1. The Health of Children in Foster Care: Where Policy meets Practice David Rubin, MD MSCE Director of Research & Policy Safe Place: Center for Child Protection & Health Children’s Hospital of Philadelphia

2. Objectives What do we know about the health of children in foster care? What is the relationship between the Medicaid Program and children in foster care? What protections for children in foster care were provided in the Deficit Reduction Act of 2005? What major vulnerabilities remain?

3. Background 3,000,000 children reported to CPS each year: 1 in 20 will enter foster care. 1 out of every 2 children entering a new episode of foster care will remain in foster care for more than 18 months Of children who return home, 1 in 3 children will return to foster care within 2 years. A quarter of children will remain in foster care until adolescence.

4. What do we know about needs? 1 of every 2 children in foster care has chronic medical problems unrelated to behavioral concerns 40%-80% have serious behavioral or mental health problems Sources: GAO, 1995; Halfon et al, Arch Ped Adol Medicine 1995; Trupin et al, Child Abuse & Neglect 1993; Urquiza et al, Child Welfare 1994; Garland et al, Children's Services: Social Policy, Research, & Practice 2000; Simms, J Dev Behavioral Pediatrics 1989;

5. The Northwest Alumni Study Source: Casey Family Programs, 2005

6. How well are we addressing needs? Only half of children with behavioral problems in foster care receive services Up to 1/3 of children circa 1995 failed to receive appropriate immunizations 1 in 8 were not receiving preventive care Sources: GAO, 1995; Burns et al. JAACAP, 2004; Rubin et al. Pediatrics 2004; Hurlburt et al. J Gen Psychiatry 2004; Harman et al. Arch Ped Adol Med 2000; Halfon et al. Pediatrics 1992

7. The importance of Medicaid Children in foster care have 8-11 times the levels of service use of other Medicaid-enrolled children. 1,2 In 2001, per capita expenditures for children in foster care were more than triple that of non- disabled children covered by Medicaid 3 Although children in foster care represent 3% of all enrollees, they account for 25-41% of mental health expenditures. 2,4 1 Harman et al. Archives of Ped Adol Medicine, 154(11): 2000 2 Halfon et al. Pediatrics, 89(6): 1992 3 Geen et al. Urban Institute, 2005 4 Takayama et al. JAMA, 271(23): 1994

8. The Urgency of Access ED Visits before and after placement changes

9. Eligibility and Coverage IV-E children are mandatory coverage group Most if not all states extend optional coverage to the entire population of children in foster care Chafee Independence Act of 1999 granted a state option to extend coverage for children aging out of foster care to 21

10. Growing Congressional Oversight Adoption and Safe Families Act (ASFA) 1997 – –Focus on permanency for children in foster care – –Mandate to also protect well-being Chafee Independence Act of 1999 – –Extending coverage to adolescents aging out Child Family Service Reviews (post-2000) – –Specific documentation of program improvement around child well-being

11. Focus on Health Care Partnerships Necessary and appropriate growth of case management and needs assessment services within child welfare systems To improve the quality of available care,states have augmented their programs to coordinate services across public programs This has created unique funding needs, relying on both state and federal funding, particularly targeted case management funding through Medicaid

12. Targeted Case Management Children and adolescents in foster care who are receiving TCM services are more likely to use multiple health care services 15% of all TCM funds allocated by the Medicaid program are for children in foster care Source: Geen et al, Urban Institute, 2005

13. Medicaid Reform and The DRA New Documentation Requirements Changes to Coverage Design: Benchmark and Wrap-Around Co-pays and Premiums Restrictions on the use of Targeted Case Management Funding No exemption for children in foster care Exemptions for children receiving Title IV-E services Ambiguity between explicit protections in foster care and third party liability Exemptions for children receiving Title IV-E services

14. Where are the Vulnerabilities? Documentation Requirements are likely to increase barriers to accessing care How do we address coverage for children returning home? Should contact with child welfare trigger an easy access option to comprehensive coverage design Pegging services to IV-E status is flawed as health considerations are independent of funding status How are co-pays and premiums to be determined for families who foster children? What will the effects be on recruiting caregivers? How will states meet their requirements to improve well- being without the flexibility afforded by TCM in the Medicaid Program?

15. Summary Data across the last couple of decades has demonstrated a disproportionate burden of medical and mental health needs for children in foster care. Despite better awareness of health care needs, access to appropriate health services remains a problem. Timely and appropriate access is an issue of urgency, particularly because of acute crisis and loss of information that results from a change in a child’s home Broad strokes to Medicaid policy have the potential to disproportionately affect fringe beneficiaries, some of whom are among the most vulnerable populations served by the program.