If you have seen Short Term 12, an indie film darling making the rounds on Netflix, then you know the importance of behavioral healthcare for youth in foster care and those who have just aged out of foster care. The film follows Grace (Brie Larson) working at a group home for teenagers who are in and out of foster care. The children display a range of distressing behavioral health issues including self-harm, autism, and aggression.

For the purposes of Hollywood, the behavioral health issues displayed in foster youth can be, at times, charming. But for the 400,000 children currently in foster care, behavioral health care challenges are all too real.

As pointed out in the CCF and Community Catalyst brief:

“…children and youth in foster care have high rates of acute and chronic medical, mental health and development problems, making it vitally important that they be provided with high-quality, coordinated health care.” 

Behavioral Health Needs for Foster Youth

Chronic conditions and multiple chronic health problems are common in foster youth, leading to utilization of health care services at a much higher rate than the general pediatric population. Foster youth with behavioral and mental health disorders are over-prescribed and inappropriately prescribed psychotropic medication without accompanying behavioral health services (e.g., therapy and other forms of intensive behavioral treatment services).

The Center for Health Care Strategies (CHCS) recently published an iconographic highlighting the disparities between behavioral health care use in Medicaid for the general child population versus children in foster care. The striking disparities underscore the importance of ensuring foster youth get the coverage they need to meet their healthcare needs.

Using data from a national analysis of children’s behavioral health care use in Medicaid, CHCS has highlighted different ways the child population at large versus children in foster care access behavioral health services, physical health services, and psychotropic drugs.

According to CHCS:

• Foster youth account for one-third of the Medicaid child population using behavioral health care services, five times greater than Medicaid enrolled children
• Half of children in foster care are prescribed psych medication receive more than one prescription, compared to only one-third of Medicaid-enrolled children

In short, compared to the population of Medicaid-enrolled children, children in foster care account for a disproportionate number of behavioral health services, have higher Medicaid expenditures for such behavioral services, and are prescribed psychotropic medication at higher rates.

These findings, that foster youth are over-prescribed major antipsychotic drugs, are in line with previous studies from Pediatrics and the Government Accountability Office (GAO). As expert Laura Boyd summarizes:

“…foster youth are disproportionately being treated with major antipsychotic drugs instead of the psychosocial, behaviorally tested, evidence -informed clinical treatments that can address and ameliorate their trauma, destructive behaviors, and mental or emotional illnesses. Trauma and behavioral health issues do frequently follow the experiences of abused and neglected youth who are removed from their families for their own protection and well-being.”

Foster Youth and the Affordable Care Act – The Importance of Medicaid and CHIP

The CHCS graphic underscores higher rates of behavioral health disorders in foster youth and the fundamental importance of Medicaid in providing behavioral heath services for youth in foster care. The Affordable Care Act (ACA) allows former foster care youth to retain Medicaid coverage up to age 26, the corresponding ACA provision that allows young adults to remain enrolled in a parent’s employer-based coverage up to age 26 (an option not readily available for most foster youth). In addition, former foster youth are enrolled in full Medicaid benefits rather than alternative and often less comprehensive plans offered to newly eligible adults under the ACA.

Medicaid coverage for mental health services vary by state but the Affordable Care Act offers important protections for insured foster youth. Essential health benefits packages broaden access to mental health and behavioral health services and parity requirements ensure that Medicaid plans will provide patients with services that are comparable in price and quality to other types of health care. Most separate CHIP programs cover outpatient and inpatient mental health services with few limitations, thus making these services more affordable and accessible to vulnerable youth populations.

CHCS recommends policy changes that include coordinated care systems, improvements to medication oversight and monitoring, and expanding access to appropriate behavioral health services. Advocates have encouraged states to use additional ACA provisions and Medicaid to improve and coordinate care for foster youth including expanding maternal, infant, and early childhood home visiting programs and increased flexibility to provide home and community-based services such as health homes.

While there is certainly room for improvement in coordinating care and access to mental and behavioral health services, it is important to recognize the critical role that Medicaid is playing for foster youth and children. Without it, hundreds of thousands of vulnerable foster youth and children would be left without affordable health care that they so desperately need.