7% 19%

White, non-Hispanic

35% 7% 45%

Black, non-Hispanic

45% 13% 17%

Child Outcomes

*= estimates based on sample sizes too small to meet standards for reliability or precision1 http://www.childhealthdata.org/browse/survey2 http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf3 http://nces.ed.gov/nationsreportcard/naepdata/report.aspx

5. Health Practitioners Are Key toEarly and Timely Response

Summary of Part One: What We KnowAbout Health Equity

• America is becoming more diverse and young children areleading the way • This diversity can be a strength, but only if America addressesissues of health disparities in healthy development in theearliest years of life

• Health practitioners have a key role toplay, as first point of contact/responders

• Addressing health disparities involvesissues of equity and responding to familystress, isolation, and exclusion (often the result of discrimination/racism)

6a. Affecting the Health Trajectoryof Young Children is Essential

Source:BUILDIni0a0veandtheChildandFamilyPolicyCenter(February2013

6b. Which Child HealthPractitioners Can Help Achieve

(ears)Physical health and development

• No undetected hearing or vision problem• No chronic health problems without a treatment plan• Immunizations complete for age• No undetected congenital anomalies

Emotional, social and cognitive development• No unrecognized or untreated delays

Family’s capacity and functioning• Parents knowledgeable about child’s physical health

status and needs• No unrecognized maternal depression, family violence,

or family substance use• No undetected early warning signs of child abuse or

neglect Schor, E. Healthy Child Story Book.

7a. There Are ExemplaryPrograms on Which to Build …

HealthLeads

7b. …Which Share CommonAttributes

8a. Exemplary Practices Can Become theRoutine Standard But Are Not Today

Primary and Preventive Health Services for Children(0-5)

%

Child reported as having some form of health insurance coverage 94.5%

Child reported as having preventive, well-child visit in past 12 months 89.4%

Child reported as having coordinated, ongoing comprehensive carewithin a medical home

54.4%

Child reported as having been screened for being at risk ofdevelopmental, behavioral, and social delays, using a parent-reportedscreening tool during a health care visit (10 months to 5 years only)

National Survey for Children’s Health 2011-12

30.8%

1. Creating Awareness of the Need for andAbility to Change

2. Promoting/Incentivizing New Practice and

Investing in Innovators and Innovation

3. Developing Mainstream Management,Financing, and Accountability Systems to MakeExemplary Practice the Norm

8b. Moving From ExemplaryTo Routine Requires Intentionality

8c. States Can Play Key Roles, ParticularlyThrough Medicaid

PARTICIPATION IN MEDICAID AND EPSDT BY CHILDAGE (416 FORMS AND ACS DATA) – ALL STATES 2011

0-2 Medicaid/EPSDT Enrollment of all 0-2 year olds as percent ofall children

56.0%

Average Number of EPSDT Visits Annually for Enrolled Child 2.1

3-5 Medicaid/EPSDT enrollment of all 3-5 year olds (416/ACS) 51.5%

Average Number of EPSDT Visits Annually .71

6-17 Medicaid/EPSDT Enrollment of All 6-17 year-olds (416/ACS) 35.6%

Average Number of EPSDT Visits Annually .42

9a. Neighborhoods Matter Too

Source: Village Building and School Readiness (2007).

Implication: Improving child health in theseneighborhoods requires community-building as well asindividual child service strategies.

COMPARISONONTENINDICATORSOFCENSUSTRACTSWITHNOCHILDVULERNABILITYFACTORSWITHTRACTSWITH6ORMOREVULNERABILITYFACTORS

Indicators NoVulnerabilityFactors 6-10VulnerabilityFactors

%SingleParentFamilies 20.5 53.1

%PoorFamilieswithChildren 7.2 41.4

%25+noHighSchool 13.5 48.0

%25+BAorHigher 28.7 7.1

%16-19notworking/inschool 3.0 15.0

%HoHonPublicAssistance 4.9 25.5

%HoHwithWageIncome 80.6 69.1

%HoH–Int/Div/Rent/Income 42.3 11.0

%18+LimitedEnglish 1.9 17.5

%Owner-OccupiedHousing 71.0 29.6

9b. .. And Are Critical for YoungChildren and Children of Color

While 1.7% of all white, non-Hispanic Americans live in thehighest-risk neighborhoods, 20.3% of all African-Americansand 25.3%e of Hispanic/Latinos live in these highest-riskneighborhoods

Breakdownbyrace/ethnicityofwholivesincensustractswith0andwith6+vulnerabilityfactors

RacialComposi,on NoVulnerabilityFactors 6-10VulnerabilityFactors

%WhiteNonHispanic 83.2 17.6

%Black 6.2 38.0

%Asian 3.7 3.3

%Hispanic 6.1 39.4

%AmericanIndian/NaMveAlaskan

0.5 1.2

ChildComposi,on

%ofpopulaMonthatis0-4yrs. 6.1 9.2

10a. Investments Pay Off Over theLife Course

Young Child Child-Adolescent Adult

Health Costs Preventable injuriesTrauma-inducedtreatment

Preventable injuriesTrauma-inducedtreatmentPsychiatric careType 2 diabetesOther emerging healthconditions

All adult healthconditions (ACEs)Costs from riskylifestyles (smoking, druginvolvement, etc.)Offspring health risks

Other Costs Child welfare/foster care Special educationChild welfare/foster carejuvenile justiceGrade retention

Public welfareLost earnings/taxesCriminal justiceinvolvementOffspring at high-risk

10b. … AndMust Be Financed for the Long-Term

Estimating the Benefitsof Investments andHealth andOther Dividends

•Life-course return-on-investment: high multiples (5:1to 20:1 +), increasing with time•First dollar payback oninvestment: 3-10 years•Annual Rate of Return: 7-10%

The Iowa Experience/Cast of Dozens

• 2003-2006 Iowa ABCD Initiative (developmentalscreening and surveillance/Medicaid changes)• 2006 state funding for demonstration HELP MEGROW/1st FIVE Initiative• 2010 Membership in HMG national network• 2012 Further coverage of features of 1st Five underMedicaid (administrative claiming)• 2013 Expansion of State Funding for 1st Five/Linksto Child Health Specialty Clinics• 2013 Incorporation of child health metrics andfocus on children within state SIM grants

We Can Use This Knowledge toLead at the State Level

The mother comes in with her child for the 36-monthwell-child visit. Her daughter is looking forward tocoming, knowing she will receive a free book and excitedto tell the nurse she will be going to Head Start nextmonth with her best friend from the Hispanic familycenter. The mother has an ASQ form, completed at herfamily day-care home, and a set of questions for thepractitioner about her daughter, who’s already startingto read but mixing up letters, and is wondering if theremight be dyslexia. The mother is in a mutualassistance group with other parents and wants helpfrom the practitioner in getting more dentistswho will serve children in their community.

Realizing the Opportunity