On Wednesday, July 30, the Senate Foster Youth Caucus hosted a “Discussion on Child Welfare Finance Reform.” For months, the caucus has been hosting a series of different presentations to update Senate staff on a range of child welfare topics. They issued an open invitation to organizations that wanted to offer varying proposals. For this roundtable approximately 17 different proposals were discussed by a number of different organizations. The proposals (Senate Foster Youth Discussion) ranged from ideas to change the current funding structure to more targeted reforms including ideas to better align and improve on Medicaid and mental health services, changing the current eligibility link to foster care, realigning funding such as SSBG to expanding funding to services such as post permanency and reunification support and the appropriate use of residential care.
CWLA, building on its earlier policy statement issued in April, Finance Reform & Child Welfare: A Balanced Approach submitted a proposal to realign the Social Services Block Grant (SSBG) to update the current definitions of programs and to highlight its significant role in funding child protective services, prevention and intervention services, other child welfare services as well as other vital human services including domestic violence and special services for the disabled. The $1.7 billion in SSBG funding has been targeted for total elimination under some House proposals.
During the various presentations there were some overlapping issues and concerns that were raised that offer potential incremental change such as the need to strengthen access to mental and behavioral health services, better coordination between state Medicaid and state child welfare agencies, there was also agreement on the desire to do away with the eligibility link between foster care and AFDC and the need to strengthen the child welfare workforce. There was no conclusion to the event but the series will continue to focus on key issues and issue areas. The forum is envisioned as a way to continue a policy education effort for congressional staff.
In light of the Senate’s inability to pass an adoption reauthorization bill later in the week, there appears to be little opportunity to enact anything comprehensive this year. It is still hoped by some advocates that an end of the year budget deal that may have to deal with a range of delayed policy issues could include a small child welfare piece such as the Administration proposal to incentivize coordination between Medicaid and child welfare that would improve health care access for children in foster care and also reduce the incidence of over-medication.
The National Quality Improvement Center on Differential Response in Child Protective Services (QIC-DR) has released the final report from the Cross-Site Evaluation on Differential Response. Differential Response (DR) represents a different way of structuring a state’s child protective services system (CPS). DR allows CPS agencies to respond differently to child abuse and neglect based on the level of risk and needs of the family without compromising child safety. It is sometimes referred to as “dual track,” “multiple response system,” “alternative response,” and “family assessment response” in various jurisdictions. Lower risk cases may be directed to an alternate path while more serious cases will still be evaluated under the more traditional investigative response (IR).
The research represents the fourth major evaluation report coming out of the QIC-DR this year, following three individual site evaluation reports from Colorado, Illinois and Ohio. All of the reports are available on the website, under the “evaluation” tab. On Tuesday, July 29th from 12:00-1:30PM ET, Marc Winokur, Social Work Research Center, School of Social Work Colorado State University; Raquel Ellis, Westat; and Ida Drury, Colorado Department of Human Services, will be presenting a free webinar on the findings from their study of Differential Response in five counties in Colorado. Space is limited, so sign up early by visiting the website.
Part of the conclusion of the report states,
“In two of the three QIC-DR sites, the entire CPS system was impacted by the introduction of the new AR pathway. Most of the changes observed in Colorado’s and Ohio’s implementations of DR were not reserved for AR (alternate response) families, but rather the modifications became embedded into child welfare systems for all CPS families. The AR pathway, like the IR pathway, is guided by procedures and policies, and influenced by the skills and characteristics of caseworkers.
Although AR might be considered to be merely an alternative to IR, as its name implies, a fully implemented DR system may have deep impacts upon the community and its families; the CPS workforce; the policies, practices, and procedures guiding child protection casework; and the child welfare agency mandate. These impacts may not be solely in terms of different outcomes for those who have come to the attention of CPS, but rather may widen the reach and influence of CPS to other families who may be at risk or vulnerable. DR may indeed reshape the core mission of CPS.”
Some states have implemented their DR practices under more rigorous evaluation including the states of Ohio and Minnesota which included random control studies designs. There is no federal regulation or definitions as states implement this approach but the QIC-DR was a five year project funded by HHS and intended to help in that process.
On Thursday, June 19 Congressman James Langevin (D-RI) introduced the Permanent Families for All Act, legislation that would implement parts of the Annie E Casey child welfare finance proposal. The bill would do away with the current link to the 1996 AFDC program in determining a child’s eligibility for federal foster care funding (de-link) but it would accomplish that by reducing the federal matching funds state receive. Currently the federal government provides a match based on what is called the “FMAP” rate for each eligible child with a state’s match based on an annual formula. A state may get a match of as low as 50 percent (meaning one state dollar brings in one federal dollar) while some states receive a match as high as 80 percent (meaning one state dollar brings in four federal dollars) Under the proposal, states would have that rate reduced accordingly to assure all children in foster care are covered. It would not provide more federal funding but would cover all children in foster care.
In addition the bill would, most controversially, time limit federal coverage of foster care to 36 months in a lifetime under the theory that it will drive states to move children out of foster care quicker. The last AFCARS report indicated that 18 percent of children in foster care (70,000 children) have been in foster care for 36 consecutive months or longer. The AFCARS numbers do not indicate total months in foster care if a child has had several spells in and out of foster care over that child’s lifetime. Under the legislation if a child had a cumulative total of more than three years, federal funding would be cut off.
In another area of controversy the bill would limit institutional care to one year of federal reimbursement. Again the assumption is that a limit on federal funding will drive states to find foster care homes or other placements rather than institional care. Currently 6 percent of children are in group homes (23,000 children) and another 9 percent (34,000) are in institutional care. Again the limit is over a lifetime and the AFCARS measures current spells and not a child’s lifetime experience in care.
While the re-design in funding is based on an argument that changing federal funding will change practice, a recent GAO report shows that nearly six years after the enactment of Fostering Connections to Success, states have had difficulty in finding enough foster homes despite the mandates around keeping siblings together and have also had difficulty in youth placements. States have also been reluctant to expand foster care to age twenty-one despite the 2008 law giving states the option to expand care. A total of 19 states have extended foster care to 21 but 9 states, according to the report, had already extended care before federal funding was available.
Other provisions of the bill would expand caseworker training funds for training ‘on child-focused recruitment and retention.’ It would amend the Higher Education Act to allow child welfare workers to be eligible for loan forgiveness after five years instead of the current ten years. Current loan forgiveness applies if you are in one of a number of public service jobs including child welfare and you work in the same profession for ten years. There is also another five year loan forgiveness program in the Higher Education Act that applies to a number of professions including various teacher categories, child care and Head Start workers as well as child welfare workers but that loan forgiveness program is a discretionary funded program and appropriators have never funded it.
CWLA has expressed concerns to congressional staff regarding the imposition of arbitrary time limits.
Last Tuesday, March 11, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius came before the House Ways and Means Committee to testify on the President’s proposed budget for FY 2015. While much of the discussion focused on the Affordable Care Act and its implementation, the Secretary did include comments on the new proposal to target a small amount of funding between child welfare and Medicaid to address a better and more limited use of psychotropic medication and to improve alignment of health care services for children in foster care.
Sebelius described it as, “$500 million for a new Medicaid [Centers for Medicare and Medicaid Services (CMS)] demonstration in partnership with [the HHS Administration for Children and Families] ACF to provide performance-based incentive payments to states through Medicaid, coupled with $250 million in mandatory child welfare funding to support state infrastructure and capacity-building.” She went on to say, “This transformational approach will encourage the use of evidence based screening, assessment, and treatment of trauma and mental health disorders among children and youth in foster care in order to reduce the over prescription of psychotropic medications. This new investment and continued collaboration will improve the social and emotional outcomes for some of America’s most vulnerable children.”
The Administration proposes, for each of the next five years, $50 million through ACF along with an additional $100 million a year through Medicaid. Many of the specifics are still to be worked out, but the funding awarded through ACF would help build capacity by enhancing the child welfare workforce; providing reliable screening and assessment tools; and facilitating coordination between child welfare and Medicaid, especially Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT); training for foster parents, adoptive parents, guardians, and judges; implementing evaluation tools and providing data. At the same time, CMS would provide incentive grants to state Medicaid agencies if they could achieve certain targets and goals regarding services to children in foster care and similar children.
The goal is to enhance services that would not just reduce the over use of psychotropic medications for children in foster care but also enhance the therapies and services to children and families in this population: it has the potential to improve services for a population of children and families beyond foster care placements. ACF data show that 18 percent of the approximately 400,000 children in foster care were taking one or more psychotropic medications at the time they were surveyed (NSCAW II data collected Oct. 2009 – Jan. 2011). The Government Accountability Office (GAO) has estimated an even higher range of 21 to 39 percent. Children in foster care are prescribed psychotropic medications at far higher rates than other children served by Medicaid, and often in amounts that exceed the Food and Drug Administration’s guidelines.
Passing the funding request in Congress may be a challenge since it is mandatory, requiring passage through the authorizing committees rather than going through the annual appropriations (which also would be a challenge). For the ACF funding, the authorizing committees are the House Ways and Means Committee and the Senate Finance Committee.