Disparities in Early Childhood
Connecticut Children’s 2019 Community Health Needs Assessment (CHNA) highlights many disparities between Hartford residents and state residents in regards to income, poverty, high school graduation rates, chronic school absenteeism, health insurance, and disabilities.[1]
The CHNA also articulates another deeply concerning issue – although all children have access to free public education, children in Hartford are entering our public education system already behind their suburban peers. Children in other urban areas face the same problem. Only 33% of Hartford children enter kindergarten on track and ready to learn, according to the Hartford Foundation for Public Giving’s report of the Early Development Instrument completed by kindergarten teachers in Hartford and West Hartford.[2] Our schools cannot make up for all the disparities that are set in motion before children even enter their classrooms.
When we look at the reasons why children are not ready for school – documented in large, national, longitudinal studies – we see that health concerns and social-emotional issues exist for two-thirds of the children who lag behind in cognitive skills in kindergarten.[3] Health and behavioral health are within the purview of pediatric primary care, a service that just about all children use frequently during the years before school entry. Therefore, the value of transforming pediatric primary care to increase its contribution to child well-being has far-reaching implications for the future of children and our population as a whole. Healthy children can attend, do well in, and benefit from school and ultimately participate in the workforce and our democratic society.
The question then becomes, what do we need to do to transform child health services to better address children’s well-being?
Essentials for Transformation to Enhance Child Well-being
With funding from the Children’s Fund of Connecticut and the Connecticut Health Foundation, the Child Health and Development Institute convened a study group to explore transformation of pediatric primary care to increase its contribution to population health, promote health equity, and achieve better integration with community services.[4] The study group’s work identified several essential components of transformed pediatric primary care, but I think three are most important.
First, we must connect child health services to the broader community, and all of its supports for children and families. Such connections allow child health services to better address the social determinants of health. By strengthening connections between child health and community services, we take advantage of all of the services that contribute to children’s well-being, including childcare, schools, home visiting, nutrition and housing services. Currently, the United States spends more on healthcare and less on social services than any other developed nation. Yet, we have the worst health outcomes.[5] By embracing an “all sectors in” approach to healthcare transformation, we can start to reduce those overall costs and improve the overall health and well-being of our population, beginning with children.
Second, we need to identify and commit to outcome metrics that are shared across sectors. We will never achieve the outcomes that are predictive of lifelong success unless we gain cross-sector commitment to shared outcomes. States are increasingly holding health services accountable for such outcomes as school readiness, school attendance, third grade reading, and rates of high school graduation. If health care organizations continue to measure and monitor only their own performance in isolation from the larger set of services that contribute to children’s well-being, we will yield little to no forward progress. We must commit to and measure outcomes that are the result of service systems working together.
Third, we need to ensure that value-based payment reform recognizes and rewards the promotion and prevention opportunities in pediatric primary care. In addition, all payers must participate in new payment models as pediatric primary care sites cannot transform for one or a few payers only; they provide a universal service and need to deliver services equally for all children. Reform also needs to encompass payment for other services beyond office visits. Some of the services that can bring value include: telehealth, co-management, and home visiting.
