High Hopes for Medicaid Reform

By Gail Robinson

A 2012 analysis by the Citizens’ Committee for Children of New York estimated that more than 47,000 children under the age of 5 in New York City have “behavioral”—meaning emotional or mental health—problems. Children are more likely to have these difficulties if they are low-income, in foster care, living in a violent home or if their parent has a mental illness, is depressed or a substance abuser.

Unfortunately, the mental health issues facing most young kids now fall through the cracks of the health care system. By one estimate, 70 percent of children with developmental disabilities and mental health problems are not identified until they start school.

You want to get to young children early. You’re not looking for kids to develop a full-blown mental health issue.

Now, advocates and others in New York State are looking to a redesign of Medicaid to help attack this problem. The Children’s Medicaid Redesign Team Behavioral Health Subcommittee, which has been tasked by the governor to help reform Medicaid, hopes that changes set to take effect in 2017 will result in more screening of the youngest New Yorkers for possible behavioral problems, better coordination of the various services that children may need, and improved care for parents and children together. They also want to tailor care for specific groups of children, such as those in foster care, and to provide services to babies and toddlers in their homes and child care centers, where they’re easy to access, not just in clinics.

Currently, clinics and doctors are reimbursed for specific mental health services they provide to toddlers. Experts offer a number of reasons why this is problematic.  

For one, they say that Medicaid may not adequately reimburse health care providers for screenings, or for the kind of treatment that infant mental health specialists say works best for young children. Under the existing Medicaid system in New York, there is considerable confusion in the early childhood mental health field regarding who can and cannot be reimbursed for this so-called dyadic care—where the parent is treated along with the child. 

Nor does Medicaid coordinate care across areas. All too often, advocates say, children may get care for physical issues in one place, developmental issues in another and any emotional and behavioral help in still another, with little coordination. Day care providers who see a child all day may have little to no contact with the professionals addressing a child's emotional trauma or physical problems. "Families are often served by a disjointed, overlapping, non-comprehensive and costly series of services," stated a 2011 report by the Children’s Medicaid Redesign Team Behavioral Health Subcommittee.

Under the planned redesign of Medicaid, the existing fee-for-service system for covering treatment of toddlers with emotional and behavioral problems will be replaced by a managed care approach, similar to what now exists for medical care, in which families enroll their child in a plan provided by a private insurance company that provides the child with primary care as well as whatever specialized medical services are needed. This, its supporters believe, will put a new focus on screening for social and emotional issues. The goal, described in a presentation by the Children’s Medicaid Redesign Team Behavioral Health Subcommittee, is to serve "children more effectively—the right services, at the right time, in the right dose."

"You want to get to young children early. You're not looking for kids to develop a full-blown mental health issue," explains Gail Nayowith, former executive director of the nonprofit social services agency SCO Family of Services and member of the Behavioral Health Work Group.

The Medicaid redesign team proposes that screenings be a routine part of well-child visits, not just something called upon when a doctor suspects something is amiss. By the time a child is 3, he or she is expected to have had 11 such routine visits, giving ample opportunity for the child to be screened for social and emotional problems.

Nayowith believes that the proposed changes will also better coordinate services and allow care to be tailored to specific populations, such as children in foster homes. The redesign team has written that it hopes to break down "silos" and "better align systems to yield continuity of care, access and cost efficiency" as well as better integrating primary and behavioral-health care.

While some advocates see the Medicaid redesign as key to getting vulnerable kids the services they need, it alone will not address the many deficiencies in mental health services for young kids in New York. For instance, many providers may not be aware of the importance of detecting problems early or of the significance of these problems.  They may, for example, believe that a child's upset is a passing phase or not be knowledgeable of the effect that a parent's depression, say, or witnessing a violent incident can have on even the youngest children.

"There's a lot of information about early childhood attachment that nurses don’t get in their training" and pediatricians don't either, says Candida Cucharo, the infant mental health planning specialist at Adelphi University's Institute for Parenting.

Too often, those kids who do get screened and are determined to need help are then met with a dearth of services. In its 2012 analysis, the Citizens’ Committee for Children found that the Bronx, Brooklyn and Staten Island had only 270 slots for mental health treatment for children aged 4 and under—1 percent of what the committee found was needed. (No data were available for Queens and Manhattan.) 

This lack of services may arise partly from skepticism about how effective treatment is. But advocates say the evidence is clear. "There are interventions that work and change the life course for very young children and interrupt the cycle of mental health problems," Nayowith says.

To help others get on board, some experts urge better training in mental health issues for all who work with young children and public education efforts aimed at parents, health care providers and others. "Infant mental health is not just the responsibility of mental health professionals but everyone one who serves the child. Every system really needs to look at families of young children and build support," says Susan Chinitz, the former director of the Early Childhood Center at Albert Einstein College of Medicine.

The specifics of the managed care approach have not yet been worked out but much of it will "be detailed…by the end of the calendar year," a spokesperson for the state Office of Mental Health said in an email. The State's redesign committee has not, for example, confronted the reimbursement issue or how to deliver services to kids in their homes or day care centers.

Meanwhile, advocates are clamoring to make their voices heard. The state Early Childhood Advisory Council, a group of experts appointed by the governor to advise the states on issues affecting young children, for example, has proposed an increase in screening for maternal depression—which can impact a child’s behavior—as well as for "evidence-based services" that have been demonstrated through research to work for children and their families, including dyadic treatment and parenting education.

So far, Nayowith said, the redesign team's group has been largely in agreement on key issues, but she added, "Once we get to financing and implementation things will get more complicated." 

Find more information about New York's Medicaid redesign here.