The blog of the Urban Institute
April 29, 2020

Three Ways to Improve the Health Safety Net to Stabilize Children

April 29, 2020

Stability is foundational for health and paramount for children’s ability to thrive, and having stable access to quality health care and the ability to address health problems can play an important role in children’s healthy development and family stability. Yet, as the COVID-19 pandemic continues to spread, health care systems are experiencing stress, threatening the stability and well-being of children and families across the country.

Our recently released conceptual model, Stabilizing Children’s Lives, shows that health and health care providers are part of an interdependent web of stabilizing supports for children. We spoke with Lisa Dubay, a senior fellow for the Health Policy Center at the Urban Institute, about three ways changemakers can engage the safety net to improve children’s health and access to health care. 

1. Address gaps in the current health care safety net

In some ways, the health care safety net for children is strong. The most recent data suggest 38 percent of children younger than 18 nationwide have health insurance through Medicaid and the Children’s Health Insurance Program (CHIP), and only 5 percent of children nationwide are uninsured.

Yet there are still several gaps that need to be addressed.

First, despite the overall coverage numbers, the number of uninsured children in the US increased between 2016 and 2018, with particularly distressing indicators for certain groups. Part of this is related to recent efforts to repeal and replace the Affordable Care Act, as well as the Trump administration’s reduction in outreach and enrollment efforts for Medicaid. Additionally, Latino children are almost twice as likely to be uninsured nationwide compared with other children, and in some states, Latino children are nearly four times as likely to be uninsured. Even before it was put into effect, the new “public charge” rule appears to have already dampened access to care and curbed enrollment for immigrant families, even for those who were citizens.

Behavioral health services for all children, not just those on Medicaid, also need to be increased, as roughly 20 percent of children have mental or behavioral health problems but only one in five of them (PDF) are treated by a specialized mental health care provider. This provider shortage poses a bigger risk to children on Medicaid, which offers far fewer dollars toward services than private payers, contributing to the scarcity of access for low-income children.

Increasing the fees physicians and other behavioral health providers are paid for providing care to children covered by Medicaid and CHIP could help reduce providers’ reluctance to serve Medicaid enrollees because of the program’s low reimbursement rates. Increasing the amount providers receive could increase the number of providers willing to serve families receiving Medicaid, thus promoting access for more families. But given the overall shortage of behavioral health providers, raising fees will not likely fully solve the problem.

Additionally, increasing the number of providers and the supports and resources they have to serve children is critical. Recent efforts to integrate behavioral and mental health care with primary care have taken steps to address this goal. Some primary care providers have colocated medical and behavioral health services, added onsite care coordination, or facilitated consultations with specialists. These efforts leverage limited behavioral health resources to make treatment more efficient and effective.

2. Improve coordination across health and social contexts

In addition to behavioral health integration, better coordination across contexts can help children receive timely and appropriate care. Child health, social, and educational services exist in silos, with limited infrastructure to facilitate coordination across sectors.

The Integrated Care for Kids Model is testing whether a child-centered local service delivery approach combined with Medicaid and CHIP payment reform can reduce expenditures and improve care quality for children covered by Medicaid and CHIP through prevention, early identification, and treatment of priority health concerns, including behavioral and physical health.

The model, which is being implemented in seven states with funding from the Center for Medicare and Medicaid Innovation, places children at the middle of a coordinated network of care. It organizes both Medicaid- and non-Medicaid-covered services such as housing, child welfare, services from Title V of the Maternal and Child Health Services Block Grant, food and nutrition, schools, early care and education, and mobile crisis response. As a result, children and their primary caregivers will have one primary point of contact who can efficiently coordinate all their core child service needs.

3. Help parents improve their own health

Finally, as has become even more evident during the pandemic, it’s impossible to support children without also supporting their parents’ health and well-being. Health challenges experienced by any member of the family can destabilize children if appropriate buffers (such as health insurance, paid leave, and disability insurance) are not in place. Supporting parents’ stability entails ensuring parents have access to health care, stable employment, child care arrangements, and safe housing.

Expanding Medicaid coverage to adults with incomes up to 138 percent of the federal poverty level across all states is one of the easiest and most impactful ways to improve the safety net for parents. An Urban Institute report shows that increasing coverage for adults would also expand coverage for children who are eligible but unenrolled. Children are more likely to have a source of care and receive annual well-child visits when their parents have Medicaid coverage.

Although the existing health safety net plays a critical role in stabilizing millions of American children’s access to health care, notable gaps leave certain groups of children vulnerable. Taking these three steps can help reduce gaps in the affordability and availability of the health safety net and could help mend the web of stabilizing supports for children to thrive.

Yemeni Rodriquez holds her five day old daughter, Isabella Prado, during a checkup with Dr. Krista Lavonas at the Inner City Health Center in Denver, Colorado on March 15, 2017. Dr. Lavonas is one of three doctors on staff at ICHC. Inner City Health Center was founded in 1983 and offers medical, dental, and mental and behavioral health services to the uninsured and underserved populace of Denver County and surrounding Colorado communities. Services are offered to patients based on a sliding scale, and 65% of the patient population is below 200% of the federal poverty level. ICHC serves more than 22,000 patients annually. (JASON CONNOLLY/AFP via Getty Images)

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