The Health of Children in Foster Care: Where Policy meets Practice

1. The Health of Children in Foster Care: Where Policy meets Practice David Rubin, MD MSCEDirector of Research & PolicySafe Place: Center for Child Protection & Health Children’s Hospital of Philadelphia

2. Objectives • What do we know about the health of children in foster care? • What is the relationship between the Medicaid Program and children in foster care? • What protections for children in foster care were provided in the Deficit Reduction Act of 2005? • What major vulnerabilities remain?

3. Background • 3,000,000 children reported to CPS each year: 1 in 20 will enter foster care. • 1 out of every 2 children entering a new episode of foster care will remain in foster care for more than 18 months • Of children who return home, 1 in 3 children will return to foster care within 2 years. • A quarter of children will remain in foster care until adolescence.

4. What do we know about needs? • 1 of every 2 children in foster care has chronic medical problems unrelated to behavioral concerns • 40%-80% have serious behavioral or mental health problems Sources: GAO, 1995; Halfon et al, Arch Ped Adol Medicine 1995; Trupin et al, Child Abuse & Neglect 1993; Urquiza et al, Child Welfare 1994; Garland et al, Children's Services: Social Policy, Research, & Practice2000; Simms, J Dev Behavioral Pediatrics 1989;

5. The Northwest Alumni Study Source: Casey Family Programs, 2005

6. How well are we addressing needs? • Only half of children with behavioral problems in foster care receive services • Up to 1/3 of children circa 1995 failed to receive appropriate immunizations • 1 in 8 were not receiving preventive care Sources: GAO, 1995; Burns et al. JAACAP, 2004; Rubin et al. Pediatrics 2004; Hurlburt et al. J Gen Psychiatry 2004; Harman et al. Arch Ped Adol Med 2000; Halfon et al. Pediatrics 1992

7. The importance of Medicaid • Children in foster care have 8-11 times the levels of service use of other Medicaid-enrolled children.1,2 • In 2001, per capita expenditures for children in foster care were more than triple that of non-disabled children covered by Medicaid3 • Although children in foster care represent 3% of all enrollees, they account for 25-41% of mental health expenditures.2,4 1 Harman et al. Archives of Ped Adol Medicine, 154(11): 2000 2 Halfon et al. Pediatrics, 89(6): 1992 3 Geen et al. Urban Institute, 2005 4 Takayama et al. JAMA, 271(23): 1994

8. The Urgency of Access ED Visits before and after placement changes

9. Eligibility and Coverage • IV-E children are mandatory coverage group • Most if not all states extend optional coverage to the entire population of children in foster care • Chafee Independence Act of 1999 granted a state option to extend coverage for children aging out of foster care to 21

10. Growing Congressional Oversight • Adoption and Safe Families Act (ASFA) 1997 • Focus on permanency for children in foster care • Mandate to also protect well-being • Chafee Independence Act of 1999 • Extending coverage to adolescents aging out • Child Family Service Reviews (post-2000) • Specific documentation of program improvement around child well-being

11. Focus on Health Care Partnerships • Necessary and appropriate growth of case management and needs assessment services within child welfare systems • To improve the quality of available care,states have augmented their programs to coordinate services across public programs • This has created unique funding needs, relying on both state and federal funding, particularly targeted case management funding through Medicaid

12. Targeted Case Management • Children and adolescents in foster care who are receiving TCM services are more likely to use multiple health care services • 15% of all TCM funds allocated by the Medicaid program are for children in foster care Source: Geen et al, Urban Institute, 2005

13. Medicaid Reform and The DRA • New Documentation Requirements • Changes to Coverage Design: Benchmark and Wrap-Around • Co-pays and Premiums • Restrictions on the use of Targeted Case Management Funding No exemption for children in foster care Exemptions for children receiving Title IV-E services Exemptions for children receiving Title IV-E services Ambiguity between explicit protections in foster care and third party liability

14. Where are the Vulnerabilities? • Documentation Requirements are likely to increase barriers to accessing care • How do we address coverage for children returning home? • Should contact with child welfare trigger an easy access option to comprehensive coverage design • Pegging services to IV-E status is flawed as health considerations are independent of funding status • How are co-pays and premiums to be determined for families who foster children? What will the effects be on recruiting caregivers? • How will states meet their requirements to improve well-being without the flexibility afforded by TCM in the Medicaid Program?

15. Summary • Data across the last couple of decades has demonstrated a disproportionate burden of medical and mental health needs for children in foster care. • Despite better awareness of health care needs, access to appropriate health services remains a problem. • Timely and appropriate access is an issue of urgency, particularly because of acute crisis and loss of information that results from a change in a child’s home • Broad strokes to Medicaid policy have the potential to disproportionately affect fringe beneficiaries, some of whom are among the most vulnerable populations served by the program.