What’s Next for Child Health Coverage: 2015 Edition The panel discussed the challenges and opportunities in children’s coverage, particularly the complexities in the current environment. Speakers addressed the future of child coverage by focusing on questions surrounding the future of CHIP and agreed that it would be detrimental to children’s health and coverage to dismantle CHIP without having a good sense of what would replace it. Chris Koller moderated the panel featuring Cathy Caldwell, Alabama Department of Public Health; Melinda Dutton, Manatt, Phelp & Phillips, LLP; Patricia Riley, National Academy for State Health Policy; and Anne Schwartz, Medicaid and CHIP Payment and Access Commission. Koller introduced the discussion with a ‘glass-half full’ approach: there is progress on getting coverage for children, 6.5% of kids were not covered in 2013. Of the challenges exist in the current system, however, “churning,” or interruptions in insurance coverage due to transitioning between coverage types, is a notable one. Dutton noted that churning is due to lack of stitching between programs, resulting in disjointed enrollment experiences for families. Another challenge discussed were variations across states due to Federalism. Caldwell put the discussion into a state perspective and argued that getting parents and children into the same plan is not necessarily the ‘magic solution’ to coverage and access. Parents and children have differing needs and therefore require different providers. Echoing Dutton, she noted the need to stitch the various vehicles for getting coverage together in order to make the experience of choosing coverage seamless and easy to navigate for parents. Dutton added that it would be an enormous loss to children's health to dismantle CHIP before we have a good sense of what we are replacing it with and how the priorities of CHIP (accessibility, benefits, outreach strategies, and infrastructure for implementation) would be included in a future solution. Riley highlighted the need to understand and address the true cost of child health to further the discussion. The Many Faces and Impact of Children of Immigration Policy on Children Speakers provided an overview of immigrant children’s health and how current policies in social services, education, health, and immigration fall short of addressing the adverse health outcomes of this population. Glenn Flores, from UT Southwestern and Children’s Medical Center Dallas, introduced policy solutions to immigrant health disparities such as addressing language barriers through third party reimbursement for medical interpreters and reforming foster care to keep families together regardless of status. Mara Youdelman of the National Health Law Program overviewed current laws on immigrant health eligibility, in federal programs. She emphasized that the ACA does not fully cover lawfully present immigrant kids. National Immigration Law Center’s Angel Padilla covered a more controversial topic, undocumented kids and health.  When detained, kids receive basic health screening, but post-release are only provided care through local communities. Federal programs do not cover this subset of immigrants. Finally, Sonya Schwartz from Georgetown University discussed the Deferred Action for Parental Accountability (DAPA) program, which allows undocumented parents to stay with their U.S. citizen kids.  She emphasized that we must communicate to immigrant populations about the opportunities to cover their kids through DAPA. All of the speakers agreed that even for the lawfully present immigrants,  low coverage and enrollment rates in federal options indicate drastic health disparities. Language barriers and community interventions are key to informing immigrants about their options for health. Ensuring Optimal Helath for Every Child: Closing the Gap Sandra Hassink led the panel discussion on how to close the disparity gap in children’s health, which included Eugene Steuerle, Irene Dankwa-Mullan, and Gail Christopher. Steuerle opened the discussion by noting that while the U.S. is currently focusing on consumption rather than investments that will ensure health for all children, it is not a time of austerity, but of extraordinary opportunity. While health spending on children as a percent of the total federal spending on children is increasing, their slice of the budget is still not very large. Changing the mindset from consumption to investment, Steurele noted, will advance children’s health and will help make the 21st century the century of the child. Dankwa-Mullan highlighted how sciences advances and inform policy and practice to address child health. She pointed to scientific examples of how adverse childhood events can result in disparities and consequences throughout life including brain architecture and cycles of stress. Brain architecture is experience dependent, so early childhood adversity leads to disruptions. Vicious cycles of stress can lead to permanent alternations in brain architecture, leading to poor adult health outcomes. Applying scientific research findings, she emphasized the importance of health in all policies and the need to invest in children and environmental interventions to advance their health. Gail Christopher opened up her discussion by asking a key question:  “What do we need to do to help children born into adversity have the capacity for resiliency?” She outlined the power of the implicit bias in affecting children’s health. Christopher expressed that we must think about how to change social norms to support all children and families. All panelists stressed the importance of examining other environments and social determinants that impact the health of children. They emphasized the opportunity that exists in the current landscape to improve and invest in children’s health. Evidence and Innovations to Address Adverse Childhood Experiences 47.9 % of US children experience one or more (out of 9 measured) adverse childhood experiences (ACEs) in their early childhood. Dr. Christina Bethell of the Child and Adolescent Health Measurement Initiative (CAHMI) highlighted the key data around ACEs to open up the breakout. Jack Shonkoff of Harvard University emphasized the importance of understanding terminology. Common terms such as toxic Stress, trauma, and ACEs are related terms but are not one in the same.  In order to address ACEs, Shonkoff expressed the important of transforming the lives of the adults who care for kids facing adversity. Strong interventions that seek larger impacts will be more successful in addressing ACEs. ACEs Connection’s Elizabeth Prewitt discussed the existing state data on ACEs scores. ACE scores measures can vary, including both quantitative and qualitative measures. She also shared anecdotes of how the ACEs study has been used in local interventions/non-health settings such as schools, churches, and courtrooms. Sandra Bloom brought a unique perspective on ACEs as an adult psychiatrist from Drexel University.  She shared that almost every adult patient she sees, has illnesses that could have been prevented in childhood.  Bloom emphasized the role of our fragmented health care system and workforce stress  as a challenge to addressing ACEs; we have so much knowledge in all different sectors related to ACEs, but they are not integrated. Social models and workforce training must shift to ask the right question, to help individuals facing adversity. The session concluded with an inspiring discussion on the way each childhood adversity should be measured in a meaningful and consistent manner. The speakers recognized that while there is data on many aspects of ACEs, there are still several gaps in design and understanding of the issue on a societal and community level. For more information on ACEs, please visit our website: www.academyhealth.org/aces. System & Model Innovations Community-based partnerships are providing alternative sites of delivery for children's health care. This session explored innovations in child care delivery across the country. Jeanene Smith discussed aligning health and the early learning system transformation in Oregon. Health transformation and education transformation have to go hand in hand, she stated, not only for the economy, but also to improve health. The state is committed to achieving the triple aim to improve children’s health while also getting children ready for kindergarten. Important aspects of achieving the goals of both the health and the education initiatives include community involvement, a collective impact approach, cross-system learning, and a clear and shared measurement system. Bergman spoke about innovations in care being done at the delivery system level and discussed the treatment of children with medical complexities, which is a small population (about 1% of all children), but one that consumes a lot of resources and has a high impact on families. Bergman’s work is on innovations in the care project, which is an effort to coordinate all resources effectively to improve care. He highlighted the benefit of the grant being two-pronged: he is charged with looking at payment reform (policy and advocacy) and care delivery reform (quality and safety) with care in the middle. His recommendations included sustained and active care through enhanced monitoring and telecommunication, hospital care at home, parent and child self-management, and the integration of school and community services to maximize the quality care. Allison Gertel-Rosenberg, Nemours Children's Health System, spoke about her team’s work on leveraging innovations and spreading best practices across the country, specifically answering the question of how do we harness, develop, test, and spread the adoption of population health innovations aimed and improving the health and wellbeing of communities. The goal, she noted, is to build the field of evidence to create a ripple effect across multiple communities to make sure that kids are growing up healthy. All speakers emphasized the importance of the use of the delivery system and partners in other sectors to help drive change, share best practices, and improve children’s health.

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