Health Equity and Young Children: The Imperative and Opportunity to - - PowerPoint PPT Presentation

Charles Bruner BUILD Ini1a1ve and Child and Family Policy Center February 2014

Health Equity and Young Children: The Imperative and Opportunity to Achieve the “Triple Aim”: Colorado Edition

Of all the forms of inequality, injustice in

health care is the most shocking and inhumane.

• - Martin Luther King

We cannot allow a child’s zip code or color

• f skin determine the child’s health.
• - Maxine Hayes

THE IMPERATIVE

A mother brings her one-year-old in for a check-up and it’s clear that the mom is stressed, if not depressed, and shows little sign of responding to the child’s cues for attention. While the child isn’t “diagnosable” today, if things proceed as the primary health practitioner expects, in two years there will be significant indicators of development delay and likely social and emotional problems, including a DSM-IV diagnosis. The primary health practitioner does not want to wait two years to take action and the mom seems receptive to receiving help. At the same time, pointing out problems without offering help could be considered malpractice.

The Opportunity

1. Our youngest are our most diverse and most in 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 and preventable 5. Affecting children’s health trajectory is essential to improving health

What We Know About Health Equity and Young Children

1. Health practitioners are key to early and timely response. 2. There are exemplary programs upon which to build 3. These exemplary practices can become the routine standard 4. Neighborhoods matter too 5. Investments pay off– and must be financed for the long-term

What We Can Do About Health Equity and Young Children

• 1a. Our Youngest Are Our Most

Diverse

COLORADO Racial/Ethnic Information By Age

Source: United States Census, 2012 American Community Survey

United States: Percent of Popula4on Combined Non-white and Hispanic 0 to 5 years: 49.0%; 6 to 17years: 45.2%; 18 to 64 years: 35.7%; 65 + years: 20%

• 1b. Our Youngest Are

Our Most in Need

Source: United States Census, 2012 American Community Survey

COLORADO Poverty/Income Level by Age Group

United States: Percentage of Popula5on Below Poverty, By Age: 0-5 years: 24.8%; 6-17 years: 20.0%; 18-64 years: 14.2%; 65 + years: 9.0%

• 1c. Our Most Diverse Youngest

Are Our Most in Need

Source: United States Census Bureau, 2009-2011 Public Use Microdata Sample

Poverty/Income Level by Race/Ethnicity: 0-5 Year Olds

• 2a. The First Years

Are Most Critical …

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

conditions

• Epigenetics
• The impact of social determinants
• n 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 Pediatric Neurology and Developmental Pediatrics, Children’s Hospital of Michigan

• 2b. … But Where We Invest the Least

BUILD Initiative. Early Learning Left Out (2013).

Per Child Expenditure by Age Group as % Per Child (6-18) Expenditure

US CO Per child (0-2) Exp as % Per Child (6-18) 7% 5% Per Child (3-5) Exp as % Per Child (6-18) 25% 13% Per Child (0-5) Exp as % Per Child (6-18) 16% 9%

For the first time in our country’s history, children face the prospect of growing up less healthy and living less long lives than their parents– not because of medical care but due to demographics, social determinants, and exercise, nutrition, and obesity.

• 3a. Child Health is in Jeopardy

• 3b. This Jeopardy Affects a

Large Proportion of Children

4a.Health Disparities are Profound …

Select Child Health Disparities by Race/Ethnicity and Income from National Survey 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,

behavioral or 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 household is fair or poor

• 4b. … and Reflected in Family

Demographics

Race/Ethnicity Child Poverty1 25-34 year-olds with Associates Degree or Higher2 Children in Single Parent Families3 Teen Birth Rate (per 1,000)4 Hispanic 31% 16% 32.5% 55 White, non-Hispanic 10% 51% 20.7% 18 Black, non-Hispanic 41% 32% 51.4% 36

Colorado Data: Family Demographics

* = estimates based on sample sizes too small to meet standards for reliability or precision S = 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 and

Stressors

Race/Ethnicity Live in an Unsupportive Neighborhood Fair/Poor Maternal Mental Health Parents are Usually or Always Stressed about Parenting Hispanic 28% 7%* 17% White, non-Hispanic 13% 3% 7% Black, non-Hispanic 33%* 19%* 3%*

Colorado Data: Family Concerns and Stressors

http://www.childhealthdata.org/browse/survey * = estimates based on sample sizes too small to meet standards for reliability or precision

• 4b. … and Reflected in Child

Outcomes

Race/Ethnicity Concerns About Child’s Development1 Low – Birthweight2 Percent Proficient

• r above on 4th

Grade Reading NAEP Assessment3 Hispanic 46% 9% 23% White, non- Hispanic 36% 8% 52% Black, non- Hispanic 43%* 14% 19%

Colorado Data: Child Outcomes

*= estimates based on sample sizes too small to meet standards for reliability or precision 1 http://www.childhealthdata.org/browse/survey 2 http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf 3 http://nces.ed.gov/nationsreportcard/naepdata/report.aspx

• 5. Affecting the Health Trajectory of

Young Children is Essential

Source: BUILD Ini0a0ve and the Child and Family Policy Center (February 2013)

Summary of Part One: What We Know About Health Equity

• America is becoming more diverse and young children are

leading the way.

• This diversity can be a strength, but only if America

addresses issues of health disparities.

• Healthy young child development is key

to long-term success.

• Addressing health disparities involves

issues of equity and responding to family stress, isolation, and exclusion (often the result of discrimination/racism).

• 6a. Health Practitioners Are Key to

Early and Timely Response …

• 6b. …Across Both Biomedical and

Social Determinants of Health

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 Exemplary Programs
• n Which to Build …

Health Leads

• 7b. …Which Share Common

Attributes…

• 8a. Exemplary Practices Can Become

the Routine Standard But Are Not Today

Colorado Data: Primary and Preventive Health Services for Children (0-5) US CO Child reported as having some form of health insurance coverage 94.5% 92.4% Child reported as having preventive, well-child visit in past 12 months 84.4% 84.8% Child reported as having coordinated, ongoing comprehensive care within a medical home 54.4% 55.3% Child reported as having been screened for being at risk of developmental, behavioral, and social delays, using a parent-reported screening tool during a health care visit (10 months to 5 years

• nly)

30.8% 47.0%

Source: National Survey for Children’s Health 2011-12

1. Creating Awareness of the Need for and Ability to Change 2. Promoting/Incentivizing New Practice and Investing in Innovators and Innovation 3. Developing Mainstream Management, Financing, and Accountability Systems to Make Exemplary Practice the Norm

• 8b. Moving From Exemplary

To Routine Requires Intentionality

• 8c. States Can Play Key Roles, Particularly

Through Medicaid

PARTICIPATION IN MEDICAID AND EPSDT BY CHILD AGE (416 FORMS AND ACS DATA) – US and Colorado 2011

US CO

0-2 Medicaid/EPSDT Enrollment of all 0-2 year olds as percent of all children 56.0% 46.5% Average Number of EPSDT Visits Annually for Enrolled Child 2.2 1.78 3-5 Medicaid/EPSDT enrollment of all 3-5 year olds (416/ACS) 51.5% 43.4% Average Number of EPSDT Visits Annually .71 .51 6-17 Medicaid/EPSDT Enrollment of All 6-17 year-olds (416/ACS) 35.6% 28.3% Average Number of EPSDT Visits Annually .42 .29

• 9a. Neighborhoods Matter Too

Source: Village Building and School Readiness (2007).

Implication: Improving child health in these neighborhoods requires community-building as well as individual child service strategies.

COMPARISON ON TEN INDICATORS OF CENSUS TRACTS WITH NO CHILD VULERNABILITY FACTORS WITH TRACTS WITH 6 OR MORE VULNERABILITY FACTORS

Indicators No Vulnerability Factors 6-10 Vulnerability Factors % Single Parent Families 20.5 53.1 % Poor Families with Children 7.2 41.4 % 25+ no High School 13.5 48.0 % 25+ BA or Higher 28.7 7.1 % 16-19 not working/in school 3.0 15.0 % HoH on Public Assistance 4.9 25.5 % HoH with Wage Income 80.6 69.1 % HoH – Int/Div/Rent/Income 42.3 11.0 % 18+ Limited English 1.9 17.5 % Owner-Occupied Housing 71.0 29.6

• 9b. .. And Are Critical for Young

Children and Children of Color

While 1.7% of all white, non-Hispanic Americans live in the highest-risk neighborhoods, 20.3% of all African-Americans and 25.3%e of Hispanic/Latinos live in these highest-risk neighborhoods Source: Village Building and School Readiness: Closing Opportunity Gaps in a Diverse Society

Breakdown by race/ethnicity of who lives in census tracts with 0 and with 6+ vulnerability factors Racial Composi,on No Vulnerability Factors 6-10 Vulnerability Factors % White Non Hispanic 83.2 17.6 % Black 6.2 38.0 % Asian 3.7 3.3 % Hispanic 6.1 39.4 % American Indian/NaMve Alaskan 0.5 1.2 Child Composi,on % of populaMon that is 0-4 yrs. 6.1 9.2

• 10a. Investments Pay Off

Over the Life Course

Young Child Child-Adolescent Adult Health Costs Preventable injuries Trauma-induced treatment Preventable injuries Trauma-induced treatment Psychiatric care Type 2 diabetes Other emerging health conditions All adult health conditions (ACEs) Costs from risky lifestyles (smoking, drug involvement, etc.) Offspring health risks Other Costs Child welfare/foster care Special education Child welfare/foster care juvenile justice Grade retention Public welfare Lost earnings/taxes Criminal justice involvement Offspring at high-risk

• 10b. … And Must Be Financed

for the Long-Term

Estimating the Benefits of Investments and Health and Other Dividends

• Life-course return-on-investment:

high multiples (5:1 to 20:1 +), increasing with time

• First dollar payback on

investment: 3-10 years

• Annual Rate of Return: 7-10%

The Iowa Experience/Cast of Dozens

• 2003-2006 Iowa ABCD Initiative (developmental

screening and surveillance/Medicaid changes)

• 2006 state funding for demonstration HELP ME

GROW/1st FIVE Initiative

• 2010 Membership in HMG national network
• 2012 Further coverage of features of 1st Five under

Medicaid (administrative claiming)

• 2013 Expansion of State Funding for 1st Five/Links to

Child Health Specialty Clinics

• 2013 Incorporation of child health metrics and focus on

children within state SIM grants

We Can Use This Knowledge to Lead at the State Level

The mother comes in with her child for the 36-month well- child visit. Her daughter is looking forward to coming, knowing she will receive a free book and excited to tell the nurse she will be going to Head Start next month with her best friend from the Hispanic Family Center. The mother has an ASQ form, completed at her family day-care home, and a set of questions for the practitioner about her daughter, who’s already starting to read but mixing up letters, and is wondering if there might be dyslexia. The mother is in a Mutual assistance group with other parents and wants help from the practitioner in getting more dentists who will serve children in their community.

Realizing the Opportunity

• Top 10 Things We Know about Young Children and Health

Equity… and Three Things We Need to Do with What We Know

• Fifty State Chart Book: Dimensions of Diversity and the

Young Child Population

• The Healthy Child Storybook
• Clinical Health Care Practices and Community Building:

Addressing Racial Disparities in Healthy Child Development

• Federal Health Reform and Children’s Healthy Development:

Opportunities for State and Community Advocacy and Foundation Action

Additional Resources

The Fifty State Chart Book provides detailed information on the indicators listed below: 1. Racial and Ethnic Population of Children in the United States 2. Young Child Poverty Levels by Race and Ethnicity 3. Maternal Education Attainment for Women Age 16 and Over with Children 0- 5 4. Low Birthweight by Race and Ethnicity 5. Infant Mortality Levels by Race and Ethnicity 6. Late or No Prenatal Care by Race and Ethnicity 7. Health Insurance by Race and Ethnicity 8. Access to Medical Home by Race and Ethnicity 9. Immunization Rates for Children 19-35 Months 10. Percent of Children Having Well-Child Visits 11. Children 10 Months to 5 Years Screened for Developmental, Behavioral, and Social Delays 12. Percent in Part C by Race and Ethnicity 13. Children Under 6 Years Exposed to Risk Factors 14. Mothers’ Mental Health by Race and Ethnicity 15. Neighborhood Safety by Age and Race and Ethnicity 16. NAEP 4th Grade Reading Proficiency Scores

Fifty State Chart Book: Dimensions of Diversity and the Young Child Population

The BUILD Initiative and the Child and Family Policy Center are collaborating to create a Health Equity and Young Children Center and Learning Community. The BUILD Initiative is a national initiative which supports state early childhood systems building through a comprehensive approach that integrates health, family support, and early childhood education, with a special focus upon developing inclusive and culturally responsive systems. The Child and Family Policy Center is the research partner with BUILD and works nationally and in Iowa on developing more comprehensive, community-based systems of services and supports to improve child well-being.

About the BUILD Initiative and Child and Family Policy Center

BUILD Initiative: Gerrit Westervelt, Director www.buildinitiative.org Child and Family Policy Center: Charles Bruner, Director www.cfpciowa.org Center for Health Equity and Young Children: Mary Nelle Trefz and Angelica Cardenas-Chaisson mnt@cfpciowa.org; acardenas@cfpciowa.org

Contact Information