policy

As representatives of organizations committed to improving the health and wellbeing of our nation’s children and families, we are writing to urge your support for a new and important initiative outlined in the Administration’s 2016 budget. This five-year collaborative demonstration, involving the Administration for Children and Families (ACF) and Centers for Medicare and Medicaid Services (CMS), is designed to encourage states and tribes to provide evidence-based psychosocial interventions to children and youth in foster care and to reduce the inappropriate use and overprescription of psychotropic medications for this population.

We appreciate the recent attention that Congress has brought to this important issue in the form of oversight hearings and request for governmental reviews of state practice. We believe that the proposed demonstration builds on recent Congressional efforts, and if implemented, will lead to improved outcomes for vulnerable children with behavioral health challenges and children exposed to trauma – often resulting from child abuse and neglect.

The joint proposal put forth by ACF and CMS will help coordinate efforts to build state and tribal capacity within child welfare and health care systems to more appropriately address the high rates of children who may be unnecessarily receiving psychotropic medications, often several at one time, even as few receive appropriate outpatient mental health services. The project will encourage the utilization of effective evidence-based therapeutic interventions, including therapeutic foster care, intensive inhome and community-based approaches, Multisystemic Therapy, and mobile response and stabilization services.

State prescribing practices received considerable attention in 2011 with the release of a Government Accountability Office (GAO) report1, which reviewed medication utilization under the Medicaid program. The report found that 20-39 percent of children in state foster care received prescriptions for psychotropic medication in 2008, compared with only 5-10 percent of children on Medicaid not in foster care. More alarming, the report also found that children in state foster care are prescribed dosages at far higher rates than their peers served by Medicaid, and often in amounts that exceed guidelines issued by the Federal Food and Drug Administration (FDA). GAO’s findings are supported by a large number of recent studies. As a follow up to GAO’s report, in 2011, the Senate Homeland Security and Governmental Affairs Committee also held a hearing on this issue. Additionally, just last May 2014, the House Ways and Means Human Resources Subcommittee held a hearing to explore how the federal government can continue to work with States to improve oversight of prescribed medications and ensure youth in foster care receive appropriate care to meet their needs.

Available data speaks to the need for immediate Congressional action to implement strategies aimed at improving the psychosocial wellbeing of our most vulnerable children. To that end, the 2016 budget proposal specifically requests a five-year joint project through ACF and CMS to promote more effective evidence-based interventions targeting children in foster care beginning in 2016. Under ACF, the budget includes an investment proposed at $50 million a year to fund state infrastructure and capacity building to ensure improved coordination between CMS and child welfare agencies.

We also encourage the inclusion of tribal governments in this collaborative demonstration to address issues related to American Indian and Alaska Native children who are affected by the inappropriate or over use of psychotropic medication. American Indian and Alaska Native children can be in either state or tribal foster care systems with medications being provided by agencies that are sometimes in different jurisdictions. Improving coordination between these jurisdictions is critical to effectively addressing medication issues with this population. This funding could be used to better train stakeholders (including foster parents and adoptive parents, judges, etc.), provide reliable screening and assessment tools, implement evaluation procedures and improve data collection. These efforts will better help children in foster care who sometimes fall through the cracks of a fragmented health planning process.

Simultaneously, the CMS investment is proposed at $100 million a year to provide incentives to states that demonstrate improvements in these areas. The overall goals of this important and timely initiative are to reduce inappropriate prescribing practices and over utilization of psychotropic medications, increase access to evidence-based and trauma-informed therapeutic interventions, promote child and adolescent wellbeing, and improve child welfare outcomes (as related to safety, increased permanency, fewer disrupted adoptions and reduced entries and re-entries into foster care).

Although small in terms of budget requests, this demonstration project will build on existing priorities and recent reforms led by Congress, and will help to not only curb inappropriate use of psychotropics, but also to incentivize the use of a variety of evidence-based psychosocial interventions that have been found to be effective. We believe it will also make critical improvements needed in the child welfare system and help to better address the effects of trauma on children in foster care, those placed in adoptive families and all young victims of child abuse and neglect.

Moving forward, we can better serve children and youth and help keep them safe in families by developing a more coordinated and comprehensive approach to addressing the behavioral health care needs of children served by Medicaid, many who are victims of child abuse, are in foster care or exposed to various forms of trauma including sexual exploitation and trafficking.

We strongly urge you to help ensure that Congress authorizes the proposed funding set forth by ACF and CMS for important improvements needed, and recognized first by Congress, so that we, together with states, can carry out better policies, promote transparency, and improve health outcomes for our nation’s children and families.

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