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.
On July 5th, the Centers for Medicare & Medicaid Services (CMS) issued a final rule implementing provisions of the Affordable Care Act (ACA) including Medicaid and Children’s Health Insurance Program (CHIP) eligibility, benefits, and enrollment rules. While the final rule does not cover all of the topics in the proposed rule issued in February, it does focus on the changes that are most needed to implement the changes made by ACA starting in 2014. Additionally, it addresses key provisions deemed critical to former foster youth and children and youth currently in care.
The final rule clarifies that former foster children are already a population that is eligible to be determined presumptively eligible (the rule does not extend to current foster youth as they are already Medicaid eligible and don’t need to be determined presumptively eligible). The rule also clarifies that individuals under age 21 will continue to receive Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) services either through the Alternative Benefit Plan (ABP) or as additional coverage that supplements the ABP. The final rule makes clear that CMS does not have statutory authority to require states to provide EPSDT services beyond age 21, but acknowledges that states have the flexibility to design and offer voluntary enrollment in an ABP targeted to former foster care children that provides a more comprehensive array of health coverage than is provided through the regular state plan.
Despite recommendations that former foster youth be exempt from premiums and cost sharing, the final rule explains that while there are populations upon which states may not wish to impose cost sharing, there was no clear basis to support a federally-mandated exemption. The rule does state that agencies may not impose premiums or cost sharing on children receiving child welfare services under title IV-B as well as children in foster care and individuals receiving benefits under title IV-E, regardless of age.
One key issue not addressed in this rule that remains of concern to child welfare advocates has to do with state of residency of former foster youth. The ACA requires that in order for an individual to be eligible under this category, the individual would have to have been in foster care under the responsibility of “the state” and be enrolled in Medicaid under “the state plan” or an 1115 demonstration. Under the proposed rule, CMS interprets the requirement as meaning that the individual was in foster care and enrolled in Medicaid in the same state in which coverage under this eligibility group is sought. CMS does propose giving states the option to cover individuals under this group who were in foster care and Medicaid in any state at the age of 18 or at the point of aging out. However the proposed rule does not require states to cover former foster youth who were in care and enrolled in Medicaid in any state at the time the individual reached age 18 (19, 20, or 21), as advocates had hoped.
Today the Senate Appropriations Committee approved the FY 2014 Labor, Health and Human Services, Education and the Legislative Branch (L-HHS-Education) bill by a vote of 16-14. The bill provides $165.6 billion in discretionary budget authority to make investments to reduce healthcare costs and improve the quality of health care delivery, improve early childhood care and education, and improve school safety and access to mental health services, among other things.
In her opening statement, Chairwoman Barbara Mikulski (D-MD) highlighted some key investments that the L-HHS-Education bill makes in early childhood education. The bill would increase funding for Head Start, Early Head Start, and Child Care Development Block Grants. The L-HHS-Education bill also funds universal Pre-K, which supports the President’s initiative to ensure that every four-year old can attend preschool. Finally, the bill fully funds the President’s request for implementing the Affordable Care Act.
The bill will now head to the Senate floor for consideration by the full Senate. The House has yet to mark up its Labor-HHS bill, so there is no way to provide a direct comparison at this time.
Today the White House hosted a national conference on mental health. In his opening remarks, President Obama took a moment to thank everyone in attendance as well as the folks across the country who work on behalf of those suffering from mental illness. He said the main goal of the conference was not to start a conversation about mental health but to elevate that conversation to a national level and to bring mental illness out of the shadows. The President talked about mental health parity and acknowledged former Representative Patrick Kennedy and his colleagues who worked tirelessly to ensure that individuals have access to mental health coverage that is comparable to what is offered for physical health. Unfortunately, as he noted, many individuals still do not have access to much needed treatment. He called on the country to do more to recognize the early signs of mental illness. President Obama concluded his remarks by offering a plea for individuals suffering from mental health to seek help. He assured them that they are not alone, and encouraged Americans to help those in need heal and thrive.
Health and Human Services Secretary Kathleen Sebelius moderated the morning panel which focused on addressing the stigma surrounding mental health and ways to break down the barriers that are preventing far too many people from seeking the help they need. The panel consisted of individuals with personal connections to mental illness.
The next panel was led by Education Secretary Arne Duncan and consisted of presentations by experts and organizations that have been successful in using creative ideas to address mental health. The presentations also highlighted techniques that can be used to reduce mental health stigma and help the millions of Americans struggling with mental health problems recognize the importance of reaching out for help.
Vice President Joe Biden delivered the closing remarks for today’s conference. He reiterated themes that had been discussed throughout the day and also made a plea for those suffering to not be ashamed of their condition but to know that help is available.