Policy Considerations for Routine Screening for Adverse Childhood Events (ACEs)

Abstract

In October of 2021, California enacted SB 428, the ACEs Equity Act, which mandates commercial insurance coverage of adverse childhood experiences (ACEs) screening in addition to ACEs screening already covered for the state's Medicaid enrollees. California is the first state to expand ACEs screening coverage, but it is possible other states may follow similar paths given the increasing interest in policy action to address ACEs. Increase in stress and trauma among Americans and evidence of the disproportionate impact ACEs have on historically marginalized and disadvantaged communities has increased the urgency with which policy makers, clinicians and researchers have sought to address ACEs and encourage trauma-informed care delivery to better meet the needs of patients. Family practice and other primary care providers are at the core of prevention and are arguably the largest group of stakeholders at the forefront of movements toward increasing ACEs screenings. However, debate persists among policy makers, clinicians, and researchers on whether the ACEs screening approach improves outcomes and avoids harms. In this health policy article, we describe key issues under debate with regards to ACEs screening and estimate potential change in screening utilization and expenditures due to the new ACEs legislation in California. The lessons being learned in California are applicable to other states and the US as a whole.

Disparities in Screening for Adverse Childhood Experiences

“…These findings also provide a critical baseline for rates of screening, before new reimbursement policies for ACEs screening that will likely increase the uptake. 13 However, as efforts to screen for ACEs expand, clinician reported barriers to screening, such as lack of mental health resources to refer patients to, insufficient time to screen, lacking confidence, fear of retraumatization, lack of appropriate screening tools, and beliefs that screening for ACEs does not have a positive impact 7,37,38 should be considered and addressed. One potential avenue to address these barriers would be to provide more clinicians training on screening, including working to increase self-efficacy and reducing fears around screening.…”

“…This evolution is continuing as several states in the United States have passed legislation that reimburses clinicians for ACEs screening administered to Medicaid patients. 13 These efforts have been expanded in California, which will require private health insurance to also cover ACE screening. 13 In addition, in California, clinicians are required to complete a 2 hour training that covers ACEs screening and how to incorporate the results of ACE screening into patient care, to be eligible to be reimbursed for screening under Medicaid.…”

“…13 These efforts have been expanded in California, which will require private health insurance to also cover ACE screening. 13 In addition, in California, clinicians are required to complete a 2 hour training that covers ACEs screening and how to incorporate the results of ACE screening into patient care, to be eligible to be reimbursed for screening under Medicaid. 14 Although there are hypothesized benefits to ACEs screening, these remain largely untested and many argue that more research is needed to fully understand the health benefits of ACEs screening.…”

Family Medicine Researchers Explore the Social Determinants of Health, COVID-19 Issues, and Cancer Survivor Care

“…This issue's health policy article looks at California's new law that makes them the first state to mandate coverage of the financial costs of health care for people with adverse childhood experiences. 21 In Addition. .…”

Life course history of physical and sexual abuse is associated with cardiovascular disease risk among women living with and without HIV

“…ACEs are associated with a many poor physical, behavioral, and mental health outcomes across the life course [1,5], with sexual and physical abuse (the most severe ACEs) yielding the strongest associations with later life outcomes [3,4,6]. Increasingly, providers are screening for ACEs in pediatric and adult primary care settings [7,8], with California recently mandating insurance coverage for ACE screening statewide [9]. Thus, while ACEs are an important concern for children, ACEs also have farreaching impacts for health and clinical practice for adults.…”