Medicaid Managed Care for Foster Care Children and Youth: A Natural Experiment with Little Transparency

There’s a natural experiment underway involving a highly vulnerable population: children and youth in foster care. The experiment is a test of whether MCO/FCs outperform other ways of furnishing needed health care to this population.  No, MCO/FCs are not a soccer team in the English Premier League. The initialism stands for Medicaid managed care organizations (MCOs) that enroll only children and youth in foster care (FC) and similar groups (e.g., justice-involved youth). So how is the experiment going? Because there’s so little transparency, we just don’t know.

First, some background.  Children and youth in foster care who receive assistance through Title IV-E of the Social Security Act are automatically eligible for Medicaid.  Like all other children under age 21 enrolled in Medicaid, they are entitled to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, among others. The EPSDT benefit is particularly important for foster care children and youth because of their acute medical and behavioral health needs.

State Medicaid programs vary in how they deliver EPSDT and other services to children and youth in foster care. Ten states rely on the fee-for-service delivery system for all of their beneficiary populations, including children and youth in foster care. Medicaid agencies in another 31 states and the District of Columbia contract with MCOs to deliver services to a broader range of program beneficiaries, but not all of them enroll foster care children and youth in these MCOs. Finally, Medicaid agencies in nine states contract MCO/FCs on a statewide basis to deliver EPSDT and other services primarily or exclusively to children and youth in foster care:  Arizona, Florida, Georgia, Illinois, Kentucky, Tennessee, Texas, Washington, and West Virginia.  (The MCO/FC in Wisconsin operates on a sub-state basis).

Are foster care children and youth better off in fee-for-service, MCOs, or MCO/FCs?  Which delivery system provides the best access to EPSDT services?  The highest quality?  The best outcomes (e.g., increased use of psychosocial counseling as the first line of treatment and decreased reliance on antipsychotics)?

As a first step in attempting to answer this question, we searched the websites of state Medicaid agencies, state child welfare agencies, and MCO/FCs in the six states in which they were operating in 2018: Arizona, Florida, Georgia, Tennessee, Texas, and Washington. The full results are available here. Long story short: we did not find any data on EPSDT performance, and we found substantial information on quality measures for only three of the six MCO/FCs that were operational that year. None of the quality measures we were able to find were disaggregated by race or ethnicity.

This echoes the lack of transparency we observed in a scan for child health performance data on 56 MCOs in 13 states (Arizona, Georgia, Illinois, Iowa, Kansas, Kentucky, Mississippi, Missouri, Nevada, Pennsylvania, Tennessee, Utah, and West Virginia). Out of the 13 states, only three posted the total number of children enrolled in each MCO.  None of the 13 states posted MCO-specific EPSDT screening metrics, and none posted MCO-specific child health quality metrics disaggregated by race or ethnicity.

In the absence of these basic data, meaningful comparisons of performance among MCO/FCs, or between MCO/FCs and MCOs with broad child enrollment, are not possible.  This is particularly concerning because of the importance of Medicaid to the well-being of children and youth in foster care, and because of the financial incentives that risk-based MCOs have to provide fewer rather than more services to their enrollees.

Fortunately, this is a solvable problem.  Either state Medicaid agencies or state Child Welfare agencies could stand up a child health dashboard on their websites that displays the performance data for each MCO and, if applicable, the MCO/FC. The data specific to foster care children and youth and related populations is routinely collected by state agencies and already paid for.  Maintaining a dashboard would simply make the data available to the public, allowing researchers, advocates, and stakeholders to track this natural experiment as it plays out and hold the state agencies, MCOs, and MCO/FCs accountable for results.

A population this vulnerable deserves nothing less.

Transparency in Medicaid Managed Care for Children and Youth in Foster Care