How Health Reform Can Help Child Welfare Families

An Early Look at Opportunities and Options for Action

SPARC Webinar February 19, 2013

Olivia Golden, Institute Fellow Dina Emam, Research Assistant The Urban Institute

Trying to Understand How the ACA Applies to You….

Why Is It So Hard to Connect?

Medicaid/ Health n  Incredibly busy and

overwhelmed (ACA) n  Thinking about functions

that have to be in place for health reform.

n  Don’t understand child welfare and don’t have time to learn it.

n  Cost-conscious

Child Welfare n  Incredibly busy and

overwhelmed (crises) n  Thinking about

populations.

n  Don’t understand Medicaid/ ACA and don’t have time to learn it.

n  Advocate for services

Our Paper

n  Goal: to bridge the gaps. n  Reviewed available resources n  Interviewed health and child welfare experts. n  Intensive help from colleagues in Health

Policy Center (but remaining mistakes are ours).

n  Final review and update going on now. n  Paper will be available in March.

Plan for Today

n  Why Does the ACA Matter So Much? n  Three Major Opportunities: Parents,

Children, and Youth n  Today’s Focus: Foster Youth Aging Out n  What Should You Do Right Away?

WHY DOES THE ACA MATTER SO MUCH?

It takes a lot of effort to connect the child welfare and health worlds. Why is it worth it?

What Does the ACA Do?

n  Increases the number of people with health insurance.

n  Streamlines enrollment and renewal n  Requires behavioral health as well as

medical benefits. n  Promotes innovation to integrate health care. n  Provides coverage till age 26 for aging-out

foster youth.

Why Do the Links Matter to Child Welfare?

n  Parents, children, youth have major health and mental health needs.

n  Good treatment serves child welfare goals. n  BUT today, they often don’t get help.

q  Parents/ youth lack insurance. q  Children’s coverage is interrupted. q  Health/ mental health care is hard to navigate

n  “Biggest social services change in decades”

Why Do the Links Matter to Health/ Medicaid?

n  Child welfare agencies can find and bring in people who might otherwise not enroll.

n  Systems for enrollment are being redesigned right now, at mostly federal cost.

n  States may want to enroll high-need individuals promptly, to avert costs.

n  Helping maltreated children and preventing abuse and neglect may have wide appeal.

THREE MAJOR OPPORTUNITIES

Parents, Children, Youth

Parents

n  Only 40% of parents of children reported for maltreatment report good or excellent health. (NSCAW II 2012)

n  20% have had a major depressive episode in the past 12 months and 46% in their lifetimes (NSCAW II 2012)

n  Treatment could prevent maltreatment and promote reunification.

n  3.3 million reports of maltreatment (ACF 2010)

Opportunities for Parents in the ACA

Coverage n  State option to expand

Medicaid coverage to 133% of poverty

n  Streamlined enrollment, whether or not state expands

Care n  Benefit package including

mental health and substance abuse services

n  Integrated care options (i.e., health homes)

Forthcoming sources…..

n  Golden and Emam. How Health Reform Can Help Children and Families in the Child Welfare System: Options for Action. Washington, DC: The Urban Institute. Expected in March 2013.

n  Howell, Golden, and Beardslee. Emerging

Opportunities for Addressing Maternal Depression under Medicaid. Washington, DC: The Urban Institute. Expected in February 2013.

Children

n  Major health, mental health, developmental needs. q  Children reported and children in the system.

n  Most have Medicaid coverage now. n  Areas for improvement:

q  Continuity of health insurance coverage q  Quality and continuity of care q  Maintaining/ improving current waivers or state-

specific strategies

Opportunities for Children in the ACA Coverage n  Streamlined eligibility

determination and redetermination

Care n  Integrated care options n  Home and community

based care option n  Home visiting programs

Foster Youth Aging Out

n  29,000 youth age out each year n  Major health and mental health needs n  22.2% experience homelessness within a

year of leaving foster care (Pecora et al. 2006).

n  1.8 times as likely to have a child by age 26 as other youth (Courtney et al. 2011)

A Specific Provision in the ACA Covers These Youth Coverage n  States must enroll youth

aged out of foster care and not yet age 26 in Medicaid.

n  Effective date 1/1/2014 n  Not affected by Supreme

Court decision. n  CMS proposed rule

makes cross-state coverage optional.

Care n  Full Medicaid benefits

(not the “alternative benefit plan”)

n  EPSDT benefits until age 21

n  Integrated care options (as for all others)

FOSTER YOUTH AGING OUT

What It Will Take: Evidence from State Experiences Under Chafee

n  States varied in how they enrolled youth. n  More automatic enrollment meant more youth on

Medicaid (month before their 19th birthday) q  More youth involvement meant less enrollment.

n  Child welfare involvement in design was associated with more automated enrollment and integrated data.

n  Source: Pergamit et al. Providing Medicaid to Youth Formerly in Foster Care Under the Chafee Option. HHS/ ASPE, 2013. http://aspe.hhs.gov/hsp/13/ChafeeMedicaidReport/rpt.pdf

More on the Chafee Experience

n  Important role of child welfare – Medicaid communication and leadership

n  Challenges posed by lack of knowledge n  Enrollment is the first step, not the final one. n  Youth and social workers need to understand

the coverage if youth are to use it. n  Source: Pergamit et al. Providing Medicaid to Youth Formerly in

Foster Care Under the Chafee Option. HHS/ ASPE, 2013. http://aspe.hhs.gov/hsp/13/ChafeeMedicaidReport/rpt.pdf

The Headline:

Get ready now.

State Child Welfare Leaders: Action Steps to Consider

1.  Engage with state Medicaid leaders to discuss: a)  Enrollment for youth aging out now; b)  Enrollment for youth who aged out in prior years; c)  Automatic reviews to ensure continuity until age 26

(or move out of state); d)  How enrollment and automatic redetermination will fit

into system decisions being made NOW; e)  Benefits available to youth, plans that would work

best for them, potential demos or initiatives.

Actions to Consider, continued

2.  Gather and share information about foster youth aging out in your state.

a)  Data (needs, numbers) b)  Policy goals (including future cost savings) c)  Lessons learned from Chafee experience

3.  Inform cross-state choice (if state option). 4.  Consider focus groups with aged out youth,

other outreach to help inform strategies.

Actions to Consider, continued.

5.  Design an active role for child welfare agency, including enrollment help, outreach, support to youth.

6.  Train child welfare agency staff and partners, soon and often.

Federal Child Welfare and Health Leaders: Action Steps to Consider

1.  Joint technical assistance to states from ACF, CMS, and SAMHSA.

2.  Identify and disseminate best practices. 3.  Promote an effective cross-state framework. 4.  Track coverage for youth; support state data

collection and tracking. 5.  Address specific challenging issues in ongoing

policy and guidance.

Examples of Challenging Issues

n  Youth moving from child welfare to juvenile justice

n  Youth in guardianship settings n  State arrangements that may not be foster

care n  Don’t let these slow you down!!

Philanthropy: Action Steps To Consider

1.  Amplify federal and state technical assistance and outreach to reach larger audiences.

a)  Advocates, community organizations b)  Youth and families, broader public c)  Direct service staff

2.  Create collaborative network of stakeholders – multiple states, multiple perspectives.

3.  Identify and disseminate best practices. 4.  Support advocates/ experts to track and report results,

recommend improvements. 5.  Stay the course!

It’s a Marathon AND a Sprint.

Those we interviewed said that gaining the benefits of the ACA for children, youth, and families involved with child welfare requires BOTH starting now AND staying the course.

Questions?