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 will be the likely impact of the citizenship documentation requirements?

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. 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

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

8. 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

9. 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

10. 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

11. Where are the Vulnerabilities? Documentation Requirements are likely to increase barriers to accessing care Pegging exemptions to IV-E status is flawed as health considerations are independent of funding status Citizenship documentation is merely one of several threats brought about by the DRA, that also includes coverage design, cost sharing, and targeted case management.

12. Summary Data across the last couple of decades has demonstrated a disproportionate burden of medical and mental health needs for children in foster care. 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.