PBH 805: Week 6 Slides

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Week 6
Chapters 18 & 20
Instructor: Gina Crosley-Corcoran, MPH
PBH 805 – Maternal & Child Health

Chapter 18
Assessment and Program Planning

Key Program Planning Components
A public health approach to
program planning combines
a population health
perspective; community
engagement with a board
group of stakeholders; and
a structed approach to
assessment, design,
implementation, and
evaluation
Program planning in
maternal and child health
(MCH) requires several
important steps, each of
which is associate with
guiding frameworks and
tools.
Offers providers, planners,
decision makers,
policymakers, funders, and
community leaders the
ability to incorporate an
equity frame into their
efforts
Approach the work with a
health equity perspective
and and a multidisciplinary
team that can represent
stakeholder perspectives

The Five Steps in Program Planning

Step 1: Context
Begin by understanding the problem
or issue and the setting (context),
then conduct a literature review and
reviews of the policy and program
landscape and secondary data.
Consider the policy and legal
environment; geographic and physical
landscape; socioeconomic, cultural,
and demographic aspects of the
community; and community
concerns.
Talk with the people who are affected
by the problem and listen to their
feedback: what has already been tried
and they they think will work.
A systems perspective that multiple
inter-related components must work
together will help identify relevant
programs that affect a particular
population or health issue.
Incorporate input from community
leaders so that scientific literature
and policy is evaluated through the
lens of equity and inclusion.

Literature Review
 Uses peer-reviewed journal articles found through
literature search engines such as Google Scholar and
Web of Science as well as literature databases such as
PubMed
 Resources for a literature review rarely include
include books or agency reports, and journals
typically do not print articles on programs that have
been tried but were not successful.
 Scientific literature may not be written by those who
bring perspectives of equity and inclusion.

Program and Policy Landscape Review
 University centers and institutes publish white paper
reports and agencies at all levels publish reports,
known as gray literature, on program activities, MCH
outcomes, and changes in policy.
 These materials might not be objective or
scientifically valid as the organizations that publish
them often have political agendas.
 The identity and lens of those that produce these
reports may not have input from stakeholders and the
findings may not be relevant to certain populations.

Reviewing Secondary Data
 Vital statistics and Census data are common sources,
some of which is available for highly granular
information that can be examined across small areas
(census blocks, census tracts, zip codes) or for
broader geographical areas that cover a whole state
or census region.
 The smaller the population is, the more likely those
counts will suppressed for privacy protection.
 Useful to evaluate gaps in data collection and analyze
how program categorize, disaggregate, and evaluate
race and ethnicity data.

Step 2: Community Assessment
 The ultimate goal of an assessment is to identify a
community’s issues and concerns, and then develop
strategies to address those needs.
 Essential ingredients of a community health
assessment are community engagement and
collaborative participation.
 The Community Toolbox suggests first developing a
comprehensive plan for conducting the needs
assessments that conveys its purpose, partners, and
process.

Purpose
 The purpose of the needs assessment, such as
identifying a particular health or social need in a
community, should be established upfront.
 Asset-based community development (ABCD) is a
framework that is engaged with broad representation
of the community and focuses on the unique
resources in the specific neighborhood that can build
community capacity for positive transformation.

Partners
 ABCD helps residents, associations, organization, and
government entities work together as “co-producers of
their community’s well-being” and is founded on the
premises that:
 Everyone has gifts
 Everyone has something to contribute
 Everyone cares about something and that passion is their
motivation to act
 Incorporating multiple perspectives and understanding
root causes will help the team identify potential strategies
that will be appropriate and relevant.
 Ultimately, the community should always be at the core of
a community assessment.

Process
 Consists of reflecting on what is known, collecting
information on what is unknown, then coming to a
consensus on where to go next
 Data may exist or can be collected, but the key to
conducting an effective needs assessment is to
consider data from multiple levels.
 Population, community, organizations, and individual
perspectives
 Reflect on the data and use the results for informed
decision-making in partnership with a diverse array of
stakeholders

Case Study: Florida MIECHV Needs
Assessment
First step was to create an Advisory Group of partners with diverse
perspectives.
Second step was to determine what areas were the most in need.
Third step was to calculate a composite risk score based on data.
Fourth step was to survey over 700 stakeholders to better
understand community gaps and needs as well as availability, quality,
and coordination aspects.
Purpose was to determine which communities are in the highest need of home visiting
programs that support pregnant women and families with young children

Step 3: Program Design
 Goals and objectives are extremely important to choose in
a collaborative manner with the community.
 Goals are broad directions of intent.
 Objectives are specific and answer who, what, how much,
and by when.
 SMARTIE objectives are:
 Specific
 Measurable
 Achievable
 Realistic
 Time-limited
 Inclusive
 Equitable

Action Plans
 Helpful for groups to clearly identify how they will
accomplish their objectives
 Should cover every stage all they way through
evaluation and sustainability
 Include components on what will happen, the person
responsible, the date to be completed, the resources
required, potential barriers or resistance and how to
overcome them, and collaborators

Planning Models Used in Health Promotion
Programs (1 of 2)
Modified from McKenzie, J. F., Neiger, B. L., & Thackeray, R. (2017). Planning,
implementation, and evaluating health promotion programs: A primer (7th ed.). Boston,
MA: Pearson

Planning Models
Used in Health
Promotion
Programs (2 of 2)

Step 4: Implementation
Decide whether to use an existing evidence-based intervention or
develop a new approach
•Is there sufficient evidence to show that intervention has been successful?
•Is there sufficient evidence to show the intervention has been successful with a similar
population to the current priority population?
•Is there evidence that the intervention was successful in more then one setting?
•Are there similar resources available in the target setting to ensure intervention fidelity?
•Is the new environment similar to the identified environment?
Can you answer “yes” to these questions about the existing program:
If not, then it should be adapted or a new intervention needs to be
developed.
Once adapted, new materials and resources should be pretested.

Logic Models
 An intervention will be stronger if it’s grounded in a
theory of change, which should communicated
through a logic model.
 A logic model identifies the program inputs, activities,
outputs, and short-, mid-, and long-term outcomes,
all leading to the ultimate goal or vision of the
program.
 Conveys to internal and external stakeholders exactly
what the program does and how it will lead to the
intended outcomes

Example Logic Model

Implementation Science
 There is often a gap between the evidence that is found during the evaluation stages
or in well-established programs and what happens when they are implemented in a
less controlled environment.
 Implementation science provides the necessary research and tools for carrying out the
selected evidence-based service or program and achieving the intended outcomes in 2
to 4 years.
Exploration and
adoption
Program
installation
Initial
implementation
Full operation Innovation Sustainability
Stages of implementation are:

Implementation Frameworks
Implementation
Teams
• Support the
execution,
sustainability,
scale-up, and
determine the
best fit
Implementation
Drivers
• Infrastructure
needed to
support the
practice,
organization,
and systems
change
Usable
Interventions
• Critical
components
necessary for
building and
implementatio
n infrastructure
Stages
• Specific
activities that
the
implementatio
n team should
conduct during
each stage to
ensure
success
Improvement
Cycles
• Tailor part of
the
intervention for
the specific
context using
an intentional,
scientific
process

Step 5: Evaluation and Continuous Quality
Improvement
 Communities are always changing; programs are always
evolving; and new knowledge, technology, and strategies
are constantly being developed.
 While quality management is important, researchers agree
that stakeholder engagement is a critical piece of
evaluation and quality improvement.
 Stakeholder engagement helps to determine whether the
program requires adaptations or a complete overhaul to
ensure that it is meeting the needs of the community and
continues to evolve with new knowledge of best practices.
 Program must not only evaluate their outcomes, but also
disseminate their results.

Continuous Quality Improvement
 Continuous quality improvement (CQI) can be
described as a systematic, structured approach to
achieving the goals of a given program.
 Another aspect of quality improvement is
determining whether programs or providers are
following best practice guidelines, using studies
involving diverse populations and engagement
with consumers and stakeholder groups for input
and feedback.
 CQI incorporates data collection, utilization of
technology and knowledge, high-functioning
diverse project teams, collaborative decision
making that includes program participants, and
the adaptation of work processes to generate
knowledge and ultimately to improve practice.

Chapter 20
Medicaid and CHIP Coverage for Women and Children:
Politics and Policy

Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Background texture © Bunphot/Getty Images.
Medicaid and Medicare

From Medicare to Medicaid: Medicaid Policy for
Pregnant Women and Children, 1965–1976
Medicaid and Medicare were enacted as part of the Social Security Act in
1965.
Kiddycare was proposed by Secretary of Health, Education, and Welfare
(HEW) Wilbur Cohen in 1968 to provide universal social insurance, rather
than the means-tested approach of Medicaid
• Would have provided coverage for maternity care (prenatal, birth, and postpartum) for all
mothers and infant care for the first year after birth
• Delayed due to budgeting
• Republican Richard Nixon won presidential campaign in 1968
• Thus, the political path turned to extend coverage only to the poorest pregnant women and
children through Medicaid.

From CHAP to CHIP: Medicaid Policy for Pregnant
Women and Children, 1977–1997 (1 of 5)
 Efforts in the late 1970s to pass federal laws requiring
Medicaid to cover all poor pregnant women and children
also did not succeed.
 Due to political battles over Medicaid financing of abortion,
pressures to create a national health insurance program, and
concerns over expanding entitlements in a time of recession
 Child Health Assessment Program (CHAP) was never
brought to the House or Senate floor
 Would have expanded Medicaid coverage to an additional
700,000 poor children younger than age 6
 During President Reagan’s first term, restrictions on
Medicaid eligibility were adopted, and support for low-
income families from an array of other social safety net
programs was curtailed.

 By the mid-1980s, the issue of infant mortality—and associated
coverage for prenatal and postpartum care—had become a
driving topic in MCH policy.
 It took 6 years to incrementally enact the coverage envisioned in
CHAP.
 Only in 2002 was its implementation completed to cover all poor
children.
 In 1984, advocacy organizations, particularly the Children’s
Defense Fund, joined with members of Congress and began to
advance legislation that largely followed the design of CHAP.
 As a result, between 1984 and 1990, this series of incremental
expansions that embodied many of the elements of the CHAP
proposals was adopted by Congress and signed into law by
Presidents Ronald Reagan and George H. W. Bush.

• Delink Medicaid from cash assistance by requiring states to cover poor children
who were born after September 30, 1983; pregnant women who would qualify
for AFDC cash assistance once the child was born (typically single women
pregnant for the first time); pregnant women living with the father of the child
would meet the qualifications of the AFDC unemployed parent program once
the child was born
• ~200,000 pregnant women and babies gained eligibility
• Mandated automatic newborn and continuous infant coverage in Medicaid
Deficit Reduction
Act of 1984
(DEFRA)
• Continued Medicaid eligibility expansions for pregnant women and children
• Mandated Medicaid coverage of all pregnant women with family income and
resources below the AFDC financial eligibility levels
• Mandated an additional 60 days of postpartum coverage for all women whose
Medicaid eligibility
• Prohibited any Medicare-funded hospital facilities from refusing to treat or
appropriately transfer emergency patients, including those in active labor—
known as the Emergency Medical Treatment and Labor Act (EMTALA)
Consolidated
Omnibus Budget
Reconciliation Act
of 1985 (COBRA):
March 1986

Omnibus Budget Reconciliation Act of
1986 (OBRA 86, aka the Sixth
Omnibus Budget Reconciliation Act of
1986 or SOBRA)
• Gave states the option to extend
Medicaid coverage to all pregnant
women and children younger than
age 5 year by year basis
• Amended the Title V Maternal and
Child Health Block Grant to assure
greater accountability by states
• Gave states the option to cover
pregnant women and infants in
families with incomes up to 185% of
the federal poverty level
• Gave states option to cover children
up to age 8 in families with incomes
below the poverty line
Medicare Catastrophic Coverage Act
of 1988 (MECCA)
• Required all states to extend
Medicaid coverage to pregnant
women and infants in families with
incomes up to 100% of the federal
poverty level
OBRA 89
• Mandated coverage Medicaid and
Medicare of pregnant women,
infants, and children younger than
age 6 with family incomes at or
below 133% of the federal poverty
level
• Clarified and improved the
definition of child health benefits
under the EPSDT component of
Medicaid
• Assured children comprehensive
coverage for medically necessary
services and treatment of identified
conditions

OBRA 90
• Mandated phased-in Medicaid coverage by October 2002 for all poor children born after September 30, 1983
• Continued coverage for the infants who came in under DEFRA and added all poor children over time
• Made changes to extend presumptive eligibility, reinforced automatic and continuous eligibility for infants, and
reinforced the 60-day postpartum coverage for women
Medicaid
• Extended Medicaid coverage for seniors aged 65 and older, which resulted in Medicaid coverage for low-income
seniors operating in parallel to private supplemental insurance.
• Medicaid pays the Medicare premiums for beneficiaries with low incomes and, for those below the poverty line,
Medicaid also pays for Medicare deductibles and cost-sharing charges.
• Medicaid is the primary payer for long-term services for the elderly.
• Nursing home care, home health, medical equipment, mental health, and some dental care
While all poor seniors qualified for Medicaid in 1992, all poor children did not until 2002.
• Many older poor children were left without health coverage for a generation.

Medicaid Policy and Program Change in the
1990s (1 of 4)
Personal Responsibility and
Work Opportunity
Reconciliation Act (PRWORA)
1996
•Welfare reform
•Repealed the AFDC individual
entitlement to cash assistance
and replaced it with the
Temporary Assistance for
Needy Families (TANF) block
grant to states
•Number of individuals
receiving cash assistance
declined sharply in the years
thereafter, as states
implemented the federal law
and adopted their own
innovations
Balanced Budget Act of 1997
(BBA)
•Established the State
Children’s Health Insurance
Program (SCHIP)
•States rapidly adopted SCHIP
•ACA expanded CHIP again in
2010; funding and program
modifications
•Re-authorized program known
as CHIP
•Operating CHIP as a Medicaid
extension means more
extensive benefits (i.e.,
including EPSDT), no waiting
period for enrollment, and
less cost-sharing for covered
children.
Since 1993, a majority of states
have expanded eligibility for
Medicaid coverage of family
planning services
•By 2020, half of states had
federal approval (17 via state
plans and 9 via waivers) to
extend Medicaid eligibility for
family planning services to
individuals who would not
otherwise be eligible.

1990s (2 of 4)
Medicaid CHIP coverage for children with special health care needs
Children with special
health care needs
(CSHCN) are defined
as those who have or
are at increased risk
for chronic physical,
developmental,
behavioral, or
emotional conditions
and who also require
health and related
services of a type or
amount beyond that
required by children
generally.
States’ Title V
Crippled Children
Services (now Title V
Children with Special
Health Care Needs)
programs were linked
under federal law to
EPSDT.
Medicaid coverage is
also mandatory for
those individuals who
receive Supplemental
Security Income (SSI)
cash assistance
benefits on the basis
of blindness or
disability (est. 1972).
1999 Supreme Court
ruled that unjustified
institutional isolation
of people with
disabilities was
unlawful
discrimination under
the Americans with
Disabilities Act (ADA)
in Olmstead v. L.C.

1990s (3 of 4)
 Beginning in 1981, states have used Medicaid waivers under Section
1915(c) of the Social Security Act to establish home- and
community-based services programs.
 Waivers allow states to finance services for people who would otherwise be
in an institution.
 In 2018, all states except one used either a home- and community-based
services waiver or their option under the Katie Beckett program to extend
Medicaid coverage to children with significant disabilities living at home who
might have otherwise been institutionalized.
 Play a critical role in ensuring eligibility and financing needed
services for children with disabilities and other special health care
needs
 Children ages birth to 21 served under programs of the Individuals
with Disabilities Education Act (IDEA).
 Includes Part B special education for children ages 3 to 21 and Part C early
intervention programs for infants and toddlers ages birth to 3
 Use Medicaid to fund the health-related services for infants and toddlers

1990s (4 of 4)
In 1970, only 9% of children
with special health care
needs were participating in
Medicaid
By 2017, Medicaid and CHIP
together covered nearly half
(47%) of the estimated 13.3
million children with special
health care needs ages birth to 17
Dramatic Impacts of Policy Changes

Medicaid and the Affordable Care Act Era
(1 of 2)
Patient Protection
and Affordable
Care Act of 2010
(ACA)
As enacted, would have expanded Medicaid eligibility to include nearly all individuals
younger than age 65 with income up to 133% of the federal poverty level
The U.S. Supreme Court ruled (National Federation of Independent Business v. Sebelius)
that Congress did not have the authority to set a single national (i.e., federal,
nationwide) Medicaid eligibility level and compel states to adopt this Medicaid
expansion; mandatory Medicaid eligibility expansion determined “unconstitutional”
As of May 2020, 36
states and the
District of Columbia
had used their
option to expand
their Medicaid
programs under
the ACA
In states that did not expand their Medicaid programs, as of January 2020, the median
eligibility level for parents was 41% FPL.
Many adults without children are not eligible in those states; millions of poor and near-
poor young adults are left without eligibility for coverage under Medicaid or ACA
marketplace exchange plans.

Medicaid and the Affordable Care Act Era
(2 of 2)
Expansion
associated
with:
Increases in coverage, service utilization, and quality of care
received
Some studies have shown associated improvements in birth
outcomes.
ACA had
less
impact on
children.
Coverage expansions for children had actually begun decades
earlier under Medicaid and CHIP.
Improved the use of preexisting coverage for children when
their parents' obtained coverage in publicly subsidized programs

The Impact and Legacies of Medicaid
Policy Change

Structural Changes (1 of 3)
 Medicaid became the single largest source of financing for
maternity care and child health services, as well as the
single largest public source of funding for family planning.
 State to state variations but access to maternity care, including prenatal, birth, and postpartum
services, was expanded
 Mixed results regarding the impact of Medicaid expansion on birth outcome
 Continuing challenges in securing access to quality care in settings where they are treated with
respect and where there is cultural competency or congruency
 Policy trends over the past 35 years also point to the failure to provide coverage and services to
women of childbearing age.
 Medicaid family planning coverage expansions are associated with lower average annual birth
rates and generally offset the cost of MCH expenditures that would have been incurred through
unintended pregnancies, but have reached too few women.
 Expansions not only led to fewer uninsured children, but also provided more comprehensive
coverage through EPSDT amendments.
• EPSDT amendments politically unpopular and often cited as one pf the objectionable “unfunded
mandates.”
 The politics of the ACA overall and the politics of Medicaid collided.

 Social learning and block grants
 Social learning: a deliberate attempt to adjust the goals or
mechanisms of policy in response to past experience
 The political pressure for Medicaid block grants or waivers that
mimic block grants reflects elements of policy debates over the
last two decades
• States’ requests to use alternative waiver approaches are a reflection of conservative
governors’ long-held views about state flexibility in Medicaid administration
• Continued in the Trump administration
 Disability and special needs
• Family Voices and other organizations have been active advocates for ensuring that children
with disabilities, complex medical conditions, mental health needs, and other special needs
have Medicaid coverage.
• Parents’ political influence and advocacy impact has grown over time.
– Advocacy efforts to block repeal of the ACA and its Medicaid provisions and organized
opposition to Medicaid block grants by people with disabilities and parents of children with
disabilities.

 The legacies of CHIP
 Conservatives’ desire to avoid entitlements in favor of block grants set the U.S. Congress on a
path to creation of CHIP outside of Medicaid.
 Creation of CHIP had its largest impact on children’s health coverage.
 Also influenced other political and health policy trends, particularly block grant policy
• While any state could have extended Medicaid to the children ultimately covered by CHIP, Congress
designed the program as a block grant.
• Millions of children enrolled in CHIP did not have access to EPSDT benefits, limits on cost-sharing, and
other protections of Medicaid.
 Over time, more states saw the advantages of combining Medicaid and CHIP
• Most states now use the option to incorporate CHIP into Medicaid and thus make children eligible for
EPSDT services.
• Positions states to administer just one program and means that they do not have to negotiate or
coordinate with private health insurance plans.
 The CHIP benchmark benefit packages and premium support model was ultimately used in the
ACA.
 In the process for reauthorization of the originally bipartisan CHIP program, partisan politics
became a driving factor.
• President George W. Bush vetoed two attempts to reauthorize and further expand the program.
• President Barack Obama immediately signed the Children’s Health Insurance Reauthorization Act of 2009
(CHIPRA) into law.

Medicaid’s Comprehensive Child Health
Benefits EPSDT

The Uniquely Childhood-Focused and Preventive
Purposes of EPSDT
Medicaid’s Early Periodic Screening, Diagnostic, and Treatment (EPSDT) child health benefit
Anyone younger
than age 21
enrolled in
Medicaid receives
coverage for
EPSDT checkups
to identify
physical, dental,
developmental,
and mental
health conditions
Covers so-called
screening visits
“to detect
physical and
mental
conditions,”
which are
covered at
established,
periodic intervals
(based
“periodicity
schedules”) and
whenever a
problem is
suspected
Treatment
component is
broadly defined.
Federal law
specifies that
coverage must
include all
“medically
necessary”
diagnostic and
treatment
services that fall
within the federal
definition of
Medicaid medical
assistance,
regardless of
whether such
services are
otherwise
covered for
adults.
States also have
an affirmative
obligation to
make sure
families know
about the EPSDT-
covered services
and to help them
gain access to
those services.
Other benefits
include assistance
in scheduling
appointments,
arranging for
treatment, and
financing for
transportation to
keep
appointments.

The Origins of EPSDT in the War on Poverty
 Introduced by President Johnson
 EPSDT amendments to Medicaid were enacted as a
policy response to two distinct sets of information
that had an impact on how Johnson thought about
child health policy.
 Since 1967, the purpose of the EPSDT program has
been:
 “to discover, as early as possible, the ills that handicap our
children” and to provide “continuing follow up and treatment
so that handicaps do not go neglected”

The Ongoing Failure to Implement EPSDT
(1 of 2)
 Medicaid and EPSDT are operated under a federal–state partnership,
with many key implementation, eligibility, coverage, and payment
decisions made by states
 EPSDT linked to the Title V Maternal and Child Health Program from beginning
 Currently, the law requires state Title V programs to:
 Assist with coordination of EPSDT, establish coordination agreements with
their Medicaid programs, provide a toll-free number for families seeking
providers, provide outreach to and facilitate enrollment of Medicaid-eligible
children and pregnant women, share data collection responsibilities, and
provide services for children with special health care needs and disabilities not
covered by Medicaid
 Partnerships between a state’s two primary MCH programs—
Medicaid and Title V— have contributed to the success of both
entities in terms of achieving their goals for improved MCH.

(2 of 2)
 Problems implementation continued reflect a larger problem related to
equity in access for poor children.
 States’ implementation of EPSDT remains uneven today.
 Even when implemented, poor families were not receiving the well-
child screening services to which they were entitled and that few
referrals were documented.
 States have resisted the call to finance treatment under EPSDT, in large
part due to cost concerns.
 Inconsistency of guidelines
 Persistent underutilization and/or underreporting of EPSDT well-child
visits
 Most states did not meet the national goal for 80% participation for the
years between 2006 and 2013.

(Figure 20-1)
Example of EPSDT participation ratio data by state for toddlers
ages 1 and 2. The national average fell just short of the 80%
performance goal, with 79% of toddlers enrolled

Role of Medicaid and CHIP in Health
Coverage for Children

Trends in Public and Private Health Coverage for
MCH Population (1 of 2)
 With enactment of the ACA in 2010 and its implementation in 2014
 Many more women of childbearing age and men were able to secure
health coverage through Medicaid or ACA marketplaces
 The proportion of births, family planning, and other reproductive health
and preventive services financed by Medicaid was increased further
 Extension of coverage to parents made a difference in children’s
insurance, whether that coverage was obtained through Medicaid,
CHIP, or ACA policy
 Medicaid/CHIP expansion policy has been effective in reducing the
number of children without health insurance, largely offsetting
reductions in employer-based coverage overall and for dependents.

MCH Population (Figure 20-2)
Figure shows long-term trend in child health coverage,
beginning in 1978 around the time of the CHAP
proposals.

MCH Population (2 of 2)
 States that expanded their Medicaid programs for adults also had
substantial gains in child enrollment.
 During the COVID-19 emergency (as declared by the U.S. Department
of Health and Human Services), Congress, CMS, and states all used
Medicaid as a key element of the response.
 Medicaid coverage for millions of people who lost their jobs as a result of
the pandemic
 Every state had the opportunity to:
• Quickly expand Medicaid eligibility to more uninsured individuals, further streamline enrollment processes,
guarantee continuous enrollment until the end of the emergency, reimburse for virtual services at the same
rate as face-to-face encounters (e.g., by telephone or Internet connections), extend the community
settings where care can be delivered, and reimburse a wide sector of the workforce (e.g., home visitors,
community health workers, mental health counselors, school nurses)
 State Medicaid agencies could permit flexibility in delivery of prenatal,
birth, and postpartum care, including home births assisted by nurse–
midwives and support of trained doulas, along with virtual prenatal visits.

Medicaid as a Program to Advance
Equity

Advancing Equity
 Medicaid expansions of the past 30 years had greater impact on health
coverage rates for poor children of color than their White counterparts.
 Variations in Medicaid coverage that reflect differences in both state eligibility
policy and poverty rates by race/ethnicity.
 State variations in child poverty rates and Medicaid income eligibility levels
 Among CSHCN covered by Medicaid, two-thirds are children of color.
 Lackluster outreach efforts, unfriendly application processes, and wrongful
disenrollment continue to limit the reach of coverage expansions.
 Pressures on immigrant families are another force dissuading families from
seeking out coverage through Medicaid and CHIP.

Summary
 For women, Medicaid coverage remains insufficient in many states—and, even
where they are eligible, appropriate, unbiased, and high-quality services for
women may not be available
 In reproductive and perinatal healthcare:
 Coverage that meets the recommendations and standards of the Women’s
Preventive Services Initiative and federal recommendations for women’s clinical
preventive services is essential
 While approximately 95% of children in the U.S. now have health coverage, trends
suggest an erosion of coverage rates in the most recent years. Thus, protecting
and maintaining children’s health coverage is a priority.
 Medicaid and EPSDT must play a continuing role in advancing equity.
 To eliminate health disparities and achieve health equity, Medicaid and CHIP must
achieve the optimal performance and operate as an effective source of financing
for the children, women, and other low-income Americans they cover.

Week 6 Assignments
Discussion Board
Quiz on Chapter

PBH 805: Week 6 Slides

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