On September 21,2021 the Senate Finance Committee asked the public for their comments on ways to address substance use and mental health services.  In the letter Committee Chairman Ron Wyden (D-OR) and Ranking Member Mike Crapo (R-ID) asked members of the behavior health community and other interested parties about how the committee can best address behavioral health challenges especially in light of the pandemic.


Specifically, they said they are looking for evidence-based solutions and ideas to advance behavioral health care in a) strengthening the workforce, b) increasing integration and coordination and access to care, c) ensuring parity between behavioral and physical health care, d) furthering the use of telehealth, and e) improving access to be health care for children and young people.  The letter adds specific questions under improving access for children and young people they ask:


  • How should shortages of providers specializing in children’s behavioral health care be addressed?
  • How can peer support specialist community health care workers, and non-clinical professionals, and paraprofessionals, play a role in improving children’s behavioral health?
  • Are there different considerations for care integration for children’s health needs compared to adults’ health needs?
  • How can federal programs support access to behavioral healthcare for vulnerable youth populations such as individuals involved in the child welfare system and the juvenile justice system?
  • And what key factors should be considered with respect to implementing and expanding telehealth services for pediatric populations?


Both mental health and substance use are what some people have labeled “the elephants in the child welfare room.”  In the last three years, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) highlighted how substance use (opioids) have had an impact on child welfare. In one report, The Relationship Between Substance Use Indicators and Child Welfare Caseloads, data at the county level and supplemented that research with 180 interviews in 11 communities across the country found a clear link between the recent years surge in opioid use and foster care increases. Last month ASPE released the report, Foster Care Entry Rates Grew Faster for Infants than for Children of Other Ages, 2011-2018, that found that infants accounted for more than 70 percent of the total increase in foster care entries in recent years at the national, state, and county-level, at least some of this due to substance use.

In the last several reports, the annual AFCARS reports have included new statistics on mental health and substance use and its impacts on foster care placements.  The 2019 data indicates that one of the reasons for a child being in foster care was the caretaker’s inability to cope (14%) with an additional 8% due to a child’s behavioral problem and 34 percent a parent’s drug abuse with an additional 2 percent a child’s drug abuse.

The Family First Prevention Services Act opens two potential new sources of funding under title IV-E for substance use treatment and mental health services, but those funds (for candidates for foster care) can only be spent on substance use and mental health services that have a program manual/instruction that are approved by the new evidence-based clearinghouse.  These new Title IV-E funds for such health services are secondary to Medicaid funding. That means it will be important for greater coordination between child welfare and Medicaid systems.

Medicaid access for child welfare services continue to be a challenge based on how CMS and some regional offices interpret Medicaid laws and regulations and how Congress does or does not react to these roadblocks.  Over the past 15 years, examples include, legislation to clarify the definitions and use of therapeutic foster care through Medicaid, the use of Medicaid to cover the cost of targeted case management services for children in the child welfare system and most recently, the mixed messages on whether or not facilities meeting the new child welfare

Title IV-E Qualified Residential Treatment Programs (QRTP) standards are restricted by Medicaid definition of Institutions for Mental Diseases (IMD).

According to a 2015 MACPAC report while the population of children coming from child welfare (approximately 1 million) is small relative to the rest of the Medicaid program— accounting for less than 1 percent of all Medicaid enrollees and about 3 percent of non-disabled child enrollees—the complex health needs of these children require an array of specialized services and costs.  That report points out some barriers for these children complicated by:

  • Frequent changes in placement that may affect continuity of care, as well as changes in caregivers who may lack information on their health needs and prior service use and whose ability to provide consent for treatment may vary;
  • Trauma experienced both prior to and because of removal from the home;
  • Significant behavioral health needs that may not be appropriately addressed, with overreliance on psychotropic medication and a shortage of providers trained to diagnose and treat childhood trauma;
  • Fragmentation across Medicaid, child welfare, and behavioral health financing streams and delivery systems, with a lack of intensive health care management that may be needed to supplement routine caseworker services; and
  • Poor interagency coordination and data sharing, with a lack of knowledge among program staff about each other’s benefit programs (Allen and Hendricks 2013).