Say Ahhh!

By Tom Birch, National Child Abuse Coalition

For the first time, with the passage of health care reform in March, federal funding will be available to states to support a range of voluntary home visitation services to pregnant women, young parents and their children, designed to improve maternal and child health, foster healthy child development, and prevent child maltreatment.  Priority for services would go to low-income families living in communities in need of services. 

The new measure authorizes $1.5 billion over five years - with $100 million in 2010 - for the Maternal, Infant, and Early Childhood Home Visiting Program funded by HRSA, in collaboration with the HHS Administration for Children and Families (ACF), through the Title V maternal and child health block grant.  A three-percent share of the funds is reserved for grants to Indian tribes.

Research over the years has produced a strong body of evidence that early childhood home visitation programs are effective in reducing the incidence of child abuse and neglect and in improving child health and development.  While a majority of states already provide early childhood home visitation services to a relatively small number of families, the challenge has been to take this proven effective prevention approach to scale.  The new home visiting program can help to move toward that goal.  

The new funding promises potential for a significant positive impact on children's health care.  Home visiting programs link families to health care resources and focus on healthy outcomes.  Through a strong emphasis on prenatal care, significant costs associated with pre-term births and developmental disabilities are reduced.  Linking families to consistent primary care and immunizations means reduced emergency room costs and reduction in chronic illness. 

Studies have proven the results we hope to see.  Families who received home visiting services were found to be more likely to have health insurance and a medical home, to seek prenatal and well-child care, and to get their children immunized.  Instances of child maltreatment have been lowered significantly.  Babies of parents enrolled prenatally in home visitation services have shown fewer birth complications and higher birth weights.  

On July 21, HHS announced the allocation of $88 million for the first year of funding of the home visiting grants to states, the District of Columbia and each of the five territories.  The allocations are based on the size of the population of children under the age of five living at or below 100% of the federal poverty level in each state. The grant amounts to the states in the first year range in size from $7.78 million to California down to $557,408 to Vermont.

States have completed or are now in the process of conducting statewide assessments to identify existing home visiting programs and areas of high need. States each have immediate access to $500,000 of their allocations for preparing the needs assessments and begin planning their programs.  The remainder of the grant funds will be released in September, after approval of a state's plan for addressing the home visiting needs identified. The law directs states, in conducting a needs assessment, to coordinate with and take into account other needs assessments already ongoing, including those required by the Maternal and Child Health Block Grant, Head Start, and Title II of the Child Abuse Prevention and Treatment Act (CAPTA).

The Administration for Children and Families (ACF) is taking the lead, in partnership with HRSA, in administering grant support for the Tribal Maternal, Infant, and Early Childhood Home Visiting Grant Program.  Applications are being accepted for a total of $3 million in funding available for award in fiscal year 2010.

In applying for the home visitation grants, states must establish quantifiable benchmarks to demonstrate improvements at intervals of three and five years for families participating in the program.  The benchmarks address maternal and newborn health, prevention of child maltreatment, school readiness, reduced crime or domestic violence, family economic self-sufficiency, and coordination with community support services.

The new grant program requires states to allocate at least 75 percent of funding to support home visiting models that are research-based and rigorously evaluated through randomized control trials or quasi-experimental research designs.  The remaining 25 percent of grant funding could go to support promising approaches yet to be evaluated by a similar rigorous process. 

On July 23, HHS published proposed criteria for evidence of effectiveness of home visiting program models to inform the funding decisions for the new program. Comments on the proposed criteria are due by August 17, 2010. 

In future years, the funding for the program would increase from $100 million in 2010 to $250 million in 2011, $350 million in 2012, and $400 million in each of 2013 and 2014 -- HHS plans to allocate the additional funds competitively.  While HHS proposes to give significant weight to the strength of the available evidence of effectiveness of the model or models employed by a state, HRSA and ACF are open to comments on what criteria are appropriate to judge states competitively.  It is anticipated that the criteria for evidence-based models will need to be altered over time as the state of the field changes, so HHS intends to review the evidence base for home visiting models on an ongoing basis to ensure that new evidence is incorporated.  How program models are evaluated and rated will be the key to allocating the competitive funds. 

The views expressed by guest bloggers do not necessarily reflect the views of the Center for Children and Families.

For all those wondering what was going on with the 2010 federal poverty level, your answer arrived today in the Federal Register. But while I have your attention, here's the back-story.

A decline in the average CPI-U during 2009 would have required HHS to issue poverty guidelines in 2010 that were actually lower than those in 2009, leading to a reduction in eligibility for the safety net programs that rely on the guidelines, including Medicaid. (This would have been an unprecedented event - the only reduction since the issuance of the first poverty guidelines in 1965).

In December, the Department of Defense Appropriations Act (go figure) included a provision to freeze the poverty guidelines at 2009 levels through March 1, 2010. This freeze has been extended twice more until at least May 31, 2010. (I say at least, because all three extensions included language stipulating that the poverty levels would remain in place until updated guidelines were published, hence the somewhat fungible deadlines).

I don't know about you, but I've been on pins and needles since the end of May waiting for the publication of the updated guidelines. Well, the wait is over... ASPE modified the procedure for updating the guidelines to take into account the changes in the CPI-U during the freeze. (Typically, ASPE uses price changes through the most recent "completed" year. In this case, they also took into account the changes between January 2009 and May 31, 2010.) 

The percentage increase in the CPI-U was so small that as a result, the poverty guideline figures for the remainder of 2010 are unchanged from the 2009 poverty guideline figures. These guidelines will remain in effect until ASPE publishes the 2011 guidelines, which are expected in late January 2011.

One of the many lessons learned about advancing children's health coverage is how critical retention in Medicaid and CHIP is to our coverage goals. Dr. Benjamin Sommers drove this point home in a study that concluded that one-third of all eligible, uninsured children in 2006 had actually been enrolled in Medicaid or CHIP in the prior year. A recent update of Dr. Sommer's study in Health Affairs shows that we have made progress on this front with this key statistic dropping to 25% in a little over two years.

Over the years the importance of customer retention, a long-standing best practice in the business world, has gained equal footing with outreach and streamlining enrollment as effective strategies to reduce barriers to coverage. Dr. Sommer's report is good news for states that have made retention a priority and is a contributing factor in our continuing success in reducing the number of uninsured children. 

While the drop-out rate improved, there was some evidence in the study that take-up or new enrollment may have slipped. Dr. Benjamin Sommers points out that this change in trend coincided with new federal rules imposing complex paperwork requirements on states and applicants to document citizenship. The negative impact of the citizenship verification requirement on eligible, citizen children has been well documented. 

I'm optimistic that if Dr. Sommers updates his report in another three years we'll see improvement in both areas. More than one-third of states have had impressive results with a new data exchange with the Social Security Administration (SSA) to verify citizenship rather than requiring paperwork from individuals. Many more states are testing or planning to develop the SSA electronic interface as a means of documenting citizenship.

Additionally, states continue to innovate and replicate effective enrollment and retention strategies through major initiatives such as the Robert Wood Johnson funded Maximizing Enrollment for Kids and the State Health Access Grant Program.

Dr. Sommers research shows how policy and procedural decisions can make a difference, both positive and negative.  Taking stock of what is working in Medicaid and CHIP to promote enrollment and retention is essential to the expansion of coverage as we implement the Affordable Care Act efficiently, cost-effectively and with optimal results.