Children in foster care are at a higher risk for having physical and mental health needs, 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 faces of trauma, including domestic violence, abuse, parental mental health problems and substance abuse, neglect, and poverty. Once placed in out-of-home care, separation from familial ties and the continued instability that often ensues only exacerbate this vulnerability.
Numerous studies have documented that children in foster care have medical, developmental and mental health needs that far surpass those of other children, even those living in poverty. One study found that 60% of children in care have a chronic medical condition and one-quarter have three or more chronic health problems. 1Many also experience developmental delays in regards to language and cognition. 2When compared to the general population, children younger than six in out-of-home care have higher rates of respiratory illness (27%), skin problems (21%), anemia (10%), and poor vision (9%). 3 In regards to mental health, it is estimated that between 54% and 80% of children in out-of-home care meet clinical criteria for behavioral problems or psychiatric diagnosis. 4 In one study, researchers found that between 40% and 60% of children in out-of-home care had at least one psychiatric disorder and that this population of children used both inpatient and outpatient mental health services at a rate 15 to 20 times higher than the general pediatric population. 5
If a child is not reunified, adopted, or placed in another form of recognized and supported permanency such as kinship care, he or she will continue to travel through the system until the age of eighteen, at which point federal funds are cut off and the youth “ages out.” For the 20,000-25,000 youth who age out of care each year, many times their health needs linger into adulthood. Foster care alumni experience a disproportionate amount of both physical and mental health issues, including post-traumatic stress disorder and major depression. Compounding this problem is the fact that 33% of foster care alumni lack health insurance-a rate almost twice as high as the general population. 6
Importance of Medicaid
When removed from their home base, child welfare agencies are responsible for meeting the health and mental health needs of all children in state custody, and virtually all children in foster care are eligible for and obtain health care services for both acute and long-term conditions through Medicaid. Because other existing federal programs do not guarantee such comprehensive coverage that is necessary in light of children in foster care’s unique health needs, Medicaid must be preserved as an entitlement program for low-income children, youth, and families.
Of particular note, Medicaid’s Early, Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit requires states to ascertain physical and mental defects in children under the age of 21 and provide any corresponding, necessary treatment that will correct or ameliorate the defects or chronic conditions found. EPSDT also mandates that states inform children of the availability of EPSDT services, their benefits, where and how to obtain them, as well as provide transportation and scheduling assistance if requested. Unfortunately, despite EPSDT’s broad benefits aimed at helping the neediest children, studies have repeatedly shown and the GAO reported in 2001 7 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. Also, many parents are simply unaware of their children’s right to EPSDT services.
Beyond funding the direct provision of basic physical health care services, Medicaid currently grants states the option of providing critical rehabilitative, therapeutic, psychiatric, and targeted case management (TCM) services to children in foster care. Such funding is a critical component to ensuring that children in foster care receive the necessary physical and mental health attention and assistance while in protective custody. TCM allows states to target a select population to receive in-depth case management services-even across child-serving systems-thereby assisting the child in accessing much needed medical and social services. At least thirty-eight states employ the TCM option to provide greater coordination of care for children in foster care and the children who receive TCM services fare better in a wide array of areas. Specifically, TCM recipients are more likely to receive physician services (68% compared to 44%); prescription drugs (70% compared to 47%); dental services (44% versus 24%); rehabilitative services (23% versus 11%); inpatient services (8% versus 4%) and clinic services (34% compared to 20%). 8
Medicaid also provides the optional Rehabilitative Service benefit for children in the child welfare system. Rehabilitative Services aim to reduce physical or mental disabilities and help recipients reach their optimal functioning level. Examples of rehabilitative services include therapeutic or treatment foster care, behavioral management services, day treatment services, and family functioning interventions. Use of the rehabilitative services Medicaid option often plays a critical role in allowing states to provide essential mental health services in the least restrictive setting to children in foster care.
CWLA believes that there is a shared mission between Medicaid and child welfare services to provide not only for the basic safety of children in foster care, but also to improve their overall well-being, including close attention to both physical and mental health care outcomes. With the physical and mental health needs of these children being great, Congress must ensure that the already limited funding streams for critical physical and mental health services to children in foster care, including EPSDT and the Medicaid options of Targeted Case Management and Rehabilitative Services, are protected. Aggressive efforts must be made to thwart any contrary actions so that Medicaid may fulfill its purpose of bettering the health of some of our nation’s most vulnerable children.
Access To Health Care
The recent federal Child and Family Service Reviews (CFSRs) as required by the Adoption and Safe Families Act (ASFA; P.L. 105-89) and conducted by the U.S. Department of Health and Human Services investigated each state’s provision of child welfare services and found that many times, states are not able to fully meet the physical and mental health needs of children in care. Only half of the states were found to demonstrate strength in the provision of health care services, with the great majority of those states demonstrating strength in meeting children’s physical health care needs (20 states) and only four demonstrating strength in meeting children’s mental health needs. Only one state was found to be in substantial compliance of meeting both children’s physical and mental health needs.
Many of the challenges associated with the provision of health care for children in out-of-home care relate to funding, specifically the constraints posed by the Medicaid program. In many states, providers report very low reimbursement rates and long waits for payment. In some communities, providers have declined to continue to see patients who have Medicaid as their health care coverage. As the number of providers for children in out-of-home care decreases, access and choice diminish, waiting lists become commonplace, and services are delayed. At the same time, a number of states have mandated that children in out-of-home care shift from fee-for-service Medicaid to Medicaid managed care. These changes in the delivery and funding of health care services have led to concerns that services for children in out-of-home care will be rationed and that services that were already difficult to obtain under the fee-for-service model, particularly mental health services, will become even more difficult to access. 9
In addition, health care providers often lack experience in treating the physical and mental health problems that children in out-of-home care experience. They may face serious obstacles in obtaining accurate medical histories for children, including information about current and prior medications. On the child welfare workforce end, child welfare caseworkers are often young, have limited professional experience, and are managing caseloads that far exceed recommended standards-all of which likely contribute negatively to the timely and appropriate provision of health care for children in foster care. Final concerns include: distance to providers and lack of transportation, placement changes while in out-of-home care, barriers to information sharing between the health care and child welfare systems, and failures to coordinate the child’s health care and child welfare plans. 10
Alcohol and other drug problems devastate the lives of hundreds of thousands of American children and their families each year. A major factor in child abuse and neglect, substance abuse is associated with the placement of at least half of the children in child welfare custody. 11 Substance abuse is a factor in one to two-thirds of cases of children with substantiated reports of abuse and neglect and in two-thirds of cases of children in foster care. 12 Furthermore, children whose parents use drugs or alcohol are three times more likely to be abused, and four times more likely to suffer from neglect. 13 In addition, 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 once in out-of-home care, are likely to remain there longer. 14 The recent increased use of methamphetamine especially threatens the lives and security of our nation’s children.
The significant rise in the number of children entering out-of-home care due to parental drug use over the last two decades represents one of the most serious policy and practice challenges to the field. The overall shortening of timelines and movement to make quicker permanency decisions in out-of-home care cases required by the Adoption and Safe Families Act (ASFA) of 1997 has increased the sense of urgency and further emphasized the pressing need within the child welfare system to develop adequate capacities to address parental substance abuse issues. Clearly already strained child welfare agencies cannot stand alone in serving the complex needs of children and families struggling with substance abuse. Good assessment, early intervention, and comprehensive treatment are key to determining when and if a child can safely stay at home or be reunited with his or her family. New relationships must be formed between state and local government child welfare and drug and alcohol agencies and parallel non-government programs to provide high quality, effective services.