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Implications for Policy| Volume 17, ISSUE 7, SUPPLEMENT , S136-S143, September 01, 2017

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities

DOI:https://doi.org/10.1016/j.acap.2017.04.007
Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities
Previous ArticleDeveloping a Community-Wide Initiative to Address Childhood Adversity and Toxic Stress: A Case Study of The Philadelphia ACE Task Force
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      Abstract

      Adverse childhood experiences (ACEs) occur when children are exposed to trauma and/or toxic stress and may have a lifelong effect. Studies have shown that ACEs are linked with poor adult health outcomes and could eventually raise already high health care costs. National policy interest in ACEs has recently increased, as many key players are engaged in community-, state-, and hospital-based efforts to reduce factors that contribute to childhood trauma and/or toxic stress in children. The Affordable Care Act (ACA) has provided a promising foundation for advancing the prevention, diagnosis, and management of ACEs and their consequences. Although the ACA's future is unclear and it does not adequately address the needs of the pediatric population, many of the changes it spurred will continue regardless of legislative action (or inaction), and it therefore remains an important component of our health care system and national strategy to reduce ACEs. We review ways in which some of the current health care policy initiatives launched as part of the implementation of the ACA could accelerate progress in addressing ACEs by fully engaging and aligning various health care stakeholders while recognizing limitations in the law that may cause challenges in our attempts to improve child health and well-being. Specifically, we discuss coverage expansion, investments in the health workforce, a family-centered care approach, increased access to care, emphasis on preventive services, new population models, and improved provider payment models.

      Keywords

      Adverse childhood experiences (ACEs) refer to traumatic experiences that result in the activation of unrelenting toxic stress. ACEs have been linked to lifelong consequences and implications for adult health, health care, and costs.
      • Bethell C.
      • Gombojav N.
      • Solloway M.
      • et al.
      Adverse childhood experiences, resilience and mindfulness-based approaches.
      Child Adolesc Psychiatr Clin. 2016; 25: 139-156
      , 
      • Felitti V.J.
      • Anda R.F.
      • Nordenberg D.
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults.
      Am J Prev Med. 1998; 14: 245-258
      , 
      • Shonkoff J.P.
      • Garner A.S.
      Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics
      The lifelong effects of early childhood adversity and toxic stress.
      Pediatrics. 2012; 129: e232-e246
      , 
      Centers for Disease Control and Prevention
      Adverse childhood experiences (ACEs).
      2016
      http://www.cdc.gov/violenceprevention/acestudy/
      Approximately 35 million children in the United States have experienced one or more types of childhood trauma, representing almost half (47.9%) of US children.

      National Survey of Children's Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement Initiative. Data Resource Center for Child and Adolescent Health. Available at: http://www.childhealthdata.org/browse/survey/results?q=2614&r=1. Accessed June 7, 2016.

      While some forms of ACEs are well recognized (eg, child abuse, neglect, or witnessing intimate partner violence), household dysfunction (divorce, parental substance abuse), and stressful experiences endemic to families living in poverty (food shortages, housing insecurity, worry about neighborhood safety) have also been shown to have significant impact on children.
      Centers for Disease Control and Prevention
      About the CDC-Kaiser ACE study.
      2016
      http://www.cdc.gov/violenceprevention/acestudy/about.html
      Moreover, because the sources of stress are abundant in the environments of poor and at-risk parents and children, poverty itself can lead to conditions that increase stress on all family members.
      • Brooks-Gunn J.
      • Duncan G.J.
      The effects of poverty on children.
      Future Child. 1997; 7: 55-71
      Further, the effects of these adverse events are cumulative: the greater number a child is exposed to, the more likely and profound the impact.
      Centers for Disease Control and Prevention
      Adverse childhood experiences (ACEs).
      2016
      http://www.cdc.gov/violenceprevention/acestudy/
      Since the Centers for Disease Control's landmark ACEs study over 20 years ago,
      Centers for Disease Control and Prevention
      About the CDC-Kaiser ACE study.
      2016
      http://www.cdc.gov/violenceprevention/acestudy/about.html
      evidence has continued to mount on the many ways that ACEs are linked to chronic diseases and poor adult health outcomes, as well as overall cost of care.
      • Lanius R.A.
      • Vermetten E.
      • Pain C.
      The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic.
      Cambridge University Press, New York, NY2010
      However, studies have also shown that interventions, especially if implemented early in childhood, can prevent or mitigate the effects of adverse experiences on a child's life and can improve their health and well-being, including physical, emotional, and psychological health.
      • Bethell C.
      • Gombojav N.
      • Solloway M.
      • et al.
      Adverse childhood experiences, resilience and mindfulness-based approaches.
      Child Adolesc Psychiatr Clin. 2016; 25: 139-156
      , 
      • Shonkoff J.P.
      • Garner A.S.
      Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics
      The lifelong effects of early childhood adversity and toxic stress.
      Pediatrics. 2012; 129: e232-e246
      The Affordable Care Act (ACA) is a landmark effort to overhaul and reform the US health care system. Many policy and programs initiatives launched over the last 5 years as part of the implementation of the ACA provide the opportunity for health systems and providers to engage and collaborate to address ACEs in new ways. At the time of publication, the national policy conversation is centered on whether, how, and when the ACA would be repealed, replaced, or repaired. Nevertheless, the ACA is still playing a key role in transforming the US health system, and here we highlight several features of the ACA that are relevant to mounting a comprehensive approach to ACEs. These include coverage expansion, investments in the health workforce, a family-centered care approach, increased access to care, emphasis on preventive services, new population models, and improved provider payment models. If appropriately leveraged, ACA-initiated reforms can help mitigate the impact of ACEs on children's health and well-being.

      Role of Health Care System in Addressing Social Determinants

      Social determinants of health recognize that an individual's health is deeply influenced by his or her social and physical environments.
      • Cole B.L.
      • Fielding J.E.
      Health impact assessment: a tool to help policy makers understand health beyond health care.
      Annu Rev Public Health. 2007; 28: 393-412
      As the number of uninsured children continues to decline
      Kaiser Family Foundation
      Key Facts About the Uninsured Population.
      2015
      http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
      and children's access to care improves, the health care system has an opportunity to reach more children and improve their well-being by working with other sectors to address the social determinants of health. Having health care systems engage in the more upstream determinants of health outcomes for children is not a new concept.
      Council on Community Pediatrics
      Poverty and child health in the United States.
      Pediatrics. 2016; 137: e20160339
      One of the oldest examples of the critical role that health care providers can play in identifying and addressing social issues dates back to Henry Kempe and the description of “battered child syndrome” in 1962.
      • Kempe C.
      • Silverman F.N.
      • Steele B.F.
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      The battered-child syndrome.
      JAMA. 1962; 181: 17-24
      More recently, there are an increasing number of examples of providers and the health care system successfully addressing the educational, legal, and other needs of families, usually in partnership with community or governmental agencies, including Reach Out and Read and the Medical-Legal Partnership.

      Reach Out and Read. About us. Available at: http://www.reachoutandread.org/about-us/. Accessed June 7, 2016.

      , 

      The need. National Center for Medical-Legal Partnership; Milken Institute of Public Health; George Washington University. Available at: http://medical-legalpartnership.org/. Accessed June 7, 2016.

      Capitalizing on Health Care Transformation to Address ACEs

      While many of the ACA's provisions are directed at adults, especially high-cost adults, the general framework for reform within the ACA in addition to the dramatic changes in health care systems across the country, have benefited children's health. We focus on several provisions that should support a comprehensive strategy for addressing ACEs while considering the additional steps that are needed in health care reform for children experiencing ACEs to fully benefit from the law.

       Coverage for Parents and Children

      A child's well-being is closely linked to his or her parents' or caregivers' stability. Research shows that a parent's ability to act as a buffer from toxic stress greatly affects early childhood development.
      • Shonkoff J.P.
      • Fisher P.A.
      Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy.
      Dev Psychopathol. 2013; 25: 1635-1653
      Coverage mechanisms in the ACA have provided an opportunity for families to be covered through the same insurance plan, through the individual mandate and Medicaid expansion. Increased coverage has also promoted the use of appropriate health care and evidence-based preventive services by decreasing out-of-pocket costs and providing clearer information about health care choices. In addition, increased coverage has been coupled with new community-based approaches such as health care navigators and an emphasis on patient- and family-centered care.
      • Rosenbaum S.
      • Trevino Whittington R.P.
      Parental Health Insurance Coverage as Child Health Policy: Evidence From the Literature.
      Department of Health Policy, School of Public Health, George Washington University, 2007
      http://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/Parental_Health_Insurance_Report.pdf
      Coverage reforms through the ACA can increase the likelihood that children will receive care, allowing health care providers to prevent and mitigate the impact of ACEs early to ensure children are resilient to its effects across the life span. Additionally, it provides the opportunity for parents to receive the health and social services they may need to address their own ACEs and provide children a more positive environment. Finally, increasing (or retaining existing expansions of) coverage, decreasing out-of-pocket expenses, and improving access help free up critical resources for families—resources that can be used for employment, financial planning, child care, school readiness, and safety, thus allowing even low-income families to provide a more nurturing environment for children, mitigating some of the toxic effects of poverty and community disinvestment.
      • Ku L.
      • Broaddus M.
      Coverage of Parents Helps Children, Too.
      Center on Budget and Policy Priorities, 2006
      http://www.cbpp.org/research/coverage-of-parents-helps-children-too
      The major coverage reforms include the individual mandate and the new Medicaid eligibility at 133% of the federal poverty level.

      Centers for Medicare and Medicaid Services. HealthCare.gov: how to qualify for Medicaid and CHIP health care coverage. HealthCare.gov. Available at: https://www.healthcare.gov/Medicaid-chip/getting-Medicaid-chip/. Accessed June 7, 2016.

      The data indicate that 64% of children in Medicaid have experienced one or more ACEs, and 75% of all children with emotional, mental, and developmental problems have ACEs.
      • Teich J.L.
      • Buck J.A.
      • Graver L.
      • et al.
      Utilization of public mental health services by children with serious emotional disturbances.
      Adm Policy Ment Health. 2003; 30: 523-534
      Since March 2016, 32 states have expanded their Medicaid programs.
      Kaiser Family Foundation
      Status of State Action on the Medicaid Expansion Decision.
      2016
      http://kff.org/health-reform/state-indicator/state-activity-around-expanding-Medicaid-under-the-affordable-care-act/
      Other ACA changes that are expected to increase health insurance coverage among children include tax credits for plans available in the health insurance exchanges (marketplaces), health insurance market reforms, and coverage of basic preventive services.

      Gates J, Karpman M, Kenney GM, et al. Uninsurance among children, 1997–2015: long-term trends and recent patterns. Available at: http://www.urban.org/research/publication/uninsurance-among-children-1997-2015-long-term-trends-and-recent-patterns. Published April 19, 2016. Accessed June 7, 2016.

      , 
      • Kenney G.M.
      • Haley J.M.
      • Anderson N.
      • et al.
      Children eligible for Medicaid or CHIP: who remains uninsured, and why?.
      Acad Pediatr. 2015; 15: S36-S43
      Studies, including multiple surveys, have begun to document the impact of the ACA on coverage for children since 2013 and indicate a significant increase in health care coverage for children over the last few years.

      Gates J, Karpman M, Kenney GM, et al. Uninsurance among children, 1997–2015: long-term trends and recent patterns. Available at: http://www.urban.org/research/publication/uninsurance-among-children-1997-2015-long-term-trends-and-recent-patterns. Published April 19, 2016. Accessed June 7, 2016.

      , 
      • Martinez M.E.
      • Cohen R.A.
      • Zammitti E.P.
      Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey.
      National Center for Health Statistics, Centers for Disease Control and Prevention, 2016
      http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201602.pdf
      , 

      Kenney GM, Haley JM, Wang Pan C, et al. Children's coverage climb continues: uninsurance and Medicaid/CHIP eligibility and participation under the ACA. Available at: http://www.urban.org/research/publication/childrens-coverage-climb-continues-uninsurance-and-Medicaid-chip-eligibility-and-participation-under-aca. Accessed June 7, 2016.

      , 
      State Health Access Data Assistant Center
      State Level Trends in Children's Health Insurance Coverage.
      2016
      http://www.shadac.org/sites/default/files/publications/Final%20Kids%20Report%202016_0.pdf
      , 
      • Alker J.
      • Chester A.
      Children's Health Insurance Coverage Rates in 2014: ACA Results in Significant Improvements.
      Center for Children and Families, Georgetown University Health Policy Institute, 2015
      http://ccf.georgetown.edu/ccf-resources/childrens-uninsured-rate-2014-affordable-care-act/
      Most recently, Gates et al

      Gates J, Karpman M, Kenney GM, et al. Uninsurance among children, 1997–2015: long-term trends and recent patterns. Available at: http://www.urban.org/research/publication/uninsurance-among-children-1997-2015-long-term-trends-and-recent-patterns. Published April 19, 2016. Accessed June 7, 2016.

      found a significant drop in uninsured children after implementation of the ACA's key coverage provisions from 7.1% in 2013 to 4.8% in 2015.
      However, there remain many inconsistencies in the implementation of the ACA, which have further exacerbated the current fragmentation of parental and child coverage. As a result, there is a patchwork of insurance options available to children across Medicaid, State Health Insurance Program for Children, the insurance exchanges, and employer-based coverage. Children still may not be in the same plan as their parents, and they may even have a different network of physicians available to them.
      • Heberlein M.
      • Huntress M.
      • Kenney G.M.
      • et al.
      Medicaid Coverage for Parents Under the Affordable Care Act.
      Center for Children and Families, Georgetown University Health Policy Institute, 2012
      http://ccf.georgetown.edu/wp-content/uploads/2012/08/Medicaid-Coverage-for-Parents.pdf
      This fragmentation can inhibit a health care system's ability to offer the family-oriented care important in addressing ACEs.
      • Weil A.
      • Regmi S.
      • Hanlon C.
      The Affordable Care Act: Affording Two-generation Approaches to Health.
      National Academy for State Health Policy, 2014
      http://www.nashp.org/sites/default/files/ACA.8Sept2014.pdf

       Payment and Delivery System Models and Incentives

      In addition to coverage expansions, numerous ACA provisions enhance the ability to deliver effective primary care through payment and delivery system reforms. These reforms are likely to continue and be amplified by more recent policies, even in the face of changes to the coverage provisions of the ACA. Major examples of delivery system reforms include patient/family-centered medical homes (P/FCMHs), which began in pediatrics and then moved to adults, health homes, and accountable care organizations (ACOs). Payment reform initiatives have been designed to reinforce the delivery system reforms; they include higher reimbursement for primary care, bundled payments, and other reforms that emphasize value. While high-cost adults are the focus of many of these reforms, children also can benefit.

       Primary Care Transformation Through Implementation of Patient-Centered Medical Homes

      Team-based care has the potential to provide family support and care coordination, which has been shown to have positive impacts on the toxic stress resulting from ACEs in children and may even help prevent future ACEs.
      • Rushton F.E.
      • Kraft C.
      Family support in the family-centered medical home: an opportunity for preventing toxic stress and its impact in young children. Child health care providers offer valuable support and connections for families.
      Child Abuse Negl. 2013; 37: 41-50
      As discussed in the article by Vu et al
      • Vu C.
      • Rothman R.
      • Kistin C.J.
      • et al.
      Adapting the patient centered medical home to address psychosocial adversity: results of a qualitative study.
      Acad Pediatr. 2017; 17: S115-S122
      in this supplement, a number of the ACA's reforms seek to transform primary care through the PCMH model. The health home for Medicaid enrollees with chronic conditions is a related concept that permits states to bring PCMH to chronically ill children; approximately 17 states now have state plan amendments that permit them to implement health homes. This includes section 2703, the health home provision that has given many state programs the ability to bring PCMH to children. For example, Rhode Island has a program that is specifically geared to special needs children, while many other programs focus on behavioral health, which is directly related to addressing ACEs.

       Improving Quality Through ACOs

      The ACO model is a recognition that health is affected by more than what happens in the provider's office and that many aspects of care require cooperation and engagement of other parts of community systems. PCMHs have served as a foundation for the development of ACOs, and to be maximally effective in addressing ACEs, ACOs would need to recognize health outcomes related to diagnosis and treatment of ACEs and would need to have payment incentives tied to these.
      Since 2011, the Center for Medicare and Medicaid Innovation has launched 70 program models, 11 of which are ACOs,

      Center for Medicare and Medicaid Innovation. Innovation models. Available at: https://innovation.cms.gov/initiatives/index.html#views=models. Accessed June 7, 2016.

      or organizations of health care providers that agree to be accountable for the quality, cost, and overall care of beneficiaries, and in return receive incentive payments based on quality and cost containment instead of volume and intensity.

      Centers for Medicare and Medicaid Services. Overview: accountable care organizations (ACOs). Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/; 2015. Accessed June 7, 2016.

      The majority of the early ACO program models focused on the Medicare population and did not include children. However, future ACOs are specially targeted to children through the Pediatric Demonstration Project, which is in the process of being implemented through 2016.

      Centers for Medicare and Medicaid Services. Overview: accountable care organizations (ACOs). Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/; 2015. Accessed June 7, 2016.

      The American Academy of Pediatrics has outlined a set of “critical success factors for pediatric ACOs.”

      Zimmerman E. Accountable care organizations (ACOs) and pediatricians: evaluation and engagement. American Academy of Pediatrics. Available at: https://www.aap.org/en-us/professional-resources/practice-support/pages/Accountable-Care-Organizations-and-Pediatricians-Evaluation-and-Engagement.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR:+No+local+token. Accessed June 15, 2016.

      Some published studies are beginning to shed light on the impact of ACO models on pediatric care. Kelleher et al
      • Kelleher K.J.
      • Cooper J.
      • Deans K.
      • et al.
      Cost saving and quality of care in a pediatric accountable care organization.
      Pediatrics. 2015; 135: e582-e589
      found that a pre-ACA Medicaid ACO in Ohio was able to slow the growth in costs compared to fee-for-service Medicaid and maintain quality. On the other hand, Gleeson et al
      • Gleeson S.
      • Kelleher K.
      • Gardner W.
      Evaluating a pay-for-performance program for Medicaid children in an accountable care organization.
      JAMA Pediatr. 2016; 170: 259-266
      found that incentives in a pediatric ACO led to only modest changes in physician performance and that other interventions at the disposal of the ACO may have been even more effective. Finally, Chien et al
      • Chien A.T.
      • Schiavoni K.H.
      • Sprecher E.
      • et al.
      How accountable care organizations responded to pediatric incentives in the alternative quality contract.
      Acad Pediatr. 2016; 16: 200-207
      found that most ACOs in the Alternative Quality Contract payment model (which gives provider groups an annual budget for meeting all the health care needs of their patients while still hitting quality targets) group had poor infrastructure to address pediatric needs but reported intensifying their pediatric quality improvement efforts in response to pediatric metrics in the Alternative Quality Contract.

      Paying for results, not treatments. Los Angeles Times, December 31, 2012. Available at: http://articles.latimes.com/2012/dec/31/opinion/la-ed-medicare-ending-fee-for-service-20121231. Accessed September 6, 2016.

      These early findings point to the future potential of quality measures and incentives to reward providers focusing on ACEs. It should be noted, however, that as we identify the best education, assessment, and treatment practices to address ACEs, it is critical to advance new and validated metrics as well as innovative interventions to fully integrate ACEs into delivery measures and payment incentives, as discussed by Bethell et al
      • Bethell C.
      • Carle A.
      • Hudziak J.
      • et al.
      Methods to assess adverse childhood experiences of children and families: towards approaches to promote child well being in policy and practice.
      Acad Pediatr. 2017; 17: S51-S69
      in this issue and in the supplement's foreword.
      Children have also been included in a number of Centers for Medicare and Medicaid Services' (CMS) Healthcare Innovation Awards, which provided organizations an opportunity to create new models that improve the coordination for children's care, especially those with complex health care needs who are likely to have higher ACE scores.
      • Bethell C.D.
      • Newacheck P.
      • Hawes E.
      • et al.
      Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience.
      Health Aff (Millwood). 2014; 33: 2106-2115
      In 2016, 8 Healthcare Innovation Awards totaling over $79 million are specifically addressing child health.
      Centers for Medicare and Medicaid Innovation
      Health Care Innovation Awards.
      2016
      https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/
      , 
      Children's Hospital Association
      Children's Hospitals Applaud CMMI for Awarding $79m in Grant Funding to Children's Health.
      2014
      https://www.childrenshospitals.org/newsroom/press-releases/2014/childrens-hospitals-applaud-cmmi-for-awarding-79m-in-grant-funding-to-childrens-health
      For example, Seattle Children's Hospital has received $5 million to implement and test the Pediatric Partners in Care model, which focuses on providing community-based management for children and their families.
      Centers for Medicare and Medicaid Innovation
      Health Care Innovation Awards Round Two.
      2016
      https://cmmicoordinator.polldaddy.com/s/was-this-helpful?iframe=https%3A%2F%2Finnovation.cms.gov%2Finitiatives%2FHealth-Care-Innovation-Awards%2FRound-2.html&ft=1
      This model can ensure that children and their families have resources in the community to support positive environments in the home and promote resilience. The University of Illinois has received $19 million to experiment with a medical neighborhood model, the Coordination of Healthcare for Complex Kids (CHECK), which brings together different providers to where kids live, play, and go to school.
      Centers for Medicare and Medicaid Innovation
      Health Care Innovation Awards Round Two.
      2016
      https://cmmicoordinator.polldaddy.com/s/was-this-helpful?iframe=https%3A%2F%2Finnovation.cms.gov%2Finitiatives%2FHealth-Care-Innovation-Awards%2FRound-2.html&ft=1
      This model can increase access to care for children and mitigate the effects of ACEs early while linking health care to the various environments children are typically in, allowing the promotion of well-being. Most notably, the Children's Hospital Association has received $23 million to test a new model, Coordinating All Resources Effectively (CARE), for children with complex medical conditions at children's hospitals across states.
      Centers for Medicare and Medicaid Innovation
      Health Care Innovation Awards Round Two.
      2016
      https://cmmicoordinator.polldaddy.com/s/was-this-helpful?iframe=https%3A%2F%2Finnovation.cms.gov%2Finitiatives%2FHealth-Care-Innovation-Awards%2FRound-2.html&ft=1
      Given the intergenerational transmission of ACEs and its impact on children in complex ways, this model can help us in supporting those who have been most affected by childhood adversity.
      Unfortunately, most ACOs have not been able to address social determinants of health because the return-on-investment window is too short. Also, most ACOs have not yet integrated with social services to refer patients to various services they may need outside of health care. One of the challenges of ACOs for children is that they represent a dichotomous population with very different cost profiles: children with chronic and complex conditions, and all other children. Those experiencing ACEs could be in either group. Compounding the issue is that the actuarial challenges are significant with children because of the lack of year-over-year predictability of cost. Finally, evaluations of the ACOs models are only just beginning, and to our knowledge, none yet examine the model's ability to address ACEs and promote resilience.

      Reforming Provider Payment

      For too long the ability of providers to tackle the complex nature of ACEs and their impact on multiple aspects of a child's health has not been supported by provider payment models, which focus on the volume of services. This is changing, with public and private sector initiatives to move from volume to value, as well as with the launch of several new payment model demonstrations under the ACA to test various ways to redesign provider payment. For example, CMS's launch of a new multipayer Comprehensive Primary Care Plus (CPC+) program, which could involve more than 20,000 physicians and 25 million Medicare, Medicaid, and privately insured patients, is intended to move 50% of primary care provider to a pay-for-value model.
      Atlantic Information Services
      CMS's new multipayer CPC+ program could move 50% of PCP pay to value. AIS Health Value Based Care News.
      https://aishealth.com/sites/all/files/marketplace_pdf_samples/vcb0516.pdf
      Date: 2016
      As with other ACA initiatives, these payment demonstrations are largely focused on adult care but could be adapted for child health services.
      Another payment innovation that is being tested is bundled payments. Several models have been initiated, where a single reimbursement, or lump sum, for all the services required for a medical condition, regardless of setting or provider, is paid to the lead provider (often a hospital).
      • Delbanco S.
      The payment reform landscape: bundled payment. Health Affairs (blog).
      http://healthaffairs.org/blog/2014/07/02/the-payment-reform-landscape-bundled-payment/
      Date: 2014
      In fact, one of the new bundles that has been launched by Medicaid and commercial insurers is for maternity care, with early results already being reported in Ohio, Minnesota, and New Jersey.
      Atlantic Information Services
      Insurers, large employers test maternity care bundle; some see promising results. AIS Health Value Based Care News.
      https://aishealth.com/sites/all/files/marketplace_pdf_samples/vcb0516.pdf
      Date: 2016
      Eventually this approach could be tested for its applicability to managing children with ACEs to incentivize providers to focus on early childhood experiences.
      • Delbanco S.
      The payment reform landscape: bundled payment. Health Affairs (blog).
      http://healthaffairs.org/blog/2014/07/02/the-payment-reform-landscape-bundled-payment/
      Date: 2014
      It should be noted that this approach does conflict with the ACO model as it carves out payment for a defined condition from the total costs of all care for a patient.
      The momentum to reform provider payment has only increased since the ACA. In 2015, the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) put into place a sweeping overhaul of how Medicare pays physicians and is the most significant change in provider payment since the establishment of the Resource Based Relative Value Scale in 1989. Reimbursement will be based on 4 areas: quality, cost, technology use, and practice improvement. While the passage of MACRA has no direct relationship to child health or pediatrics, the American Academy of Pediatrics (AAP) led efforts to comment on the MACRA proposed rule and wrote letters to support reauthorization because they recognized that models in Medicare are often adopted and adapted to Medicaid, the Children's Health Insurance Program (CHIP), and private payers in a trickle-down phenomenon.
      • Miller D.
      AAP's advocacy for CHIP, homevisiting pays off. AAP News.
      http://www.aappublications.org/content/aapnews/36/6/1.1.full.pdf
      Date: 2015
      , 
      • Dreyer B.P.
      Letter from the president: celebrate your role in victories for child health in 2015. AAP News.
      http://www.aappublications.org/news/2016/01/26/Letter012616
      Date: 2016
      , 
      • Parry L.
      Merit-based Incentive Payment System Comments by CHA and AAP.
      Children's Hospital Association, 2015
      https://www.childrenshospitals.org/issues-and-advocacy/Medicaid/letters-and-testimony/2015/merit-based-incentive-payment-system-comments-by-cha-and-aap
      The AAP has recognized how MACRA could help create emphasis and measures for quality in pediatrics, thus improving care.
      Proactively engaging in the development of additional evidence-based measures relevant to pediatric care for ACEs would support their eventual use in MACRA-like approaches in Medicaid and CHIP and under private sector plans.

       Extending the Role of Health Care Providers

      As important as coverage is, and as important as delivery system and payment reform could be, in any strategy to address ACEs, alone they will make little difference in achieving optimal care for children experiencing ACEs. While the ACA mandates that basic preventive services, including pediatric services and behavioral health services, for children under the health insurance exchanges be available at no cost (first dollar coverage),

      Find out what Marketplace health insurance plans cover. HealthCare.gov. Available at: https://www.healthcare.gov/coverage/what-marketplace-plans-cover/. Accessed June 15, 2016.

      the benefit package offered under the exchanges is not as robust as in Medicaid, and it will likely be insufficient to ensure appropriate assessment, treatment, and referrals for children with ACEs.
      Medicaid coverage includes the important requirement for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services.

      Centers for Medicare and Medicaid. Early and periodic screening, diagnostic, and treatment. Available at: https://www.medicaid.gov/medicaid/benefits/epsdt/index.html. Accessed June 7, 2017.

      Thus, assessments for ACEs under Medicaid coverage would fall under the EPSDT requirements, and if proactively pursued by state Medicaid programs, it could have a significant impact on children's health and well-being (as discussed by Rosenbaum
      • Rosenbaum S.
      ACEs and child health policy: the enduring case for EPSDT.
      Acad Pediatr. 2017; 17: S34-S35
      in this issue). However, it should be noted that health plans in the exchanges usually do not have requirements for comparable screening and treatment, potentially hindering the ability of providers to identify and address ACEs.

      Early and periodic screening, diagnostic, and treatment. Medicaid.gov. Available at: https://www.Medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html. Accessed June 15, 2016.

      For the first time, the ACA has linked recommendations from the United States Preventive Services Task Force (USPSTF) to coverage by health plans. The USPSTF makes recommendations on the types of screening, counseling services, and preventive medicine that should be implemented in a primary-care setting.

      US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/. Accessed June 15, 2016.

      The USPSTF not only helps determine the types of services covered under the ACA but also advises Congress on priority research areas.

      US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/. Accessed June 15, 2016.

      Any service with evidence deemed to be strong (ie, A- or B-level evidence) must have what is known as first-dollar coverage—that is, not counted in the deductible and with no copay.

      US Preventive Services Task Force. USPSTF A and B recommendations—US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/. Accessed June 15, 2016.

      However, it has been notoriously hard for pediatric prevention and screening services to secure the A or B assessment from the USPSTF.
      • Melnyk B.M.
      • Grossman D.C.
      • Chou R.
      • et al.
      USPSTF Perspective on evidence-based preventive recommendations for children.
      Pediatrics. 2012; 130: e399-e407
      , 
      • Grossman D.C.
      • Kemper A.R.
      Confronting the need for evidence regarding prevention.
      Pediatrics. 2016; 137: e20153332
      It is not at all clear when the evidence will be sufficient on the importance of assessing screening for ACEs to secure such a recommendation by the USPSTF. As the article in this issue by Bethell et al
      • Bethell C.
      • Carle A.
      • Hudziak J.
      • et al.
      Methods to assess adverse childhood experiences of children and families: towards approaches to promote child well being in policy and practice.
      Acad Pediatr. 2017; 17: S51-S69
      make clear, there is no nationally recognized ACEs screening tool recommended for all health care providers to use in patient visits. Furthermore, Bair-Merritt and Zuckerman
      • Bair-Merritt M.H.
      • Zuckerman B.
      Exploring parents' adversities in pediatric primary care.
      JAMA Pediatr. 2016; 170: 313-314
      recently cautioned about screening adults for their ACE score because there is “insufficient evidence supporting an effective response or meaningful intervention for parents who have high ACE scores.” We do believe, however, that eventual recognition of the importance of assessing ACEs by the USPSTF would significantly enhance provider willingness to include ACEs assessment as part of well-child care.

       Health Care Workforce Innovation

      Adequate coverage, aligned provider payments, and sufficient evidence to recommend ACE assessment in practice settings will go a long way to spurring action within health care systems. However, these strategies need to be complemented by a diverse and well-trained workforce able to deliver integrated health and social interventions. Here, the ACA has spurred substantial activity to reconsider the roles and responsibilities of our current workforce and its deployment as well as develop new models that emphasize the role of context on one's health, including the importance of addressing social determinants of health. Recent studies are beginning to document how workforce models are evolving.
      • Auerbach D.I.
      • Staiger D.O.
      • Muench U.
      • et al.
      The nursing workforce in an era of health care reform.
      N Engl J Med. 2013; 368: 1470-1472
      , 
      • Kirch D.G.
      • Henderson M.K.
      • Dill M.J.
      Physician workforce projections in an era of health care reform.
      Annu Rev Med. 2012; 63: 435-445
      , 
      • Staiger D.O.
      • Auerbach D.I.
      • Buerhaus P.I.
      Health care reform and the health care workforce—the Massachusetts experience.
      N Engl J Med. 2011; 365: e24
      In addition to expanding existing models, newer workforce models are including peer navigators and health leads, individuals who assist parents and families in finding the right resources for their health and well-being.
      • Flores G.
      • Lin H.
      • Walker C.
      • et al.
      A cross-sectional study of parental awareness of and reasons for lack of health insurance among minority children, and the impact on health, access to care, and unmet needs.
      Int J Equity Health. 2016; 15: 44
      The ACA is also supporting these new workforce models through grants from the Administration of Children and Families and a substantial expansion of the Maternal and Child Health Bureau's Home Visiting program.
      • Bovbjerg R.
      • Eyster L.
      • Ormond B.
      • et al.
      Opportunities for Community Health Workers in the Era of Health Reform.
      2014
      http://www.urban.org/research/publication/opportunities-community-health-workers-era-health-reform
      The Home Visiting program has proven to be successful in addressing social determinants of health by engaging both the parent and the child, or a 2-generation approach that recognizes the link between a child and parent's well-being.

      Maternal and Child Health Bureau; Health Resources and Services Administration. Home visiting. Available at: http://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting. Accessed July 20, 2016.

      Provisions in the ACA include $1.5 billion in mandatory funding over 5 years to support high-quality, evidence-based, voluntary early childhood home visitations services.

      Detailed summary of the home visitation program in the Patient Protection and Affordable Care Act. Center for Law and Social Policy (CLASP). Available at: http://www.clasp.org/resources-and-publications/publication-1/home-visiting-detailed-summary.pdf. Accessed June 17, 2016.

      Additionally, the US Department of Health and Human Services has allocated over $240 million to support medical loan repayment programs to increase access to primary care in underserved communities, providing opportunities to prevent the long term impact of ACEs in already vulnerable children and families through a renewed emphasis on primary care in our health systems.
      HHS Awards More Than $240 Million to Expand the Primary Care Workforce. US Department of Health and Human Services (HHS), 2015
      http://www.hhs.gov/about/news/2015/10/14/hhs-awards-more-240-million-expand-primary-care-workforce.html
      This program is especially important for children experiencing ACEs in that adverse circumstances can be identified and addressed.
      Recently the Health Resources and Services Administration funded a grant that applied NEAR (neuroscience, epigenetics, ACEs, and resilience) science to home visiting, recognizing that home visiting professionals are in a valuable position to talk with parents about their ACE history and how it may affect their parenting and overall well-being.

      [email protected] Toolkit: a guided process to talk about trauma and resilience in home visiting. Thrive Washington. March 10, 2015. Available at: https://thrivewa.org/nearhome-toolkit-guided-process-talk-trauma-resilience-home-visiting/. Accessed July 20, 2016.

      All of these programs can and should play a role in helping families address their social context and mitigate the development and effects of ACEs.
      • Garner A.S.
      Home visiting and the biology of toxic stress: opportunities to address early childhood adversity.
      Pediatrics. 2013; 132: S65-S73
      Workforce innovation and its impact on outcomes is also being investigated through grants from the Patient Centered Outcomes Research Institute (PCORI), and some of these focus on children.

      Patient-Centered Outcomes Research Institute (PCORI). Available at: http://www.pcori.org/. Accessed June 17, 2016.

      For example, the Family VOICE study is partnering with parents/family advocates, child-service agencies, and health providers to link families of children with mental health conditions with family navigators, who are individuals who have cared for their own child with mental illness.
      • Reeves G.
      The Family VOICE Study: A Randomized Trial of Family Navigator Services Versus Usual Care for Young Children Treated With Antipsychotic Medication.
      Patient-Centered Outcomes Research Institute (PCORI), 2012
      http://www.pcori.org/research-results/2012/family-voice-study-randomized-trial-family-navigator-services-versus-usual
      PCORI could call for evaluations of comprehensive interventions that deploy existing and newer workforce models to address the underlying social determinants that contribute to ACEs.
      A component of the workforce that is not addressed by the ACA but needs to be considered in our attempts to leverage the health care system to address ACEs is the very real primary-care health provider burnout that occurs from the physical and emotional toll of proactively identifying and striving to address the effects of ACEs when so many factors are outside of a provider's control. Increasingly, health professions' training and continuing education are incorporating a focus on mindfulness, self-awareness, and self-healing, which should also help alleviate the impact of trauma on providers giving care.
      • McClafferty H.
      • Dodds S.
      • Brooks A.
      • et al.
      Pediatric integrative medicine in residency (PIMR): description of a new online educational curriculum.
      Children. 2015; 2: 98-107
      , 
      • McClafferty H.
      • Brown O.W.
      Section on Integrative Medicine; Committee on Practice And Ambulatory Medicine
      Physician health and wellness.
      Pediatrics. 2014; 134: 830-835

       Supporting Research and Innovation on ACEs

      A final aspect of the ACA is expanded support for research, a critical aspect of building a stronger evidence base for effective approaches to the identification and treatment of ACEs. Two noteworthy investments are the creation of PCORI and the elevation and expansion of the Center for Minority Health to the National Institute of Minority Health and Health Disparities (NIMHD). PCORI focuses on promoting the importance of the patient perspective in health care to yield better and more effective outcomes through research and evaluation.
      • Frank L.
      • Basch E.
      Patient-Centered Outcomes Research Institute
      The PCORI perspective on patient-centered outcomes research.
      JAMA. 2014; 312: 1513-1514
      NIMHD prioritizes minority health and the reduction of health disparities; existing literature indicates that minority families are exposed to a disproportionate amount of toxic stress and adversity compared to their white counterparts.
      • Thoits P.A.
      Stress and health: major findings and policy implications.
      J Health Soc Behav. 2010; 51: S41-S53
      , 
      • Geronimus A.T.
      • Hicken M.
      • Keene D.
      • et al.
      “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States.
      Am J Public Health. 2006; 96: 826-833
      Both these investments have the potential to address ACEs in our most vulnerable children through improved research, evaluation, and implementation of innovations.

      Learning From Change: The Importance of Knowing What Works

      The new policies and programs launched or stimulated by the ACA are beginning to radically restructure care through coverage expansion, payment reform, and workforce innovation. While the coverage and tax provisions of the ACA are under debate, many other provisions have been set in motion to drive the health care system toward rewarding value and outcomes. These reforms are creating a backdrop within which health care systems can design and implement approaches to systematically address ACEs. However, there continue to be obstacles to preventing, diagnosing, and treating ACEs. The ACA alone falls short of providing the programs and policies we need to create an adequate system that supports family health and well-being, and the future of the ACA is unknown. Fortunately, the ACA is a strong foundation for moving toward a more holistic approach to health care, and while there may be changes to the ACA by the new administration, the emphasis on measurement and value in health care is likely to endure. To keep and strengthen policies aimed at ACEs, explicit system-level infrastructure and system-level measurement (eg, measures of ACE screening) are needed to drive attention to ACEs.
      Moreover, in order to inform health care policies in the future, we need to learn when effective approaches to ACEs in one system or community would be appropriate to other settings or for different child and family contexts. Thus, a systematic and significant investment in robust and timely evaluations, coupled with strategies to quickly disseminate early results and promote replication and spread of those models of care for ACEs found to be successful, is just as important as innovations in policy and practice. This commitment to learning what is working is being done for adult innovations through a number of commissioned evaluations as well as support for various networks such as the Health Care Payment Learning and Action Network (funded by CMS).

      Centers for Medicare and Medicaid Innovation. Health Care Payment Learning and Action Network. Available at https://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network/. Accessed June 7, 2017.

      Just as important as learning from interventions that are being deployed and tested, new research (through PCORI, the Agency for Healthcare Research Quality, and the National Institutes of Health) on all aspects of ACEs—their causes and impact as well as new interventions for prevention, screening, and treatment—is sorely needed. We are at a major turning point in health care as a result of the various opportunities the ACA has created to improve our nation's health. Preventing and treating ACEs by building on the ACA's accomplishments is a critical investment that not only helps our youngest and most vulnerable population but also promotes well-being across the life span.

      Acknowledgments

      We thank Michele Solloway and Christina Bethell for their comments.
      Financial disclosure: Publication of this article was supported by the Promoting Early and Lifelong Health: From the Challenge of Adverse Childhood Experiences (ACEs) to the Promise of Resilience and Achieving Child Wellbeing project, a partnership between the Child and Adolescent Health Measurement Initiative (CAHMI) and Academy-Health, with support from the Robert Wood Johnson Foundation (#72512).

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      Article Info

      Footnotes

      Conflict of Interest: The authors declare that they have no conflict of interest.

      Identification

      DOI: https://doi.org/10.1016/j.acap.2017.04.007

      Copyright

      © 2017 by Academic Pediatric Association

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