PLACEMENT & PERMANENCY

The Child Welfare League of America (CWLA), representing public and private nonprofit, child-serving member agencies across the country, is pleased to submit testimony to the Subcommittee on Income Security and Family Support. CWLA commends the Subcommittee for its continued attention to the multi-faceted needs of children in foster care. The health of this vulnerable population, a topic to which the Subcommittee turns today, is yet another overarching issue that demands careful consideration and improvement.

Children enter out-of-home care for a variety of reasons. Some enter out-of-home care because of abuse or neglect. In other cases, families voluntarily place their children as a result of health, social, or economic stresses within the family, and sometimes children enter out-of-home care because their families are not able to cope with the children’s behavioral or emotional issues. Regardless of the reason, once children are placed in state custody, public and private child welfare agencies assume responsibility for the children’s safety and well-being, including meeting their unique physical and mental health needs. With at least 800,000 children spending at least some time in foster care each year, this is indeed a feat, but one that must be met with a sense of duty and vigor so that each of these children-who have often already experienced a great deal of strife-has the opportunity to grow up and be a healthy, successful, contributing member of society.

Health Status of Children in Foster Care

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

Substance Abuse
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.

Legislative Solutions

The Child Welfare League of America desires for all children in foster care to receive coordinated, continuous, comprehensive, and culturally competent services and supports legislation working toward that goal. ¹⁵ Services must be coordinated in terms of providing cross-system training and continuity in service both while the child is in state custody and after he or she leaves as a result of reunification, placement with a relative, adoption, or aging out of care. Because children in foster care experience a wide array of and disproportionate amount of health needs, services must be comprehensive and address children’s medical, mental, dental, emotional, and developmental needs. This is not just a goal or desire of CWLA, but it is a necessary component to reducing the number of children in foster care. Something we all seek.

Health Care for Youth Transitioning Out of Foster Care
The Medicaid Foster Care Coverage Act of 2007, H.R. 1376, has been introduced by Representative Dennis Cardoza (D-CA-18). This bill addresses a critical issue for young people leaving foster care, the fact that 33% of foster care alumni lack of health insurance.

As stated previously, given their high rates of physical and mental health problems including depression and PTSD, access to health services is a critical factor as young people transition from foster care to adulthood. Current law does provide mechanisms by which to cover this vulnerable population. Some states, for example, have implemented the Chafee option to extend Medicaid to youth aging out through the Foster Care Independence Act of 1999. Strides have been made, but because young people who age out of the system often lack financial resources and a place to live, and have little or no support from family, friends, and the community, there is much more work to be done. CWLA agrees with a growing number of advocates that the best way to assure access to comprehensive coverage is simply to require Medicaid coverage for these former foster youth until at least the age of 21. H.R. 1376 would mandate such coverage until the age of 21 and CWLA strongly urges its passage.

Access to Health Care Services
Actions over the past several years have undercut the states’ ability to use Targeted Case Management services (TCM), thereby restricting access to needed and effective care for children in foster care. The Centers for Medicare and Medicaid Services (CMS) is expected to issue regulations in the near future that may further restrict access to both the TCM and Rehabilitative Services options under Medicaid. CWLA is extremely concerned about what has happened and what the future holds for these vital services. CWLA urges Congress to be vigilant and to take action to halt any overreaching regulations that disallow reimbursement for permissible Medicaid services. Before CMS goes any further, careful assessment must be made of efforts to restrict the use of these services and the possible negative impact these actions could have on children in foster care by cutting off the road to care. This is not a cost saving issue, but rather an issue of preserving access to physical and mental health care for one of the most vulnerable segments of our population-children in foster care.

To address the mental health needs of children in foster care, in addition to preserving the TCM and Rehabilitative Services options under Medicaid, Medicaid funding should be used to ensure that children entering the foster care system receive EPSDT services, the comprehensive screenings and periodic interventions guaranteed to them by federal law. By identifying mental and developmental health needs early, children in foster care can be treated accordingly, thereby increasing their chance for success.

Mental Health Services
CWLA urges Congress to pass the strongest possible mental health parity legislation. The Paul Wellstone Mental Health and Addiction Equity Act of 2007, H.R. 1424, has been introduced in a bipartisan fashion by Congressmen Patrick Kennedy (D-RI-1) and Jim Ramstad (R-MN-3). Lack of affordable access to mental health care has a major impact on the nation’s child welfare system, as low-income families are heavily represented in the child welfare population. In 2003, the Government Accountability Office documented how the lack of affordable access to children’s mental health coverage led to over 12,700 children being placed into the child welfare or juvenile justice system solely to obtain mental health services. ¹⁶ Substance abuse is also of pressing concern within the child welfare community, as it is estimated to be 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. Mental health parity would finally formally recognize equal rights of those with mental health and substance abuse needs, in turn assisting countless families to access necessary health care so that their home environments may be stabilized.

Substance Abuse Services
It is vital that agencies work together to prevent and effectively treat substance abuse in families involved in the child welfare system. Additional federal resources are necessary to facilitate this. In 2006, this Subcommittee was the starting point for a congressional reauthorization of the Promoting Safe and Stable Families program (PSSF, S.3525). It included $145 million in mandatory funding dedicated over a period of five years to support competitive grants for projects addressing methamphetamine and other substance abuse as it affects the child welfare system. While we have great concerns how these mandatory funds were generated, we are pleased that the challenge of substance and child welfare is beginning to receive attention. The funds provided by these grants are to be used to support family-based, comprehensive, long-term substance abuse treatment services, including a range of components such as early intervention and preventative services for children, counseling for children and families, mental health services, parenting skills training, and/or replication of successful models of comprehensive family treatment. The comprehensive family treatment model includes the entire family unit in treatment efforts and focuses on integrating mental health, domestic violence, sexual abuse, and family therapy counseling services.

We urge Congress to go further. In past sessions, members of this Subcommittee and Chairman Rangel have supported the Child Abuse/Alcohol and Drug Partnership Act. This act encompasses the comprehensive family treatment model and addresses the need for additional substance abuse treatment for caregivers involved in the child welfare system. The bill would provide five-year grants to state child welfare and substance abuse agencies that agree to take steps together to develop and increase treatment services, establish appropriate screening and assessment tools, or improve strategies to engage and retain parents in treatment and provide aftercare support. The activities must be directed to families with substance abuse problems who come to the attention of the child welfare system. State child welfare and substance abuse agencies, working together, would have the flexibility to decide how best to use these new funds to enhance treatment and services. This would allow states to develop or expand comprehensive family-serving substance abuse intervention and treatment services that include early intervention services for children that address their mental, emotional, and developmental needs, as well as comprehensive home-based, outpatient, and residential treatment for parents with alcohol and drug abuse dependency. Evaluation components of the legislation would also lead to much needed improvement in data systems and strategies that identify the effectiveness of treatment-particularly those parts of substance abuse treatment collaborations with child welfare which have the greatest positive impact on families. This legislation needs to be reintroduced in the 110th Congress.

CWLA also supports the Family-Based Meth Treatment Access Act of 2007 (S. 884/H.R. 405), introduced in the House by Congresswoman Barbara Cubin (R-WY). H.R. 405 would provide $70 million each year from 2008 to 2012 for the Center for Substance Abuse Treatment (CSAT) to award funding for programs that provide comprehensive, family-based substance abuse treatment to pregnant and postpartum women. Such treatment, again, incorporates the whole families’ needs, along with mental health counseling, medical treatment, parenting, education, and legal services. Priority would be given to certain programs, including those that serve rural areas or locations forced to deal with a shortage of mental health professionals. The Secretary of HHS would also have discretion to award grants to local jails and detention facilities so that such comprehensive, family-based substance abuse treatment services could be used to assist non-violent offenders. A 2001 Center for Substance Abuse Treatment (CSAT) study found that six months post-family-based treatment, 60% of mothers remained alcohol and drug-free, 38% had obtained employment, and 75% had physical custody of one of more children. ¹⁷ With greater availability of family-based treatment, it seems that the cycles of addiction and entry and re-entry into the criminal justice and child welfare systems can finally be broken so that mothers can focus on what really matters-their lives and their families.

SCHIP Reauthorization 
Finally, Congress must reauthorize the State Children’s Health Insurance Program (SCHIP) in a timely manner so that the six million low-income children currently enrolled maintain coverage. In addition, Congress should deliver on its pledge of $50 billion over five years in new funding so that the millions of low-income children who are currently eligible but not enrolled can be covered. Health insurance coverage for all children and their families, through Medicaid, SCHIP, or private insurance, can prevent children from ever needing the child welfare system in the first place. The availability of such health services can also help families remain intact or aid family reunification efforts. Although Medicaid coverage is available to almost all children while in foster care, broadening health coverage for low-income children and families that fall outside of that bracket-namely at-risk families and children transitioning out of foster care-through reauthorization of SCHIP is critical.

As part of SCHIP reauthorization, Congress has a fortunate opportunity to improve upon the program’s great success. CWLA has supported several policies including: providing outreach funding so that states may capture underserved populations; offering incentives to states that successfully enroll low-income uninsured children; establishing a new child health quality initiative within HHS; granting states the option to implement express lane eligibility; guaranteeing access to mental health and dental services; ensuring mental health parity in SCHIP programs; and state flexibility to cover certain populations. This reauthorization also offers and opportunity to address the issue of continued access to comprehensive health care for youth that age out of foster care.

CONCLUSION

CWLA appreciates the opportunity to offer our comments to the Subcommittee in regard to health care for children in foster care. If the goals of both the Congress and CWLA are to prevent the removal of children from their homes and to provide permanency for children who are in foster care, access to health care including mental health services is a critical stepping stone to reaching these goals. We cannot reunify children, successfully place children in adoptive homes or in kinship homes until and unless we address health care needs in a comprehensive fashion. As this Subcommittee moves forward, we look forward to a continued dialogue with its members and all Members of Congress. We hope this hearing serves as a building block for future efforts that work to ensure coordinated, continuous, and comprehensive health care coverage for all children-especially those at-risk of placement, those already in foster care, and those transitioning out of the child welfare system into adulthood.

Notes

1. Simms, M.D., Dubowitz, H., & Szailagyi, M.A. (2000). Needs of children in the foster care system. Pediatrics, 106 (Supplement), 909-918.

2. Halfon, N., Mendonca, A., & Berkowitz, G. (1995). Health status of children in foster care: The experience of the Center for the Vulnerable Child. Archives of Pediatric and Adolescent Medicine, 149, 386-392.

3. Takayama, J.I., Wolfe, E., & Coulter, S. (1998). Relationship between reason for placement and medical findings among children in foster care. Pediatrics, 101, 201-207.

4. Clausen, J., Landsverk, J., Ganger, W., Chadwick, D., & Litrownik, A.J. (1998). Mental health problems of children in foster care. Journal of Child and Family Studies, 7, 283-296; Halfon et al. (1995); Urquiza, A.J., Wirtz, S.J., Peterson, M.S., & Singer, V.A. (1994). Screening and evaluating abused and neglected children entering protective custody. Child Welfare, 123, 155-171.

5. dosReis, S., Zito, J.M., Safer, D.J., & Soeken, K.L. (2001). Mental health services for foster care and disabled youth. American Journal of Public Health, 91, 1094-1099.

6. Pecora, P.J., Kessler, R.C., Williams, J., O’Brien, K., Downs, A. C., English, D., White, J., Hiripi, E., White, C. R., Wiggins, T., & Holmes, K. (2005). Improving family foster care: Findings from the Northwest Foster Care Alumni Study. Available online. Seattle, WA: Casey Family Programs.

7. U.S. General Accounting Office (GAO). (2001). Medicaid: Stronger efforts needed to ensure children’s access to health screening services (GAO-01-749).Available online.

8. Geen, R., Sommers, A., & Cohen, M. (August 2005). Medicaid Spending on Foster Children. Available online. Washington, DC: The Urban Institute.

9. American Academy of Pediatrics. (2002). Health care of young children in foster care: Committee on Early Childhood, Adoption and Dependent Care.Pediatrics, 109, 536-541.

10. Child Welfare League of America (CWLA). (2007). Standards of Excellence for Health Care Services for Children in Out-of-Home Care. Washington, DC: Author.

11. Alcohol and other drug survey of state child welfare agencies. (1997, February). Available online. Washington, DC: Child Welfare League of America.

12. U.S. House of Representatives, Committee on Ways and Means. (2004).Substance abuse, section 11. (In 2004 Green Book). Washington, DC: U.S. Government Printing Office.Wells, K., & Wright, W. (2004, Sept. 14). Medical summit. Presented at Idaho’s Second Annual Drug Endangered Children Conference, Post Falls, Idaho.

13. Wells, K., & Wright, W. (2004, Sept. 14). Medical summit. Presented at Idaho’s Second Annual Drug Endangered Children Conference, Post Falls, Idaho.

14. Semidei, J., Radel, L.F., & Nolan, C. (2001). Substance abuse and child welfare: Clear linkages and promising responses. Child Welfare, 80(2), 109-128.

15. Child Welfare League of America (CWLA). (2007). Standards of Excellence for Health Care Services for Children in Out-of-Home Care. Washington, DC: Author.

16. GAO (2003). Child welfare and juvenile justice: Federal agencies could play stronger role in helping states reduce the number of children placed solely to obtain mental health services (GAO-03-397). Available online.

17. Center for Substance Abuse Treatment (CSAT). (2001). Benefits of residential substance abuse treatment for pregnant and parenting women. Washington, DC: Substance Abuse and Mental Health Services Administration (SAMHSA).