| Federal Law and Child Welfare Reform The Research-Policy Interface in Promoting Permanence for Older Children and Youth ROSEMARY J. AVERY |
EIGHT |
In this chapter, I respond to and elaborate on observations made by Madelyn Freundlich in chapter 7 regarding policy issues surrounding youth exiting from care. I discuss independent living programs and the lack of emphasis on family and social connections for youth transitioning from foster care to adulthood, health care coverage and health service access issues for youth who have exited foster care, and service coordination issues. Recent research has focused on the exit end of the foster care system—that is, youth aging out of care—and has well demonstrated the perilous position that federal policy creates for young foster care alumni, both before and after they exit foster care. Of particular concern is the lack of rulemaking requiring every child to have a committed adult willing to be in a supportive and personal (not clinical) relationship with the youth before, during, and after their transition to adulthood. Equally concerning is the inattention that has been given to health care issues that affect this group of youth.
Each year across this country, between twenty thousand and twenty-five thousand youth are discharged from the child welfare system to their own resources (English et al., 2006). In years past, when youth comprised fewer than 25 percent of the child welfare caseload, this group of children in foster care was not such an urgent concern. Caseload demographics, however, have changed radically, and public concern is becoming focused on this vulnerable group of state wards. In 2005, more than 200,000 youth aged thirteen or older were in the foster care system, close to 40 percent of the foster care population; in that same year, 24,407 foster youth exited care to emancipation (U.S. Department of Health and Human Services, 2006). Current policy allows these youth to be discharged from care to “independent living” with no one to rely on but themselves (English et al., 2003; Georgiades, 2005). The majority of these youth have no personal connections to committed adults to help them through this difficult transition period and beyond or to support them when the inevitable adverse circumstances befall, including ill health, victimization, unemployment, unplanned parenthood, or homelessness. Some youth temporarily turn to birth parents or other kin for support and shelter; the majority, however, must learn to navigate the world on their own.
An important question faces policy makers: To what extent is the foster care system preparing these foster care youth for self-sufficiency, independence, and effective community living? An equally important question faces practitioners: What is the best practice to ensure that youth's transition to adulthood is a successful one? With the exception of providing health care, child welfare policy has remained ambivalent about the systems’ responsibility for ensuring the safety and well-being of youth after they exit care. Empirical research has not provided evidence as to how best to prepare youth for life after care (Mech, 1994; Voices Issue Brief, 2004), and practice has focused on the importance of providing “life skills” rather than “life connections.”
Research since the late 1980s has provided ample evidence that aging out of foster care poses particular problems for youth with tenuous family ties, weak community connections, and poor prospects for stable housing, employment, or support resources. Edmund Mech (1994) found that if youth are not connected with at least one key personal support resource before they leave care, their chances of successful community integration are significantly diminished. Teresa Cooney and Jane Kurz (1996) and Debra Umberson (1992) found that successful functioning after leaving care is inextricably linked to relationships with the family of origin. It is imperative that future policy initiatives address areas of practice that would make it mandatory for caseworkers to vigorously explore ties with biological family, siblings, relatives, former foster families, or other caregivers well before a youth's date of exit from care and to ensure that no youth be discharged from care before age twenty-one without one committed, caring adult connection. Failure to make these connections for youth should be grounds for an extension of foster care past the age of majority.
Great policy strides were made in 1999 for older youth in care with the passing of the Foster Care Independence Act (FCIA), which doubled federal financial support for transitional services and created the John H. Chafee Foster Care Independence Program. The goals of the program are to provide youth with tools that could help them develop better education, vocation, and life skills; prepare youth for education after high school; support youth's personal and emotional needs; provide former foster youth ages eighteen to twenty-one with a variety of supports; and help youth access funds for education and training.
The primary objective of independent living (IL) programs is to prepare foster youth for effective adult living and independence after they exit care, but, to date, we have very little evidence that these programs actually work. Given the short history of IL programs and the traditional lack of federal funding for child welfare systems research, only a few studies have been done on the effectiveness of IL programs, and our knowledge of their effectiveness is limited and conflicting (Georgiades, 2005). Most of the studies that have been completed so far suffer from methodological limitations such as lack of an appropriate comparison group (comparable foster youth who did not participate in independent living programs), limited sample size, limited duration of observation following exit from care, and limited nature of the outcome data studied (for a review of these studies, see Georgiades, 2005).
Studies completed relatively more recently and with fewer methodological limitations indicate that the effect of IL programs on youth outcomes in the medium-term (one to three years) is primarily in domains such as education and employment (Mallon, 1998; Scannapieco et al., 1995), early parenting prevention, anger control, and self-evaluation outcomes (Courtney et al., 2001). A more recent study by Savvas Georgiades (2005) using an appropriate comparison group (foster youth who aged out but did not go through IL training) failed to find a relationship between IL program participation and better social support, better parenting competence, lower incidence of substance abuse, lower levels of sexually risky behaviors, reduced depression, and increased knowledge in interpersonal, money management, job-seeking, and job-maintenance skills.
A comprehensive evaluation needs to be undertaken to determine the relative merits and costs of these type of “independence” programs compared with other strategies, such as increasing the discharge age from foster care to twenty-one for all foster youth who have not been permanently placed with families and providing services such as postdischarge mentor programs. The questions for policy makers and researchers are the following: What types of life skills are successfully taught in a classroom setting? Does IL training result in youth who are more “functional” as young adults in terms of living and survival skills, social skills, and economic independence?
Policy strides have been made in the last few years in providing health care insurance for youth exiting care. The impact of these efforts, however, is still questionable. The bipartisan Foster Care Independence Act (FCIA) of 1999 provides an important extension to services and supports for youth making the transition from foster care. Subtitle C of Title I of the act offers states an important opportunity to provide continued Medicaid coverage to young people aged eighteen to twenty-one who have exited care. FCIA established a new optional Medicaid eligibility group for “independent foster care adolescents,” young people who are are or were in foster care on their eighteenth birthday. States, however, are responsible for the nonfederal share of Medicaid, and the federal medical assistance percentage ranges from 50 percent to 76.8 percent, depending on the state's per capita income. This same cost-sharing rule applies to the expanded eligibility in FCIA.
If a state takes full advantage of the Medicaid option under FCIA, all foster care youth who are not yet twenty-one could be automatically eligible for Medicaid without regard to their income status (that is, no income or resource test would be required for these young adults). However, this full coverage is optional for states, and, in addition, states have the option to restrict eligibility to subgroups based on income and other resource tests, age, or previous foster care eligibility status. In an effort to encourage states to participate in this federal program, Patricia Montoya (Commissioner on Children, Youth, and Families in the U.S. Department of Health and Human Services) and Timothy Westmoreland (Director of the Center for Medicaid and State Operations Health Care Financing Administration) (2002), wrote letters to all state child welfare and Medicaid directors urging them to take advantage of the new Medicaid options under the FCIA to ensure that children transitioning from foster care get the physical and mental health care they need.
Automatic enrollment of all youth exiting from foster care in Medicaid or other state-funded health insurance programs would significantly enhance the likelihood that youth would receive essential health care services after exiting foster care. Research indicates that youth exiting care without health insurance are unlikely to obtain medical care when needed (Newacheck et al., 1995). Currently, there are no uniform or comprehensive data available to assess what states are doing to take advantage of health care coverage options for youth exiting care. Abigail English and colleagues (2003) interviewed independent living coordinators in forty-three states to examine how Medicaid and State Children's Health Insurance Programs (SCHIPs) could improve health care access for youth aging out of foster care. The researchers found that when states had not implemented the FCIA Medicaid expansion option, the major reason was budgetary constraints. Budgetary considerations also were cited as the leading obstacle to implementation in the states that had chosen to implement the FCIA Medicaid expansion option. Most states reported that both state budgets and Medicaid budgets were in crisis. In the conclusion to their study, the researchers suggested that it was unacceptable to cite budgetary constraints as a reason for not implementing the FCIA Medicaid expansion option given that the actual number of youth covered under this expansion would be small, the youth are a particularly vulnerable population group, and failure to cover these youth would result in significant social and economic costs in the long run.
Of particular policy concern is the differential access that exiting youths have to continued health care coverage, depending on their state of residence. A youth's access to health care insurance after leaving care should not depend on the state in which they live. To better understand issues of differential access, researchers need to address such questions as the following: What accounts for the significant variation in FCIA Medicaid extension participation patterns among states? What accounts for differences in benefits packages among states? What is the rate of youth utilization of services through this program once they leave foster care?
The group of young people who age out of foster care each year is a small but vulnerable population with multiple health concerns, intense health care needs, and few resources for securing health care (English et al., 2003). Eligibility for health insurance coverage, standing alone, will not address the health care problems facing these youth (Allen and Bissell, 2004). Large numbers of former foster youth are homeless, poorly educated, unemployed, and living in poverty. Even when youth have health care coverage through programs such as Medicaid, they often do not have the skills to independently navigate the health care system; they may find that their health care coverage does not fully pay for the services needed, and there is likely to be a dearth of health care providers who can meet the comprehensive and integrated health care service needs of transitioning youth. A number of enrollment and service barriers exist that may be especially problematic for young adults navigating the system on their own for the first time. Specifically, youth may encounter challenges in finding health care providers who will accept Medicaid coverage, given the low reimbursement rates, burdensome administrative requirements, and inefficient payment system; in insuring continuity of care as they move frequently from one living situation to another; and in coordinating wrap-around medical services with mental health and substance abuse treatment services.
J. Curtis McMillen et al. (2005) found that older youths in the foster care system have disproportionately high rates of lifetime and past year psychiatric disorders. Studies have shown that children in foster care suffer more frequent and more serious medical, developmental, and psychological problems than nearly any other group of children (Gollan et al., 2005; Ito et al., 1993, 1998; Perry and Pollard, 1998). Foster youth are undoubtedly at a higher risk for continuing health problems after they exit care because of the circumstance that brought them into care and the ongoing instability they may experience once they enter into care.
Although some smaller studies have documented the health status of youth at the time they exit care and report high rates of physical and mental health problems, no studies have been conducted using nationally representative samples to gauge the true extent of these youth's health problems. Our knowledge of the health status of other at-risk youth (homeless and runaway youth and those living in poverty) is also limited but equally important, as many former foster care youth experience poverty and homelessness soon after leaving care. Courtney and Amy Dworsky (2006) found that a large number of aged-out youth continue to struggle with health and mental health problems, suffer from persistent mental illness or substance use disorders, and find themselves without basic health coverage.
Some states have developed progressive ways to track the health care of children in foster care (such as through electronic “health passports”), and others are making creative use of funds from Medicaid and other state programs to expand access to health services while children are in care. No state tracks the health status of youth leaving foster care, and none has committed to providing support systems for continuity of care after exit. This challenge has yet to be addressed at the national policy level.
It is known that between one-third and one-half of youth aging out of care lose their Medicaid coverage once they transition out of care (Rosenbach, 2001). Concerted efforts are necessary to ensure that youth leaving care are not among the uninsured, for whatever reason. Furthermore, policy makers should closely examine the effect of termination of Medicaid eligibility on young adults after their twenty-first birthday, especially because youth leaving care often obtain low-paying jobs that do not provide health insurance.
A related issue that needs urgent federal policy attention is the coordination of services for parents, children, and youth aging out of care with regard to substance abuse, mental health, and violence. Legislation targeted at this problem has not been enacted, and, as a result, many states have not developed appropriate screening, assessments, and comprehensive treatment options for families and older youth in care. Currently, there are no laws that specifically address the links between child welfare and substance abuse, mental health, and domestic violence, although several laws have been proposed (Allen and Bissell, 2004).1 Some states, including Connecticut, Delaware, Illinois, and Washington, among others, have used the Title IV-E demonstration waiver authority to respond more creatively to service coordination needs, but others have not, and the authority to grant new waivers has expired. There is currently no comprehensive federal legislative effort in place to address these coordinated service needs.
In summary, comparative research is needed on the outcomes for youth aging out of care from various placement settings such as family-based care, kin care, and institutional settings. The need for program evaluation and program impact research on independent living preparation and outcomes is urgent. Furthermore, the research on the postdischarge young adult functioning of former foster youth is insufficient and needs to be federally funded if there is to be an evidence-based foundation for future policy initiatives in child welfare.
1. The Child Protection and Alcohol Drug Partnership Act was introduced into the 106th, 107th, and 108th (2003–2004) Congresses. As of this writing, it had not as yet been introduced into the 110th Congress.
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