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A groundbreaking study of health care services provided under Medicaid for children in foster care indicates there is a major need to ensure continuity of coverage and thus continuity of care. "Making sure these children have access to continuity of coverage, rather than being covered off and on, is a top priority," says Margo Rosenbach, vice president of Mathematica Policy Research Inc. in the Cambridge, MA, office.
"We also want to be sure that the nation’s health care system recognizes the special needs of foster children," she adds. "They are a very vulnerable population and have big needs." Many of the children studied have physical, emotional, or developmental problems, sometimes resulting from abuse or neglect.
Ms. Rosenbach studied services provided to children in foster care for 1994 and 1995 in California and Florida and for 1993 and 1994 in Pennsylvania. Three comparison groups were children under age 19 who received either adoption assistance, Aid to Families with Dependent Children (AFDC), or Supplemental Security Income (SSI) benefits because of disability.
The study captured only health care utilization and expenditures that were paid by Medicaid; foster care children may have received health care that was not billed to Medicaid or that was paid by other sources. As a result, Rosenbach says, the study underestimates the total amount and cost of health care services provided to children in foster care.
Ms. Rosenbach tells State Health Watch there was a need for this study because foster care children have very high health needs and little has been known broadly about the care and treatment they receive. She says there are pros and cons in using data from the early 1990s, but they were the latest available at the time of the survey. "There have been some state initiatives since then, and so care may have improved. On the other hand, since states are moving toward managed care, there could be less care. We’d like to think that things have gotten better, but we need a more recent study to be sure."
Ms. Rosenbach’s key findings were:
• Children in foster care represented between 1% and 3% of Medicaid children, but between 4% and 8% of Medicaid expenditures.
• Most children were enrolled in Medicaid before they entered foster care, but between one-third and one-half lost their Medicaid coverage when they left foster care.
• Children in foster care were more likely than other groups of Medicaid children to have a mental health or substance abuse condition.
• Health care utilization varied considerably across the three states studied.
Too many lose Medicaid
Research has shown that continuous, year-round health insurance coverage is related to improved access to care," Rosenbach’s report says. "Children in foster care had less continuous Medicaid coverage than children receiving SSI benefits and children in families receiving adoption assistance. And in all three states studied, significant numbers of children lost Medicaid in the month they left foster care."
Children in foster care were more likely than other groups of Medicaid children to have a mental health or substance abuse condition, either alone or in combination with a physical condition. They also had a higher likelihood of comorbidities than AFDC and adoption-assistance children, but they were less likely than SSI children to have multiple diagnoses.
Generalizing on the variation in health care services, Rosenbach says that foster care children in California were less likely to receive health care services than were children in Pennsylvania and Florida. More than 80% of foster care children in Florida and Pennsylvania had at least one provider visit in 1994, compared with 65% in California.
The likelihood that foster care children received a preventive checkup during 1994 ranged from 28% in Florida to 41% in California. Many foster care children did not receive routine checkups, despite recommendations for an annual physical and mental health assessment each year. Very few foster care children received an assessment during the first two months of a foster care placement. Children with no prior Medicaid coverage received early assessments more often, suggesting that providers were more likely to perform assessments on those who were newly enrolled in Medicare.
Foster care children were far more likely to receive dental care than were other groups of Medicaid children, and foster care children were more likely than other groups of Medicaid children to receive mental health or substance abuse services.
Average monthly Medicaid expenses for foster care children ranged from $154 in California to $375 in Washington. Medicaid spending for foster care children was two or more times higher than expenditures for all Medicaid children. By contrast, Medicaid expenditures for AFDC children were well below the average for all Medicaid children.
Ms. Rosenbach says the study provides four main policy implications:
1. Continuity of coverage is important. Discontinuities in health care coverage can have an adverse effect on access to care. Policy-makers should focus on ways to improve continuity of health insurance coverage for children in foster care.
2. Medicaid may be underutilized as a funding source. States have considerable flexibility in how they use Medicaid to pay for services for foster care children. Medicaid can fund a comprehensive continuum of care, ranging from screening and assessment to follow-up treatment and ongoing therapies.
3. A broad-based concept of care coordination is needed.
4. The structure of managed care systems should recognize foster children’s needs.
Ms. Rosenbach says efforts to ensure continuity of coverage are important because foster care children often are involved in many different health and juvenile justice systems, but still can fall through the cracks.
She says that while her study documents the differences that existed in the three states surveyed, there is a need to find out why the variations occur.
"Possible factors include health care services for children in foster care, the role of the courts in mandating health care for children in foster care, characteristics of state programs [such as the use of health passports, level of staff caseload, and availability of transportation services], variations in the Medicaid benefit package, availability of providers to serve the population, provider knowledge concerning services needed by the population, generosity of reimbursement rates, differences in case mix, and level of stigma about accessing services," Rosenbach explains.
Another question raised by the study is the extent to which needs are unmet.
"Without external benchmarks against which to evaluate patterns of care, coupled with more detailed clinical assessments, we cannot tell whether lower rates of utilization are indicative of access barriers or simply lower health care needs," she adds.
"To gain a better understanding of unmet needs in the foster care population, policy-makers and researchers could perform a medical records review or conduct a survey of foster care families and caseworkers," Ms. Rosenbach says.
[Contact Ms. Rosenbach at (617) 491-7900.]