ACTION ALERT: Meet With Your Members of Congress in August while they are home. Ask them to support the Foster Care-Medicaid Demonstration Proposal
Concern: The Administration has proposed (in next year’s budget) new revenue that will help local foster care (and state child welfare) agencies coordinate with state Medicaid programs to provide better health care services to children in foster care. Congress needs to act this year on this proposal as part of a final budget for 2015, either before or after the election.
Message: Children and youth in foster care have significant health and mental health needs, often far greater than their peers. Bipartisan congressional hearings and a number of recent media stories have brought attention to the over-utilization of psychotropic medication (psychiatric medicines that alter chemical levels in the brain and impact mood and behavior) for children and youth in foster care.
We can better serve children and youth and help keep them safe in families by developing a more coordinated and comprehensive approach to addressing the behavioral health care needs of children served by Medicaid, many who are victims of child abuse, are in foster care or exposed to various forms of trauma including sexual exploitation and trafficking. Although small in terms of budget requests, this demonstration project will build on existing priorities and recent reforms led by Congress, and will help to not only curb inappropriate use of psychotropics, but also to incentivize the use of a variety of evidence-based psychosocial interventions that have been found to be effective.
- The Administration has proposed a five-year program that will incentivize foster care (child welfare) agencies to better coordinate health care services with state Medicaid programs.
- Bipartisan hearings in the House and the Senate have shown that children in foster care are over-prescribed medications that are not appropriate and that as many as 70% of foster youth do not get the mental health treatment they need.
- Government Accountability Office (GAO) reports issued in 2011 and 2014 on state practices around psychotropic medications for foster children show the same concerns.
- The proposal would provide $50 million a year in competitive state grants to child welfare agencies to improve casework, coordination, training and to provide better services for children in foster care. It would also provide $100 million a year in competitive grants to state Medicaid agencies if they meet specific targets and areas for improvement, including reducing the inappropriate use of medications and increasing access to effective therapies for children in foster care.
- In September or soon after the election, you will approve a final budget. This proposal—which will help children in foster care and over time, save money through reduced medication use and better outcomes for children—must be a part of the final budget agreement.
- In May, the Subcommittee on Human Resources (House Ways and Means Committee) held a hearing, Caring for Our Kids: Are We Overmedicating Children in Foster Care? The hearing was not the first time Congress has looked at the overmedication of children and youth in the foster care. In 2011, the Subcommittee on Federal Financial Management (Senate Committee on Homeland Security and Governmental Affairs) also held a hearing, The Financial and Societal Costs of Medicating America’s Foster Children.
- The hearings followed a number of media stories about trends in the over-utilization of psychotropics (psychiatric medicines that alter chemical levels in the brain impacting mood and behavior) for children and youth in foster care. Stories are backed by a body of research citing questionable prescribing practices including polypharmacy (use of multiple medications at one time), alarming dosages, use of psychotropics in treating infants, lack of adequate monitoring or appropriate therapeutic interventions and “off-label” use (use other than approved by the FDA) of antipsychotics for children and youth in foster care. These concerns are supported by GAO reports issued in 2011and 2014.
- While the pharmaceutical industry has marketed prescription medications to Medicaid, therapeutic alternatives are limited in scale and lack the marketing behind pharmaceuticals. The therapeutic interventions that work for children exposed to trauma, such as Multidimensional Treatment Foster Care (MTFC), Parent-Child Interaction Therapy (PCIT), Multi-systemic Therapy (MST), Functional Family Therapy (FFT),and Trauma-Focused Cognitive Behavioral Therapy (CBT) are not often scaled for broader replication, frequently because of cost-constraints.
- A promising opportunity is a new five-year collaborative demonstration proposal in the Administration’s FY 2015 budget aimed at reducing inappropriate prescribing practices and the over-utilization of psychotropic medications. The proposal requests a five-year joint project through ACF and CMS to promote effective evidence-based interventions targeting children in foster care. The proposal will help coordinate efforts to build state and tribal capacity within child welfare and health care systems to more appropriately address the high rates of children who may be unnecessarily receiving psychotropic medications, often several at one time.
- Foster youth are less likely to receive appropriate mental health services. The project will encourage the utilization of evidence-based therapeutic interventions, including therapeutic foster care, intensive in-home and community-based approaches, Multisystemic Therapy, and mobile response and stabilization services.
- The proposal invests $50 million a year, through ACF to build state infrastructure and capacity to ensure improved coordination between state Medicaid programs and child welfare agencies. In conjunction, CMS funding is proposed at $100 million a year in incentives to states that show improvements. The goals of this important initiative are to reduce inappropriate prescribing practices and over-utilization of psychotropic medications, increase access to evidence-based and trauma-informed therapeutic interventions, promote child and adolescent wellbeing, and improve child welfare outcomes (as related to safety, increased permanency, fewer disrupted adoptions and reduced entries and re-entries into foster care).
- We are currently spending millions of dollars on medications alone and not getting the best outcomes for children and youth. The CMS Office of the Actuary (OACT) found that in 2008, $532 million was claimed for psychotropic drugs for Medicaid children in foster care. This proposal can help bring better outcomes for children and improved efficiency under the Medicaid program.