TMA Testimony by Marjan Linnell, MD
House Appropriations Subcommittee on Article II
- Texas Pediatric Society
- Texas Medical Association
- Texas Academy of Family Physicians
Feb. 19, 2019
Chairwoman Davis and committee members,
Thank you for the opportunity to testify today on the vital importance of the Early Childhood Intervention (ECI) program for some of Texas’ most at-risk and vulnerable infants and toddlers. I am Dr. Marjan Linnell, a practicing pediatrician in Kyle. Today I am speaking on behalf of the Texas Pediatric Society, Texas Medical Association, and Texas Academy of Family Physicians.
The Texas ECI Program Effectively Improves Child Outcomes and Saves Taxpayer Dollars
ECI is a statewide program for families with children, birth to age three, with disabilities and developmental delays. Over the past 30 years-plus, ECI has supported more than 800,000 families in helping their children reach their potential through targeted developmental services and parent counseling and training. What makes ECI different from other services is its focus on training parents and other caregivers, such as grandparents, or child care facilities on how best to help a child achieve specific goals and developmental milestones.
The benefits of early intervention services, like Texas’ ECI program, are numerous in both child health outcomes and economic advantages to the family and society. A substantial amount of longitudinal research has demonstrated that access to early intervention for children shows marked improvement in verbal abilities, receptive language scores, and overall cognitive abilities, which can translate later in life to less risky behaviors, fewer arrests, and lower dropout rates. By intervening early, when a baby’s cognitive and physical health are still being formed, we can reduce costs in other domains and interventions, such as school-age special education services, and improve a child’s functional trajectory for life. Furthermore, early intervention services such as ECI are vital to more high-risk populations of children including those with mental health issues and those who come from environments of abuse and neglect, culturally diverse backgrounds, or economically deprived backgrounds.
It is also important to note that Texas’ ECI program, compared with the national average, has demonstrated that when children do receive service the program is especially effective in producing results. On the three Global Health Outcomes reported to the federal Office of Special Education Programs, Texas children significantly increased their rate of growth in the following key domains:
- Positive social-emotional skills including getting along with other children and relating to adults;
- Acquisition and use of knowledge and skills including reasoning, problem-solving, and early literacy and math skills; and
- Use of appropriate behaviors to meet their needs including feeding, dressing, self-care, and following rules related to health and safety.
ECI Services Are a Core Referral Source for Primary Care Physicians
As a practicing primary care pediatrician, I have the pleasure of caring for children with a wide variety of behavioral and developmental needs. Most experience normal behavioral issues, including the so-called “terrible twos.” But a subset suffers from hearing or speech delays, swallowing or walking difficulties, developmental delays, or other physical or developmental challenges that may affect one or more areas, including cognition, motor skills, and language. Delays may be mild or more far-reaching and can stem from a variety of causes, including autism, Down syndrome, or spinal muscular atrophy.
Given what science tells us about the importance of early intervention in restoring or mitigating the effects of developmental delays, I am thankful for the ECI program, which provides early identification of development delays and in-home services to children from birth to three years. In fact, federal law requires physicians to refer a child under the age of three with a developmental delay or disability within seven days of identification. Texas physicians make up most of the referrals to ECI programs and as such depend on a robust network of contractors across the state to meet the law and to address a child’s development needs.
ECI Is in Jeopardy With Contractors Dropping From the Program
Unfortunately, this robust network of statewide ECI contractors is in major jeopardy because of the program’s constant change in the past several biennia. These changes have led to a reduction in the number of contractors providing ECI services, from 58 in 2010 to 42 in 2019 – a nearly 25-percent drop.
Two major factors have overburdened many contractors, causing them to shut their doors:
- A state obligation passed onto contractors to serve every child deemed eligible without the matching funds to do so, and
- Decreasing per-child allotments to contractors who now must serve a higher-need population of children based on eligibility restrictions.
Simply put, ECI caseload growth as requested by the Texas Health and Human Services Commission (HHSC) has not been fully funded in many sessions. This leaves little room for HHSC to provide appropriate contract funding to providers when more children are deemed eligible in their service area than originally anticipated. This strain on ECI providers reduces the availability of front-line staff to perform “child find” activities, where proactive outreach within the community identifies children who would qualify for services. As a result, ECI has seen an overall decrease in enrollment since 2011 despite the birth-to-age-three child population increasing in Texas over that same period.
This translates directly to less intervention available to my patients – patients like Sam, who was born with a serious heart condition and had a stroke during heart surgery when he was just a few weeks old. Due to his stroke and likelihood of developmental problems, he was referred to ECI. Thankfully, initial evaluations showed Sam is doing just great and was on track developmentally. Most recently, though, at his last check-up, I became worried about speech and other developmental problems. Because he was already in the system, he was reevaluated and enrolled in services very quickly. As a lack of funding continues to put a strain on ECI providers, babies like Sam are put on long waitlists to receive these critical services, and I fear that at some point down the road I will have no one to refer Sam to.
Additionally, ECI providers report that the per-child formula amount HHSC provides them has decreased over time, putting further strain on already overloaded organizations. Couple this with reductions in functional eligibility, where children must have higher levels of delay to qualify, and the cost of care for those remaining in the program, which has increased because of their higher average level of need.
The Time to Invest in Texas ECI Is Now
Children, their families, and their physicians need reassurance from the legislature that the program will be there to serve all children who qualify.
The Texas Pediatric Society, the Texas Medical Association, and the Texas Association of Family Physicians urge the committee to fully fund the $70.7 million HHSC Legislative Appropriations Request Exceptional Item No. 5, which will ensure ECI keeps pace with caseload growth and increases in the cost of providing services, and retains contractors who provide these critical services.
Our organizations strongly stand by the ECI program as a cost-effective, best practice model of care to address developmental delays and improve outcomes for the youngest children in our state.
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