• December 2015
  • Vol. 16, No. 9

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Commissioner's Page

The following is the monthly message from Rafael López, the Commissioner of the Administration on Children, Youth and Families. Each message focuses on the current Children's Bureau Express Spotlight theme and highlights the Bureau's work on the topic.

Children and youth in foster care often enter care with significant health challenges. Child abuse and neglect, poverty, parental substance abuse or mental illness, and disruption caused by removal from the home can all contribute to health and mental health issues. Therefore, ensuring that children and youth in foster care receive the medical and mental health services they need is of paramount importance to their overall well-being.

Recent mandates stipulated in the Patient Protection and Affordable Care Act (ACA) aim to facilitate access to health and mental health services for this population, and especially for older youth in or formerly in care. However, youth may need guidance to understand the benefits they are eligible for and how to access them. Below, two young adults formerly in foster care, Emmie and Desiree, share their experiences with receiving health-care services during and after care and words of wisdom for youth and for the professionals who serve them.1

How did you come into contact with foster care, and what was your experience like?

Emmie: I sought out foster care around the age of 15 when I realized the home I was living in was not anything like my peers, but much worse. Foster care is not perfect, but it seemed like a refuge in comparison to the conditions of my family's home. I only moved a few times and was fortunate to find one placement with my foster mom, Paula, who ended up being a home to me for nearly 3 years. To this day, Paula is a mom to me. I transitioned out of foster care on my 19th birthday straight into my freshman year of college and lived on campus independently.

Desiree: I entered foster care at the age of 4 with my three siblings (two older brothers and a younger sister) due to abuse and neglect. Placement was difficult for our large sibling group. We were able to be with one another in our first placement. However, my brothers were eventually placed in a different home and my sister and I were also sent to a different home in the same school district as our older brothers, which allowed us to remain close and form healthy relationships. We had weekend visits with one another, with our grandparents, and with our father, when he was able to visit. Our mother's whereabouts were unknown and would remain so until I was 18. As a sibling group, foster care allowed us to experience both joys and sorrows. I stayed in my third placement for the last 11 years of my time in care. There, I received the nurturing and support needed to ensure that I would have a successful future.

Have you ever had trouble accessing health care while you were in foster care or after?

Emmie: Just before moving to Portland, OR, to continue my bachelor's degree, I discovered that I wouldn't be covered by my same insurance while I was out of State and that Oregon wouldn't cover me even though I had been in foster care in another State [Wyoming]. This was just after the ACA had taken effect and States had the option to choose who they covered.2 I was one of the people that decision directly affected, and one of the people who they decided not to cover. Luckily, my scholarship covered my junior year of student health insurance, but this year they changed their terms and wanted us to use the ACA to cover our own health insurance. I was back to square one, but fortunately my partner offered to include me in her health insurance and I'm covered again in a great insurance plan that includes dental.

Other difficulties were largely due to the limited providers who accept Medicaid. In Wyoming, I skipped dentist appointments from the age of 16 until just recently as I could not find a dentist who would take my insurance. I had no dental coverage under my student insurance in Oregon, and the cost of student dental services on campus felt like spending food and school money. Prioritizing what is most important in life is a constant battle [for youth in care]. Seeing a dentist or doctor regularly seems like a luxury to me, not a necessity. I feel like this is probably the mindset of other youth in care, too.

Desiree: While in care [in Wisconsin], I was a fairly healthy child, so I accessed health care minimally and with ease. However, accessing dental care was always difficult. Due to low Medicaid reimbursement rates, many dentists in my area were unwilling to accept State insurance. [After foster care], I experienced difficulty accessing health care through coverage I had purchased through my employer. I no longer qualified for State insurance [the ACA provision expanding Medicaid coverage to youth formerly in foster care until age 26 had not yet become effective]. This proved to be costly due to increased charges for out-of-network providers and traveling for [the care I needed], which was not available in my community.

How familiar are you with ACA provisions affecting older youth in or formerly in foster care? Did your caseworker talk to you about your health-care options while in foster care and/or after you transitioned out of care?

Emmie: I'm more familiar now than when I moved to Oregon or when I was in Wyoming getting ready to start college. I know that I'm not covered by Medicaid until 26, unlike my peers who can stay on their parents' insurance until that age or other foster youth who either live in the State [where they were in foster care] or in a State that accepts out-of-State foster youth into their health-care programs. There was not much discussion with my caseworker about health-care options as I was transitioning because I was planning to stay in Wyoming at the time.

Desiree: As a former special needs adoption social worker, I am aware of these ACA provisions. In 2008, State health-care options were less beneficial for youth. At that time, wards of the State [of Wisconsin] were able to maintain State coverage if they were full-time students or employed. Fortunately, I was a full-time student. In 2011, when I turned 21 and was no longer eligible for State care based on my foster care status, I paid for insurance through my place of employment. [In 2014, the ACA provision extending Medicaid coverage to youth formerly in foster care until age 26 became effective.]  My caseworker had little to do with my knowledge of medical benefits during care and after. Most of my knowledge came from foster parents, former youth, and trial and error.

Overall, how do you feel about the health care you have received while in foster care and after? Do you feel your concerns and wishes regarding your own health care have been heard? Is there anything you think would have made it easier for you to access health care?

Emmie: The health-care providers I found on my college campus have been amazing, and I'm so glad I stumbled upon them. While in care, [I never consistently saw] one primary doctor, which added to the anxiety of finding a primary care physician when I left care and moved out of State. I was not [provided with my full medical records]. I'm happy that is behind me, but I hope that youth in care now do not have to struggle so long to have their basic health needs met. They have so much going on already—their physical and mental health should be a top priority, not a burden.

Desiree: I think I was provided accurate and timely health care, disregarding dental, while in care. I never experienced stigma or discrimination due to my State health insurance coverage. After care, I have continued to receive excellent [health] care. Increasing the reimbursement rate or providing incentives to dental clinics would improve access to health care. There are few dental offices that accept Medicaid, and the ones that do have waitlists that are months out.

Do you have any advice for older youth in foster care about accessing health care?

Emmie: Know your resources and don't be afraid to ask, research, and explore. Find out who is in your area, what has worked and what has not worked, look online at reviews, and do not expect anyone to do it for you. If you need something, do anything you can to get to it. Also, read carefully if you sign up for anything relating to health care. If you can't receive health care for free as a youth because you are not in the State in which you spent time in care, use caution when getting a plan through the health-care exchange so you get the best deal for your money and needs.

Desiree: Know your benefits and stay informed. If you are up for the renewal process and need to provide documentation for continued insurance, do not wait—be proactive. Once coverage is ended, it is more difficult to sign up for coverage, as all documentation is once again needed. Keep copies of your medical records and immunization records. If a medical facility sends you a balance statement requesting you pay, call your State Medicaid office to clarify. Always advocate and protect your rights and benefits as a former or current foster youth!

Do you have any advice for caseworkers about the health care of the youth with whom they work?

Emmie: Take the time to truly help [youth] understand what they may come up against after leaving care. Don't let moving out of State and losing health insurance come as a surprise. Inform [youth] of their options and make them aware of plan B's and C's if things were to go differently than expected.

Desiree: Ensure that youth are well informed of their benefits for health care and that they complete necessary documentation prior to discharge from care. Enable them to be successful in the future by teaching them how to complete needed paperwork, instead of completing it for them.

Do you have any advice for medical professionals who work with youth in foster care?

Emmie: Going to a doctor is not always a normal experience for youth in or from foster care, for various reasons. Many haven't been to doctors regularly growing up; they don't want to have to tell their life story over and over again to new doctors and for some, a doctor's office is where foster care may have started for them. Take the time to treat them like any other patient while hearing them out for their individual needs through an unbiased lens. It can be scary enough coming to you for help, but once we are there, help us know we made the right choice by coming to you.

Desiree: Be trauma informed!


1 These interviews express the personal opinions and experiences of two youth formerly in foster care and include information about how certain laws and policies were applied to their individual cases. This information is not intended to represent a review of Federal or State laws and policies.

2 The Centers for Medicare and Medicaid Services interprets the ACA as giving States the option to cover youth who were formerly in foster care in another State. For more information, see here (PDF - 106 KB).

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