States Could Not Terminate Medicaid for Juveniles in Custody Under Bill


WASHINGTON — States would be prohibited from terminating Medicaid coverage for incarcerated juveniles under legislation introduced today in the House and Senate.

States could suspend coverage while juveniles were in custody rather than cutting off their coverage, a change the bill’s sponsors said would ensure a smooth transition for youth as they re-enter the community.

States would be required to automatically restore Medicaid enrollment when a juvenile was released.

Many juveniles rely on Medicaid coverage for physical and behavioral health care. The National Conference of State Legislatures estimates that as many as 70 percent of children in the juvenile justice system suffer from a mental disorder.

Federal law prohibits states from drawing down Medicaid funding for people who are incarcerated. Some states, though not all, already suspend rather than terminate coverage for juveniles.

“We as legislators have an opportunity to flip the switch and make sure health coverage does not get taken away from children who need it most. The positive impacts of automatically reinstating coverage for children post detention far outweigh the negatives,” said Rep. Tony Cárdenas, D-California, a sponsor of the bill, in a news release.

Cárdenas sponsored the “At-Risk Youth Medicaid Protection Act” along with Rep. Morgan Griffith, R-Virginia. Sens. Cory Booker, D-New Jersey; and Chris Murphy, D-Connecticut introduced a version in the Senate. The bill was first introduced in 2014.

“If kids are incarcerated, they need their medication when they come out. But many states block them from getting the medication and treatment they need. The easiest way to guarantee that a kid will be locked up again is to deny him the medication needed to live a normal, productive life,” Murphy said in a news release.

The federal Centers for Medicare & Medicaid Services previously has encouraged states to suspend rather than terminate Medicaid coverage for juveniles. The states have reported some barriers to doing so, such as problems with their information management system, according to a 2014 report from the National Academy for State Health Policy.

The bill’s supporters include the National Disability Rights Network, the National Juvenile Justice Network and the Robert F. Kennedy National Resource Center for Juvenile Justice.

Jenny Collier, project director for the Robert F. Kennedy Juvenile Justice Collaborative, said the bill would ensure incarcerated young people have access to medical and behavioral health services as soon as they leave a facility.

“Access to such care and treatment will help to support more successful reentry, which is good for kids, communities, and our nation,” Collier said in an e-mail.

The Health and Human Services Department also released guidance today that clarifies that individuals who are on probation, parole or in home confinement are not considered inmates of a public institution and federal Medicaid dollars can be used for their care. The guidance also extends Medicaid eligibility to people living in community halfway houses.

New Report Uncovers “Alarming” Rate of Child Hospitalization Due to Abuse

The March 2012 issue of Pediatrics will contain the first quantified findings detailing the hospitalization rates of children due to serious physical abuse in the United States.

The report, released by the Yale School of Medicine, uncovered 4,569 instances of children being hospitalized due to serious abuse in 2006, with approximately 300 cases in which the children died as a result of serious injuries. According to the findings, children were at their highest likelihood for serious injury within the first 12 months of life, with a projected 58.2 per 100,000 children within the age group being hospitalized for abuse.

Researchers at Yale-New Haven Children’s Hospital used data from the Kids’ Inpatient Database (KID) to estimate the number of incidences in which children younger than 18-years-old were hospitalized due to serious physical abuse in 2006. The Kids’ Inpatient Database was prepared by the Healthcare Cost and Utilization Project, under the Agency for Healthcare Research and Quality.

Head researcher Dr. John M. Leventhal, professor of pediatrics and medical director of the Child Abuse and Child Abuse Prevention Programs at Yale-New Haven Children’s Hospital, said the findings were “alarming.”

“These numbers are higher than the rate of sudden infant death syndrome,” he said.

The report also found that children covered by Medicaid had serious abuse rates that were almost six times higher than children not covered by Medicaid. Additionally, research estimates the national cost for child abuse hospitalizations to be almost $74 million per year.

“This speaks to the importance of poverty as a risk factor for serious abuse,” Leventhal commented. “These data should be useful in examining trends over time and in studying the effects of large-scale prevention programs.”

New Study Finds Georgia Foster Kids are Over-Medicated

Giovan Bazan testifying before a state House Committee

Georgia's foster children are being over-medicated, often to sedate them or control their behavior rather than treat a medical condition, a new study confirms.

The question is: What should Georgia do about it?

One solution being considered by state legislators calls for oversight of medications given to adjust the mood or behavior of thousands of foster children in Georgia. The bill calls for written standards for the dosages and combinations of psychotropic drugs given to those children, as well as an independent clinical review to assess all such medications and related treatments twice a year.

But some child psychiatrists, worrying about second-guessing and lengthy delays in treatment, told state lawmakers last week that they object to a provision that would require the state's pre-authorization for certain medications or unusual doses. They also cautioned about the consequences of language that would require the informed consent of children 14 and older before taking a new psychotropic drug.

"These medications can be very problematic if stopped abruptly," said Dr. Peter Ash, chairman of child psychology at Emory University School of Medicine. "What happens if an adolescent refuses? ... The reality is we have to care for them nevertheless."

Georgia recently launched a similar pre-authorization process for children on Medicaid, but officials say there's not enough data yet to determine whether there have been inappropriate delays in treatment.

Rep. Ben Watson (R-Savannah), a physician, and other lawmakers worried that state monitoring of prescriptions might discourage psychiatrists from treating foster children. "Is this going to reassure [doctors] in their treatment or be more cumbersome?" Watson asked.

Two witnesses testified last week about their own experiences in Georgia's foster care system and the dangers of inadequate medical oversight.

Giovan Bazan, now 21, said he almost died at 16 when a combination of medications caused him to convulse and vomit. A sedative made it difficult for him to sit up in bed, Bazan said, and he would have suffocated if the staff at his group home hadn't recognized the danger and come to his aid.

Bazan told the state House Health and Human Services Committee that foster parents had used more medications and stronger doses to control his behavior. He said juvenile justice officials also warned that they would not end his probation unless he kept taking his medication.

"Obviously as a youth we have a bit of rebellious spirit," he said, "but that doesn't mean that we are mentally ill."

Mason McFalls, 24, said nearly every child he met in 14 years in foster care was taking psychotropic medications.

"I've seen kids literally shaking from being so wound up on the medication," McFalls said.

Frequently, foster children are treated by a different doctor every time they're moved to a new foster home, authorities say. Those doctors generally do not have access to a child's medical history, so they may diagnose different disorders and prescribe different drugs and treatment.

At Department of Juvenile Justice facilities, Bazan said, "they would prescribe me a different medication even if I was only staying there a week."

Over-medication was the common thread in a draft report on 93 so-called "cold cases" -- children who've spent years shuttling between foster placements without finding a permanent home.

The study found high rates of children taking multiple behavioral medications and frequent use of the drugs for the convenience of caregivers.

"Those expedient solutions ... tend to be the most popular," said Melissa Carter, executive director of Emory's Barton Child Law and Policy Center, which conducted the study.

Many foster children were given multiple medications at the maximum recommended dosage for adults, the study found. Most psychotropic drugs, because of the costs involved, are not tested for effectiveness and optimum doses when prescribed for children.

Sometimes, there was no evidence in the case files to justify the prescriptions, said Dr. Brent Wilson, a child psychiatrist who studied the cold case files for the project.

Some children in the study were taking as many as eight different psychotropic medications, Wilson said. Those multiple prescriptions can make it difficult to determine which one is causing an unwanted side-effect, he said, and the lack of reliable medical histories makes it tough for doctors to know whether a drug is still necessary.

Thirty-two percent of Georgia foster kids were taking psychotropic medications in 2010. Of those, one in three was also prescribed at least one anti-psychotic drug, and nearly 5 percent received at least four psychotropic medications.

Those prescriptions cost Georgia's Medicaid program $7.8 million in 2010, said Rep. Mary Margaret Oliver (D-Decatur), sponsor of the proposed Foster Children's Psychotropic Medication Monitoring Act.

Oliver's bill addresses a federal mandate for states to monitor the use of psychotropic medications among foster children. Her bill does not call for standards for children in Georgia's juvenile justice system, which is not part of the federal mandate, although many children move back and forth between that system and foster care.


Photo: Jim Walls

Enrollment in Kids’ Health Insurance Programs Grow Under Medicaid Bonus Program

Last month, the Centers for Medicare & Medicaid Services awarded 23 states approximately $296 million in bonuses for increasing the number of children enrolled in health insurance programs.

The bonuses, funded by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), came a week after the Centers for Disease Control and Prevention released a report stating that about 1.2 million more children have health insurance in the United States than three years prior.

According to the most recent estimates, approximately 93 percent of the nation’s children now have some form of health insurance coverage, a 2 percent increase from federal levels around 2008. When the Children’s Health Insurance Program was initially created in 1997, the national statistics hovered around 86 percent.

In addition to providing performance bonuses for states that simplify and increase coverage for children, CHIRPA provisions allow states to enroll children using information culled from other public programs, as well as automatic eligibility for babies whose mothers are already covered by Medicaid or CHIP programs.

Cindy Mann, deputy administrator of the Centers for Medicare & Medicaid Services, said that although the nation faces “serious fiscal challenges,” she still believes that children’s health should remain “a top priority” for states. “Not only have more states qualified for performance bonuses in the past,” she said, “but many have continued to improve the efficiency of their programs.”

In 2010, the Centers for Medicare & Medicaid Services awarded more than $217 million in CHIPRA Performance Bonuses to 16 states, all of which qualified for performance bonuses again in 2011.

States qualifying for FY2011 CHIPRA Performance Bonuses include: Alabama, Alaska, Colorado, Connecticut, Georgia, Idaho, Illinois, Iowa, Kansas, Louisiana, Maryland, Michigan, Montana, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oregon, South Carolina, Virginia, Washington and Wisconsin.

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California Foster Care, Mental Health Reforms

Under a new agreement, California will begin providing intensive mental health services, both home- and community-based, for children in foster care or at risk of entering the foster care system as part of the early periodic screening, diagnosis and treatment (EPSDT) requirements mandated by federal law.

The new services will be available to a class of children covered under Medicaid, a requirement virtually all foster kids and those at risk of entering foster care meet, according to advocates.

The agreement is the result of a settlement reached after nearly two years of negotiations in a class action suite, Katie A. v. Bonta, aimed at statewide child welfare and health reform. The case, first filed more than nine years ago, charges county and state agencies with neglecting to provide federally-mandated mental health services to children in the state’s foster care system.

The California suit is just one of many that is in the process of or has already been filed across the country seeking to force states to comply with federal Medicaid requirements concerning the well-being of children.

“These services will ensure that thousands of Medicaid-eligible children obtain access to the mental health services they need to live in a family and succeed in school and later life,” Robert Newman, attorney for the plaintiffs, of the Western Center for Law and Poverty said in a press release.

Los Angeles County, where the original case was filed, began providing mandated mental health services in 2003 after settling with the plaintiffs in the case, but state-wide compliance has largely varied by county -– a trend the suite filed against the state hopes to eliminate. Previous rulings from the case established the state's obligation to ensure such services are made available.

“It’s a very good thing for the children,” said Kimberly Lewis, Managing Attorney of the California Office at the National Health Law Program. “Families sometimes think they have to enter the system to get help, whether it be the foster care system of juvenile justice system, but that’s not the case.

In addition to providing home- and community- based services, California officials will be required to take a number of steps to ensure the state’s children in need received the appropriate services:

  • Determine what “Therapeutic Foster Care” services are covered under Medicaid;
  • Instruct providers on delivering therapeutic foster care as a Medicaid service;
  • Convene an interagency taskforce to advance keeping children with mental health issues with their families; and
  • Create a system to identify children in need of the covered mental health services, and link them to those services.

Federal EPSDT requirements, first mandated in 1967, were expanded in 1989 to cover any necessary medical treatment for children covered under Medicaid even if state programs weren't in place to provide those services. Since then, states around the nation have had varying degrees of success in meeting the requirements. Suites have been filed in more than a dozen other states around the nation, including Maine, Massachusetts, West Virginia, Pennsylvania Illinois, and Tennessee.

"The larger implications of this issue is that some people come from the perspective that these kids are going to end up in jail at some point," said Aaron Rapier, attorney with The Collins Law Firm in Illinois and plaintiff attorney for a recent EPSDT law suite in that state. "So they're almost indifferent to their medical needs [before they reach incarceration]."

In California, an estimated 70,000 to 80,000 children would receive needed mental health services within the next three years if the settlement is finalized. California state Judge A. Howard Matz issued preliminary approval Sept. 27, with a final settlement approval expected in early December.

The children in the plaintiff class, Katie A. v. Bonta, are represented by a coalition of a half-dozen advocacy and legal groups.

Selena Teji On California’s Broken Juvenile Detention System

In 1858, the San Francisco Industrial School, California’s first large juvenile facility opened its doors and ushered in a new era of large dormitory-style institutions that would plague California to the present day.  Rife with scandal, abuse, violence and a significant deficit of programming, congregate care institutions have proven a failed model since the 19th century. While Missouri and Washington have abandoned this broken system and rebuilt their juvenile justice systems anew, focusing on smaller therapeutic regional facilities; California continues to fixate on an archaic system with large training schools that cannot be repaired.

Currently, California operates a dual system of juvenile justice -- probation, group homes, ranches and camps are provided by its 58 counties, while the state provides youth prisons reserved for adolescents who have committed a serious or violent offense as defined in the state’s Welfare and Institutions Code.

All parole and reentry services are provided by the counties. Currently, there are only 1,193 youths housed at the state level, approximately 190 of them are juveniles tried as adults but who are too young to be housed in adult prison.

The state youth prisons, operated by the Division of Juvenile Facilities (DJF, formerly the California Youth Authority), have a devastating history. In 1996, California housed approximately 10,000 juveniles in its youth prisons, at more than 150 percent its capacity. As with all overcrowded correctional institutions nation-wide, these facilities were rampant with violence, gang activity and abuse. Programming was minimal, and suicide rates were high.

In 2003, after a string of investigations and public outcry, a lawsuit was brought against the state demanding it improve its conditions to a constitutionally-mandated level of care. This was followed in 2007 by Senate Bill 81, requiring that only the highest risk offenders could be housed in the state facilities, resulting in a dramatic decrease in its population, to 1,193 youth today.

Seven years after the court ordered the state to reform its facilities, California is still struggling to meet its mandate. While progress has been made in reducing its population and improving its medical care, many of the needed reforms have not happened.

 According to a recent 2011 audit, incarcerated youth with mental health needs are receiving education in closets, showers and storerooms due to inadequate staffing and high levels of ward violence, if they receive education at all. Many youth are housed in confinement for 23 hours at a time, violating institutional policies and “willfully disobeying” the court’s order. On Oct. 27, 2011, the court will decide if DJF will be held in contempt of court for its continued inappropriate use of isolation.

Since the 1980's, California has known that the optimal way to serve this high-risk youth population is to deliver programs locally and in smaller facilities. Individual counties such as San Francisco, Santa Clara and Santa Cruz have already developed and implemented effective interventions locally and currently serve this population with high rates of success. By innovative use of Medicaid funding for example, San Francisco County has been able to provide specialized mental health services to at-risk youth, avoiding reliance on incarceration or out-of-home placement.

The state, the courts, national experts and advocates all agreed on what is needed. A model juvenile justice system emphasizes alternatives to incarceration, local community-based services and evidence-based programs that target the highest-needs youth. Individual counties should collaborate to provide a cohesive and consistent approach to juvenile justice statewide, and California's state role should be limited to monitoring, funding and coordinating these county efforts.

Why then has it not happened? In February of this year Gov. Jerry Brown proposed the elimination of the DJF and realignment of all juvenile offenders to the counties. However, concern about county capacity fueled by interest groups such as the California District Attorneys Association, and an ingrained institutional culture has prevented California from breaking the cycle of youth incarceration and state-dependence.  Rather, California continues to invest in an archaic and harmful state-managed juvenile justice system in the hopes that it can be reformed, at the annual cost of more than $224,000 per incarcerated youth.

California is clinging to a broken and irreparable system. Instead, it should abandon the derelict institutional model, and build a more meaningful and responsible approach to change.