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How Health Reform Could Improve Outcomes in Child Welfare

If human services officials want to take advantage of the Affordable Care Act, they need to get involved in its implementation now.

While most of the discussion around the Affordable Care Act (ACA) has been how it will affect the general population and their ability to access affordable, quality health care, the ACA actually has significant implications for those being served by children and family services systems as well.

But in order to take full advantage of the ACA, according to an Urban Institute report due out next month, children and family services officials need to start getting involved in implementation now to ensure that the populations they serve get the full range of medical and mental health services that will become available to them under the law.

For example, starting in January 2014, kids in foster care will now be covered by Medicaid until age 26 -- coverage originally ceased upon their 18th birthday. (It's estimated that around 29,000 youth age out of foster care a year.) Unlike the expansion of Medicaid coverage for adults up to 133 percent of the poverty level, which the U.S. Supreme Court made optional for states, this expansion is required for all states. Former foster kids must be covered at the regular Medicaid rate but not the enhanced federal reimbursement rate for newly enrolled adults.

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The potential quirky downside of the 2014 provision -- and a concern already being voiced by some national child welfare advocacy groups like the Annie E. Casey Foundation -- is that children under certain guardianship and kinship arrangements may not be identified as officially "in foster care."

In general, however, the Urban Institute report, co-authored by fellow Olivia Golden and research assistant Dina Eman, notes that the ACA offers significant opportunities for child welfare systems. One advantage: It requires a much more streamlined eligibility process, including a provision that eligibility can be determined by third-party data whenever possible. This spars sparing applicants the need to fill out long forms asking for a wide variety of personal information.

As it is, there's significant variation when it comes to enrolling youth in Medicaid (and in doing redeterminations). Some states still require that individuals to go to a Medicaid office to sign up, which, the report notes, has a dampening effect on enrollment. Obviously, the more streamlined states can make the whole process, the better, including tying into other eligibility systems where possible in order to facilitate a smoother, more one-stop approach to enrollment.

The ACA could also have profound implications for adults who are involved with the child welfare system as well, inasmuch as they experience significantly higher levels of health, mental health and substance abuse problems than the general population. Getting as many of those adults as possible enrolled in an insurance plan has the potential to significantly improve outcomes for families, and presumably improve system performance in reducing maltreatment and removal, while enhancing the chances of reunification.

The implications for adults in child welfare families are especially profound because so many of these adults are not eligible for Medicaid today, since state eligibility standards often set extremely low-income limits for parents, well below the poverty level. In addition, the ACA requires that all adults will have a benefit package that includes both behavioral health -- mental health and substance abuse -- as well as medical services. Also important for these parents, ACA demands much more coordination between health and mental health providers, including making provisions for integrated health-care homes, home and community-based services, and maternal and early childhood home visits.

As the upcoming Urban Institute report points out, though, none of this is going to happen automatically. Children and family services officials need to start reaching out now Medicaid officials -- and also their counterparts in cash assistance (Temporary Assistance for Needy Families, Supplemental Nutrition Assistance Program, etc.) -- to figure out how to take full advantage of the opportunities accorded by the ACA.

It's also worth pointing out -- as was mentioned in a previous column -- there is still federal money available to make the sort of IT improvements aimed at streamlining things like intake, enrollment re-enrollment and so forth, and that's money that states and localities shouldn't leave on the table.

Of course, this is all easy to say. As the Urban Institute report notes, both health-care and child welfare staff are "overwhelmed" at the moment both by implementing the ACA and by day-to-day service and administrative demands. Here's hoping that officials throughout human services use the ACA as a catalyst for coordination. The potential for improved outcomes for children and families here is huge.

Elizabeth Daigneau is GOVERNING's managing editor.
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