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CWLA 2009 Children's Legislative Agenda
Increasing Access to Health Care
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Children in foster care are at a higher risk for physical
and mental health issues, stemming either from the
maltreatment that led to their placement, or from preexisting
health conditions and long-term service needs. Before
they even walk through the door, many children who come
into contact with the child welfare system have been exposed
to several facets of trauma, including domestic violence,
physical and emotional abuse, parental mental health problems
and substance abuse, neglect, and poverty. Infants and
toddlers, being in extremely formative years, if exposed to
such trauma, may be at particular risk of developing hardto-
overcome emotional difficulties and developmental
delays. Once placed in out-of-home care, separation from
familial ties and the continued instability that often ensues
only exacerbate the child's initial vulnerability.
Numerous studies have documented that children in
foster care have medical, developmental, and mental health
issues that far surpass those of other children, even those
living in poverty.
Medicaid
Child welfare agencies are responsible for meeting the
health and mental health needs of all children in state custody.
Virtually all children in foster care are eligible for and
obtain health care services for both acute and long-term
conditions through Medicaid. To receive federal matching
funds, state Medicaid programs must provide beneficiaries
with certain mandatory services. A mandatory service that
is particularly important for children in foster care is
Medicaid's comprehensive Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) benefit. EPSDT requires
states to periodically screen and ascertain physical and
mental defects in children and provide any corresponding
necessary treatment that will correct or ameliorate any
defects or chronic conditions.
Studies have repeatedly shown, and the Government
Accountability Office (GAO) reported in 2001, that not all children
are receiving the EPSDT services to which they are entitled
by federal law. Access problems exist for several reasons,
including a low provider participation in Medicaid, especially
among mental health providers and dentists. Many parents
are simply unaware of their children's right to EPSDT.
Beyond mandatory services, states may cover and
receive Medicaid matching funds for approved, optional
services. Two optional services that have proven to be
extremely beneficial to children in care are rehabilitative
services and targeted case management (TCM). Medicaid
Rehabilitative Services work to reduce physical and mental
disabilities that many children in care experience as a result
of abuse, neglect, or similar trauma, and restore them to
optimal functioning level. Rehab services provide strong
support for therapeutic foster care (TFC) programs.
Maintaining a full continuum of care is important so that
each child can receive the most appropriate intervention for
his or her particular situation. TFC is an integral part of
that continuum, as it provides clinically and cost-effective
individualized treatment within a family setting for children
and adolescents experiencing serious mental illness, emotional
or behavioral disorders, or other disabilities. Taking
into account the vulnerability and complex needs of children
in foster care, including health needs, at least 38 states
employ the Medicaid TCM option to ensure children in foster
care receive a comprehensive approach and greater coordination
of care.
In 2007, the Bush Administration issued a proposed regulation
dealing with rehabilitative services and an interim
final regulation dealing with TCM services. These regulations
were issued alongside several other similarly restrictive
Medicaid regulations that, in the aggregate, would devastate
our nation's health care safety net. The rehab and
TCM rules established ambiguous "intrinsic to" or "integral
to" tests that appear to wholly shift costs to already struggling
state child welfare and foster care systems. The
110th Congress included a moratorium on six Medicaid
regulations, including rehab and TCM, in the Supplemental
Appropriations Act of 2008, which was signed into law on
June 30, 2008 (P.L. 110-252). The rehab and TCM rules are
therefore delayed until April 1, 2009.
Several other longstanding access issues need to be
addressed regarding Medicaid. Low provider payment rates,
heavy administrative burdens, and other factors have led
to a chronic shortage of health care providers willing to accept Medicaid patients. For foster families and other
caregivers, this has diminished access and choice, particularly
in geographic areas where transportation is difficult,
such as rural America. The limited pool of providers that
do accept Medicaid patients may lack experience in treating
the unique physical and mental health problems that children
in out-of-home care experience. They may also face
serious obstacles in obtaining comprehensive, accurate
medical histories for children who have endured multiple
placement changes and corresponding discontinuity in coverage
and care.
Although Medicaid should be available for youth in
foster care until age 18, many youth transitioning out
of the system—facing an array of difficulties, and often
having little or no support from their families, friends, or
communities—are left without health insurance. States can
extend Medicaid to youth formerly in care beyond age 18,
but significant gaps remain.
Recommendations
Short-Term Actions:
- The new Administration should protect the Medicaid
targeted case management (TCM) and rehabilitative
services options by rescinding regulations issued by the
Bush Administration on these streams of care.
- Congress and the new Administration should include in
a stimulus package a temporary increase in the Federal
Medicaid Assistance Percentage (FMAP) to aid with the
ailing economy.
Long-Term Actions:
- Congress and the new Administration should extend
Medicaid coverage to all youth formerly in foster care
until at least age 21.
- Congress and the new Administration must preserve the
federal guarantee of Medicaid as an entitlement program
for low-income children, youth, and families. They should
oppose efforts that attempt to restrict eligibility and
reduce access and/or benefits for beneficiaries. To
improve the program, both the legislative and executive
branches must work to increase the number of qualified
providers accepting Medicaid and ensure that these
providers are properly trained to handle the unique physical
and mental health needs of children in foster care.
- Congress and the new Administration should ensure the
availability of and accessibility to comprehensive preventive
health care services guaranteed in federal law
through the Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) benefit.
- Congress should conduct oversight of efforts to implement
Medicaid provisions of the Deficit Reduction Act
(DRA) to ensure that they do not negatively impact vulnerable
children and families.
- Congress should conduct proper oversight of the
Medicaid program to combat fraud and abuse. At the
same time, Medicaid funds must remain available for legitimate TCM and rehabilitative services for children
involved with the child welfare and foster care systems.
- The new Administration should use the new requirements
under the Fostering Connections Act to encourage collaboration
between the state child welfare and Medicaid
systems so that the physical and mental health needs of
children in their care are properly addressed.
- The new Administration and Congress should establish
therapeutic foster care (TFC) as a Medicaid-reimbursable
service.
Mental Health
Despite the dismal fact that anywhere between 50% and
80% of children in foster care experience moderate to
severe mental health and behavioral problems, findings from
the federal Child and Family Service Reviews (CFSRs) reveal
that the mental health needs of these vulnerable children
often are not met. Most states have committed to better
address the mental health needs of children and families in
their child welfare systems by including appropriate action
steps in their Program Improvement Plans (PIPs).
Thoroughly screening children involved with the child
welfare and foster care systems to identify their mental
health needs, and providing appropriate treatment, is essential.
There is growing concern about the use of psychotropic
medications with children, partly because very few of these
medications have been approved by the Food and Drug
Administration for treating mental health disorders in children.
Studies have shown that children involved with the
child welfare system are three to four times more likely than
are other Medicaid recipients to receive psychotropic medications.
Although some extreme situations certainly warrant
the use of psychotropic medications with children, their
prescription and administration must be monitored closely.
The Children's Mental Health Services Program funds
comprehensive, community-based systems of care for children
with serious emotional disturbance (SED) in the
nation's child welfare, juvenile justice, and special education
programs. The Community Mental Health Services
Performance Partnership Block Grant is the principal federal
program supporting community-based mental health
services for children and adults. For SED children, these
funds support services such as case management, emergency
interventions, residential care, and 24-hour hotlines
to stabilize children in crisis, as well as coordinate care for
individuals with schizophrenia or manic depression who
need extensive support.
The Mental Health Programs of Regional and National
Significance promotes the implementation of effective, evidence-
based practices for adults and SED children. Recent
areas of importance include services for children and adolescents
with post-traumatic stress, coordination of crosssystem
mental health activities and services, and prevention
of youth violence and suicide.
In the 110th Congress, historic mental health and addiction
parity legislation was enacted that will help erase longstanding
discrimination between physical and mental health conditions. Such policy will greatly help all Americans with
mental health and substance use problems, particularly vulnerable,
lower-income families and those involved with the
child welfare system who experience a disproportionate rate
of such struggles.
Legislation was also introduced in the 110th Congress that
would ease the transition to adulthood for individuals ages
18–26 with serious mental illness (Healthy Transition Act, S.
3195/H.R. 6375). This legislation would provide grants for
states to develop coordination plans to better help this vulnerable
population. It specifically urges states to target disproportionately
affected populations, such as those involved with
the child protection system.
Recommendations
Short-Term Actions:
- The new Administration should use the new health planning
requirements for state child welfare agencies
enacted through the Fostering Connections Act to
ensure the provision of early and more routine mental
health screenings for children entering foster care.
- The new Administration should use the new health planning
requirements enacted as part of the Fostering
Connections Act to assist states and local agencies in
assuring better coordination of mental health needs and
services between various child- and adolescent-serving
systems, particularly for young adults with serious mental
illness who are aging out of foster care and often
lose their Medicaid coverage.
- The new Administration should use the new health planning
requirements enacted as part of the Fostering
Connections Act to assist states and local agencies to
ensure proper oversight of prescription and administration
of psychotropic medication to children in care. This could
be done by requiring states to report the percentage of
children in out-of-home care who are receiving psychotropic
drugs and how many medications they are receiving.
Long-Term Actions:
- Congress and the new Administration should extend
Medicaid coverage to all youth formerly in foster care
until at least age 21.
- Congress and the new Administration should increase
funding for the Children's Mental Health Services
Program, the Community Mental Health Services
Performance Partnership Block Grant, Mental Health
Programs of Regional and National Significance, and key programs that target the social and emotional
development of infants and toddlers at heightened risk
for mental health problems.
- Congress and the new Administration must ensure
availability and accessibility to comprehensive preventive
health care services, including physical and mental
health screenings and interventions, for children in foster
care who are guaranteed the services under federal
law through the Early Periodic Screening, Diagnosis,
and Treatment (EPSDT) program for children younger
than 21 receiving Medicaid. Particular attention should
be paid to infants in foster care, ensuring that they
receive a comprehensive mental health evaluation and
follow-up services.
- Congress should enact legislation to address acute
shortages of qualified child and adolescent mental
health professionals. Changes would provide more funding
to properly train child and adolescent mental health
professionals dealing with children and youth involved
in the child welfare and foster care systems regarding
this population's special needs.
Children's Health
Insurance Program (CHIP)
Although Medicaid coverage is available to almost all
children in foster care, the Children's Health Insurance
Program (CHIP) has successfully broadened health coverage
for low-income children and families, including at-risk
families and children transitioning out of foster care. With
the program set to expire in 2007, the 110th Congress
passed two compromise bills (H.R. 976 and H.R. 3963)
that would have reauthorized and strengthened CHIP, but
President Bush vetoed both measures. As a result of this
gridlock, CHIP was extended through March 31, 2009, with
sufficient funding to maintain current enrollment and avoid
shortfalls (P.L. 110-173).
On February 4, 2009, the 111th Congress passed and
President Obama signed into law a four-and-a-half-year
reauthorization of CHIP that will maintain coverage for
over 7 million children and expand coverage to 4.1 million
children who would otherwise be uninsured.
The reauthorization makes several improvements to
the program, including: guaranteed dental benefits and
mental health parity; a state option to implement express
lane eligibility; $100 million in grants for outreach and
enrollment; and establishment of a child health quality
initiative. Another large accomplishment advocated for
by CWLA and many other organizations is that the law eliminates the five-year waiting period for legal immigrant
children and pregnant women to enroll in Medicaid or CHIP.
Also in early February 2009, President Obama sent a
memo requesting that the August 17, 2007 and May 7, 2008
letters restricting flexibility sent to state health officials be
withdrawn. Recognizing states are very differently situated—
in terms of costs of living, for example—the federal government
has long afforded states flexibility to uniquely tailor
certain aspects of their CHIP programs, including the ability
to set income eligibility limits, as long as the Centers for
Medicare and Medicaid Services specifically approves. The
Bush Administration's August 17, 2007 controversial directive,
however, would have made it next to impossible for
state CHIP programs that are already covering or desire to
cover children in families who earn over 250% of the federal
poverty level to do so.
Recommendations
Long-Term Actions:
- Monitor the implementation of CHIP reauthorization, as
signed into law on February 4, 2009. Ensure that new and
adjusted policies reach their goal of providing nearly 11
million children with accessible, quality health coverage.
Substance Abuse
Children's exposure to parental alcohol and other drug
(AOD) use—whether through prenatal exposure or environmental
observation—undoubtedly puts them at risk.
Substance abuse is estimated to be a factor in one- to twothirds
of cases of children with substantiated reports of
abuse and neglect, and in two-thirds of cases of children in
foster care. Children from families with substance abuse
problems tend to come to the attention of child welfare
agencies younger than other children, are more likely than
other children to be placed in out-of-home care, and are
likely to remain there longer.
If not treated properly, parental substance abuse is troublesome;
in addition to being a root cause of child abuse
and neglect, often it is cyclical and intergenerational in
nature. Studies have shown that children who grow up in
homes plagued by AOD use and abuse very often choose
risky behavior and develop their own AOD problems.
To ensure safety and permanence for these children, and
appropriate alcohol and drug treatment for their families,
increased treatment and other services must be directed to
their special needs. This will require increased resources
and new partnerships between child welfare and AOD agencies, other service providers, courts, community leaders,
and family members. In past Congresses, legislation has
been introduced to provide grants to state child welfare and
alcohol and drug agencies to address the effects of alcohol
and drug abuse on children and families who come to the
attention of the child welfare system.
In recent years, Congress has provided some limited
nationally competitive grants with the goal of funding treatment
programs. Enacted as part of the Deficit Reduction Act
(DRA) in 2006, one model of program potentially served by
these grants is a family-based treatment program. These
grants, allocated through the Title IV-B PSSF program, were
limited to $40 million in the first year, decreasing to $20
million in the fifth. They were also weighted toward the use
of methamphetamines, which could limit their access in
certain parts of the country.
Recently, Congress included in the Fostering
Connections Act a limited amount of funds that may also be
used for such initiatives. Although important, these national
grants fall short of the vast need. Nationally, there is a
shortage in all types of publicly funded substance abuse
treatment opportunities for those in need, especially for
women. All states report long waiting lists for services.
Recommendations
Long-Term Actions:
- Congress and the new Administration should provide
expanded federal resources to increase substance
abuse treatment capacity within the child welfare system
and stimulate effective partnerships between child
welfare and substance abuse agencies.
- Congress and the new Administration should provide
more funding for comprehensive family-based treatment
through legislation that would provide specific grants to
state child welfare and substance abuse agencies or
expand the current substance abuse grants provided
through Title IV-B Promoting Safe and Stable Families
program to target family-based treatment programs for
all forms of substance abuse.
- Congress and the new Administration should increase
funding for the Substance Abuse Prevention and
Treatment Block Grant.
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