Research shows that children who are born healthy and have access to reliable, consistent, and timely health services are more likely to be school-ready. Children have a better chance of learning math, reading, and other subjects if they have the glasses they need to see the whiteboard, the medications they need to return to school after they’re out sick, and the support they need for any disabilities, developmental delays, or mental health challenges. Women’s access to health care before, during, and after pregnancy is also critical for ensuring a healthy pregnancy, a healthy birth, and a healthy baby.
Unfortunately, Texas lags behind the rest of the country in both children’s and women’s access to health insurance and enrollment in early interventions for addressing developmental challenges. The lack of access contributes to many children not being school-ready and falling behind their peers due to unmet needs, which can profoundly impact a child’s health and learning for a lifetime.
Addressing children’s health and developmental needs requires a holistic approach, including supporting healthy pregnancies, healthy births, access to affordable health coverage, and early childhood support for disabilities and developmental delays.
A healthy childhood starts with a healthy mother and a healthy pregnancy and continues with access to postpartum care and early childhood support for parents and infants. Multiple factors contribute to maternal and infant health, but health insurance coverage is a critical piece of the puzzle. If a woman has limited access to health care before or during her pregnancy, she may not be able to address conditions like heart disease or diabetes that can lead to preterm births, low birth weight births, birth defects, infant mortality, and maternal death. Also, with limited access to mental health care, new parents suffering from postpartum depression may not receive help, which increases safety risks for babies, interferes with parent-child bonding, and can contribute to language delays and behavior challenges in a child. In fact, research shows that increased access to health coverage for women with low incomes before, during, and after pregnancy is associated with lowered rates of maternal and infant mortality – particularly for Black women and babies – as well as improved use of preventive care and health counseling before pregnancy, higher birth weights for infants, and reduced postpartum hospitalizations.
While most states offer Medicaid to adults with low incomes, under Texas policy, uninsured women with low incomes typically are only eligible for insurance through Medicaid while pregnant and, until recently, for two months after the pregnancy. Beginning March 1, 2024, Medicaid coverage was extended to twelve months after pregnancy. Allowing new mothers to keep their health insurance for 12 months after pregnancy is an excellent step in ensuring new moms can access health care. Still, consistent access to health coverage before, during, and after pregnancy is essential to improve pre-pregnancy health, reduce premature births, and further address infant and maternal mortality.
Unfortunately, Texas is by far the worst in the country when it comes to women with low incomes accessing health insurance. Nearly half (46 percent) of Texas women of childbearing age with low incomes do not have health insurance – which is more than twice the national average (21 percent). Every region in Texas has an uninsured rate far exceeding the national average; the Hidalgo region has the highest rate at 65 percent.
A child born prematurely arrives before the 37th week of pregnancy. Because premature birth occurs before full-term pregnancy when important development is still occurring, premature babies are born at risk of more health problems. Premature birth can result in low birth weight, and it increases the risk of challenges with breathing, feeding, vision, and hearing, as well as long-term intellectual and developmental disabilities. To boost the number of children who are school-ready, policymakers need to support healthy pregnancies that lead to fewer birth complications and healthier newborns.
Unfortunately, more than 1 in 10 Texas babies are born preterm. Furthermore, Black babies are more likely to be born preterm compared to White and Hispanic babies. While no single factor explains this disparity, researchers have identified a number of potential causes of racial disparities in preterm births, including implicit biases in health care; chronic stress, including the physical toll of stress related to structural racism; past and present discrimination negatively affecting social determinants of health such as housing, air pollution, food scarcity, and education; and lack of access to health insurance.
Health insurance plays a critical role in ensuring children can attend regular check-ups, identify disabilities or developmental delays and receive early interventions, address mental health challenges, and get healthy and back to school when they’re out sick.
Unfortunately, nearly 200,000 Texas children under age six are uninsured. Texas ranks near the bottom of all states in the country in the percentage of children under age six who are uninsured, and the state’s rate (10.1 percent) is more than twice the national average (4.4 percent). All Texas regions have uninsured rates for children under age six that exceed the national average, but the Lubbock area has the worst rate (11.7 percent), followed by West Texas (10.4 percent) and the Dallas region (10.3 percent). By contrast, the Austin area (5.6 percent) and Corpus Christi area (5.7 percent) have the lowest uninsured rates in the state for young children.
Texas children in families with low incomes typically are eligible for insurance either through Medicaid or the Children’s Health Insurance Program (CHIP) if they are U.S. citizens or lawfully present in the U.S. Recent research by Texas 2036, which looks at all uninsured Texans, reveals that nearly half of uninsured children in Texas are eligible for Medicaid or CHIP. However, inadequate health coverage outreach efforts, unintended bureaucratic barriers, delays that families encounter when they attempt to apply or remain enrolled, and other systemic barriers keep eligible children out of health coverage.
It is critical for school readiness that infants who are sick can receive the medication and health services they require. It is also essential that infants visit their pediatricians routinely so doctors can track growth and development, offer immunizations that help prevent illness, identify potential developmental delays or disabilities, address any concerns that parents have, and establish a trusting relationship with a child and their parent.
The American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child visits known as the “periodicity schedule.” The schedule recommends eight well-child visits within the first 15 months of life.
Unfortunately, too many infants are not receiving these critical well-child check-ups. In Texas, more than 40 percent of infants enrolled in Medicaid do not receive at least 6 of the recommended 8 well-child visits. There is little regional variation on this metric; although the rates in West Texas and the Panhandle are slightly worse than the other regions.
Well-child visits are also critically important for a toddler’s health and school readiness. The American Academy of Pediatrics recommends well-child visits every six months from age 18 months to 3 years old.
In Texas, 30 percent of toddlers enrolled in Medicaid do not receive the recommended two or more well-child check-ups between ages 15 and 30 months. There is little regional variation on this metric; however, the rates in West Texas and the Panhandle are the worst.
We often think of a child’s growth as height and weight, but a child under age six should also reach milestones in how they play, learn, speak, act, and move. For some young children, healthy development may not be a clear path. Developmental delays or disabilities can take many forms, including medical conditions such as Down Syndrome and hearing or vision impairments; delays in language or speech; trouble interacting with others; cognitive issues that affect learning, problem-solving, or reasoning; and delays in motor development that can impact walking, eating, and writing.
In addition, children in households with low incomes are at greater risk of health concerns and developmental delays. This is, in part, because children in homes with low incomes may face more risks, such as poor housing conditions, contributing to problems such as lead poisoning or asthma, nutritional deficiencies, or parental depression that affects parent-child attachment and impacts a baby’s brain development.
Developmental delays can range in severity and scope, but it is clear that early identification and intervention are key to optimizing a child’s health and educational success. Developmental screenings during regular checkups help families and health professionals recognize milestones and identify possible social, behavioral, and developmental delays that can be addressed with early interventions. When children have delays or disabilities, providing Early Childhood Intervention (ECI) services or other support while they are still infants or toddlers is more effective than waiting until they are older.
The screening process also creates an opportunity for health professionals to help families understand age-appropriate expectations and learn how to guide their children to school readiness and effectively address challenges that may arise.
The American Academy of Pediatrics recommends developmental screenings using a standardized tool for children at 9 months, 18 months, and 30 months, or if a caregiver expresses a concern with their child. In Texas, according to a measure reported from health providers to Medicaid health plans and then to the state, less than half (46 percent) of children age three and under who are enrolled in Medicaid completed a developmental screening in the 12 months before their last birthday. This reporting method likely results in an undercount of the actual developmental screenings that take place. While children receive many services during a pediatric well-child visit (such as immunizations, physical exams, and screenings), many pediatricians submit a standard “bundled” billing code for the entire visit rather than specifying that a developmental screening was done with the child and caregiver. The well-child visit rates for infants and toddlers in Medicaid may be a better indicator of whether young children see a health professional and receive routine screenings. While the reporting method likely results in an undercount of developmental screenings, since the goal is for every child under age 3 to receive developmental screenings at 9 months, 18 months, and 30 months, there are certainly opportunities to make sure more young children are screened early before challenges get worse.
Early identification of disabilities or developmental delays – combined with a strong system of support for infants, toddlers, and caregivers – can prevent early challenges from having lasting effects and give children a greater opportunity to meet developmental goals. Texas Early Childhood Intervention (ECI) is an effective federal-state program that contracts with community organizations to provide life-changing therapies and services to children under age three with autism, speech delays, Down syndrome, and other disabilities and developmental delays. The state is required by federal law to provide these services to all eligible children under age three.
Working with caregivers, ECI helps children learn to walk, communicate with their families, and meet other developmental goals. ECI services prevent further delays, reduce the need for costly special education services, and help children develop independent living skills in the long term. In fact, a national study that tracked children from states’ early intervention programs as they entered elementary school found that only 58 percent were receiving special education services when they entered school. Thirty-two percent of children were considered to no longer have a disability or developmental delay, while ten percent had a disability or delay but did not receive special education services.
Research indicates that the prevalence of children under age three with disabilities and delays whose development could improve with ECI services is between 13 and 20 percent. However, the rate of children under three who are enrolled in ECI is much lower. In fact, Texas is worse than the national average in children’s enrollment in ECI. Only 2.7 percent of Texas children under age three are enrolled in ECI services, trailing behind the national average of 3.7 percent. Additionally, only 1.8 percent of Black children under age three in Texas are enrolled in ECI services, underscoring that Black children are likely under-enrolled and less likely to receive ECI services in the state. Further research is needed to understand the cause of these disparities and potential solutions.
Policymakers can ensure more babies are born healthy, mothers have the health care they need before, during, and after pregnancy, and all eligible children have health coverage and early interventions to get them off to a strong start. Learn more about the Dashboard’s policy recommendations to enhance good health and development in the first five years of life here.
