1. How Health Reform Can
Help Child Welfare Families
An Early Look at Opportunities and
Options for Action

2. SPARC Webinar
February 19, 2013
Olivia Golden, Institute Fellow
Dina Emam, Research Assistant
The Urban Institute

3. Trying to Understand How the ACA
Applies to You….

4. Why Is It So Hard to Connect?
Medicaid/ Health Child Welfare
n Incredibly busy and n Incredibly busy and
overwhelmed (ACA) overwhelmed (crises)
n Thinking about functions n Thinking about
that have to be in place populations.
for health reform.
n Don’t understand child n Don’t understand
welfare and don’t have Medicaid/ ACA and don’t
time to learn it. have time to learn it.
n Cost-conscious n Advocate for services

5. 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.

6. 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?

7. It takes a lot of effort to connect the child welfare and health worlds.
Why is it worth it?
WHY DOES THE ACA MATTER
SO MUCH?

8. 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.

9. 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”

10. 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.

11. Parents, Children, Youth
THREE MAJOR
OPPORTUNITIES

12. 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)

13. Opportunities for Parents in the ACA
Coverage Care
n State option to expand n Benefit package including
Medicaid coverage to mental health and
133% of poverty substance abuse services
n Streamlined enrollment, n Integrated care options
whether or not state (i.e., health homes)
expands

14. 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.

15. 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

16. Opportunities for Children in the
ACA
Coverage Care
n Streamlined eligibility n Integrated care options
determination and n Home and community
redetermination based care option
n Home visiting programs

17. 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)

18. A Specific Provision in the ACA
Covers These Youth
Coverage Care
n States must enroll youth n Full Medicaid benefits
aged out of foster care (not the “alternative
and not yet age 26 in benefit plan”)
Medicaid. n EPSDT benefits until age
n Effective date 1/1/2014 21
n Not affected by Supreme n Integrated care options
Court decision. (as for all others)
n CMS proposed rule
makes cross-state
coverage optional.

19. FOSTER YOUTH AGING OUT

20. 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

21. 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

22. The Headline:
Get ready now.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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!!

28. 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!

29. 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.

30. Questions?