Washington Post on foster care: old tropes and false narratives

The Donald R. Kuhn Juvenile Center in Julian, W.Va., where Geard Mitchell, now 17, spent part of his childhood. A lawsuit says 10 states’ agencies tasked with caring for children failed, “jeopardizing their most basic needs.” (Sarah L. Voisin/The Washington Post)
Image: Washington Post

Foster care has finally made it to the front page of the Washington Post, and a sad story it is. The story highlights the growing crisis in many states due to the increase in drug addiction bringing in its wake a cascade of child removals into foster care, outstripping the supply of  foster homes and other placement. The problems outlined in the article are real and urgent, but the analysis and prescriptions offered in the article and subsequent editorial reveal the authors’ lack of understanding of the issues, which results in the repetition of false narratives and common misleading tropes.

The Post‘s front-page article focused on a growing crisis caused by increased drug addiction among parents, especially the opioid crisis. The author, Emily Wax Thibodeaux, zeroed in on West Virginia, one of the epicenters of the crisis. She introduced us to Arther Yoho, a young man who spent more than two years in a detention center because there was no foster parent available to take him in. Locked up with 27 juveniles with criminal convictions, Arther was failed by the system that was supposed to protect him.

Thibodeaux reports that other desperate states are using emergency shelters, hotels and out-of-state institutions to house youth for whom there is no foster family home available. This is tragic and true, and I wrote about it in a recent post, although the placement of foster youth in detention centers along with criminally charged youth may be unique to West Virginia with its cataclysmic foster care crisis. Thibodeaux reports Oregon’s use of refurbished detention centers to house foster youth, which is certainly not ideal but is quite different from housing them with juvenile offenders. In any case, Thibodeaux is right to point out that many young people in foster care are being placed in inappropriate (and often harmful) placements because appropriate ones are not available.

However, Thibodeaux takes an unwarranted conceptual leap by linking the placement of children in inappropriate facilities to states’ use of congregate care, a term used to connote placements that are not families. These include what are generally known as group homes, as well as residential treatment centers, which are part of the accepted continuum of care for foster youth. While detention centers are never appropriate for foster youth who have not been charged with a crime, group homes and residential treatment centers may be the appropriate placement, often for a limited time, for some youths in foster care. These are the young people who cannot be maintained in a regular foster home because of their defiant, violent, or self-destructive behavior. Many of these children might be able to “step down” to foster care after spending time at a therapeutic residential facility.  It is possible that some of these young people could be helped in a professional therapeutic foster home staffed by salaried and trained foster parents, an approach that is gaining increasing interest, but programs so far are few and small and not likely to meet the need for therapeutic placements.

Thibodeaux cites the common trope that “Compared with foster children living with families, those housed in congregate care settings are more likely to drop out of high school, commit crimes and develop mental health problems.” That is very true. But it is a matter of correlation, not causation. It is the younger and less damaged children who end up in foster homes in the first place. Not surprisingly, they are likely to have better outcomes. Concluding that congregate care causes the negative outcomes may well be akin to concluding that fire trucks cause fire damage since buildings that have been visited by fire trucks are far more likely than typical buildings to have sustained fire damage. We don’t have a body of research on what happens to children with similar risk factors who spend time in foster homes compared to those who spend the same amount of time in group homes.

Thibodeaux appears to be unaware that some of the states with the lowest proportions of children in congregate care are those that are struggling the most with inappropriate placements. Washington and Oregon are among the states with the highest proportions of foster children placed in families as opposed to congregate care facilities, according to federal data cited in a recent report from the Annie E. Casey Foundation. Both states have been the subject of disturbing media reports that foster youth are staying in hotels, offices and substandard and abusive out-of-state facilities. That’s not surprising, since appropriate options are not available.  In Washington, ten years of group home closures led to the current crisis. The director of Washington’s child welfare agency has requested funding to expand the capacity of therapeutic group home beds to accommodate the children who are now staying in hotels and offices. The director of Oregon’s agency has cited a reduced number of treatment beds as a cause of children being sent to substandard and abusive out-of-state facilities.

By implying that all congregate care placements are inappropriate, Thibodeaux lays the groundwork for false conclusions about policy. Rather than saying that states need to beef up their therapeutic options, whether they are professionally-trained therapeutic foster parents or therapeutic group homes or residential treatment centers, Thibodeaux suggests that the new Family First Prevention Services Act, which makes it more difficult to obtain federal reimbursement for congregate care stays, may solve the problem.

Actually, the Family First Act may well make things worse. By making it harder to license therapeutic group homes, there is reason to fear that Family First will exacerbate the placement crisis. This has already happened when group homes closed in in jurisdictions like Oregon, Washington, New York City, and Baltimore. In California, the closure of group homes due to their Continuum of Care “reform” (a predecessor of the Family First Act) has resulted in, according to one veteran service provider, “fewer kids in group homes, but only because there are fewer group homes and counties have inappropriately been pushing challenging, difficult-to-manage youth into lower levels of care.”

The Washington Post followed Thibodeaux’ article with an editorial, “The Crisis in Foster Care,” which repeated and further distorted some of Thibodeaux’s questionable statements. Where Thibodeaux reported that 71% of foster children aged 12 to 17 are in congregate care placements in West Virginia (a high number to be sure), the editorial page erroneously stated that seven in ten of all foster children are in such foster care placements. That is a huge difference as older children are much more likely to be in such placements.

The opinion writers go on to repeat Thibodeaux’ misleading statement from the Casey Foundation about children in group homes doing worse than those in foster homes. However, they also cite discouraging outcome data about children growing up with foster parents. Because both options seem bad, the opinion writers suggest that “the least-bad option for many children” may be staying or reuniting with their parents, “unless there is abuse in the home. “They go on to cite one of the most persistent tropes of all that child protective services workers “often remove minors from neglectful parents who, while a far cry from being good caregivers, may still be better than group homes.”

The trope that child neglect is “less than ideal parenting” is belied by some of the stories that have come out of West Virginia and other states in the throes of the opioid crisis. We’ve all heard the stories: infants born addicted to drugs to mothers unable to care for them,  children who lost their parents and even their extended families due to opioid overdoses, children abandoned at home without food while parents seek drugs, children strapped in cars while their parents get high, babies and toddlers who ingest heroin, alcohol or meth; children whose parents are incarcerated due to substance abuse or dealing; and more. This is not “imperfect parenting” but something much worse. Living with an addicted parent is has a host of negative consequences that may be lifelong and is in itself considered an Adverse Childhood Experience (ACE).

One article from the Seattle Times documents the impact of the drastic increase in infants born addicted to drugs when they reach school age. “[The lives of children who grow up with drug-abusing parents are marked frequently by the presence of police, the constant fear of a mother or father’s incarceration and the likelihood of sudden death by overdose — all traumas shown to impede brain development and learning.”

To add insult to injury, the Post did not even seek to find out what is happening in its own back yard. Only two weeks before Thibodeaux’s article, a hearing was held in the 30-year-old LaShawn class action case to discuss the current placement crisis in the District of Columbia. The Judge referred to a letter from the court monitor that 31 children, including seven children between eight and ten years old, experienced a total of 60 overnight stays at the Child and Family Services Agency between April and November of 2019. All of these children had challenging behaviors that excluded them from existing placements. The agency director acknowledged that the District needs more therapeutic placements (either in family or group settings) for these children. The District is in the process of developing  a new group home and “a couple of” professional foster parents. The District is a small jurisdiction and its crisis is dwarfed by that of West Virginia, but its 60 office stays deserved a mention in our hometown paper.

The Washington Post‘s treatment of foster care illustrates the consequences of letting reporting and editorial staff without subject matter expertise tackle a complex subject like foster care. Repeating false narratives and tropes from alleged authorities is easy and saves time. But it does not help readers to understand what is wrong and what is needed and on the contrary leads them to look for “solutions” that may make things worse.

 

 

First “Family First” Plan to be approved shows limits of new law

PuttingfamiliesfirstDCOn October 29, 2019, the Administration on Children and Families (ACF) announced its first approval of a Title IV-E Prevention Plan to be submitted under the Family First Prevention Services Act (“Family First”). This plan, called Putting Families First in DC, was submitted by the District of Columbia’s Child and Family Services Agency (CFSA). While it is encouraging that the District was successful in gaining federal support for its plan, it is disheartening that there will be very little expansion of services under this new legislation, and that Family First will have no impact on the shortage of critically needed mental health services for parents.

Family First widened the population of children and families that can be served under Title IV-E of the Social Security Act from children in foster care to children who are “candidates for foster care” and their families.  A “candidate for foster care” is defined as a child who is identified in the jurisdiction’s prevention plan is being at “imminent risk of entering foster care” but who can remain safely at home or in a kinship placement if services are provided.  Each state sets its own definition of a candidate for foster care in its Title IV-E plan. CFSA has chosen a fairly broad definition, which includes many types of families that have been investigated by CFSA after an allegation of child abuse or neglect

Most interestingly, CFSA has chosen to include as “candidates for foster care” children of pregnant or parenting youth who are in foster care or have left foster care within five years. The inclusion of these families is particularly significant because it allows services to families in which abuse or neglect has not taken place. Rather than preventing the recurrence of abuse or neglect (known as “tertiary prevention”) this extends  the use of Title IV-E funds to preventing the first occurrence to a high-risk population (known as “secondary prevention”).  This  represents a more “upstream” approach, which many experts and child welfare leaders have long been arguing deserves more support.

However, the effects of this expansion of the eligible population are drastically constrained by the severe limitation on what services can be provided under Family First. The Family First Act extends the use of Title IV-E funds to services designed to prevent placement of children in foster care. Three categories of services are allowed: “in-home parent skill-based services,” mental health services, and drug treatment. (“Navigation” services to kin who are caring for children are also covered). So far, so good. But when specific services are considered, things become complicated.

As I described in earlier posts, the decision of Congress to make Medicaid the payer of last resort rules out using Title IV-E to fund many mental health and drug treatment programs that are crucial to keeping families together safely. And Congress’ decision to limit reimbursement to programs that are included in a Title IV-E Prevention Services Clearinghouse rule out support for many promising and supported programs that jurisdictions are already using or might want to use to support their struggling families.

Through a Program Instruction, ACF recently gave states an option to claim “transitional payments” for services that have not yet been approved by the clearinghouse, by conducting an “independent systematic review” of such services. But the funding will be cut off if the Clearinghouse decides not to approve the service, and it is not clear if any states will use this option. The District of Columbia has elected not to do so. As a result, after all the hoopla, the District is claiming only one evidence-based prevention service for funding under Family First! That is the Parents as Teachers (PAT) home visiting program, which is already being provided by the DC Department of Health using federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funds. CFSA will be using local dollars, matched by federal Title IV-E funds, to add slots to this program to meet the needs of its foster care candidates and their parents.

It is worth noting that the evidence on PAT’s potential to prevent child maltreatment or its recurrence not very compelling.  The California Clearinghouse for Evidence Based Practices in Child Welfare (CEBC the leading organization of its kind) rates it as only “promising” (not “supported” or “well supported”) on primary prevention and does not even rate it on prevention of maltreatment reduction. Since the CEBC rated the program, a new study was released testing the potential of PAT to reduce maltreatment among parents who already have been found neglectful or abusive. The study found no overall effect, though they did find that there was a reduction in maltreatment reports for parents who were not depressed and did not have a significant history with Child Protective Services–in other words, the easiest-to -treat minority of the population of parents involved with CPS.

It is likely that CFSA will eventually receive Title IV-E support for a second service. Motivational Interviewing (MI) was approved by the Title IVE Prevention Services Clearinghouse after CFSA had already submitted its plan. MI is a method of counseling to facilitate behavior change, especially regarding substance abuse. It is typically delivered over one to three sessions.  However, CFSA has included Motivational Interviewing in its plan as a “cross-cutting” program rather than a program addressing substance abuse. The agency states that it intends to use MI as a “core component” of its case management model, rather than a two-or-three-session freestanding program. Brenda Donald, CFSA’s director, told the Chronicle of Social Change that she expected to be able to claim IV-E reimbursement for case management once it was added to the clearinghouse. Other jurisdictions are moving in the same direction, according to the Chronicle.

CFSA included in its Family First Plan other programs eligible for Title IV-E funding but is not planning to claim federal funds for these programs because they are already supported by federal funds. Also included are several services that have not yet been approved for Family First funding and are supported by Medicaid or local dollars. It’s a large array of programs, none of which will be supported by Title IV-E funds except PAT and perhaps MI.

So under Family First, Title IV-E dollars are being used to expand one home visiting program in the District and perhaps can be used to match funds spent on case management if CFSA succeeds in making the case that the use of the MI approach makes case management reimbursable. In the meantime, District parents with children at risk of foster care placement are desperately seeking needed services, especially mental health services to treat their mental disorders, such as depression and Post Traumatic Stress Syndrome (PTSD) that contribute to child abuse and neglect.  As recently reported by the District of Columbia’s Citizen Review Panel (CRP), there is such a shortage of basic  mental health services for parents that social workers are doing therapy themselves and also trying to substitute alternative services that may not be as effective, such as telemedicine or yoga. Lack of appropriate mental health services and long waiting lists were major themes of CFSA’s 2019 Quality Service Review, as reported by the CRP.  Poor quality of Medicaid-funded services and rapid turnover of providers are also problems that plague CFSA-involved parents and their social workers.

What a difference Family First could have made if its funds could be used to augment the supply of Medicaid-funded basic mental health services such as medication management, individual and group therapy! How many families could be strengthened if the Clearinghouse had included, or was considering, newer and exciting evidence-based mental health services like EMDR and Mindfulness Based Stress Reduction that may not be covered by Medicaid! Without federal help through Family First, parents involved with CFSA continue to wait for services they need to parent their children safely.

Another problem for CFSA lurks down the road. As CFSA describes in its plan, the law requires that 50% of IV-E spending be for practices that are “well-supported” as defined by the Act. But most of the “well-supported” practices that CFSA is using are funded by Medicaid in the District. If the Medicaid-funded programs cannot be counted as part of CFSA’s total Family First expenditures (which ACF has suggested will be the case), CFSA will not be able to show that it is spending 50% on “well-supported” practices. Congress has already passed the Family First Transition Act, which delays implementation of this requirement to 2024, with a requirement that by 2022 states have to show 50% of practices as “supported” or “well supported.” But what will happen then? The Chronicle voices the hope that more practices would have made it to the well-supported list by that time. We shall see.

With all the fanfare around Family First and CFSA’s large investment of time in developing this plan, it seems clear that the agency is gaining few resources in return for the large  burden of showing compliance with Family First.  It’s ironic that CFSA must provide extensive documentation to ACF regarding services that are getting no funds under the act. CFSA and other jurisdictions should press for amendments that make Family First more likely to achieve its objective of supporting parents to improve their parenting and keep their children safely at home.

Family First Act: no funding for important drug treatment and mental health services

Family First ActPassage of the Family First Prevention Services Act as part of the Bipartisan Budget Act early in 2018 was hailed as a game changer in child welfare.  For the first time, according to the celebrants, Title IV-E funds could be used to pay for services to keep families intact rather than place children in foster care. But the more we learn about Family First and how it is being implemented, the less cause for celebration there seems to be. In my last post, I discussed the problems caused by the decision to make Title IV-E the payer of last resort for foster care prevention services. In this post, I discuss the surprising omission of important mental health and drug treatment programs from the list of programs that have been approved or proposed to be paid for under Family First. The paucity of useful programs in the clearinghouse certainly will detract from the utility of Family First in preventing foster care placements.

In expanding the use of federal IV-matching funds beyond foster care through Family First, Congress wanted “to provide enhanced support to children and families and prevent foster care placements through the provisions of mental health and substance abuse prevention and treatment services, in-home parent skill-based programs, and kinship navigator services.” Family First allowed federal Title IV-E matching funds to be used for programs in these categories that meet criteria for being “evidence-based” as defined by the Act.

The categories  of mental health, drug treatment and parenting programs make sense in light of what we know about why children come into foster care. Anyone who has worked in foster care knows that parental drug abuse and mental illness are two of the major circumstances behind child removals, while a third major factor, domestic violence, was inexplicably left out of the Act. The inclusion of parenting programs makes sense because abuse in particular is often related to parents’ lack of knowledge about child development and appropriate disciplinary practices.

Family First established a Title IV-E Prevention Services Clearinghouse, which is being developed under contract by Abt Associates, to review and approve programs for reimbursement using Title IV-E foster care prevention funds. So far, the clearinghouse has approved nine programs for inclusion and is in the process of considering 21 more. A careful look at the programs that are included, under review, and not on either list raises some questions.

Take substance abuse treatment, the most common single factor behind child removals according to federal AFCARS data, which indicates that drug abuse was a factor in 36% of the child removals that took place in Fiscal Year 2018. The opioid crisis, often cited as a reason to pass Family First, seems to have peaked in most areas but is still wreaking havoc in many states and their foster care systems. Medication-assisted treatment is often called the “gold standard” for treating opioid addiction and is vastly underutilized. But strangely that Abt Associates chose to include in the clearinghouse only Methadone Maintenance Therapy and not the newer buprenorphine treatment, which is not even on the list of programs to be considered for clearinghouse listing.  According to the National Institute on Drug abuse, “Methadone and buprenorphine are equally effective at reducing opioid use.” And there are reasons to prefer the newer medication. As the federal Substance Abuse and Mental Health Administration (SAMHSA) states, unlike methadone treatment, “which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, significantly increasing treatment access.”

Let’s turn to mental health. It is clear that mental illness is the major factor behind many removals into foster care. AFCARS data indicate that 14% of child removals are associated with a “caregiver’s inability to cope,” but that percentage sounds small to this former social worker. It is likely that many more removals where other factors (like child abuse and substance abuse) are cited are also related to parental mental illness. Parents suffering from untreated depression, bipolar disorder, post-traumatic stress disorder (PTSD), and other mental health disorders often have difficulty providing appropriate care to their children. So it is not surprising that mental health was included as a category of services to prevent foster care under Family First.

What is surprising is the nature of the services that have been chosen so far. The clearinghouse has approved four mental health programs: Functional Family Therapy, Multisystemic Therapy, Parent Child Interaction Therapy, and Trauma-Focused Cognitive Behavior Therapy. All of these programs are geared at addressing the issues of children–not their parents. It is very odd that the clearinghouse did not include any services to address common mental disorders, such as depression and PTSD, that afflict many parents who come to the attention of child welfare agencies. After all. the California Evidence-Based Clearinghouse for Child Welfare (CEBC), the leading repository of evidence practices in child welfare, lists nine programs meeting Family First criteria as well supported, supported or promising  for treating depression and 11 programs meeting those criteria for trauma treatment for adults. Even odder, among the six mental health programs being considered for inclusion in the Title IV-E clearinghouse, only one (Interpersonal psychotherapy) could be used to treat adults although there is also a version for adolescents and the clearinghouse does not specify which one is under review.

Among the evidence based practices included in the CEBC and not included or under review by the Title IV-E clearinghouse are some well-established programs known to be effective, such as Cognitive Behavioral Therapy for adult depression and  Mindfulness Based Cognitive Therapy.  Both of these have the top rating of “well-supported” from CEBC for treatment of depression in adults. Another mindfulness-based treatment called Mindfulness Based Stress Reduction is becoming increasingly popular and supported by research for treatment of depression and anxiety. Because it is not generally covered by insurance, using Family First funds could make this treatment available to parents who could not otherwise get it. Eye Movement Desensitization and Reprocessing (EMDR), a popular trauma treatment, is also given the top rating from the California clearinghouse and not included or being reviewed by its Title IV-E counterpart.

On the other hand, the inclusion of two out of three “in-home parent skill based” programs in the Title IV-E Clearinghouse is somewhat surprising. The inclusion of Healthy Families America (HFA) raises questions because it has not yet been able to demonstrate an impact on the prevention of child abuse and neglect. There is one study with a promising result but this study was criticized by CEBC due to a very small sample size, limitation to one region, reliance on parent self-report and other factors. CEBC gave HFA as a rating of “4” (“evidence fails to demonstrate effect”) for the prevention of child abuse and neglect.

Another home visiting program, Nurse Family Partnership (NFP), has limited potential to prevent foster care among the Title IV-E eligible population. NFP is the only home visiting program given the top rating for prevention of child abuse and neglect by the CEBC; however it is approved only for first-time teenage mothers. It cannot by definition be used to prevent a recurrence of abuse or neglect. NFP can be provided under Family First in jurisdictions, like the District of Columbia, that have defined all children of teens in foster care as foster care candidates. But it is not applicable to most families eligible for prevention services under Title IV-E.

In sum, the list of programs that have been cleared by the Title IV-E clearinghouse as well as those that are being reviewed contains some disconcerting omissions and surprising entries. While some of the most exciting and promising mental health and drug treatment programs are not included, some home visiting programs with very limited applicability to the purposes of the Act have been included. When added to the decision to make Medicaid the payer of last resort, these decisions by the clearinghouse make the utility of Family First as a vehicle of foster care prevention even more dubious. Those who agree should join me in requesting that the Title IV-E Clearinghouse review and approve some of the effective practices mentioned in this post.

 

 

Family First Act: a False Narrative, a Lack of Review, a Bad Law

Family First ActThe passage of the Family First Prevention Services Act (FFPSA) was greeted with joy and celebration when it passed as part of the Bipartisan Budget Act of 2018. “The Family First Prevention Services Act will change the lives of children in foster care,” crowed the Annie E. Casey Foundation.  The new law “will change foster care as we know it,” raved the Pew Charitable Trusts. But the Act took effect on October 1 to little fanfare. Based on contacts with all the states, the Chronicle of Social Change expects only 14 states and the District of Columbia to implement the Act and 36 to delay implementation for up to two years as allowed by the law. But as of two weeks before implementation, only four states had submitted the plan required in order to implement the Act.

An Act with Many Flaws

FFPSA has been revealed (as some knew all along) as a messy and poorly written piece of legislation. It starts with a misnomer. What the Act calls “prevention services” (“in-home parent skill-based,” mental health, and drug treatment programs for parents who have already been found to have abused or neglected their children) are aimed at prevention of foster care, not of child abuse and neglect before they occur. To most experts, these would be considered to be “intervention” and not “prevention” services. But beyond this misnomer, the legislation has multiple flaws which means it may create more problems than it solves.  Among these issues, covered in detail in a recent webinar from California’s Alliance for Children’s Rights and an article in Governing, are the following:

  1. Lack of new funding: FFPSA was designed to be budget neutral, redirecting funds toward foster care prevention services from congregate care and a delay of an expansion in adoption assistance. The Congressional Budget Office has estimated that FFPSA will actually result in a $66 million reduction in federal spending over a ten-year-period. This comes on the heels of 20 years of federal disinvestment in foster care, leaving jurisdictions struggling to maintain reasonable caseloads and services.  Some states are anticipating crippling losses of of funds due to the loss of their Title IV-E waiver programs, which expire at the end of the year and were far more generous and less restrictive than FFPSA. For example, California anticipates the loss of $320 million in federal funding when the waiver ends, forcing service reductions in some of its largest counties. New York will lose support for a program that hired more social workers and supervisors and has been credited with allowing youth to leave foster care earlier.
  2. Requirement that 50% of funding be spent on “well-supported” programs. FFPSA requires that 50% of funding be spent on programs that meet a rigorous set of criteria to be defined as “well-supported.” But so far, the clearinghouse created for the purpose of this provision has designated only six programs as “well-supported”: three mental health programs, three home visiting programs, and no drug treatment programs. Some states may prefer to adopt or expand in other similar programs that are not on the list. Therefore there has been a chorus of proposals that this provision be eliminated or delayed.
  3. Interaction with Medicaid: Each state’s Medicaid program covers a different set of services, but many of the services meeting FFPSA criteria, especially mental health and substance abuse treatment, are already funded by Medicaid in most cases. Allowing Title IV-E to supplement Medicaid funds might have helped improve the quantity and quality of services available. But in its guidance on implementing the legislation, the Children’s Bureau specified Title IV-E as the payer of last resort for these services. That means that Medicaid must pay first before Title IV-E can be billed. Thus, in states with more generous Medicaid programs, the law will greatly expand the services available to families. Moreover, it appears, based on the federal government’s answer to one state’s question, that programs paid for by Medicaid may not count toward the 50% of programs that must be “well-supported,” leaving states that use Medicaid to fund these programs in a difficult situation. 
  4. Restrictions on congregate care: One of the two main purposes of FFPSA was to restrict congregate care, which is basically any placement that is not a foster home. To do so, FFPSA cuts off funding after two weeks for any placement that is not a foster home, with four exceptions. Three of these are programs for special populations and the fourth is a new category called a Quality Residential Treatment Programs (QRTP)–a new category created by FFPSA. QRTP’s must meet numerous requirements, such as accreditation, 24-hour nurse coverage, and a “trauma-informed” approach. Moreover, a child must be assessed by a “qualified individual” as needing placement in a QRTP and that decision must be approved by the family court. Furthermore, a youth may not remain in a QRTP for more than 12 consecutive months without written approval from the head of the agency. As Child Welfare Monitor has discussed elsewhere, there is concern that some group homes will have trouble meeting the FFPSA criteria. Group homes are closing around the country due to insufficient funding and state-level policy changes. Many states have desperate shortages of foster homes, and closing group homes at the same time will worsen their placement crises. Furthermore many young people, especially those with more issues, may need more than 12 months in a group home and may lose all their gains if transferred prematurely to a foster home.  There is also a problem with Medicaid and QRTP’s, as it appears they will fall into a category of “Institutions for Mental Diseases” that are not payable by Medicaid.
  5. Kinship Diversion: FFPSA creates an avenue for prevention of foster care by placing a child with relatives (often called kinship diversion) while the parents receive prevention services for up to 12 months. If reunification with the parents never happens, there is no requirement that the children be placed formally with the relatives, or that the relatives receive any assistance either financially or with services. They would be forced to rely on Temporary Assistance for Needy Families (TANF), which is much less generous than foster care payments, and to make do with any services they can find in the community. There is concern that FFPSA may encourage states and counties to use kinship diversion rather than licensing relatives as foster parents, thus entitling them to more services and assistance and ensuring that the agency does not lose track of the children.

How a bad bill was born

The passage of FFPSA was the outcome of many years of advocacy, under the mantra of “child welfare finance reform.” So how did such a flawed bill pass after so many years of proposals and discussions? The answer includes a truncated legislative process, an insistence on budget neutrality,  and a false narrative promoted by a wealthy group of organizations.

False Narrative

This call for finance reform was based on the idea that, as expressed by one of its primary proponents, Casey Family Programs, in a white paper published in 2010:

 …the major federal funding source for foster care, Title IV-E, primarily pays for maintaining eligible children in licensed foster care, rather than providing services for families before and after contact with the child welfare system. The fact that no IV-E funding can be used for prevention or post-reunification services has created a significant challenge to achieving better safety and permanency outcomes for children.

This statement was literally true. Before implementation of FFPSA, Title IV-E funds were not available for services provided to families to help them avoid placement of their children in foster care. But plenty of other funds were available to cover these services. We’ve already mentioned that Medicaid currently pays for many or most of the services that will be provided under FFPSA, with the specifics depending on the state. Other funding sources  included Title IV-B, TANF, Social Services Block Grant, and CAPTA funds.

Moreover, Title IV-E does not cover all foster care costs. The federal government reimburses states for 50 to 75% of the cost of foster care payments, depending on the state. But only 38% of foster children were eligible for federal reimbursement under Title IV-E in 2016, down from an estimated 54% in 1999. The reason for this decline is an antiquated provision (often called the “Title IV-E lookback”) that links Title IV-E eligibility to eligibility for Aid to Families with Dependent Children, a welfare program that ended in 1996. Anything calling itself finance reform should have addressed this senseless linkage, but the framers did not.

So, between the availability of other funds and the fact that states had to pay a large share of foster care costs themselves,  it is hard to accept the narrative that states had an incentive to place children in care rather than provide services to their families to keep them at home. And indeed states have for years been providing in-home services to help families avoid foster care. According to federal data, 1,332,254 children received in-home or family preservation services in FY 2017 compared to only 201,680 children who received foster care services. So the argument for “finance reform” is simply a red herring.

The idea that a foster home is almost always better than a group home or residential placement is behind the other major part of FFPSA, the strict restrictions on funding for congregate care. But this narrative ignores the fact that there are not enough foster parents, especially those who are willing, loving and gifted enough to care for older and more troubled young people. Perhaps some supporters think that these foster parents will suddenly appear once group homes disappear. But this kind of wishful thinking failed when the mental hospitals closed in the 1960’s and the promised community mental health services did not appear, and there is no reason to think it will be more accurate this time around.

So how did a false narrative gain such a large following and become accepted as the truth? This idea has been supported by a powerful coalition of organizations led by Casey Family Programs, author of the white paper quoted above. Casey’s assets totaled $2.2 billion at the end of 2018 and it spent $111 million that year in pursuit of its goals, which include “safely reducing the need for foster care by 50 percent by the year 2020.” Casey has relentlessly promoted this narrative through publications, testimony, and assistance to jurisdictions that agree to implement its agenda.

Budget Neutrality

As mentioned above, FFPSA does not add resources to the system but instead redirects them from congregate care and adoption assistance to services designed to keep families together. Much of the savings will come from states taking on the full cost of group home placements that they cannot avoid. The Congressional Budget Office estimates that about 70% of the children residing in group home placements (other than residential treatment programs) would become ineligible for Title IV-E funding in 2020. So the cost of funding this placements will be shifted to states and counties that are often already struggling to fund these necessary placements. Moreover, the continuation of the TItle IV-E “lookback” means that the federal share of foster care funding will continue to decrease.

Much of the blame for the Act’s budget neutrality goes to Casey and its fellow advocates, who have been uninterested in increasing resources for foster care. As longtime Hill staffer Sean Hughes points out, “…Congressional staffers will tell you that child welfare advocates are perhaps the only group of federal advocates that consistently decline to even ask for new resources.” According to Hughes, these advocates have been unwilling to increase resources for foster care because of their bias toward family preservation. (Remember Casey’s goal of reducing foster care by 50% by 2020). They apparently hope that “starving the foster care beast” might result in fewer foster care placements, whether or not children might be left in unsafe situations. The framers wanted a budget neutral bill, and the advocates were happy to accept it in order to reallocate resources away from foster care (through the continuation of the “lookback” and the restrictions on group homes) toward family preservation.

Lack of review

Aside from a pair of hearings that were orchestrated by the bill’s sponsors to support their vision for the legislation, there were no hearings or floor debate on the Family First Act after it was introduced in 2016. In 2017, it passed the House by voice vote, and its Senate sponsors failed to get it passed. In 2018, after failing twice to attach it to larger bills without hearings of debate, the sponsors succeeded at the eleventh hour in getting it attached to the budget act. Young people whose lives were saved by group homes were never able to tell their stories. The technical problems with Medicaid eligibility were never discussed and may not have even been noticed until long after passage.

A bill called the Family First Transition Act has been introduced to ease the transition to the new legislation. It would delay for two years the implementation of the 50% “well-supported” requirement for services reimbursement,  provide a small amount of transition funding to help states implement the Act, and provide temporary grants to jurisdictions with expiring waivers to make up for a portion of their loss under FFFPSA. However, none of these temporary fixes would cure this fundamentally flawed bill, the inevitable result of a false narrative, inadequate funding, and a truncated legislative process.

This post was updated on November 7, 2019, to specify that the Children’s Bureau made the determination that Title IV-E would be the payer of last resort for prevention services to foster care candidates. This designation of Title IV-E as payer of last resort was not made in the Act itself.