Health Care for Children in Foster Care

More than half a million children are currently in the US foster care system. This number has increased greatly over the past ten years. (Leslie.) Children in foster care are children who have been removed from parents deemed unfit to care for them, and who will supposedly be better cared for by the state; yet children in foster care have the poorest physical and mental health in the nation, and have difficulty getting access to the physical and mental health care that they need. Children in foster care need to be provided with better quality physical, developmental and mental health care.

Children entering foster care have more health issues than any other groups of children in the USA, including children living in poverty. Typical health problems of children entering foster care include asthma, vision or hearing problems, malnutrition, skin abnormalities, dental problems, anemia, and failure to thrive. Thirty to eighty percent of children entering foster care have at least one health condition. Twenty-five percent have three or more health conditions. (Leslie.) But while in foster care, children tend to receive less outpatient services than other children, including those on Medicaid. When they do receive outpatient care, they are more likely to receive it from an emergency room. In fact, children in foster care are significantly more likely to visit the emergency room within the first few days of entering foster care or changing placements, than any other time during their stay in foster care. This suggests that foster parents don't always get the information or the training they need to take care of a child with a health problem. (Houshyar.) For instance, when foster parents find that their newly placed three-year-old foster child is having trouble breathing, and they have not been told that the child has asthma or trained on how to care for a child with asthma, they're likely to rush him to the emergency room. As far as routine, preventative checkups go, only twenty-eight to forty-one percent of kids in foster care get them. (Houshyar.)

Why don't children in foster care get the health care they need? One reason is that many have not had much health care before entering foster care, so their health conditions may be undiagnosed, or untreated, before they enter foster care. (Sobel.) This leaves it up to staff members and caregivers in the foster care system to try to catch kids' health problems, without knowing what to look for. Other issues include the complicated and time consuming paper work necessary whenever a foster child needs a health care visit, the fact that health care providers often are reluctant to diagnose or treat foster children because they're afraid they'll have to testify in court, and negative judgments or preconceptions some health care providers have about foster parents and foster children. (Sobel.)

The issue of the health care for children in foster care becomes even more complicated when one considers developmental and mental health problems as well. Twenty to sixty-one percent of children in foster care have a developmental disability or delay. Common disabilities or delays seen in foster children include language disorders, poor social-adaptive skills, delayed fine-motor skills, learning disabilities, and cognitive impairments. One reason for the high occurrence of developmental delays and disabilities in foster children may be that many foster children have been put at risk by things like prenatal exposure to drugs or alcohol, or severe neglect. (Leslie.)

In addition, thirty-five to eighty-five percent of children in foster care have mental health issues. (Some professionals speculate that the number is probably even higher.) (Leslie.) Often these mental health issues stem from traumatizing things the children have experienced, such as abuse, neglect, or witnessing violence. In fact, just being removed from one's birth family and placed in foster care is often very traumatizing for children, regardless of what a child has already experienced with his birth family. Common mental health problems seen in foster children include depression and other mood disorders, anxiety, adjustment disorders, conduct disorders, post traumatic stress disorders, and oppositional defiancy disorder. (Austin.) But although so many children in foster care have mental health problems, proper treatment doesn't always happen. One study showed that, while forty-two percent of toddlers in foster care and sixty-eight percent of preschoolers in foster care show signs of developmental and behavioral problems, only twenty-three percent receive any treatment or services. Another study showed that eighty percent of children in foster care have been diagnosed with a mental health disorder, but only half of them have received services for their disorders. (Houshyar.)

One reason for the lack of mental health care for kids in foster care is that, although children generally get a health examination upon entering foster care, they are not usually screened for mental health problems. They may only be screened later if they start to demonstrate lots of disruptive behaviors in school or in their foster care placements. Child welfare staff members tend to focus on keeping children physically safe, and less on the mental and emotional needs of children. As for foster parents, they may not even be told about the mental health issues of a child put in their care. Without knowing what to look for, it can be difficult for foster parents to recognize mental health disorders. Often it is only severe behavioral problems such as anger and defiancy that eventually bring a child's mental health into question. (Austin.) A child who is quiet and withdrawn can easily be overlooked.

And then, if those in charge of a child do come to realize that a child has mental health problems and want to seek help for the child, getting treatment can be hard to do. Only a small number of professionals have been specially trained to work with kids with the issues foster children typically have, such as loss of birth parents and memories of abuse. One study showed that only three percent of mental health care providers work with foster children. Furthermore, even if mental health treatment is sought out and found for a child, the problem still is often not solved. Foster children tend to miss a lot of their appointments, go through multiple foster care placements that make it hard to continue treatment, and eventually discontinue treatment altogether if they go back to their birth parents. (Austin.)

There are even more obstacles involved in securing physical, developmental and mental health care for children in foster care.

For instance, children generally enter foster care abruptly, during a crisis. This often happens outside of regular business hours, or even during the middle of the night. Children in foster care are supposed to have a health exam right away, in order to determine any evidence of abuse or neglect, treat any existing illnesses or infections, assess the need for future health care, and get any necessary medications. This health exam ideally should take place within the first twenty-four hours of the child's being in care. But when the health exam takes place, the child's medical information and history is often unavailable. Often the birth parents are unavailable, unwilling, or unable to provide the necessary information. Or, the person bringing the child to the health exam, such as a foster parent, may not have the information to give to the health care providers. Providers can find themselves trying to treat children without knowing about the child's allergies, immunizations, and existing treatments.

Another problem involving children in foster care is that they do not have a health care coordinator. Most children have someone, usually a parent, who takes the responsibility for keeping track of all of the different medical information and records, setting and keeping appointments, exchanging information with different doctors and professionals, and other necessities. But children in foster care often don't have one person to do all of that. Instead, they have a whole team of professionals, from caseworkers to foster parents to residential care staff to school staff members, sharing the responsibility. These individuals do not always share information with each other, even when it is part of their job to do so. Also, some individuals can do some things regarding a foster child's health care, but cannot do other things. For instance, foster parents can consent to some treatments for foster children, but for other treatments birth parent consent or court order is needed. And, due to confidentiality rules, it can be difficult for foster parents to obtain information about their foster children, let alone to pass that information on to health providers. (Leslie.)

One more issue that is unique to children in foster care is the fact that they experience such frequent changes in placement. Every child in foster care experiences at least one placement change, because they are removed from foster care and put into a new home. Many kids start out in a short-term foster home or a "receiving" home, and then, when it is determined whether they'll be staying in foster care for a longer amount of time, they are moved to a long-term placement. Twenty-five percent of kids in foster care go through at least three placements in a year. Each time a child moves to a new placement, they start over with a new caregiver, and sometimes also a new social worker, or a new health care provider. The new members of the team don't always manage to get all of the information on the child in their care, and former health care providers aren't always given new contact information for the child. There is a lack of communication among all parties involved. (Leslie.)

If getting foster children diagnosed and treated for their physical, developmental and mental health problems is difficult, the problem is only made worse by the question of how to pay for all of these services that the children need. Many foster children depend on Medicaid. Some children are already covered by Medicaid while living with their birth parents, and are expected to continue being covered after entering foster care. And many states use Medicaid to cover all children in foster care. (Leslie.)

Medicaid has its advantages. Through Medicaid, each state must provide Early, Periodic Screening, Diagnosis and Treatment to all eligible children, including those in foster care. States must also provide services to treat any conditions that are caught through the EPSDT, even if those services aren't routinely provided by Medicaid. So, theoretically, children in foster care should be getting regular, thorough health exams. (Leslie.)

But Medicaid also comes with its share of problems, which are experienced by many users, not just those involved in the foster care system. For one thing, it can be very difficult to find a provider who accepts Medicaid, especially in rural or inner city areas. (Leslie.) Medicaid has lower reimbursement rates than regular insurance plans, so many providers are reluctant to accept it, or only accept a certain amount of Medicaid patients. Plus, states are allowed to determine certain parts of their Medicaid programs, including eligibility categories, program benefits, eligible providers, and reimbursement rates. So Medicaid programs differ greatly from state to state. And as for use of EPSDT, it varies. Many children, including those in foster care, don't end up getting their EPSDT's, or don't get proper treatment afterwards. (Leslie.)

The movement of many state Medicaid programs towards Managed Care models may be creating even more barriers for children in foster care. Being in a Managed Care program basically means that one is enrolled in an HMO. Instead of seeking out any provider or specialist who accepts Medicaid, as a beneficiary of a regular Medicaid program would do, one must choose a primary care provider from a list of possibilities. That primary care provider can then refer you to other providers or specialists for any extra services you may need. (New York State Dep't of Health.)

The idea behind states moving towards Managed Care programs is to provide better access to primary care services, emphasize preventative care, and save on costs. Managed Care beneficiaries have fewer out-of-pocket expenses. Managed Care programs also serve as a type of "medical home" for beneficiaries, because the primary care provider makes referrals to all other doctors, and therefore all information is linked.

But Managed Care comes with its own disadvantages as well. There are restrictions on numbers of visits to providers per year, and beneficiaries are limited to providers within a certain network. For children in foster care, Managed Care presents even more problems. First of all, when a child is taken into foster care, he is supposed to get a health exam right away. But before he can get that health exam, it must be determined whether he is already covered by regular insurance, Medicaid, or another public program. A Medicaid Managed Care program will not cover the child's exam until it can be proven that the child doesn't have any other existing coverage. Finding out that information can take quite a while, for the reasons previously discussed. Then there is the fact that Managed Care requires enrollees to wait until the next enrollment cycle for coverage, instead of being immediately covered. So a child entering foster care can go for several weeks without any type of medical coverage. Without that proof of coverage, health care providers are often unwilling to see a foster child, because they fear that if the child ends up being denied coverage, the provider won't be reimbursed. (Leslie.)

When it comes to securing proper health care for children in foster care, a big part of the problem seems to be a lack of communication between all parties involved... Medicaid, child welfare staff members, foster parents, health care providers, birth parents, and others.

One possible solution to this issue is for foster children to have a "medical home." This is a concept in which children receive high-quality, cost-effective care, and all parties are partners in the child's care. The brunt of the health care should take place in the child's community, at a place that accepts all forms of insurance, including Medicaid. Every time a child has a doctor's visit, whether it is for routine care, preventive care, or illness, he or she should see the same pediatrician... someone who understands the special circumstances of foster care, who can bond with the child, and whom the child can feel comfortable confiding in. (American Academy of Pediatrics.) For instance, in central Kentucky, children in foster care visit the Medical Home For Coordinated Pediatrics Clinic. There, they get all of their well-child examinations, immunizations, care for minor illnesses, and developmental screenings. They can also be referred to other services, if need be, but the Clinic handles as much as possible for each child. The Clinic works to consolidate appointments, so that foster parents who live farther from the clinic don't have to keep returning over and over again, and children don't have to experience as many doctor visits. The Clinic also works with children's foster parents and case workers, keeping everyone updated on the child's medical information, and keeping medical records up to date. (Kentucky Cabinet For Health and Family Services.)

When using one medical home for foster children is not possible, other things can be done to ensure that all parties involved in a child's care are on the same page. Using care coordinators is one idea. A care coordinator is a person who has the job of pursuing past medical histories, consent forms, and other information for each child who enters foster care, maintaining medical files for each child, and assisting children in getting the health care services they need. (Sobel.)

Some states also use health care passports, in order to keep all of a foster child's health care information together. Each time a child sees a health care professional, the information is added to the child's health care passport. This ensures that each health care professional has access to all of the health care information about the child. However, the health care passport model requires a lot of time, effort and paperwork, which can be difficult to keep up with for all involved. (Sobel.) For instance, in Illinois, foster parents are largely responsible for obtaining and keeping track of information for each child's health passport. Whenever a child enters a new foster home, the foster parent must contact the county's health department immediately, to choose a pediatrician for the child and set up an initial medical appointment. The foster parent is responsible for bringing the health passport to all of the child's health appointments, as well as to case reviews, and must also keep the child's case worker informed about any and all of the child's health needs. (DuPage County Health Department.) This can be a lot of work for a foster parent, especially one who has more than one foster child in the home.

The payment for the health care needs of children in foster care is also a major issue that needs to be dealt with. One solution that has been suggested is for the process of enrolling children in Medicaid to be expedited in the cases of children entering foster care. Every child who enters foster care, even for just one night, should be immediately covered by Medicaid, and this coverage should just be assumed at the time that the child enters foster care. This way, each child would be able to get health care right away, and Medicaid paperwork can be dealt with later. Or, state or county funds can be used to reimburse health care providers until a child's Medicaid coverage comes through. (Leslie.)

In order to make sure that children in foster care get all of the care that they need, a system could be created to refer foster children to whatever developmental or mental health care professionals or subspecialists they need to see. When using Medicaid Managed Care systems, provider networks could be expanded for kids in foster care. Rate adjustments could also be put into place to compensate health care providers who care for kids in foster care who have special health care needs. (Leslie.)

It is also important that foster parents be included in each child's health care team. Foster parents should be informed about and trained to deal with any health needs a new foster child has. They should also receive help with complicated paperwork, and receive reminders to schedule routine health appointments for each child. Helping foster parents deal with these duties can make it easier and less stressful for them to focus on the children in their care.

Children in foster care deal with so many physical, developmental, and mental health issues. They need, and deserve, to be cared for. We need to work harder to make sure that children in foster care receive the health care that they need.