A Chronicle of Social Change analysis of the Affordable Care Act’s provision that guarantees Medicaid for aging-out foster youths, but could potentially limit where those youths live, or their prospects for being adopted.
On January 1, 2014, every person under age 26 who turned 18 in foster care will be eligible for Medicaid, a small provision in the Affordable Care Act that provides a big boost to consistent health services for one of the nation’s most vulnerable populations.
The most direct impact of this change is, of course, that just over 100,000 young adults will immediately become Medicaid-eligible, as will the approximately 30,000 teens and young adults aging out of foster care every year.
They will receive the full benefits of Medicaid, which include:
- Screening, preventive and early intervention services
- Diagnostic services and treatment for physical and mental health conditions (both acute and chronic)
- Dental and vision care
It is a significant development for aging-out youth. Some states have used a federal waiver offered in the Foster Care Independence Act to extend Medicaid through 21 for former foster youth; many former foster youth are eligible for Medicaid without a mandate anyway, but are often left to seek enrollment on their own. In either of those situations, the full Medicaid benefits afforded in the ACA provision are not a guarantee.
But as the Department of Health and Human Services finalizes its procedures for managing ACA, child welfare advocates and policymakers are concerned about two issues related to the foster youth provision: its restriction on interstate moves by those youth, and the potential disincentive it creates for adoptions and guardianships.
The former foster youth provision mandates that the state in which a foster youth turns 18 provide Medicaid coverage until age 26. So if the youth turned 18 in foster care and somehow got a job making $100,000 per year, he could still stay on Medicaid until age 26.
But the provision does not require states to automatically enroll a former foster youth who moves there from the state where he ages out of care. If a youth were to age out in Virginia, but wanted to go to college in Florida, it would be up to Florida to decide on the youth’s eligibility.
“While we are pleased with this part of the proposed rule, we are greatly concerned about the option for states to cover a youth formerly in foster care if they were in care in another state,” said the National Foster Care Coalition, in a letter submitted to HHS. “Due to the fact that child welfare services can vary dramatically between states we ask that this health benefit be made as seamless as possible.”
Child advocacy group First Focus conveyed a similar sentiment to HHS.
“Former foster youth are an especially vulnerable and highly mobile population,” said Vice President of Child Welfare Policy Shadi Houshyar, who wrote the organization’s comment. “Given that former foster youth tend to move from place to place, and the well-documented and often significant health care needs of these youth, we urge you to reconsider this interpretation.”
The Children’s Defense Fund, in its letter to HHS, used the inverse logic.
“The only real data available on the mobility of former foster youth seems to suggest that the number of young people who leave a state where they were in foster care for a new state may be relatively small,” CDF’s comments said. “This makes it even more sensible to let all former foster youth regardless of where they are residing to be automatically eligible for foster care.”
CDF also cited the specific comments made in 2009 by Sen. Mary Landrieu, the chief sponsor of the foster youth provision, which makes no allusion to an out-of-state caveat. From the Congressional Record:
“I was proud to work on a provision that Leader [Sen. Harry] Reid included in this bill to ensure that every young person who ages out of the foster care system will be able to stay on Medicaid until the age of 26 starting in 2014.”
If HHS does not reconsider, there are nine states where former foster youth would have the lowest prospects of enrolling in Medicaid: Idaho, Nebraska, Michigan, Maine, Pennsylvania, Virginia, Georgia, Alabama and Louisiana.
Those nine states do not offer Medicaid up to 21 with the Foster Care Independence Act waiver, and are among the 16 least likely to expand the reach of Medicaid, according to the organization Advisory Board.
At a tumultuous time in the health care market, former foster youth will be protected by the ACA provision. But will the provision make potential adoptive parents or guardians think twice about pursuing a more permanent situation for older foster youths?
The provision creates the biggest fiscal quandary for potential guardians. The Fostering Connections to Success and Increasing Adoptions Act permitted states to seek federal reimbursement for guardianship assistance programs. Such programs generally aim to support a relative who is willing to care for a child, but does not want to adopt or be a long-term foster parent.
Insurance companies are required to allow policy holders to count their children as dependents until age 26, but The Chronicle of Social Change could find no federal guidance saying definitively that insurers are required to see legal guardianships the same way.
It does appear, from explanations on the websites of some insurance providers, that some providers interpret the law to mean that guardianships do count.
If an insurance provider was able to decline the addition of a youth for a legal guardian, choosing a guardianship arrangement over foster care could literally be the difference between nothing and full Medicaid benefits.
The prospects for adoption are already dubious for older foster youth, as evidenced by the fact that the foster care rolls have dropped from about 500,000 to 400,000 in the past decade, and the number of youth aging out of the system has actually increased. There were 24,407 youths who aged out in 2005, 29,730 in 2007, and 27,854 in 2010.
Adoptive parents would have the ability, like any biological parent, to keep an adopted teen on their private insurance plan until age 26. That assumes first, that they have insurance, and second, that they can afford to add a dependent to that coverage.
For a wealthy adoptive couple or parent, this might not be difficult, but the reality is that most of those couples will seek younger children. In the too-rare scenario where an older foster youth is adopted, it is more often a foster parent of modest means doing so after caring for a foster son or daughter for some time.
Is that hypothetical parent now crazy to adopt when the youth’s health care needs are far better met in foster care? What if he or she adopts, and loses a job and quality insurance the next year?
Proponents of the provision said they had heard that concern and, given the severe health and mental health challenges that young people in foster care may face, that some potentially adoptive parents may well be worried that the quality of their insurance isn’t as good as Medicaid when it comes to serving these youths.
“The view from this office is that we should never let a child age out of care,” said Rita Soronen, CEO of the Dave Thomas Foundation on Adoption. But “I’m now concerned about how it affects those children when there’s a push to get older children adopted.”
Soronen said she also supports the provision, but suggested that offering a similar Medicaid guarantee to children adopted from foster care would be appropriate.
Financially, perhaps the most reasonable way to do that would be to have adoptive parents apply for a child-only Medicaid extension, whereas the financial means of the parents and the health needs of the youth would factor into approval.