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Delivering Health Care and Mental Health Care Services to Children in Family Foster Care after Welfare and Health Care Reform.

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Title: Delivering Health Care and Mental Health Care Services to Children in Family Foster Care after Welfare and Health Care Reform.
Language: English
Authors: Simms, Mark D., Freundlich, Madelyn, Battistelli, Ellen S., Kaufman, Neal D.
Source: Child Welfare. Jan-Feb 1999 78(1):166-183.
Peer Reviewed: Y
Page Count: 18
Publication Date: 1999
Document Type: Journal Articles
Opinion Papers
Reports - Descriptive
Descriptors: Child Health, Child Welfare, Foster Care, Foster Children, Health Maintenance Organizations, Health Needs, Health Services, Mental Health Programs, Welfare Reform
ISSN: 0009-4021
Abstract: Describes the essential features of a health care system that can meet the special needs of children in out-of-home care. Discusses some of the major recent changes brought about by welfare and health care reform. Notes that it remains to be seen whether the quality of services will improve as a result of these reforms. (Author)
Entry Date: 1999
Accession Number: EJ578112
Database: ERIC
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  Value: <anid>AN0001478093;cwf01jan.99;2006Nov20.14:35;v2.2.460</anid> <title id="AN0001478093-1">Delivering Health and Mental Health Care Services to Children in Family Foster Care After Welfare and Health Care Reform </title> <p>As the 20th century draws to a close, fundamental changes in the organization, financing, and delivery of health care and welfare services, principally directed at poor families, are likely to result in an increased number of children entering out-of-home care. These children typically have significant physical, mental health, and developmental problems. Whether the quality of health care services they receive will improve as a result of health care reform efforts and new approaches to service delivery remains to be seen. This article addresses some of the major changes wrought by welfare and health care reform and describes the essential features of a health care system that can meet the special needs of children in care.</p> <p>Nearly 500,000 children are in the out-of-home care system, despite concerted federal and state efforts to prevent out-of-home placement over the past two decades [National Committee to Prevent Child Abuse 1997; Petit & Curtis 1997]. Although these children have high rates of health and mental health problems, they have difficulty accessing timely and appropriate health care services. Over a decade ago, the Child Welfare League of America (CWLA), in consultation with the American Academy of Pediatrics (AAP), published Standards for Health Care Services for Children in Out-of-Home Care to serve as a blueprint for developing effective service delivery structures for children in out-of-home care [Child Welfare League of America 1987]. More recently, the American Academy of Pediatrics Committee on Early Childhood, Adoption and Dependent Care issued a statement to pediatricians entitled Health Care of Children in Foster Care [American Academy of Pediatrics 1994]. Unfortunately, for a variety of reasons, these standards and guidelines have generally not been implemented.</p> <p>As America enters the next century, the organization, financing, and delivery of health care and welfare services to the poor are undergoing fundamental changes. At the federal level, social support programs, such as Aid for Families with Dependent Children (AFDC), are being restructured, and responsibility for the cost and delivery of basic services is being shifted to state governments. The creation of the Temporary Assistance for Needy Families (TANF) program and changes in the Supplemental Security Income (SSI) program for children with disabilities, as brought about by the Personal Responsibility and Work Opportunity Act of 1996 [P.L. 104-193], reflect a new policy environment [Green & Waters 1997]. In the area of health care, state governments are working hard to transfer the financial risk and responsibility for delivering services under Medicaid to private, managed care organizations (MCOs) [Henry J. Kaiser Family Foundation 1996]. To eliminate the ineffectiveness and limit escalating costs of these programs, policymakers are turning to "new approaches" that have no proven record of success with their respective "target" populations [Battistelli 1996]. Thus, the impact that welfare reform and health care reform efforts may have on children who enter the out-of-home care system in the next century is not clear.</p> <p>This article focuses on the health care status and needs of children in family foster care and examines how this group of vulnerable children has been affected by welfare reform, the growth in managed care, and other health care reform efforts over the past several years. It examines the significant role that Medicaid has played in meeting the health care needs of children in care and considers the impact of Medicaid managed care and other factors related to access on the ability of child welfare systems to meet the health care needs of children in the future. It concludes with recommendations that address the attributes of a health care system that must be in place so that children in out-of-home care will receive the critical physical, mental health, and developmental services they need, and their biological and adoptive families will have access to health care services on an ongoing basis.</p> <hd id="AN0001478093-2"> Welfare Reform </hd> <p>Recent changes in family policy, particularly with regard to poor children and families, likely mean that more poor children will enter out-of-home care over the next decade and that these children will enter care with significant health problems. The shrinking of the "safety net" (formerly represented by the AFDC and SSI programs) for families and the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193), popularly known as the "welfare reform" act, may have a powerful impact on the level of child poverty in the future, and consequently, on the health care status of children in general and on children who enter out-of-home care, in particular. Welfare reform ended the previously guaranteed benefits for poor families under the AFDC program (two-thirds of whose recipients were poor children); significantly reduced the Food Stamp program (with reductions primarily affecting families with children); and made substantial changes in the SSI program (with loss of benefits for thousands of children with mental health and emotional disorders and multiple impairments) [Waxman & Alker 1996; Children's Defense Fund 1996; National Health Law Program 1996].</p> <p>Reports from the field suggest that reductions in welfare, Food Stamps, and disability benefits are creating significant stresses on families that may further intensify as the full impact of welfare reform is realized. With the discretion given to them under welfare reform for the implementation of the new TANF program, many states are adopting stricter work requirements and shorter time limits than those set as minimum standards in the law [Pear 1997a]. Early reports suggest that those who have lost benefits because of these new policies are not readily finding employment. A survey conducted by the New York State Office of Temporary and Disability Assistance, for example, found that less than one-third of the people who lost benefits in New York State between July 1996 and March 1997 had secured full or part-time jobs [Hernandez 1998]. Seventy percent of the reductions in Food Stamps have impacted families with children [Children's Defense Fund 1996], more than a hundred thousand children have been denied SSI benefits, some erroneously; and a substantial percentage of children denied SSI have also lost their Medicaid coverage [Pear 1997b; Waxman & Alker 1996]. The cumulative impact of these policy and program changes, because of their effects on families' abilities to support their children, is likely to be increasing numbers of children entering out-of-home care, most of whom will be poor and whose health will be significantly compromised.</p> <hd id="AN0001478093-3"> Health Care Reform </hd> <p>Since 1965, the Medicaid program has provided health care benefits for millions of poor children and families [National Health Law Program 1996]. One key provision of this program — the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program — attempts to ensure that enrolled children receive a wide range of preventive, diagnostic, and therapeutic services. Compliance with these requirements, however has generally been poor. Despite the rapid rise in total expenditures for Medicaid generally, physician and hospital payment schedules have failed to keep pace with the rising cost of providing health care services. As a result, the number of physicians who are willing to treat Medicaid recipients has declined nationwide [Yudkowsky et al. 1990]. Thus, the very program that enables poor children to receive health care services acts as a significant obstacle, limiting their access to the best or most appropriate medical care available.</p> <p>Despite Medicaid's limitations, there is no question that it remains the single most important source of care for children in out-of-home placement and for troubled families. Most states view Medicaid, and its EPSDT program for children, as a costly federal mandate. The states want increased flexibility over implementation of the Medicaid program and both the states and Congress seek reductions in Medicaid spending. Relaxing the federal requirements or decreasing funding for this program, however, could undermine the availability of needed medical services even further.</p> <p>To limit the financial burden associated with Medicaid, to improve access to care, and to provide a higher quality of services, state governments are turning to private, managed care organizations (MCOs) and enrolling Medicaid-eligible families in managed care programs. In contrast to the "traditional" fee-for-service (FFS) insurance system, in which insurers pass excess costs for services onto the enrollees, employers, or government payers through higher premium rates, MCOs assume the full financial "risk" for providing sufficient services to their enrollees by accepting a fixed sum of money for each person covered. In turn, they distribute this risk among the components of their plan, including physicians, hospitals, pharmacies, etc. Without doubt, the major attraction of the managed care approach is its potential to limit or reduce overall health care costs. The financial pressures to contain the cost of care provides powerful incentives to identify and provide effective services in the most efficient manner. MCOs, however, walk a thin line between providing too many "unnecessary" services that drain limited dollars or providing too few "necessary" services that may result in the progression of problems and ultimately, more expensive care. Thus, the managed care paradigm relies heavily on the principle of primary, preventive care as the most cost-effective approach. Accordingly, patients in these plans are encouraged to obtain prevention-oriented services such as screening examinations to detect treatable conditions as early as possible. Medical treatments, in turn, are subjected to careful scrutiny regarding their effectiveness and cost, and managed care plans are strongly vested in tracking and monitoring the quantity and quality of care members receive. Many plans require preauthorization before consultations and tests are approved, and employ patient care managers to oversee how members move through their systems. The increased regulation of services under managed care makes it less likely that patients will "fall through the cracks."</p> <hd id="AN0001478093-4"> The Health Problems of Children in Out-of-Home Care </hd> <p>Children entering care have unusually poor health compared with their peers from similar social and ethnic backgrounds who live at home [Simms 1991]. Many of these children have suffered physical injuries as a result of abuse, and most have experienced some form of physical and/or emotional neglect prior to placement. Not unexpectedly, chronic medical conditions and mental health disorders are extremely common, as are birth defects and physical growth disorders [Hochstadt et al. 1987; Simms 1989; Chernoff et al 1994; Halfon et al. 1995; Rosenfeld et al. 1997].</p> <p>Several studies have examined the costs of providing health and mental health care services to this population. In 1992, Halfon et al. found that the major expense category for children in out-of-home care involved hospitalization, particularly for perinatal problems, mental health disorders, and infections [Halfon et al. 1992a, 1992b]. Overall length of stay for all hospitalizations was nearly twice as long for children in out-of-home care (10.9 days vs. 6.0 days), and utilization of outpatient mental health care services was strikingly increased. Although children in out-of-home care comprised only 4% of the population of children covered by Medical in 1988, they received 55% of all visits to psychologists and 45% of all visits to psychiatrists paid by the program.</p> <p>In 1990, Takayama compared the health care costs of children in out-of-home care to other children receiving AFDC in Washington State [Takayama et al. 1994]. The annual mean health care cost for a child in care was nearly six-fold greater than that for a child not in care ($3,075 vs. $543). Children in care also had significantly greater utilization of mental health care services (25% vs. 7%); supportive care from visiting nurses, physical therapists, etc. (13% vs. 1%); and hospitalization (10% vs. 5%). When the authors stratified the population according to annual amount of health care cost, they found children in care over-represented in each group. It should be noted that a small group of children (8% of the total) had annual expenses that exceeded $10,000. These children, who largely suffered from mental health, neurological, or congenital anomalies, consumed 63% of all the dollars spent on health care for children in out-of-home care.</p> <hd id="AN0001478093-5"> Obstacles to the Delivery of Health Care Services </hd> <p>Children in out-of-home care have a wide range of health care needs. Yet, despite their high rates of medical and mental health problems, most children in care do not receive the health care services they need [U.S. General Accounting Office 1995]. As a result, needed health care services are often delayed or not provided. A 1995 study by the U.S. General Accounting Office evaluated the health care received by nearly 23,000 children in out-of-home care under the age of 3 in Los Angeles, New York City, and Philadelphia, and found that many important health-related needs remained unmet [U.S. General Accounting Office 1995]. Furthermore, the study concluded that current state and federal efforts do not ensure that these children receive appropriate health care services. Indeed, the scope of the health care services provided to children in out-of-home care is often not comprehensive, nor is it matched to each child's unique circumstances. For example, as specified in the Child Welfare League of America's Standards and in the American Academy of Pediatrics guidelines, each child entering out-of-home care should have access to a range of services, including the collection of evidence that abuse and/ or neglect has occurred; an assessment for any significant urgent health care needs or restrictions on the type of placement the children will experience; an assessment of their health, dental, developmental, and mental health care needs; the development of a plan to address their identified needs; and case management and care coordination services.</p> <p>Practical experience suggests that a variety of factors act as true barriers to care for these children. For example, most public and private agencies caring for children in out-of-home care have no formal policies or arrangements to provide health care services, relying instead on local physicians and health care clinics funded by Medicaid. Information about children's utilization of health care services and their status prior to placement is often hard to obtain — in part because the children have had erratic contact with a number of different health care providers prior to placement and social workers are not always able to review the child's health history in detail with the biological parents at the time children are taken into care. Once in family foster care, much of the responsibility for obtaining health care services is placed on foster parents, who often have been given little or no training in health care issues or in accessing the health care system [Battistelli 1997]. For their part, social workers frequently lack information about the type or content of health care services that children in family foster care receive and are unable to effectively oversee the amount or quality of the care delivered. As a result, foster parents are left alone to sort out the health problems of the children in their care and to maneuver in an unwieldy health care system. Compounding this situation is the fact that many of the children have complex health problems and require care from a variety of medical specialists.</p> <p>The systems providing care to these children are often inadequate and not coordinated by the responsible child welfare agency or the courts, nor is the care integrated among the various providers of care. The inability to transfer information between providers and agencies, and the lack of collection of health status data on the children, leads to further fragmentation and poor outcomes. Unfortunately, there have been a number of "high profile" media cases involving children in family foster care who were harmed because critical health information was not known or communicated to the adults who were caring for them. This diffusion of responsibility can also result in the delay or denial of care when issues of proper authority are not explicitly resolved.</p> <p>Nearly three-quarters of children experience more than one family foster home placement during their time in the out-of-home care system. These changes in residences and caregivers often disrupt the fragile care networks that are established, since the children usually change their health care providers as well. Similarly, changes in social workers are exceedingly common and, as a result, key aspects in the planning and coordination of efforts on the child's behalf may be lost. Finally, the benefit package provided to the children is seldom comprehensive, especially in the area of mental health care services. Despite the federal guarantee of benefits for low-income children under Medicaid, state compliance has often been incomplete, particularly in the implementation of such well-designed benefits as EPSDT. Because health care systems are complex and involve the participation of multiple providers and agencies, the lack of independent evaluation of the overall effectiveness of the health care provided to children in out-of-home care hinders rational policymaking and systems development.</p> <hd id="AN0001478093-6"> Implications for Permanency Planning </hd> <p>These obstacles to health care delivery have profound implications both for the health and well-being of children and for effective permanency planning for children in out-of-home care. The entry of children into care has been consistently associated with poverty; exit from care is associated with the provision of services to families and children to ensure that families can effectively resume responsibility for meeting their children's needs [Lindsey 1994; Pelton 1989]. Analyses of length of time in out-of-home care suggest that, even with AFDC supports in place, children have remained in care for extended periods of time [Chapin Hall Center for Children 1994]. As families lose TANF benefits, Medicaid coverage, and Food Stamps, and children lose the SSI benefits that made it possible for them to obtain essential health care and developmental services, reunification may be more difficult to achieve. Even when reunification is possible, even longer periods of time to accomplish it may be required than were previously the case. Families are likely to face new challenges in regaining custody of their children, and the child welfare system may find it difficult to ensure that biological families can obtain health care and developmental services when their children return to them.</p> <p>The State Children's Health Insurance Program (established in 1997 to expand health care access for poor children and now Title XXI of the Social Security Act [P.L. 105-33]) provides no guarantee that all children will receive continuous, comprehensive health care. At the same time, the Adoption and Safe Families Act of 1997 (P.L. 105-89) may affect the permanency outcomes for many poor children and their families. On the one hand, the law targets funds from Title IV-B (now retitled the Promoting Safe and Stable Families Program) for time-limited reunification services such as counseling, substance abuse treatment, mental health services, and assistance for domestic violence — services that could potentially promote reunification through intensive efforts. On the other hand, the act's mandates will prompt states to consider termination of parental rights more quickly and may result in freeing for adoption greater numbers of children who entered out-of-home care because of poverty-based factors.</p> <p>As a consequence, the number of children in out-of-home care who will require adoption planning and services may increase. These children, like the majority of children in family foster care, will have medical and mental health care problems and will need ongoing health care services. The percentage of children in out-of-home care with special needs who are awaiting adoptive placements has been increasing steadily. National data shows that the percentage of these children rose from 47% in FY 1984 to almost 72% in 1990 [Tatara 1993]. More recent state-based data demonstrate that even larger percentages of waiting children in out-of-home care have special needs: 84% of the children adopted in New York State during 1992-93 had special needs (Avery & Mont 1994) and 95% of the children placed for adoption in California during 1993-94 had one or more physical or emotional problems [California Department of Social Services 1995]. Many of these children with special needs have physical, emotional, and mental disabilities [Tatara 1993]. It is reasonable to anticipate that the vast majority of children entering care in the future who cannot be reunited with their biological families will likewise have significant health care problems that will require medical and mental health care services during their stays in family foster care and after their adoption.</p> <p>Welfare reform, however, will create greater complexity in qualifying these "special needs" children for adoption assistance, as it links Title IV-E eligibility to eligibility for the former AFDC programs, as those eligibility rules existed on June 1,1995. As a result, eligibility for Title IV-E adoption assistance and Medicaid is linked with eligibility for a program that no longer exists (AFDC) and is based on a 1995 standard of poverty that will become less appropriate as an indicator of poverty with the passage of time. Efforts to "delink" Title IV-E adoption assistance from AFDC were unsuccessful in 1997, although the Adoption and Safe Families Act did expand health care coverage to non-Title IV-E eligible children with special health care needs. This may provide many children who are unable to qualify for Title IV-E adoption assistance (and the Medicaid coverage it carries) with health care coverage that, according to the new law, must be equivalent to the benefits offered by Medicaid. Nonetheless, the complexity associated with the current interface of welfare reform, Title IV-E adoption assistance, and the health care mandates of the Adoption and Safe Families Act raises many questions about the extent to which the child welfare system will be able to effectively meet the health care and permanency needs of children in out-of-home care.</p> <hd id="AN0001478093-7"> Managed Health Care for Children in Out-of-Home Care </hd> <p>Considering the unique health care needs of children in family foster care, and the obstacles they experience in accessing services, managed health care programs may offer several distinct advantages and potential opportunities to improve the care these children receive and to promote effective permanency planning. The emphasis that MCOs usually place on primary care and early identification of problems may increase the likelihood that all children entering out-of-home care receive timely health and mental health evaluations. The coordinated network of health care providers and patient care managers, and the information systems that MCOs employ to monitor service delivery, may also help to ensure that children have access to a full range of appropriate services and that their problems are properly attended to, even if the child welfare agency's staff is not able to adequately oversee the health care of its clients. Similarly, even if children change family foster homes or social workers, by remaining enrolled in the same managed health care plan, continuity of care and health information may be assured.</p> <p>Managed care for children in family foster care, however, is not without significant potential problems. To the extent that managed care has been successful, its benefits have largely flowed to individuals in good health, not those with special health care needs. Indeed, managed care organizations are often referred to as health maintenance organizations (HMOs). Yet, as noted previously, children in out-of-home care are generally in poor health and many require care for chronic illnesses by specialists and a wide range of habilitative and rehabilitative services. Major concerns about managed care include the restricted access to specialists for individuals with chronic diseases, particularly psychological and developmental disorders, and the huge profits that are reported by MCOs. Critics of managed care accuse MCOs of not applying their cost savings toward increasing the range of services or lowering enrollment fees. Instead, investors in MCOs react negatively when too much of the plan's funds are paid out in health care services (the so-called "medical-loss ratio").</p> <p>For children in family foster care, the actual cost of delivering the full range of appropriate health and mental health care services may be much higher than current estimates would suggest. The studies by Halfon and Takayama looked at actual costs in systems that did not specifically screen and refer children with problems; both authors suggested that their data probably underestimated the level of true need [Halfon et al. 1992a, 1992b]. Takayama et al. 1994]. If the children were to receive early evaluations and appropriate care for their conditions, however, as recommended by CWLA and AAP, the total costs might actually decline over the long run. This might be particularly true if savings resulting from improved child and family health in other areas, such as child welfare, juvenile justice, and education, are taken into consideration. Until additional data are available on how children in family foster care fare in managed care, child welfare agencies and MCOs should not expect an immediate savings in overall health and mental health care costs by shifting this population out of fee-for-service programs and into managed care. Child welfare agencies should also exercise caution when choosing or approving a managed care benefits "package" unless it guarantees sufficient access to an extensive array of pediatric subspecialists, mental health care services, and habilitative services, and complies with the provisions of CWLA's and AAP's standards for health care for this population.</p> <p>Also of concern is the fact that managed care for children in out-of-home care may not be readily transferable when children return to their biological families or are placed with adoptive families. Some level of continuity of care may be assured by managed care for children in out-of-home care, but significant issues exist concerning continuing access to quality care after children are reunited with their biological families or adopted. Eligibility issues, particularly through Medicaid, and limitations on geographic scope of coverage may mean that the benefits achieved for a child through managed health care during the child's family foster care stay will not be sustained after the child leaves care. Consideration of continuity of care and maintenance of health care benefits after care is critical.</p> <hd id="AN0001478093-8"> Recommendations </hd> <p>Regardless of the financing mechanisms or organizational structures that are put into place, any system of health care for children in foster care should have the following attributes:</p> <ulist> <item> comprehensive services with clearly stated standards of care (e.g., CWLA and/or AAP);</item> <item> portable benefits while the child remains in out-of-home care;</item> <item> presumptive eligibility for Medicaid upon removal of the child from the home, regardless of the biological parent's eligibility status;</item> <item> continuous eligibility for a minimum of 12 months and — in an effort to ensure that treatment and rehabilitative services can continue after placement — extension of eligibility for another 12 months after the child has left the out-of-home care system;</item> <item> social service case coordination and case management services;</item> <item> incentives to encourage participation by health care providers; and</item> <item> a local and state governance system that clearly identifies who is responsible for the implementation and enforcement of the standards, procedures, and guidelines.</item> </ulist> <p>The system must work in urban and rural areas with and without managed care plans and with or without a large supply of primary or specialty providers. A statewide data system should also be established.</p> <hd id="AN0001478093-9"> Conclusions </hd> <p>Children in out-of-home care are extremely vulnerable, with unusually poor health when compared to their peers who live at home. Recent changes in the nation's family policies are likely to lead to large numbers of children entering out-of-home care and even greater risks to the health and well-being of these children. The shift from fee-for-service to managed care offers the potential to improve the organization, financing, and delivery of health care services to children in the out-of-home care system, and managed care's emphasis on primary and preventive care and the coordination of services may help to overcome some of the greatest obstacles to health care for this population. Care must be taken, however, to ensure that sufficient access is provided to the services that this special group of children require.</p> <p>Society will be hard pressed to cure the ills of child welfare without improving the nation's health care system. Appropriate health insurance can prevent children and families from needing assistance by the child welfare system. Accessible, affordable, quality health and mental health care services can address problems that, left untreated, explode into devastating family and community problems. Similarly, the availability of health care services is critical to solving family problems and reuniting children with their parents. As America heads into a new century, these most vulnerable children must not be allowed to pass from a poor system into a worse one.</p> <p>© 1999 Child Welfare League of America</p> <ref id="AN0001478093-10"> <title> References </title> <blist> <bibl id="bib1" type="bt"></bibl> <bibtext>American Academy of Pediatrics, Committee on Early Childhood, Adoption and Dependent Care. (1994). Health care of children in foster care. Pediatrics, 93,335-338.</bibtext> </blist> <blist> <bibl id="bib2" type="bt"></bibl> <bibtext>Avery, R. J., & Mont, D. M. (1994). Special needs adoption in New York State: Final report on adoptive parent survey. Final report to the United States Department of Health and Human Services. Ithaca, NY: Cornell University.</bibtext> </blist> <blist> <bibl id="bib3" type="bt"></bibl> <bibtext>Battistelli, E. S. (1996). Making managed health care work for kids in foster care. Washington, DC: CWLA Press.</bibtext> </blist> <blist> <bibl id="bib4" type="bt"></bibl> <bibtext>Battistelli, E. S. (1997). Managed health care guide for caseworkers and foster parents. Washington, DC: CWLA Press.</bibtext> </blist> <blist> <bibl id="bib5" type="bt"></bibl> <bibtext>California Department of Social Services. (1995). A characteristics publication describing the characteristics of children, birth parents, and adoptive parents involved in agency adoptions in California from July 1993 through June 1994. Sacramento, CA: California Department of Social Services, Information Services Bureau.</bibtext> </blist> <blist> <bibl id="bib6" type="bt"></bibl> <bibtext>Chapin Hall Center for Children at the University of Chicago. (1994). An update from the multistate foster care data archive: Foster care dynamics 1983-1993 — California, Illinois, Michigan, New York and Texas. 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Washington, DC: CWLA Press.</bibtext> </blist> <blist> <bibl id="bib24" type="bt"></bibl> <bibtext>Rosenfeld, A. A., Pilowsky, D. J., Fine, P., Thorpe, M., Fein, E., Simms, M. D., Halfon, N., Irwin, M., Alfaro, J., Saletsky, R., & Nickman, S. (1997). Foster care: An update. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 448-457.</bibtext> </blist> <blist> <bibl id="bib25" type="bt"></bibl> <bibtext>Simms, M. D. (1989). The foster care clinic: A community program to identify treatment needs of children in foster care. Journal of Developmental and Behavioral Pediatrics, 10, 121-128.</bibtext> </blist> <blist> <bibl id="bib26" type="bt"></bibl> <bibtext>Simms, M. D. (1991). Foster children and the foster care system, Part II: Impact on the child. Current Problems in Pediatrics, 21, 345-370.</bibtext> </blist> <blist> <bibl id="bib27" type="bt"></bibl> <bibtext>Takayama, J. I., Bergman, A. B., & Connell, F. A. (1994). Children in foster care in the state of Washington: Health care utilization and expenditures. Journal of the American Medical Association, 271, 1850-1855.</bibtext> </blist> <blist> <bibl id="bib28" type="bt"></bibl> <bibtext>Tatara, T. (1993). Voluntary cooperative information system (VCIS), Characteristics of children in substitute and adoptive care [Based on FY 82 through FY 90 data]. Washington, DC: American Public Welfare Association.</bibtext> </blist> <blist> <bibl id="bib29" type="bt"></bibl> <bibtext>U.S. General Accounting Office. (1995). Health needs of many young children are unknown and unmet (GAO/HEHS-95-114). Washington, DC: U.S. General Accounting Office.</bibtext> </blist> <blist> <bibl id="bib30" type="bt"></bibl> <bibtext>Waxman, J., & Alker, J. (1996, August 19). The impact of federal welfare reform on Medicaid. [Online]. Available at <ulink href="http://www.handsnet.org/medicaid/impact.htm">http://www.handsnet.org/medicaid/impact.htm</ulink>.</bibtext> </blist> <blist> <bibl id="bib31" type="bt"></bibl> <bibtext>Yudkowsky, B. K., Cartland, J. D., & Flint, S. S. (1990). Pediatrician participation in Medicaid: 1978-1989. Pediatrics, 85, 567-577.</bibtext> </blist> </ref> <aug> <p>By Mark D. Simms; Madelyn Freundlich; Ellen S. Battistelli and Neal D. Kaufman</p> <p></p> <p>Mark D. Simms, M.D., M.P.H., is Associate Professor of Pediatrics, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.</p> <p>Madelyn Freundlich, J.D., M.S.W., M.P.H., is Executive Director, The Evan B. Donaldson Adoption Institute, New York, NY.</p> <p>Ellen S. Battistelli, B.A., is Senior Policy Analyst, Child Welfare League of America, Washington, DC</p> <p>Neal D. Kaufman, M.D., M.P.H., is Professor of Pediatrics and Public Health, UCLA School of Medicine and Public Health, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA.</p> </aug>
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  Data: Delivering Health Care and Mental Health Care Services to Children in Family Foster Care after Welfare and Health Care Reform.
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  Data: <searchLink fieldCode="AR" term="%22Simms%2C+Mark+D%2E%22">Simms, Mark D.</searchLink><br /><searchLink fieldCode="AR" term="%22Freundlich%2C+Madelyn%22">Freundlich, Madelyn</searchLink><br /><searchLink fieldCode="AR" term="%22Battistelli%2C+Ellen+S%2E%22">Battistelli, Ellen S.</searchLink><br /><searchLink fieldCode="AR" term="%22Kaufman%2C+Neal+D%2E%22">Kaufman, Neal D.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Child+Welfare%22"><i>Child Welfare</i></searchLink>. Jan-Feb 1999 78(1):166-183.
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  Data: Journal Articles<br />Opinion Papers<br />Reports - Descriptive
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  Data: <searchLink fieldCode="DE" term="%22Child+Health%22">Child Health</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Welfare%22">Child Welfare</searchLink><br /><searchLink fieldCode="DE" term="%22Foster+Care%22">Foster Care</searchLink><br /><searchLink fieldCode="DE" term="%22Foster+Children%22">Foster Children</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Maintenance+Organizations%22">Health Maintenance Organizations</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Needs%22">Health Needs</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health+Programs%22">Mental Health Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Welfare+Reform%22">Welfare Reform</searchLink>
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  Data: Describes the essential features of a health care system that can meet the special needs of children in out-of-home care. Discusses some of the major recent changes brought about by welfare and health care reform. Notes that it remains to be seen whether the quality of services will improve as a result of these reforms. (Author)
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