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Although children in foster care represent only 1% to 3% of Medicare children, they account for between 4% and 8% of Medicaid expenditures, according to a study conducted by Mathematica Policy Research for the Department of Health and Human Services.
Policy-makers are interested in foster children because they are a particularly vulnerable population. Many have physical, emotional, or developmental problems, sometimes resulting from abuse or neglect. But there have been ongoing concerns about the adequacy of the health care services those children have received. The concerns have grown as managed care has become a more dominant form of health care delivery for this group.
The study looked at health care utilization and expenditures paid by Medicaid for foster care children in California, Florida, and Pennsylvania. Health care not billed to Medicaid or paid by other sources was not considered, so the study understates the total amount and cost of health care services provided to children in foster care.
The Mathematica report said that 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. Researchers also found that children in foster care were more likely than other groups of Medicaid children to have a mental health or substance abuse condition, and health care utilization varied considerably across the three study states.
Margo Rosenbach, Mathematica vice president in Cambridge, MA, and the author of the study, tells State Health Watch that one problem with coverage is that children in foster care are a very mobile population, often being moved from foster home to foster home, or between foster home and parental home.
"With that mobility comes changes in eligibility and coverage," she says. "One way to address this problem would be to institute 12-month continuous coverage for the population or at least less frequent redetermination of eligibility."
There also are issues of continuity of care when children move across state lines, and problems if a child is moved back to his or her family and the family is not covered. Although many foster children are eligible for coverage under the Temporary Assistance for Needy Families program, Ms. Rosenbach says, there can be lags in the eligibility that could be prevented by having presumptive eligibility as soon as a child is placed in foster care.
Being able to maintain coverage is important, the report said, because research has shown that continuous, year-round health insurance coverage is related to improved access to care. But, "children in foster care had less continuous Medicaid coverage than children receiving SSI benefits and children in families receiving adoption assistance. . . . In all three states, significant numbers of children lost Medicaid in the month they left foster care."
One reason policy-makers are taking more interest in this population is that they tend to be high users of health care services with a disproportionately high amount of behavioral health and mental health concerns. The research found that children in foster care were more likely than other groups of Medicaid children to have a mental health or substance abuse condition. They also had a higher likelihood of comorbidities than Aid to Families with Dependent Children (AFDC) recipients and adoption-assistance children, but were less likely than Supplemental Security Income (SSI) children to have multiple diagnoses.
Ms. Rosenbach explains that health care utilization patterns varied considerably across the states, often as a function of different benefits and variation in practice patterns. In general, foster care children in California were less likely to receive health care services than children in the other two states. More than 80% of foster care children in Florida and Pennsylvania had at least one provider visit in 1994 (the latest data available for the analysis), compared to 65% in California. In California, foster children also were less likely than AFDC and SSI children to see a provider during the year. In the other two states, foster children were more likely than AFDC children to see a provider. In Florida they were also more likely than SSI children to see a provider during the year.
The likelihood that foster care children received a preventive checkup during 1994 ranged from 28% in Florida to 41% in Pennsylvania. In California and Pennsylvania, foster care children were more likely than other Medicaid children to have a preventive checkup during the year. Nevertheless, many foster care children did not receive routine checkups, despite recommendations for an annual physical and mental health assessment each year. In addition, very few received assessments during the first two months of a foster care placement. The report says it was interesting to find that children with no prior Medicaid coverage received early assessments more often, perhaps suggesting that providers were more likely to perform assessments on those who were newly enrolled in Medicaid.
One anomaly, at a time when other research indicates that dental care is a problem for Medicaid children and too often is delivered in the emergency department, is that foster care children were far more likely to receive dental care than other groups of Medicaid children — 60% of foster care children in Pennsylvania and 45% in California and Florida had at least one dental visit in 1994, compared with 28% to 38% of the AFDC population and 31% to 35% of the SSI population. Ms. Rosenbach says she is unable to explain the dental care finding, although says it may relate to the comprehensive assessments that some foster care children receive.
The report said there are four main policy implications:
Although the data analyzed for the study were from the mid-1990s, the problems identified still are salient, and the situation actually may have been made worse by the increased use of Medicaid managed care that has occurred, Ms. Rosenbach says. While studying three states is an improvement over studies that looked at just one state, the results cannot be generalized to all states or to the nation as a whole, she point out. But using multiple states demonstrates the extent of variation and can provide useful comparisons with other states.
One group of foster children, those who age out of foster care, got some additional help in the Foster Care Independence Act of 1999. A Dec. 14, 1999, state Medicaid director letter from federal officials urges states to take advantage of a new optional Medicaid eligibility group for children who are in foster care under the responsibility of the state on their 18th birthday.
The law gave states the options to:
In the letter, Timothy Westmoreland, Medicaid director, called on states to "elect this new option to ensure that children aging out of foster care have the health care that they need."
In her research report, Ms. Rosenbach wrote, "As the health care needs of children in foster care have garnered increasing attention, interest has grown in developing performance measures to track the effectiveness of child welfare services."
[Contact Ms. Rosenbach at (617) 491-7900, ext. 227.]