Background
I am honored to serve as co-chair of the Children’s Subcommittee of Comptroller Sean Scanlon’s Healthcare Cabinet alongside Alice Forrester, the chief executive officer of Clifford Beers Clinic in New Haven. Comptroller Scanlon formed this subcommittee following his convening of a Children’s Health Summit in September 2023 at Sacred Heart University in Fairfield. The convening included a rich discussion of key issues and opportunities to transform child healthcare to best strengthen families and promote children’s optimal health, development, and well-being. The Comptroller encouraged attendees to be both thoughtful and bold in offering comments and suggestions on policy and programmatic implications. The ensuing enthusiastic conversation identified many key concepts and principles essential to the goal of transforming, rather than merely reforming, child healthcare.
Following a series of similar statewide convenings on critical issues in healthcare, Comptroller Scanlon formed eight subcommittees to address key components of healthcare transformation, including ours on child health. He charged us with identifying policy and programmatic recommendations to advance child health and submitting these recommendations to inform his priorities and actions for 2024. The Comptroller informed us that we have a “clean slate” to identify issues and recommendations. He also emphasized his intent to continue this work beyond the initial recommendation-generating period. He cautioned against preparing a report that would simply sit on a shelf and encouraged the development of a “living, breathing document” that would continually undergo revision and updating in response to changing circumstances and evolving needs and priorities.
Throughout the two-month period of our discussions, a subcommittee of twelve members actively participated in four biweekly meetings. They also held individual discussions, shared materials, and exchanged emails. This process enabled the subcommittee to efficiently design consensus recommendations for policy and programmatic priorities. Our methodology included identifying key concepts to inform our thinking and planning, articulating critical issues demanding our attention, defining our target population, and advancing recommendations for programmatic and policy priorities.
Key Concepts
Our discussions highlighted several key concepts to inform efforts to advance children’s healthcare to achieve the desired outcomes. Examples include, but are not limited to:
• Critical importance of social, environmental, and behavioral drivers of health and well-being;
• Benefit of a clearly defined target population;
• Need for relevant data to inform priorities;
• Imperative of a focus on key issues and opportunities and the need to prioritize a select few;
• Opportunity to elevate work already in progress;
• Importance of increasing families’ access to resources to address needs;
• Need for recommendations to be aligned with similar efforts of other key subcommittees;
• Benefit of relevant and related groups coalescing and synergizing around goals and priorities;
• Imperative of encouraging and rewarding cross-sector collaboration that “connects the dots” for families, children, and youth; and the
• Utility of funding streams and structures to achieve scaling and sustainability, including the blending and braiding of funds and funding models, such as value-based contracting.
Critical Issues
The subcommittee highlighted a wide array of critical issues facing children, families, and communities, deserving of our attention. Such issues predominantly reflect the devastating impact of generational poverty and social inequity. Among a number of cited problems and concerns, subcommittee members emphasized the limited access to basic needs such as diapers, food, and housing; healthcare access and costs, including barriers to prenatal care; the mental health crisis and the lack of community-based mental health models; challenges accessing siloed programs and services; and the need for enhanced supports for caregivers, including those caring for children and the elderly.
Target Populations
We next considered how best to define the target population for our recommendations. In general, we recognized the appeal of programs and policies that benefit the entire population, acknowledging that many families, regardless of socioeconomic status, have priorities, opinions, and concerns for their children’s optimal health, development, and well-being, as well as the need to engage all lawmakers in supporting proposals, regardless of the characteristics of their jurisdictions. However, we also recognized and acknowledged the importance of meeting the daunting needs of underserved populations and ensuring their facilitated access to programs, services, and resources. Therefore, we embraced the process of targeted universalism by setting universal goals pursued by targeted processes based on the real complexities within certain populations to identify necessary, tailored solutions to ensure facilitated access by those with the greatest needs. With respect to specific groups deserving our particular attention, we highlighted those residing in the urban core and rural periphery, as well as disengaged, disconnected, so-called opportunity youth.
Programmatic and Policy Priorities
Comptroller Scanlon challenged us to offer 1-2 priorities for the upcoming legislative session, and we did our best to comply with his instructions. Ultimately, we highlighted three areas worthy of consideration.
One set of recommendations focused on increasing access to programs, services, and resources for target populations. Potential strategies to advance this priority include mental health parity, such that reimbursement rates for mental health disorders of children and youth are comparable to those for the treatment of traditional medical disorders; maximizing relief payments and services by optimizing access to and uptake of federal and state assistance programs such as SNAP and Medicaid and reinstituting such impactful pandemic relief programs as the child tax credit, earned income tax credit, the emergency rental assistance program, and loan payment relief; promoting funding model flexibility by directing congressional allocations of funds to underserved communities, committing a certain percentage of state block grant funding to strengthen vulnerable families and communities, and capturing and delivering unspent, unencumbered federal dollars to local communities instead of returning them to the federal government; and revamping service delivery locations to meet the needs of children and youth "where they are at," such as schools, community resource centers, and related organizations.
A second set of recommendations addressed the need to sustain key programs, services, and resources through an "invest-reinvest strategy." Suggested strategies include advancing return-on-investment (ROI) methodologies through state-funded technical assistance to support community-based organizations in demonstrating ROI, cost savings, and cost benefits of programs and services to enable their sustainability. We elevated a second strategy, a value-based care pilot study, as our strongest recommendation for the report. Specifically, we advocate pilot testing of a value-based care program that examines creative financing strategies for child health services in the State of Connecticut Health Plan (i.e., for state employees). We believe that success with such a plan for child health services could inform similar efforts across the lifespan and with other payers, public (i.e., Medicaid), and private.
Our third priority is to advance collaboration and system building through three specific strategies. We recommended emulating a number of states that have found children’s cabinets and family councils to function as effective vehicles for inter-agency collaboration. A second strategy targets care coordination. While we acknowledge that Connecticut has many accessible resources in place to support families in the referral and linkage process, coherent policy is necessary to ensure that such services are comprehensive, organized, and integrated to best serve families’ needs and are available to all families in all regions of the state. The third strategy is to enable access to and utilization of cross-sector, inter-agency data sharing to inform system building, performance improvement, and policy priorities. We recommend expanding the understanding of what is possible under the data privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA).
Where Do We Go from Here?
In creating the cabinet and advancing this work, Comptroller Scanlon characterized this effort as a lesson in civic engagement and political power. The hundreds of individuals who participated in convenings and on subcommittees highlight the power of civic engagement to advance this work. Now that recommendations are public, the importance of political will in advancing priorities is critical. I recall a pre-pandemic conversation in Washington, DC with John Kitzhaber, the former governor of Oregon who led that state’s impressive healthcare reform efforts. I asked Kitzhaber, an emergency medicine physician, how Oregon was able to so effectively advance healthcare transformation. His response was simple and direct-“It’s all about leadership.” We are hopeful, and even optimistic, that our elected officials, with the strong leadership of Comptroller Scanlon, will embrace our recommendations and begin to consider how to advance them. The fact that we have recently received a request to meet with Josh Wojcik, policy director for the Office of the State Comptroller, to discuss our proposal for a pilot study of value-based care is an encouraging sign. I look forward to keeping you informed as our subcommittee continues to advocate for a “children’s health services transformation first” agenda that goes beyond mere reform to strengthen families and communities to promote the optimal health, development, and well-being of all children and youth.