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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