Circle the Wagons or Stay the Course?

By: Paul H. Dworkin, MD

“Awaken our inner warrior” and be prepared to “fight, fight, fight.”

Those are just some of the poignant thoughts expressed by Dr. Kevin Marks, a pediatric colleague and tireless child health advocate from Eugene, OR, in his recent letter to the journal Pediatrics, written in response to a published article from the leadership of the American Academy of Pediatrics (AAP). One may readily surmise Dr. Marks’ dismay with the outcome of our national election by merely perusing the title of his letter, “The Dream of a National Framework for Healthy Child Development Has Turned Into a Nightmare.” His dire, albeit credible predictions, which he defends by citing the incoming Trump administration’s nominations and policy declarations, include an increase in child poverty, an acceleration in climate change, loss of health care coverage with repeal of the Affordable Care Act (ACA), a shrinkage in funding for early childhood education, and an increase in gun violence.

That letter came in response to “How the Next President Can Build a Foundation for a Healthy Future: Improving Children’s Lives,” in which AAP leaders suggest how the incoming administration may continue efforts to provide children with the essential elements needed to lead healthy and productive lives. The authors cite the recently released AAP plan, Blueprint for Children: How the Next President Can Build a Foundation for a Healthy Future, which specifically calls for the federal government to invest in, coordinate, and focus on four key themes: promoting healthy children, supporting secure families, building strong communities, and ensuring the United States is a leading nation for children. These themes certainly resonate with all who are committed to strengthening families to promote children’s optimal healthy development.

These commentaries suggest differing and even competing strategies. Marks calls upon us to unite in defense of a common interest, a “circle the wagons” approach. In contrast, the AAP perspective encourages us to continue to pursue our goal regardless of obstacles or criticism, i.e., to “stay the course.” Given the cogent and compelling arguments in support of each position, what are we to do?

Child health advocates are, understandably, worried that children and families may be adversely affected by cuts to Medicaid and the Children’s Health Insurance Program (CHIP). I recently had the opportunity to hear Joan Alker, executive director of the Center for Children and Families and a research professor at the Georgetown University McCourt School of Public Policy, at a convening in Washington, DC sponsored by the Campaign for Grade Level Reading. Alker is a nationally-recognized expert on health coverage for low-income children and families, with an emphasis on Medicaid, the Children’s Health Insurance Program (CHIP), and the ACA. Her sober assessment included the prediction that ACA repeal would double the number of uninsured children and families. She also warned that turning Medicaid into a block grant would have adverse consequences for child welfare, especially for vulnerable children such as those in foster care and those with special needs, and that it would result in severe cutbacks in prevention services. Indeed, such potentially devastating threats lend credence to Marks’ call to aggressively protect the status quo.

Also important to note, our experience partnering with many states and federal agencies to disseminate Help Me Grow® (HMG), with its focus on the early detection of vulnerable children and the linkage of these children and their families to community-based programs and services, suggests the potential for maintaining, and even accelerating our considerable momentum. I am encouraged that the good work of diverse states and “street-level bureaucrats” in various federal agencies may be the stimulus to continue to move forward. In our HMG experience, for example, we are impressed that progress does not correlate with a state’s red or blue color. In fact, we often speak of HMG dissemination as “apartisan.” A key to this progress is the careful framing of our advocacy and recognizing that “all politics is local.” We are mindful that viewing HMG as an entitlement may be politically perilous in certain venues, while the concept of supporting families to promote their children’s healthy development is generally desirable. In some jurisdictions, a “children are our future” campaign rings true and is sufficiently impactful. Yet in other discussions with highly diverse states and agencies, as well as funders, we find that promoting children’s healthy development and academic learning for building the workforce of the future, and even strengthening national security (e.g., a physically-fit military, cyber security capacity), is a compelling rationale that garners interest and support. My recent discussions with such renowned policy experts as the former US Senate Majority Leader Tom Daschle and Donna Cohen Ross, the former senior policy advisor and director of enrollment initiatives at the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and CHIP Services (CMCS), reinforce the promise of such an approach. We are also encouraged that a multitude of federal agencies have embraced and rallied around a “developmental promotion, early detection, referral and linkage” agenda that holds strong potential for comprehensive system building.

While remaining cognizant of the real threats to the welfare of children and their families, other factors may be reason for cautious optimism. For example, we are frustrated that child health services transformation is of limited interest to CMS/ Center for Medicare & Medicaid Innovation (CMMI) because it cannot compete with adult health services in contributing to the “relentless pursuit of scorable savings.” Given the relatively modest expenditures for child health services, perhaps they can remain “below the radar” in the face of likely Medicaid cuts, caps, and block grants.

I do not believe that I am naïve, nor am I prone to being pollyannaish and inclined to blind optimism. We must be vigilant in protesting devastating cutbacks that will do harm to children and families. However, I also believe that we must pledge to best continue our forward movement, going beyond the role of vocal opposition to determine how to best build on progress and common assumptions. Through such strategies as strategic framing, we may even accelerate our considerable progress. So, do we circle the wagons or stay the course? We must do both and more!

Paul H. Dworkin, MD, is the executive vice president for community child health at Connecticut Children’s, the director of the Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.

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