HHS Seems Lukewarm on Proposals by Child Fatality Commission

As required by law, the Department of Health and Human Services responded last week to the many proposals offered by the Commission to Eliminate Child Abuse and Neglect Fatalities.

The department set aside any proposals pointed at Congress, states or another executive branch, and focused on 64 that directly involved the work of HHS. Of those, HHS categorized its responses three ways:

  • Agrees fully or in part with the recommendation, and either believes HHS is doing something about it or plans to do so
  • Agrees in principle, but believes that additional money and/or legislative authority is necessary to take on the recommendation
  • Disagrees with the recommendation

HHS agreed at least in part with about 60 proposals, by Youth Services Insider’s count, and disagreed with four.

“Overall, HHS heartily embraces the Commission’s vision for a robust response to families in crisis: one that intervenes early to prevent maltreatment and strengthen families whenever possible, but also protects children aggressively as needed,” the response states at the outset.

HHS gave a mixed review to the commission’s most-discussed proposal, the idea of a state-by-state review of abuse and neglect fatalities going back five years followed by the development of HHS-approved state plans to prevent fatalities.

The response essentially expressed that the plan could be executed, with more money, but offers no confidence in the value of the process as a prevention strategy.

First, HHS notes that a recently-awarded HHS contract could support assistance to states with a five-year review, contingent on appropriations going forward. The rest of the plan, HHS said, is entirely contingent on new funding, which CECANF separately proposed to Congress.

HHS then cautions pretty forcefully against putting too much weight behind such a review:

“We caution, however, that because child maltreatment fatalities are a low incidence event, the development of a national standard is problematic. States frequently have significant year-to-year swings in the number and rate of fatalities. In small states, a single incident rather than a systemic issue can dramatically affect annual statistics. In addition, in small states an analysis of data from the past five years…would include too few cases to draw definitive conclusions.

There are several states in which the five-year cumulative total of child fatalities reported to the National Child Abuse and Neglect Data System (NCANDS) is fewer than ten children. In most states, analyses of the complexity envisioned by the Commission would need to be expanded beyond child death outcomes to include life threatening injury (where it can be identified) or other serious outcomes that put children at elevated risk of a maltreatment death.”

Several other CECANF proposals are rolled up in the commission’s support for the Family First Prevention Services Act, a bill that would permit states to seek reimbursement through the IV-E entitlement for substance abuse treatment, mental health services and parent education. Currently, IV-E funds only foster care placements. The bill passed the House over the summer, but is unlikely to pass the Senate before the end of the year.

HHS made no statement for or against Family First in its response; it has worked behind the scenes to support the bill, but the administration has not taken any official stance on it. But the response does note on several occasions that CECANF proposals that are not fiscally viable at the moment might be if the act is passed.

The HHS response notes four points of outright disagreement with CECANF. One was a rejection of the notion that using the regulatory process was appropriate for establishing best practices in the use of structured decision-making (SDM) tools for areas of the country where a “disproportionate number of child and abuse neglect fatalities have been documented.”

HHS’ response suggested that assistance with SDM is already available, but regulation was inappropriate in the absence of legislated requirements:

“While we agree in concept with the Commission’s desire to reduce bias in child welfare systems’ processes, regulations implement specific statutory requirements and are not the place for best practice guidelines.”

The other two points of disagreement involved changes in the structure of the Administration for Children and Families. CECANF proposed that the Children’s Bureau (CB) be elevated to report directly to the secretary of HHS. Presently, CB reports to the Administration on Children, Youth and Families, which reports to the Administration for Children and Families, which reports directly to the secretary.

The commission had in mind an expansion of CB’s portfolio to include the development and enforcement of national caseload standards, and oversight over the commission’s planned review of past fatalities and pursuant state plans.

The commission also proposed moving the Maternal and Child Health Bureau (MCHB) back into the Children’s Bureau. It split off from CB in 1969, and currently resides in the Health Resources and Services Administration, a separate operating agency within HHS.

Among MCHB’s programs is the Maternal, Infant and Early Childhood Home Visiting program, which was established as part of ObamaCare in 2009. The program has steered hundreds of millions of dollars to home visitation programs.

One of the home visitation models that received a huge boost is Nurse-Family Partnership (NFP), the only program in the country that the commission could verify had shown evidence of lowering abuse- and neglect-related fatalities.

In both cases, HHS replied that the commission “does not articulate a strong rationale and evidenced reasoning that this move would help reduce child fatalities.” CB would lack the regional infrastructure to manage the massive Title IV-E entitlement structure if it were moved, the response argues. In the case of MCHB, the response credits its move to HRSA as helping to incorporate “child safety into the overall public health approach.”

HHS issued a final objection to a proposed mandate that Indian tribes implement fatherhood programs and drug abuse education programs. “Given the sovereign status of Indian tribes,” HHS noted, “mandates such as the Commission suggests are inappropriate.”

Click here to read the entire HHS response.

CECANF was created in 2013 as part of the Protect Our Kids Act, and was provided with a $4 million budget through funding for the Temporary Assistance for Needy Families program. Most of that was spent on the committee’s staff of 20, and public hearings held in 12 U.S. cities.

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John Kelly
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John Kelly is editor-in-chief of The Chronicle of Social Change.