As Repeal Push Progressed, Foster Youth Became More Exposed to Medicaid Changes

The push to replace or reform the Affordable Care Act appears to be stalled for the moment, as Republicans failed to pass a bill through the reconciliation process. Now, any substantive change will require 60 votes in the Senate, which means a bipartisan deal. That’s tough to imagine, but you never know.

For Youth Services Insider, one takeaway from the past months of bill-drafting and horse-trading on health care is that there was some interest in holding foster youth harmless from any cuts to Medicaid. But that interest was not absolute; shielding of foster youth waned over time.

Child welfare contract services are fueled in many ways by state and federal Medicaid dollars. But there two guarantees central to the direct care of foster youths:

Early, Periodic, Screening, Diagnosis and Treatment (EPSDT): Guarantees assessment and treatment of health problems for children. EPSDT is a guarantee for all Medicaid-eligible kids (though several studies have suggested its underused and in need of an update), and all foster youth are Medicaid eligible.

Medicaid until 26: The ACA famously guaranteed that young adults could remain on their parent’s health insurance until the age of 26. The bill also made this guarantee to youth who reach the age of 18 in foster care: Medicaid would be guaranteed to them through age 26.

When the American Health Care Act (AHCA) was introduced in the spring, both of these areas of Medicaid were protected. Though AHCA cut out some of the presumptive eligibility rules in ACA, it left the protection for foster youth until 26 in place.

But as the bill was negotiated to gain more conservative votes, the concept of a Medicaid block grant structure entered the picture. Medicaid until 26 survived in the new deal, but EPSDT suddenly became optional. In fact, it was specifically targeted in the language of changes made to the definition of “medical assistance”:

States must provide hospital care, surgical care and treatment, medical care and treatment, obstetrical and prenatal care and treatment, prescribed drugs, medicines, and prosthetic devices, other medical supplies and services, and for children under 18, health care (but not Early, Periodic, Screening, Diagnosis and Treatment services).

Fast forward to Graham-Cassidy, the bill that nearly made it to a vote this week. Graham-Cassidy would also have offered states a chance to take Medicaid as a block grant, rendering the EPSDT optional again. But the bill also hedged a bit on the presumptive eligibility of youth who age out of foster care.

On paper, the bill does protect the category of aged-out foster youth:

“A State conducting a Medicaid Flexibility Program shall establish conditions for eligibility of program enrollees, which shall be instead of other conditions for eligibility under this title, except that the program must provide for eligibility for program enrollees to whom the State would otherwise be required to make medical assistance available under section 1902(a)(10)(A)(i).”

The presumptive eligibility of former foster youth is included in that section referenced at the end of the clause. But the phrase “must provide for eligibility” leaves states with wiggle room.

Under current law, states have to enroll foster youth through 26 if they want to be enrolled. Under Graham Cassidy, even under a block grant, a state is required to provide a path to eligibility for those young adults. But it would not be required to enroll those deemed eligible.

Bottom line: aged-out foster youthswould be guaranteed eligibility, but not enrollment if the state’s block-grant Medicaid program was underfunded.

The general lesson here is that this process began with Medicaid help for foster youth, and other at-risk children, intact. And as the process slogged on, that protection weakened.

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John Kelly, Editor in Chief, The Chronicle of Social Change
About John Kelly, Editor in Chief, The Chronicle of Social Change 1210 Articles
John Kelly is editor-in-chief of The Chronicle of Social Change. Reach him at

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