Medicaid provides basic health insurance coverage for children in the child welfare system. As a report released by the Urban Institute last year indicated, when children in foster care were enrolled in targeted case management through Medicaid 68 percent received physician’s services compared to 44 percent when they were not enrolled in TCM. 14 That same study indicated that 44 percent of foster children received dental services compared to 24 percent when they were not enrolled. 15
States also use Medicaid to fund some critical medical services not always provided by the child welfare agency, its contracted providers, or other providers of services to children and families in the child welfare system. These services include in addition to TCM, rehabilitative services, and therapeutic and psychiatric services provided in residential facilities.
Such services can be critical. Children in foster care may have been exposed to domestic violence, abuse, substance abuse, homelessness, and other traumas-plus, the loss of family is a significant pressure that can harm a foster child’s mental health and hinder his or her ability to obtain permanency and stability. Anywhere from 40% to 85% of children in foster care have mental health disorders. Medicaid plays an important role in meeting these needs.
The Urban Institute data also indicates that children enrolled in TCM services have greater access to rehabilitative, therapy and psychiatric care than when they are not enrolled. 16 Medicaid rehabilitative services are medical or remedial services provided to reduce a physical or mental disability, thereby helping recipients reach their optimal functioning level. These services include behavioral management services, day treatment services, family functioning interventions, and other similar services.
In recent months, HHS’s Centers for Medicare and Medicaid Services have challenged some states in the use of Medicaid funding to support services for children in the child welfare system working through the use of TCM and rehabilitative services. Since states vary in their use of Medicaid to address the needs of children in the child welfare system, different federal regional offices may issue different rulings on the use of Medicaid funding for child welfare services. This raises an obvious concern and possibly violates the intent of the law and what the Committee and Congress had intended. We look forward to working with the Chairman and the Committee to see that TCM and rehabilitative services are both preserved for these children and interpreted in a consistent manner. CWLA recommends that the Committee continue to monitor this important health need and make sure access to care is not reduced or eliminated.
Alcohol and Other Drug Addictions
Families in the child welfare system need access to appropriate substance abuse treatment. A common thread in child protection and foster care cases is the high percentage of children, their parents, or both who have a substance abuse problem. Up to 80% of the children in the child welfare system have families with substance abuse problems. As the Senate Indian Affairs Committee noted on April 5th, the recent meth epidemic is impacting all communities and tribal nations. 17
ASFA was designed to promote the safety and permanence of children by expediting the timelines for decision-making. That law requires that a court review plan for a child’s permanent living arrangement be made within 12 months of the date a child enters foster care. It also requires that if a child is in foster care for 15 or more of the most recent 22 months, that a petition to end a parent’s rights to the child must be filed, unless certain exceptions apply. To ensure that permanency decisions can be made for children whose families have alcohol and drug problems, special steps must be taken to begin services and treatment for the family immediately. These resources for substance abuse treatment for families are chronically in short supply. There is a national shortage in all types of publicly funded substance abuse treatment for those in need, especially for women with children. Alarmingly, over two-thirds of parents involved in the child welfare system need substance abuse treatment, but less than one-third get the treatment they need.
In previous sessions, legislation sponsored by Committee members Senator Olympia Snowe (ME)and Senator Jay Rockefeller (WV) would help address this problem. The Child Protection/Alcohol Drug Partnership Act would provide new resources for a range of state activities to improve substance abuse treatment. State child welfare and substance abuse agencies, working together, would have flexibility to decide how best to use these new funds to enhance treatment and services. States could develop or expand comprehensive family-serving substance abuse prevention and treatment services that include early intervention services for children that address their mental, emotional, and developmental needs, as well as comprehensive home-based, out-patient, and residential treatment for parents with an alcohol and drug abuse problem. CWLA recommends that the Committee review this legislation and seek ways to address the role of substance abuse in the child welfare system.
Expand the Kinship and Guardianship
CWLA believes that one area that can serve as a significant tool in providing children with a safe and permanent setting is the use of guardian kinship care arrangements. Some states have used various resources to fund this permanency option. A few states have utilized federal Title IV-E funds to support guardianship through the use of Title IV-E waivers. As indicated by the PIPs, states are looking to kinship placements as a tool to increase permanence. ASFA recognized kinship placements as one of three ways to permanence for children in care. A federally funded guardianship permanency option should be available to allow states to provide assistance payments on behalf of children to grandparents and other relatives who have assumed legal guardianship of the children for whom they have committed to care for on a permanent basis. Kinship guardianship assistance agreements and payments would be similar to the adoption assistance agreements in that they would take into consideration the circumstances and the needs of the child.
Kinship care has been shown to provide safe and stable care for children who remain with or return to their families. In 2003, 23 percent of children in care are living with relatives, some of who will not be able to return to their parents. States vary in their use of relative homes for foster care even though federal regulations state that there is a preference for relative placements. States are challenged to provide the financial, social, and legal supports that are needed to ensure safety and permanency in kinship placements. Legislation now in both houses of Congress including S. 985, the Kinship Caregiver Support Act cosponsored by Senator Olympia Snowe (ME), and Senators John Kerry (MA), and Charles Schumer (NY), would provide needed resources to state child welfare systems and enhance the use of kinship placements. CWLA strongly supports these legislative efforts.
Strengthen the Child Welfare Workforce
A quality child welfare workforce is essential to ensure positive outcomes for children in the child welfare system. No issue has a greater effect on the capacity of the child welfare system to serve at-risk and vulnerable children and families than the shortage of a competent, stable workforce. Again we refer the Committee to the PIPs and the many instances in which training of staff at all levels and the recruitment and retention of staff are part of state strategies in almost all areas: permanency, access to services, child safety and child well being.
This shortage impacts agencies in every service field. The timely review of child abuse complaints, the monitoring and case management of children in foster care, the recruitment of qualified adoptive and foster families, and the management and updating of a modern, effective data collection system all depend on a fully staffed, diverse and qualified child welfare workforce.
Child welfare work is labor intensive. Workers must be able to engage families through face-to-face contact, assess children’s safety and well-being through physical visits, monitor progress, ensure that families receive essential services and supports, help with problems that develop, and fulfill data collection and reporting requirements.
A comprehensive child welfare system cannot be maintained if the foundation of the workforce is crumbling. Workers frequently have caseloads that are two, three, or even four times what good practice demands. The result is little time for training new hires and no time for ongoing training. Moreover, supervision is often limited. These factors and others, including concerns about worker safety, create a workplace with high turnover and limited appeal when recruiting.
One way to improve the child welfare workforce is through increased training resources and opportunities. The major federal child welfare programs include training supports; training under Title IV-E is the largest and most important of these. Title IV-E Training allows states to claim a match for training of state and local agency staff and current and prospective foster and adoptive parents. CWLA proposes that access to these federal training funds be extended to support training of private agency staff, related child-serving agency workers, and court staff working with any children in the child welfare system. We also recommend that Title IV-E training funds be used for training on all subjects relevant to achieving positive outcomes for children. This includes training related to cultural and ethnic diversity both in the workforce and in the way services are provided. We urge members of Congress to be aware of the significant positive impact a strong child welfare workforce would have on the system and the children and families it serves.
Preserve Administrative Funds Under Title IV-E
Although many people envision Title IV-E Administration costs as paying for office space and utilities, it is in fact much more. Title IV-E Administration provides funding for the workforce. The time caseworkers spend preparing for and attending court hearings related to children in foster care is administrative. Meeting with families and children to discuss what needs to be done to achieve permanency for the children is also administrative. Helping foster parents cope with the problems of children in their care is administrative. Advocating for children in other systems, such as the local schools is also part of what is described as administrative. There is a great need for more foster parents and more adoptive parents. Recruitment of foster parents and adoptive parents is administrative funding.
Some have examined the level of spending under Title IV-E and raised questions about that part that is allocated or drawn down as administrative funding. Some criticize the variances that exist between states. In fact administrative funding now is classified in four general categories of case planning and management, preplacement services, eligibility determination, and other. The variances between states should not be a surprise due to the varied ways in which states have had to fund their systems and the fact that not all children in care are eligible for federal support.
CWLA rejects any proposal that would convert IV-E Administrative funding into a block grant. Such an action would undercut efforts to strengthen the workforce and would pit training of the workforce and other supports for the workforce against the need to greater access to services.
Strengthen Title IV-E Funding
There are two improvements that must be addressed when it comes to the issue of support for the child welfare system. It is nearly ten years since eligibility for foster care and adoption assistance was tied to AFDC, the cash assistance program that no longer exists. Members of the Committee have offered legislation to update this eligibility standard both for foster care and adoption assistance. CWLA believes all children who have been abused or neglected should be eligible for a federal commitment and federal support. That federal commitment now extends, by some estimates to less than fifty percent of abused and neglected children who come into out-of-home care. But if complete coverage is not possible then there are various others ways in which this eligibility can be updated while maintaining the current entitlement. Members of the Senate Finance Committee through previous legislation have sponsored some of these approaches including allowing states to link eligibility to the TANF cash assistance program. A current House Bill (H.R. 3576) offers a different approach to updating eligibility by phasing in expansion of eligibility. An additional option would allow states to link eligibility to the Medicaid program. There are many approaches to address this significant undercutting of the foster care and adoption assistance programs.
CWLA rejects any suggestion that a way to update eligibility is to simply turn current funding into a block grant. That is neither an update of eligibility nor an adequate response.
CWLA also highlights the need to update the Title IV-E program in one other significant way by providing Native American tribes with direct access to federal funding for foster care and adoption funding. Although federal law has established procedures and protections for placing Native American children in out-of-home care, adequate funding for these services has not followed. Tribal nations do not have the option of receiving Title IV-E federal foster care and adoption assistance funds directly. As a result, most Native American children placed in out-of-home and adoptive settings through tribal courts are not eligible for federal foster care maintenance or adoption assistance payments. In a few instances, some tribes have negotiated agreements with states that allow them to access Title IV-E funds. Senator Gordon Smith has introduced S 672 along with the cospsonorship of other Finance Committee members to address this flaw in the current system.