Editor’s Note: DULCE (Developmental Understanding and Legal Collaboration for Everyone), an initiative of the Center for the Study of Social Policy (CSSP), focuses on the needs of infants and their families in the first six months of life. This pediatric care intervention proactively addresses social determinants of health and mitigates the risk factors for early life stress. DULCE is delivered by a multidisciplinary care team that includes a pediatric health care provider, a family specialist and a legal partner. DULCE currently operates in 8 clinics in 5 communities: Palm Beach County, FL; Los Angeles County, CA; Orange County, CA; Alameda County, CA; and Lamoille Valley, VT. At each clinic, DULCE serves about 120 families a year.
Integrating a legal partner as a member of the health team can help children and families get the comprehensive services for which they qualify and can also improve the functioning of public benefits systems for the broader community. DULCE, a pediatric primary care intervention for children in the critical first six months of life, demonstrates how this powerful strategy can work. For example, legal partners working in California-based DULCE sites have helped to assure timely newborn enrollment in Medi-Cal and have spurred policy change efforts in LA County.
Improvements in Timely Newborn Medi-Cal Enrollment Following Performance Monitoring
Medi-Cal, California’s Medicaid program, offers free or low-cost health coverage for eligible children and adults with limited income, and many DULCE babies and their parents participate. According to federal law, babies born to mothers who are Medi-Cal beneficiaries are automatically deemed eligible for coverage through their first year. To expedite access to health care, California enrolls infants for a “gateway” period of up to two months while their Medi-Cal application is being processed. Given Medi-Cal policies in place to facilitate timely newborn enrollment, the DULCE team at Highland Hospital in Alameda County was concerned when they observed a troubling trend at the routine 4-month pediatric visit: Medi-Cal applications were being processed so slowly that the gateway access period was expiring, leaving infants uninsured and parents unwilling or unable to bring them in for well-child medical appointments for fear of incurring large bills.
Together, Highland’s DULCE staff and their legal partner, Erin Le of the East Bay Community Law Center (EBCLC), took steps to address this barrier to health coverage and care, which was affecting several families each month. Attorneys at EBCLC filed individual appeals and directly negotiated with the County on individual cases. Meanwhile, DULCE Family Specialist Laura Lopez investigated and found that the hospital’s system for submitting newborn enrollment paperwork to the County was working as designed, with applications submitted within a day of birth; therefore, the issue appeared to be a County-level problem. EBCLC took this information, along with the list of DULCE patients with recent appeals, to a meeting with Alameda County Social Services Agency management and spotlighted the barriers to Medi-Cal enrollment experienced by infants born at Highland Hospital. The County responded, and within weeks, almost all of Highland Hospital’s DULCE babies were being successfully enrolled in Medi-Cal during the gateway period. Applications have been processed on-time ever since.
Advocacy Strengthens Medi-Cal Access for Newborns
Neighborhood Legal Services of Los Angeles County (NLSLA), the DULCE legal partner at Northeast Valley Health Corporation (NEVHC), also took action to address this large-scale barrier to family health. In 2016, over 100 babies born to Medi-Cal-eligible mothers at NEVHC spent months awaiting Medi-Cal enrollment. As a result, families were compelled to cancel medical appointments while their infants’ Medi-Cal status was pending, and those infants missed critical well-child and preventive visits. The problem persisted even after families and benefit enrollment counselors at NEVHC faxed newborn referrals and related documentation directly to the LA County Department of Public Social Services (DPSS), as requested by county eligibility workers. NLSLA raised the issue with leadership at the Medi-Cal Programs Unit of DPSS and discovered there had been a change in the County’s method for processing applications for infants deemed eligible, adding extra steps to the process with no assurance of follow-up.
NLSLA advocated with DPSS for timely enrollment of deemed-eligible NEVHC babies into Medi-Cal and improvements to the enrollment process for all LA County newborns. They also successfully pushed DPSS to correct a high-stakes problem with its new case management technology. The technology was not programmed to automatically protect newborn enrollment for a full 12 months, leading a number of infants to have their Medi-Cal coverage terminated unlawfully and to lose access to medically-necessary pediatric check-ups, vaccinations, and medications for months. In at least one instance, this problem threatened an infant’s access to oxygen and special formula.
Meanwhile, NLSLA and community clinics collaborated to create a supplemental newborn enrollment referral procedure that bypassed DPSS processes. This community-driven, streamlined system has been more effective in achieving timely newborn enrollment than standard DPSS pathways. NLSLA is still in negotiation with DPSS regarding ongoing systemic barriers that block Medi-Cal-eligible newborns from timely enrollment. Given the significance of these long-standing access barriers, NLSLA recently was awarded a grant from the California Community Foundation to engage with DPSS on further policy improvements relating to newborn enrollment and a host of other barriers to family health and well-being.
Thanks to the advocacy of these DULCE teams, families in Alameda and Los Angeles Counties are more likely to experience timely newborn enrollment in Medi-Cal, meaning that children and families can gain access to health services without the burden and stress of unaffordable medical bills. The efforts of the DULCE legal partners—NLSLA and EBCLC—were pivotal in identifying persistent problems and engaging key policymakers to catalyze both short-term solutions and longer-term systems changes. Integration of legal partners in community-based health initiatives, such as DULCE, has immense potential for improving systems accountability and laying the groundwork for policy change that can benefit the broader population of young children and families.
Ciara Malaugh is a Program & Research Assistant at CSSP.
Samantha Morton is the Chief Executive Officer of MLPB.