One thing we have learned since the election of Donald Trump last week is that he may be open to modifying his campaign promise to entirely repeal and then replace the Affordable Care Act (ACA). He has already indicated a willingness to maintain some of the act’s provisions.
Repeal versus restructure is not really something his administration will control, though. There are factions in both chambers of Congress who would want to dismantle it, and others that might be willing to tweak it.
Whatever the case, it does seem certain that the discussion will happen sooner than later. Senate Majority Leader Mitch McConnell (R-Ky.) has already made it clear that junking ObamaCare as presently constituted is a top priority.
Strictly from a fiscal perspective, it is hard to imagine a political shift that will affect the child welfare system more than this during the first Trump term. The following is a look at a few of the ACA-inspired programs that relate to the child welfare field.
Aging Out with Medicaid
Among the most popular parts of the ACA is the provision that guarantees children can stay on their parent’s insurance plans until they turn 26. And in a move that ensured the provision didn’t leave out children with complicated parental pictures, the law guarantees Medicaid to youth in foster care at the age of 18 until they turn 26.
It is an offer of continuity to a group of young people who often face adulthood with many question marks. This guaranteed Medicaid for 100,000 former foster youth when it took effect in 2014, and between 20,000 and 30,000 additional youths each year.
Of all the ACA’s provisions, the Until-26 rule is the one Youth Services Insider would bet on to survive. It is not costly, and very popular. Advocates will have to make sure that the foster care extension – which could be viewed as more costly, given the involvement of Medicaid – is not forgotten while the mainstream provision is extended.
Earlier this year, the Commission to Eliminate Child Abuse and Neglect Fatalities said in a final report that it had only identified one program that demonstrated it had reduced child fatalities: the Nurse-Family Partnership (NFP) model.
NFP has roots in Colorado, but the model has proliferated greatly since the passage of ACA, which established the Maternal, Infant and Early Childhood Home Visiting Programs (MIECHV). That program provides hundred of millions in federal funds to NFP and other home-visiting programs around the country.
MIECHV survived last year with a last-minute reauthorization, and it’s hard for YSI to imagine that it has true enemies in either chamber. But if ACA is repealed, the program would need to become its own standalone authorization to survive.
Home and Community-Based Services (HCBS)
HCBS was developed as a Medicaid waiver to enable help for individuals who required an “institutional level of care” with intensive services in their homes or nearby residential facilities. This was an important offer when the nation’s mental health system, particularly the residential portion, was being dismantled.
In 2005, the GOP-led Deficit Reduction Act eased the rules on HCBS, expanding the scope of people who could be treated under the provision. And in 2010, the ACA gave states a balance that included some narrowing and some expansion.
One the narrow side, states were empowered to tailor a state plan that specified target populations who would be eligible for HCBS. On the expansive side, states were now required to serve anyone eligible in that group (no wait lists), and HCBS could not be limited to certain geographic areas.
Medicaid is a payer of last resort, so HCBS can only supplement general child welfare expenditures on foster youth. But child advocates were hopeful that, over time, states would use the new HCBS rules to develop targeted supports to youth in foster care.
While HCBS eligibility has widened over the years to include those who wouldn’t otherwise need institutional care, the Health Home model remains focused on individuals with chronic conditions who need intensive services. This can include people with physical and mental disabilities, diseases, or serious mental health illnesses. It was started as a federal program under ACA Like HCBS, it is an optional piece of a state Medicaid plan.
The hallmarks of the model are:
- Comprehensive care management
- Care coordination and health promotion
- Transitional inpatient to outpatient care
- Individual and family support
- Referrals to community and social support services
- Services linked through health information technology
Under the ACA, the feds pay for 90 percent of health home costs during the first two years of the program, after which federal support tapers off. As of fiscal 2015, 20 states had implemented at least one health home program.
Status as a foster youth does not prompt health home eligibility, but there is a significant subset within the hundreds of thousands of foster youths in this country who are eligible because of chronic disabilities or illnesses. And that is before you get to the children and parents who can benefit from the model before child protection becomes an issue.
At least one state, New York, has weaved health homes into the work of its voluntary foster care agencies (VCFA), the private providers that license and operate foster homes and/or congregate care placements. Each of New York’s licensed health homes must formally contract with at least one VCFA in its region, and the state encourages them to contract with all of the VCFA in the region.
Click here for a basic primer on New York’s binding of child welfare and health homes.
Medicaid: Block Grants and Shrinkage
Trump’s campaign plan included converting Medicaid into state block grants, which House Republicans, including Speaker Paul Ryan, have for years supported. Technically that is not a change to the ACA, but it would be a tectonic shift in federal health policy. At the same time, an ACA repeal would likely roll back an expansion of Medicaid that enabled states to increase the Medicaid-eligible universe up to 400 percent of the federal poverty line.
Critics of the block grant approach loathe the idea because it caps the flow of federal support, meaning less money over time to serve the health needs of low-income children and families. The other side of the coin is more flexibility to states in how they use their Medicaid programs, which could enable a state to focus more resources on child welfare if it wanted to make that a priority.
YSI could also see that flexibility coming into play when someone else wanted a state to make child welfare a priority via lawsuit. With states less encumbered by rules on Medicaid spending, litigants could force significant commitments in states that settle or lose class actions over the child welfare system.
Then again, a block grant scheme could just as easily permit a state to limit the guarantees it makes to children in the child welfare system. And a roll-back of Medicaid expansion will absolutely mean an increase in the number of uninsured children and families.