Meeting 1


August 7, 2017


Nancy Zimpher, Chair, First 1000 Days on Medicaid
Kate Breslin, Vice Chair, First 1000 Days on Medicaid

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Meeting Agenda

Item # Agenda Items Time Duration
1. Welcome and Introductions 11:00am 15 mins
2. Problem Definition, Committee Charge, and Process 11:15am 75 mins
3. Lunch 12:30pm 45 mins
4. Idea Generation 1:15pm 90 mins
5. Next Steps and Adjourn 2:45pm 15 mins

Participants joining by audio only: please email with your name and organization so we may record your attendance

Big Picture: Why We´re Here

Point 1: A child´s brain develops rapidly in the first 3 years of life, and we now know what kinds of interventions can help or hinder this process.

Point 2: Early experiences´ effect on the brain and body partially explain significant disparities in health and learning by school entry – especially for children living in poverty.

Picture of a graph showing percentage of children 3-4 with selected school readiness skills by povert status

Our Leaking Education Pipeline

  • 40% of children enter kindergarten not ready*
  • 42% of 3rd Graders are Proficient in Reading
  • 24% of 8th Graders are Proficient in Math*
  • 80% of High Schoolers Graduate in 4 Years
  • 65% of graduates enroll in post–secondary
  • 50.5% of SUNY 4–year students complete in 4 years; 67% complete in 6yrs
Every Child, Cradle to Career

Point 3: These early experiences have serious, long–term consequences for children in the education pipeline.

And it´s our collective responsibility to fix this.

Point 4: Medicaid has a big role to play.

Picture of a graph showing percentage of children 3-4 with selected school readiness skills by povert status


Work Group Leadership


Nancy Zimpher, Chancellor,
The State University of New York

Vice Chairs:

Kate Breslin, President & CEO,
Schuyler Center for Analysis and Advocacy

Jeff Kaczorowski, MD, Senior Advisor,
The Children´s Agenda

Work Group Members

Name Organization
Jeanne Alicandro, MD New York State Department of Health
Wilma Alvarado–Little New York State Department of Health
Benjamin Anderson Children´s Defense Fund New York
Lori Andrade Health and Welfare Council of Long Island
Angela Angell Staten Island Alliance for North Shore Children and Families
Anita Appel Sachs Policy Group
George Askew, MD New York City Department of Health and Mental Hygiene
Sonia Barbosa Healthfirst
Amir Bassiri Executive Chamber
Gary Belkin, MD New York City Department of Health and Mental Hygiene
Susan Beane, MD Healthfirst
Wendy Bender New York State Association for Infant Mental Health
Evelyn Blanck New York Center for Child Development
Donna Bradbury New York State Office of Mental Health
Alexandra Brandes Lenox Hill Neighborhood House
Carla Braveman Hospice and Palliative Care Association of New York State
Kate Breslin (Vice–Chair) Schuyler Center for Analysis & Advocacy
Rahil Briggs Montefiore
LuAnne Brown Buffalo Prenatal–Perinatal Network, Inc.
Monica Brown Health Foundation of Western and Central New York
Suzanne Brundage United Hospital Fund
John Burke WellCare of New York, Inc.
Betsy Campisi Allliance for Better Health
Dina Carreras The Staten Island North Shore Alliance for Children and Families
Joanne Casarella New York City Department of Health and Mental Hygiene
Nora Chaves Healthfirst
Meredith Chimento Early Care & Learning Council
Andrew F. Cleek McSilver Institute for Poverty Policy and Research, NYU Silver School of Social Work
Lauri Cole NYS Council for Community Behavioral Healthcare
David Collins The Children´s Village
Mary Comtois United Way
Pradine Content The New York Foundling
J. Coppola NY Association of Psychiatric Rehabilitation Services, Inc.
Shawna Craigmile–Sciacca Upstate University Health System
Maria Cristalli Hillside Family of Agencies
Barbara Crosier Cerebral Palsy Associations of New York
Enrico Cullen a.i.r. NYC
Amber Decker Independent Provider of Peer Support Services
Lauren Deutsch Healthy Baby Network
Ellyce di Paola EmblemHealth
Sean Doolan Hinman Straub
Lana Earle New York State Department of Health
MaryEllen Elia New York State Education Department
David Fagan, MD Northwell Health
Lindsay Farrell Open Door Family Medical Center
Lowell Feldman The Castleton Group
Diane Ferran, MD CHCANYS
Mildred Ferriter Community Health Center of St. Marys and Littauer
Beth Finnerty Cardinal McCloskey Community Services
Douglas Fish New York State Department of Health
Maura D. Frank, MD Weill Cornell Medical College
Taylor Frazier Community Service Society of New York
David Goldstein JCCA
Aimee Gomlak Catholic Health System
Bob Graham New York State Bleeding Disorders Coalition
Victoria Grimshaw New York City Department of Health and Mental Hygiene
Michael Grossfeld All About Kids
Lisa B. Handwerker, MD The Children´s Aid Society
Steve Hanson New York State Office of Alcoholism and Substance Abuse Services
Jennifer F. Havens, MD NYU Langone / Bellevue
Ariel Hayes Northwell Health
Christian Heiss Nurse–Family Partnership
Jason Helgerson New York State Department of Health
Zachariah Hennessey Public Health Solutions
Dirk Hightower Children´s Institute
Emily Horn Alliance for Better Health
Sajidah Husain, MD Empire BlueCross BlueShield, Healthplus
Liz Isakson, MD, FAAP Docs for Tots
Viju Jacob, MD, FAAP Urban Health Plan, Inc.
Sophia Jan, MD Northwell Health
Marilyn Kacica New York State Department of Health
Jeffrey Kaczorowski, MD (Vice–Chair) Children´s Agenda; University of Rochester Medical Center
Karen Kalaijian Nurse Family Partnership
John Kastan The Jewish Board of Family and Children´s Services
Paul Kaye, MD Hudson River Healthcare
Eunhye Grace Kim The Korean Community Service of Metropolitan New York, Inc.
Dennis Z. Kuo, MD, MHS University at Buffalo
Audrey LaFrenier Northern Rivers Family of Services
Jason Lippman The Coalition for Behavioral Health, Inc.
Jaime Madden NYC Administration for Children´s Services
Kallanna Manjanuth, MD Albany Medical Center, Better Health for Northeast New York PPS
Jennifer March Citizens´ Committee for Children of New York
Daniel Maughan St. Luke´s Cornwall Hospital
Alexandra Maul Center for Health Care Strategies
Mary McCord, MD Gouverneur Health Services (Gotham) / NYU
Bernadette McDaniel Ellis Medicine
Philip McDowell Independent Psychotherapist
Matthew McLarnon Capital Health Consulting
Adrienne Mercer Northern Manhattan Perinatal Partnership
Heather Mermel Beacon Health
Dodi Meyer, MD Columbia University Medical Center / New York Presbyterian Morgan Stanley Children´s Hospital
Margaret Mikol SKIP of NY
Acklema Mohammad, MD Urban Health Plan, Inc.
Ann Monroe Former Health Foundation for Western and Central New York
Kristen Mucitelli–Heath St. Joseph´s Health
Sandra Murawski Amerigroup Partnership Plan
Kerri Neifield Office of Governor Andrew M. Cuomo
Karen Norman ANDRUS
Chris Norwood Health People
Ciearra Norwood NYS Council on Children and Families
David Oakley Manatt, Phelps & Phillips, LLP
Briannon O´Connor Center for Collaboration in Community Health
Alex Okun, MD New Alternatives for Children
Alda Osinaga NYSDOH OHIP
Christy Parque The Coalition for Behavioral Health
Matthew Perkins, MD Children´s Services
Frank Pindiak St. Catherine´s Center for Children
Lauren Pollow NYS Health Facilities Associations
Suniti Ponkshe Optum
Sheila Poole NYS Office of Children and Family Services
Kira Pospesel Greene County DSS
Juliette Price The Albany Promise
Joyce Riemer Independent Consultant
Reneee Rider New York State Education Department
David Rock Grant Thornton
Marci Rosa Public Health Solutions
Harvey Rosenthal NY Association of Psychiatric
Sylvia Rowlands The New York Foundling
Joseph R. Saccoccio, MD The New York Foundling
Rebecca Sanin Health and Welfare Council of Long Island
Wendy Saunders Hinman Straub
Christine Schuyler Chautauqua County Department of Health & Human Services
Kalin Scott New York State Department of Health
Chad Shearer United Hospital Fund
Peter Sherman, MD, MPH Bronx Lebanon Hospital
Phyllis Silver Partnership for Quality Care
Edwin Simper, MD St. Mary´s Health Systems for Children
Brendon Smith Better Health for Northeast New York
Sheila Smith Columbia Universtity – National Center for Children
Richard Soden, OD SUNY College of Optometry
Stephen Somers Center for Health Care Strategies
Tonia Spence The Jewish Board of Family and Children´s Services
Joseph A. Stankaitis, MD YourCare Health Plan
Danny Stephens, MD The Children´s Aid Society
Marjorie Stuckle Empire BlueCross BlueShield, Healthplus
Lauren Tobias New York State Department of Health
John Torres Liberty Resources
Christopher Treiber INTERAGENCY COUNCIL of Developmental Disability Agencies, Inc.
Alia Udhiri New York City Department of Health and Mental Hygiene
Omolara Thomas Uwemedimo, MD, MPH Northwell Cohen Children´s Medical Center
Jane Vail Central New York Health Home Network
Abigail Velikov New York City Department of Health and Mental Hygiene
Susan Vierczhalek, MD NYU Langone Health
Norma Villanueva, MD, MPH Family Health Center at NYU Langone
Bridget Walsh Schuyler Center for Analysis & Advocacy
Elie Ward American Academy of Pediatrics District II, NYS
Nicholas Weatherbee Assembly Majority Leader Joe Morelle
Kristin Weller NYS Council on Children and Families
Judy Wessler Coalition to Protect Medicaid
Kara Williams The Allyn Foundation
Carrie Edwards Wolkoff Sparks Therapeutics
David Woodlock ICL
Nancy Yassa Anthem
Shawn Yetter Tioga County DSS
Fern Zagor Staten Island Mental Health Society
Nancy Zimpher, Ph.D (Chair) The State University of New York
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Defining the Problem, Work Group Charge, and Decision–Making Framework

Jason Helgerson, Deputy Commissioner and Medicaid Director, NYSDOH
Kate Breslin, President and CEO, Schuyler Center for Analysis and Advocacy

What´s the problem?

Pregnant women depend on Medicaid:

51% of all births are covered by Medicaid.

Kids depend on Medicaid:

48% of New York´s children 0–18 are covered by Medicaid.

Children in their first 1000 days of life depend on Medicaid:

59% of kids 0–3 in New York are covered by Medicaid.


1.–indicator/births–financed–by–medicaid/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22a sc%22%7D
2. U.S. Census Bureau, Population Division. Medicaid enrollment count as of December 2015.

Young Children on Medicaid...

  • Do not have high expenditures
    • Children ages 0–4 averaged only $3,837 in annual expenditures in 2014
    • Children ages 18–20 averaged $5,312
  • Use the emergency department more frequently than older kids
    • 36% of children ages 0–4 had at least one ED visit in 2014
    • No other age group is higher than 26%
  • Use primary care frequently
    • 88% of children under age 1 had at least one outpatient evaluation and management or preventive care claim in 2014 (average 8.95 claims/child)
    • 93% of children ages 1–4 had at least one of these claims (averaged 6.03 claims/child)

Source: United Hospital Fund, Understanding Medicaid Utilization for Children in New York: A Chartbook.

Medicaid serves children at highest risk for poor health outcomes

U.S. Children´s Health Outcomes and Risk, by Income Gradient, 2011 – 2012


Source: Data from Halfon N, PH Wise, and CB Forrest. 2014. The changing nature of children´s health development: new challenges require major policy solutions. Health Affairs 33(12): 2116–2124.

And at high–risk for poor lifetime outcomes

The first 1,000 days of a child´s life are a critical window for development. Exposure to adverse childhood experiences dramatically increases the potential for life–long negative health and social outcomes.

Adverse Childhood Experiences
  • Abuse
  • Neglect
  • Family Dysfunction
  • Exposure to Violence
Can Lead to....
  • Poor School Performance
  • Developmental Delays
  • Juvenile Justice Involvement
  • Poor Health in Adulthood

Source: "The First 1,000 Days: Medicaid´s Critical Role." Center for Health Care Strategies, June 2017.
Available at:–1000–days–medicaids–critical–role/.

Medicaid Already Helps Children Have Better Outcomes

  • Increases the rates of high school and college graduation
  • Medicaid results in better health and lifetime outcomes for children
  • The most important time for coverage is during pregnancy, infancy and early years
  • We get the highest return for investments in improving SDH and human development
  • Medicaid coverage also improves educational outcomes, employment, and reduces welfare dependency
  • Medicaid gives kids a better chance to maximize lifetime outcomes


Medicaid Already Helps Children Have Better Outcomes

Performance Measure New York Medicaid
Statewide Average
National Median New York Ranking
Well child visits first in the first 15 months of life 68.5 62.1 2nd Quartile of reporting states
Access to Primary Care 12–24 months 96.9 96.4 2nd Quartile of reporting states
Childhood Immunization Status at age 2 73.2 66.9 2nd Quartile of reporting states

Source: United Hospital Fund, Understanding Medicaid Utilization for Children in New York: A Chartbook.

  • We won´t be able to help kids without a focus on the social determinants of health (SDH)
  • These include poverty, unequal access to health care, poor environmental conditions, educational inequities.
  • SDH disproportionately affect poor and minority children.
  • We must work cross–system to address these issues.

What´s the charge to this group?

  • The "First 1000 Days on Medicaid" initiative will be a collaborative effort, bringing together stakeholders to develop recommendations for a ten–point plan.
  • Builds off of the successful VBP Advisory Group on Children´s Health.
  • The group´s ten–point plan will focus on improving outcomes and access to services for children in their first 1000 days: the most crucial years of their development.

Focusing the Charge

  • Goal is broad population level improvement in child health and development "Moving upstream to prevent future super–utilizers"
  • Initial phase recommendations focused on the large majority of children ages 0–3 not already receiving specialized services (e.g., OPWDD, children with medically complex conditions)

Ten–point plan should be:

  • Specific and laser focused on improving outcomes and access to services for children in their first 1000 days
  • Focused on what is doable in the near–term Affordable
  • Implementable through Medicaid levers

The group will work for a little over two months with a completion date slated for early November.

How do we get started?

Long–term Goal   Desired Outcomes for Children
Ages 0–3

Source: NYS Children´s VBP Subcommittee and Clinical Advisory Group
  Primary Drivers for Brain Development and Lifelong Health

Source: Harvard Center on the Developing Child (2010). The Foundations of Lifelong Health
All children in New York are well and thriving
Optimal birth outcomes for mother and child
Secure caregiver–child attachment established by age 1 Stable, responsive, and nurturing caregiving early in life lays the groundwork for the development of a wide range of basic biological processes that support emotion regulation, sleep–wake patterns, attention, and ultimately all psychosocial functioning.

Access to comprehensive, patient–centered medical care for pregnant women and children can help prevent threats to healthy development as well as ensure correction and/or management of health problems.

Sound and appropriate nutrition is essential at every stage of the life course, beginning with the mother´s pre–conception nutritional status, extending through pregnancy to early infant feeding and weaning, and continuing with diet and activity throughout childhood.

Safe environments, free from toxic chemicals and toxic stress, are necessary for protecting children´s immediate physical well–being as well as their future health and development.
Optimal physical health and developmental trajectory (motor, language, cognitive, and social–emotional) by age 3.

Healthy and Ready Children and Families

pK–12 Education Levers

  • Provider of pre–kindergarten services (3– and 4–year–old seats)
  • Compulsory education beginning at age 5
  • Student achievement data
  • Regulatory and State-level policy

Higher Education Levers

  • Largest provider of post–secondary opportunity
  • Reconnection efforts (EOC, non–credit/degree programs)
  • Workforce development & credentialing
  • State–level policy

Social Service Provider Levers

  • Largest provider of family support services
  • Family income support
  • Connection to child & family services
  • State–level policy

Medicaid Levers

  • Medicaid payment and incentives
  • Quality improvement infrastructure
  • Medicaid managed care contracts
  • Non–federal regulatory changes
  • Enabling innovation through pilots and more
  • Continuity of health coverage
  • Convening power
  • Provider and Community Education

Medicaid Provider Levers

  • Continued access to children and families during key years (0–5)
  • Ability to influence family decision– making
  • Connection to child & family services
  • Patient data
  • Practice–level policy

Recommendations must meet following criteria:

  1. Specifically address a foundation of health from the agreed upon framework
  2. Be evidence based, or at least strongly evidence informed
  3. Have measurable results, or include a viable strategy for collecting new data to measure results
  4. Reach a large percentage of the affected population or be a targeted pilot with strong potential for wider adoption
  5. Consider disparities in access, quality of care, and outcomes.
  6. Have sufficient detail to be actionable and implementable by New York Medicaid and any relevant partners
  7. Be affordable and cost–efficient given limited resources
  8. Consider the potential effect on various constituencies (including potential perverse incentives, political considerations)

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Idea Generation

Nancy Zimpher, Chair
Kate Breslin, Vice Chair

Long–term Goal   Key Drivers Change Ideas
Improve Outcomes in Learning, Behavior, and Health of NY´s Vulnerable Children During Early Childhood
Universal access to basic medical care for pregnant women and children Integrating physical and behavioral health in pediatric practices
Home visiting for vulnerable families Improving OBGYN / PCP referrals to home visiting programs
High–quality, center based, early education
Two–generation programs in health and education Assessing parents for referral to workforce development opportunities
Prevention and mitigation of toxic stress in early childhood Universal ACEs screening during first year of life
Economic stability supports (e.g., SNAP, TANF, EITC, child care subsidies, housing supports) Referral of all Medicaid–eligible families to local DSS for benefit eligibility check
Reducing neurotoxin exposure

Use data to drive continuous improvement and reliable implementation of effective strategies →


Pathway to Creating a Recommendation

  • What´s the outcome you are trying to improve? How does it fit into the framework?
  • What is preventing us from improving in this area? What are the barriers preventing Medicaid and partners from addressing this need?
  • What could work? What are the potential solutions to the identified issue (are they consistent with the primary drivers in the framework)?
  • Which solutions can Medicaid effect? What Medicaid system levers could be used to implement the solution(s)?
  • What´s the recommendation? How would a recommendation be framed given all of the above? What should Medicaid do?

What are your ideas?

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Next Steps

Nancy Zimpher, Chair

Hold Your Calendar

  • September 13 (webinar)
  • October 11 (webinar)
  • November 1 (in–person, Albany)

Next Steps

  • We´ll follow up with an email summarizing the ask to this workgroup, and with specific instructions for submitting recommendation ideas for the ten– point plan.
  • Join the conversation on twitter: #First1KDaysNY @NewYorkMRT

Contact Information

Chad Shearer
Vice President for Policy Director, Medicaid Institute (212) 494–0793

Suzanne Brundage
Program Director, Children´s Health Initiative (212) 494 – 0729@suzbrundage

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Outcome Metrics for Children

Medicaid Low-Birth Weight Newborns (PQI 9):

Year Statewide Average (observed rate per 1,000 births)
2012 68.11
2013 69.23


Medicaid Managed Care Child Immunization Status (Combo 3):

Year Statewide average (rate)
2009 73
2011 74
2013 73.3
2015 74.8


Percent of children ages 4 months – 5 years at moderate or
high risk of developmental, behavioral, and social delays
based on parent concern (NSCH Survey):

Year New York estimate National estimate
2007 28.6% 26.4%
2011/2012 33.1% 26.2%