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Children's Health: Health Affairs' December Issue

Bethesda, MD--The December issue of Health Affairs includes a number of studies examining current threats to the health and health care of America's children, and what can be done to meet their needs within an ever-evolving health care system. Some of the subjects covered: the role of Medicaid in reducing early-term elective deliveries; how pediatric services are covered in the state insurance Marketplaces; Medicaid spending on children with complex medical conditions; and the effect of abuse and neglect on children's health and school engagement. 
This issue of Health Affairs is supported by The W.K. Kellogg Foundation as well as by the Children's Hospital Association, The David and Lucile Packard Foundation, Nemours, the Annie E. Casey Foundation, and The Child and Adolescent Health Measurement Initiative. 
What role do state Medicaid programs play in reducing the number of early-term elective deliveries? Tara Trudnak Fowler of Altarum Institute and coauthors at AcademyHealth and two Medicaid medical directors studied the results of a project led by Medicaid medical directors that sought to coordinate quality improvement efforts related to early elective deliveries in the Medicaid population. The authors find that almost 9 percent of the 1.8 million-plus Medicaid births each year are early elective deliveries that result in a higher rate of neonate and neonatal intensive care unit admissions or transfers, compared to full-term elective deliveries. Furthermore, these deliveries add to morbidity rates and costs. The authors also find that early, elective delivery rates among Medicaid births are dropping but still need to be reduced. Finally, the authors identify policies implemented in states to reduce the rate of these births, including prior authorization (that is, patients needing permission from their Medicaid plan to have an early elective birth) and "hard stop" policies (that is, hospitals prohibiting such procedures), as well as education and feedback efforts targeting patients and physicians.
How are pediatric services covered in the state insurance Marketplaces? Aimee M. Grace of Children's National Health System and coauthors examined how state benchmark insurance plans--the base plan chosen for coverage in each state under the Affordable Care Act (ACA)--cover pediatric services
through the state insurance Marketplaces. The study finds that although pediatric services is a required essential health benefit (EHB), neither the law nor subsequent implementation rules have defined what services must be covered apart from vision and oral care, and no state has specified a specific coverage category for pediatric services in Marketplace plans. The authors find that this has resulted in patchwork pediatric coverage, with many plans that do not cover services for children with special health needs and disabilities. The authors recommend that pediatric treatment limits and exclusions be barred when the Department of Health and Human Services reviews EHB guidelines for the 2016 plan year, and that the use of Children's Health Insurance Program plans as benchmarks for pediatric services in marketplace plans should be permitted.
How can the United States save on health care spending for children on Medicaid with medical complexity? Children with complex medical conditions make up a tiny fraction of the pediatric patient population but account for much of pediatric health care spending. Jay G. Berry of Boston Children's Hospital and Harvard Medical School and coauthors look at how spending for these Medicaid patients can be controlled while ultimately improving care. The study shows that disproportionate funding of pediatric
Medicaid patients with medical complexity largely stems from their hospital stays. For example, a 10 percent reduction in hospital admissions of children with medical complexity for conditions that could be treated via ambulatory services could underwrite a budget-neutral 26 percent increase in primary care spending for these patients. The article also suggests other areas of care delivery that could be ripe for cost savings and help support increased primary and home care for these patients.  
How common is exposure to traumatic social and family experiences, and how does it affect US children? Christina D. Bethell of the Johns Hopkins Bloomberg School of Public Health and coauthors assessed the prevalence of adverse childhood experiences (ACEs) among US children, including exposure to violence, extreme economic hardship, family discord, and mental health and substance abuse problems. The authors found that while nearly one-half of US children had encountered at least one of nine types of adverse experiences; over 22 percent (or one in five) had two or more such experiences.
These children were more than twice as likely to have a chronic condition and special health care needs and were over 2.5 times more likely to have repeated a grade in school. However, the authors also found that children who learned some resiliency skills--such as the capacity to usually or always stay calm and in control when faced with a challenge--had mitigated negative effects, including being much more likely to be engaged in school. The authors find that children receiving care in a family-centered medical home were more likely to demonstrate key aspects of resilience even when they were exposed to higher numbers of adverse childhood experiences.  
Other papers of interest in the December issue include:  

About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a one-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.