Assessing Accessibility: Do Teens in Foster Care Have Access to the Full Range of Reproductive Health Care Services Under Medicaid?
This article is the second in a series looking at the alarming rates of teen pregnancy and childbirth among youth in foster care. The first article, “Cause for Concern: Unwanted Pregnancy and Childbirth Among Adolescents in Foster Care” presented data indicating higher rates of unwanted pregnancy and childbirth among youth in care than among their counterparts not in care. In addition, it discussed various barriers to reproductive health care services that might explain the higher rates of pregnancy and parenting among these teens.1
By Jennifer Friedman
Youth in foster care face an increased risk of early sexual activity, pregnancy, and teen parenting. A recent longitudinal study of foster youth in Illinois, Iowa, and Wisconsin found that teens in foster care were more likely than their peers not in foster care to become pregnant, to describe their pregnancies as unwanted and to experience a repeat pregnancy.2 At age 19, 48% of the young women in foster care participating in the study had been pregnant at least once, compared with 20% of girls the same age not in foster care.3 Of those young women in foster care who had been pregnant, 46% became pregnant more than once.4
The first article in this series identified a number of complicated factors at play that may be responsible for the higher rates of pregnancies and births among this population. These factors include complex emotional desires and impulses, social pressures, lack of training among many individuals involved in the lives of teenage foster youth such as court staff, social services, and foster parents, and, frequently, a lack of education among the teens themselves.
The higher rates of teen pregnancy among youth in care raise the question: are these teens accessing the reproductive health services they need? Foster youth cannot access care if appropriate reproductive health care is not available. This article considers one aspect of access by asking whether the full complement of reproductive health care services and education a teen may need is actually available to teens in foster care system. To address this question, this article first reviews experts’ recommendations regarding sexual health services for adolescents. It then compares the recommended level of care to the services currently available under the federal Medicaid program, which is the primary source of coverage for youth in foster care, pointing out areas in which the Medicaid framework matches or falls short of recommended guidelines for sexual health care for adolescents.
Invitation for Readers’ Feedback
As part of NCYL’s efforts, we would like to hear about your experiences and perspective on pregnancy among youth in foster care. Are you concerned about the pregnancy and birth rates among youth in care? Have you seen projects or proposals that have made an impact on access to care? We want to hear from you. For further information or to share your story or perspective, please e-mail rgudeman(at)youthlaw.org.
The Experts Recommend: The AAP’s Bright Futures Standard of Care
The American Academy of Pediatrics (AAP) is a professional medical organization dedicated to the health, safety and well-being of children. Among its many roles, the AAP recommends standards of care for children and adolescents. Bright Futures is one example. Bright Futures is a set of principles, strategies, and tools that are theory based and system oriented to improve the health and well-being of all children.5 The Bright Futures project was initiated in 1990 and funded by the U.S. Department of Health and Human Services, Health Resource Administration’s Maternal and Child Health Bureau.6 The current edition of Bright Futures was developed through the collaboration of multidisciplinary panels, including an expert panel devoted to adolescent health.7
Bright Futures has, among its priorities, established a model level of care for sexual development, pregnancy prevention and sexually-transmitted infection (STI) risk reduction in adolescents.8 It emphasizes the need for personalized information, confidential screening of risk status, health promotion, and age-appropriate counseling relating to sexual development.9 These model policies set forth in Bright Futures identify best practices in care for developing youth.
Accessing Care: The Federal Medicaid Program and Foster Youth
Medicaid is the primary source of health care coverage for youth in the child welfare system.10 All children currently in foster care are eligible for Medicaid via one of two eligibility paths.11 Beginning January 1, 2014, former foster youth will be eligible for Medicaid coverage until age 26 pursuant to the Affordable Care Act.12
Federal rules require that states make certain services available to individuals enrolled in the Medicaid program. Among other things, states are required to make available to children enrolled in Medicaid an “Early and Periodic Screening, Diagnostic and Treatment” program (EPSDT).13 EPSDT is a comprehensive package of benefits aimed at the early identification of health issues coupled with the necessary diagnostic and treatment services. The federal rules require children be provided four separate screens under EPSDT: medical, vision, dental, and hearing screens.14 Medical screening services include a comprehensive health and development history, an unclothed physical exam, appropriate immunizations, appropriate laboratory tests, and health education including “anticipatory guidance.”15 While there is no specific language in the EPSDT framework to require coverage of pregnancy prevention or reproductive health care services, there is language in the State Medicaid Manual to suggest that reproductive health care should be included,16 and in fact there are a number of access points for reproductive health care services within the mandated medical screen.
In addition to the robust benefits available under EPSDT, section 1396d(a)(4)(C) of the Medicaid Act specifically requires the States to cover “family planning services.” These services include family planning services and supplies for sexually active minors and individuals of childbearing age.17
In the following sections, this article describes the services recommended by Bright Futures and notes what is or could be made available within the Medicaid EPSDT and family planning framework to address those recommendations.
A. Comprehensive Health & Development History
The AAP calls for providers to take a health and development history at each annual visit, as well as to engage in ongoing developmental surveillance and risk assessment.18 In the adolescent years, this history should include sexuality as well as pregnancy and STI risk reduction.19 The Bright Futures guidelines specifically direct health care professionals to screen for coercive and abusive relationships among sexually active adolescents.20
EPSDT similarly requires a comprehensive health and development history of each child receiving care under Medicaid. This history includes an assessment of physical and mental health, growth, development, and nutritional status.21
While there is no specific mandate to cover sexual health history as part of the EPSDT health history, a 2011 study by the National Alliance to Advance Adolescent Health (NAAAH) found that three-quarters of states require providers to address sexual behavior as part of the comprehensive history and assessment.22 However, the NAAAH found that seven states offer no guidance on how to address sexual behavior within the context of the comprehensive health history.23
An opportunity exists for these states to bring the practice of adolescent medicine under their EPSDT program in line with the recommendations of Bright Futures by directing providers to include sexual history and development as part of the health and development history and to counsel adolescents about health sexuality.
Unclothed Physical Exam
The AAP recommends unclothed physical exams of adolescents to include a physical inspection for sexual development and signs of sexually transmitted infections.24 In the case of adolescent girls, the AAP directs practitioners to conduct a pelvic exam if clinically warranted based on sexual activity and/or specific problems such as pelvic pain.25
The EPSDT screening provision requires an unclothed physical examination.26 However, neither the Medicaid Act nor the accompanying guidelines specify the inclusion of a pelvic exam for sexually active adolescent girls.27 The NAAAH found in 2011 that notwithstanding the absence of specific direction in the Medicaid framework, 33 states explicitly require a pelvic exam for sexually active females as part of the EPSDT program.28 An additional four states implicitly require pelvic exams by requiring Pap smears as part of the laboratory tests.29 States may boost their delivery of reproductive health care services toward the model envisioned by Bright Futures by specifically requiring pelvic exams if clinically warranted for adolescent girls.
The AAP endorses using the immunization schedule set by the Centers for Disease Control’s Advisory Committee on Immunization Practices (ACIP).30 The human papillomavirus (HPV) vaccine is on the ACIP schedule.31 In recent years, the CDC has approved two vaccines to prevent against infection by certain strains of HPV.32 HPV is associated with cervical cancer and genital warts.33 It is the most common sexually transmitted infection among adolescents in the United States; an estimated 35% of 14-19 year olds are infected.34
Medicaid regulations require that the EPSDT medical screen include “appropriate immunizations” as determined by ACIP.35 This requirement is in line with the recommendation of the AAP and necessarily includes the HPV vaccine. The inclusion of the HPV vaccine among the “appropriate immunizations” under EPSDT is critical to promoting the reproductive health of youth in foster care.
Appropriate Screening and Tests for Sexually Transmitted Infections
Bright Futures directs that all sexually active patients aged 11 to 21 should be screened for sexually transmitted infections to identify when additional testing is warranted.36 The AAP has further directed, in connection with its recommendations regarding health care for foster youth, that the initial health screening evaluation for children in foster care should include “laboratory tests for HIV and other sexually transmitted diseases when indicated clinically or by history.”37 The AAP explains that laboratory tests for HIV and other sexually transmitted diseases are warranted “[b]ecause many young children entering foster care come from settings in which substance abuse and sexual promiscuity are common, they should be considered to be at high risk for HIV infection, hepatitis, and other sexually transmitted infections.”38 Acknowledging these higher risks among youth in foster care is an important step toward addressing their reproductive health needs.
EPSDT requires states to provide Medicaid-enrolled children with appropriate laboratory tests.39 The states are directed to identify as statewide screening requirements “the minimum laboratory tests or analyses to be performed by medical providers for particular age or population groups.”40 The guidelines of the Centers for Medicare & Medicaid (CMS), the agency responsible for Medicaid, direct states to determine the “minimum laboratory tests” in consultation with medical organizations, and specifically offer Bright Futures as available for reference or adoption. However, the Medicaid guidelines acknowledge that physicians providing EPSDT services must use their medical judgment to determine the applicability of laboratory tests, with the exception of mandatory lead testing.41
States could bring their EPSDT benefits in line with the recommendations of the AAP by endorsing screening and laboratory tests for sexually transmitted infections among adolescents.
E. Health Education
Bright Futures offers practitioners a model to guide conversations surrounding sexual development and activity, as well as pregnancy and STI prevention.42 Providers are directed to integrate sexuality education, along with nonjudgmental counseling and care, into their “longitudinal relationship” with their adolescent patients and their patients’ families.43 In addition, the AAP encourages providers to offer information about contraception, including emergency contraception and STI-prevention, to sexually active teens, as well as to those who plan to become sexually active.44
The EPSDT benefits package requires health education for children enrolled in Medicaid. This health education is defined as “anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention.”45 Though this catch-all enumeration is broad enough to include issues surrounding sexual health, there is no clear directive in the Medicaid framework instructing providers to address issues of sexual health, contraception and STI-prevention. Incorporating the clear message of Bright Futures’ anticipatory guidance on these issues would likely assist states in meeting the sexual health needs of adolescents.
F. Annual Visits
Bright Futures recommends annual preventive visits for adolescents between the ages 12 to 21.46 These annual visits provide a forum for the delivery of the array of services envisioned by Bright Futures.
EPSDT requires periodic health care services at distinct intervals that meet reasonable standards of medical practice.47 The Medicaid framework allows states to establish periodicity schedules and offers the AAP’s Bright Futures as one example of a “nationally recognized periodicity schedule.”48 In the end, however, states are given discretion to create their own periodicity schedule.
The periodicity schedule for adolescents in many states lags behind the schedule recommended by the AAP.49 As of 2011, only 36 states require an annual preventive visit during adolescence.50 In those states currently employing a periodicity schedule that does not provide for annual or more frequent visits, accelerating the visit schedule could be an important step in meeting the needs of sexually active teens in foster care.
G. Scheduling and Transportation Assistance
The AAP does not specifically provide recommendations for scheduling or transportation. This, however, is an important aspect of service availability and is part of the EPSDT program. The EPSDT implementing regulations require states to offer scheduling and transportation assistance for EPSDT care and services, if needed.51 Federal regulations require the states to inform adolescents and their families of their right to transportation and scheduling assistance, offer such assistance and provide it upon request.52 For many youth in care, this assistance is vital to ensuring receipt of services. This is especially true in rural areas, where the teen birth rate is disproportionally high.53 The scheduling and transportation assistance requirements could make a meaningful difference to foster youth in need of reproductive health services, especially those in rural areas.
Bright Futures offers a number of ways to assist practitioners to identify issues concerning the health and development of children; the main goal of the comprehensive screen, however, is to provide appropriate care that responds to identified needs.54 Similarly, the goal of EPSDT screening and diagnostic services is to ensure the treatment of issues identified during the screen: “Necessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures.”55 In fact, federal regulations mandate that medically necessary diagnostic and treatment services be made available and covered by EPSDT, regardless of whether the services are otherwise covered under the state Medicaid plan for adults ages 21 and older.56 In this sense, EPSDT can play an important role in making necessary reproductive health care services available to foster youth.
I. Family Planning Services and Supplies
In addition to any services that might be available as part of the EPSDT program, section 1396d(a)(4)(C) of the Medicaid Act requires the States to cover “family planning services,” which include family planning services and supplies for sexually active minors and individuals of childbearing age.57
Although family planning services and supplies are one of the few categories of care mandated by the Medicaid legislation, “family planning” is not defined within the statute.58 CMS guidelines allow States to “determine the specific services and supplies which will be covered as Medicaid family planning services so long as those services are sufficient in amount, duration and scope to reasonably achieve their purpose.”59 Thus the determination of which services to include within the purview of “family planning services” falls to the states.
Given the latitude offered to the states in determining the scope of family planning services under Medicaid, advocates must look to each state’s approach to family planning services. Under California’s Medi-Cal program, for example, “family planning services” are defined to include patient visits, counseling services, contraceptive drugs or devices, tubal ligations, vasectomies, laboratory procedures, and treatment for complications resulting from previous family planning procedures.60
The Opportunity to Improve Services for Foster Youth
As described above, in many instances, the services available under the Medicaid framework track the recommendations of the AAP’s model guidelines established in Bright Futures. In some areas, however, a gap exists between best practices and the level of service offered by the states. This presents an opportunity for states to improve service for adolescents, especially the vulnerable population of youth in foster care, in need of reproductive health care services.
Jennifer Friedman is an attorney working with Rebecca Gudeman at the National Center for Youth Law on issues of reproductive health care for foster youth.
2See Mark Courtney et al, Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Age 21 (Chapin Hall Center for Children, University of Chicago) December 2007, at 5-8.
3See Mark Courtney et al., The Risk of Teenage Pregnancy Among Transitioning Foster Care Youth: Outcomes at Age 19 (Chapin Hall Center for Children, University of Chicago) May 2005, at 54 (surveying foster youth and comparing results to a nationally representative sample of same-aged peers)
4See Amy Dworsky & Mark Courtney, The Risk of Teenage Pregnancy Among Transitioning Foster Youth: Implications for Extending State Care Beyond Age 18, 32 Children and Youth Services Review 2010, at 1; see also Science Says: Foster Care Youth (The National Campaign to Prevent Teen Pregnancy, Washington, D.C.) August 2006, at 1 (reviewing Midwest Evaluation study).
5Joseph F. Hagan, Jr. et al., Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, Introduction, Third Ed. (American Academy of Pediatrics, Elk Grove Village, IL) 2008 at ix.
7Id. at xx (describing multi-disciplinary panels to include 38 individuals representing a wide range of disciplines and areas of expertise).
8See Joseph F. Hagan, Jr. et al., Bright Futures, Guidelines for Health Supervision of Infants, Children and Adolescents, Adolescence: 11-21 Years (American Academy of Pediatrics, Elk Grove Village, Illinois) 2008; Bright Futures, Promoting Healthy Sexual Development and Sexuality, (American Academy of Pediatrics, Elk Grove, Illinois) 2008.
9Bright Futures, Promoting Health Sexual Development and Sexuality supra n.8 at 1.
10The Future of Medicaid and Child Welfare (Child Welfare League of America, Government Affairs), May 2011 at 1.
11Many are eligible because they receive foster care assistance benefits under Title IV-E of the Social Security Act. See 42 U.S.C. §1396a(a)(10)(i)(I). For those foster youth not receiving Title IV-E, all states extend Medicaid eligibility to non-Title IV-E eligible foster children. See Andy Schneider et al., The Medicaid Resource Book, Chapter 1: Medicaid Eligibility, Kaiser Commission on Medicaid and the Uninsured (Kaiser Family Foundation, Commission on Medicaid and the Uninsured, Washington DC) July 2002, at 11, 13; see also The Future of Medicaid, supra note 10.
12See Patient Protection & Affordable Care Act, Pub. L. No. 111-148 § 2004 (2010); Brooke Lehmann, ACA to Keep Foster Care Youth Covered as They Transition to Adulthood (Georgetown Center for Children & Families, Washington D.C.) August 7, 2012, at 1; see also Brooke Lehmann et al., Child Welfare and the Affordable Care Act: Key Provisions for Foster Care Children and Youth (Georgetown University Health Policy Institute, Washington D.C.) June 2012, at 2.
1342 U.S.C. § 1396d(a)(4)(B); see also Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program, Overview of the Medi-Cal Program (National Health Law Program, Washington D.C. 2008) Ch. 12 at 1.
14Jane Perkins, Fact Sheet: Early and Periodic Screening, Diagnosis and Treatment (National Health Law Program, Washington D.C.) March 1999 at 1.
15See 42 U.S.C. § 441.56(b)(1)(i); see also, Perkins, supra note 15.
16In section 5124.B of the State Medicaid Manual, the U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services (CMS) locates prenatal services within the framework of EPSDT and raises the possibility that a wider array of reproductive health care services might be included in EPSDT care. The CMS states:
Prenatal Care Services.–Just as it can provide enhanced services for at-risk infants, EPSDT can link at-risk adolescents to pre-pregnancy risk education, family planning, pregnancy testing and prenatal care. It is important that all pregnant women obtain early prenatal care and that they and newborns be cared for in a setting that provides quality services appropriate to their level of risk. Late care or no care is related to increased prematurity rates. Low birth weight is the most important predictor of illness or death in early infancy. Higher costs of care are associated with the need for neonatal intensive care, extended and repeated hospitalizations, and follow-up services for these infants born at risk.
See 42 U.S.C. § 441.56(b)(1)(i).
1742 U.S.C. § 1396d(a)(4)(C).
18See Hagan Jr., et al., Bright Futures, Adolescence supra n.8; see also Bright Futures, Recommendations for Preventative Pediatric Health Care (American Academy of Pediatrics, Elk Grove, Illinois) 2008 (chart available at http://www.cdc.gov/vaccines/who/teens/vaccines/hpv.html).
19Bright Futures, Adolescence, supra n.8 at 520.
20Bright Futures, Promoting Health Sexual Development and Sexuality supra n.8 at 174.
21See Harriet B. Fox, et al., State EPSDT Policies for Adolescent Preventive Care, Fact Sheet (The National Alliance to Advance Adolescent Health, Washington D.C.) 2011, at 4.
23Id. at 3.
24See Joseph F. Hagan, Jr. et al., Bright Futures, Adolescence, supra n.8 at 522.
26See 42 U.S.C. §§ 441.56(b)(ii)(comprehensive unclothed physical examination).
27See id.; see also CMS, State Medicaid Manual § 5123.2B (Comprehensive Unclothed Physical Examination).
28Fox et al., supra n. 20 at 5.
29Id. at 5.
30See Birth-18 Years and “Catch Up” Immunization Schedules, Centers for Disease Control (Washington D.C.) 2013 (accessed at http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html).
32See HPV Vaccine for Preteens and Teens, Centers for Disease Control (Washington D.C.) February 2013 (accessed at www.cdc.gov/vaccines/who/teens/vaccines/hpv.html on May 22, 2013); see also The HPV Vaccine: Access and Use in the United States, (The Henry J. Kaiser Family Foundation) November 1, 2011 at 1.
34Sexual Health of Adolescents and Young Adults in the United States, (The Henry J. Kaiser Family Foundation) March 28, 2013 at 1.
35See 42 U.S.C. § 441.56(c)(3); see also Medicaid.gov, Early Periodic Screening, Diagnostic and Treatment (Centers for Medicare & Medicaid Services, Baltimore, Maryland (accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-Periodic-Screening-Diagnosis-and-Treatment.html).
36Bright Futures, Recommendations, supra n.18.
37See Health Care of Young Children in Foster Care, Pediatrics (American Academy of Pediatrics, Elk Grove Village, Illinois (2002), at 3.
38Id. at 536.
3942 U.S.C. 441.56(b)(1)(v)(“appropriate laboratory tests”).
40CMS, State Medicaid Manual § 5123.2(D).
42See Bright Futures, Adolescence, supra n.8 at 532-33; see also Rachel Benson Gold, Adolescent Care Standards Provide Guidance for State CHIP Programs, The Guttmacher Report on Public Policy (Guttmacher Institute, New York) June 2003 (reviewing guidelines recommended by American Association of Pediatrics, American Medical Association and American College of Obstetricians and Gynecologists for health guidance on sexual development of adolescents).
43Bright Futures, Promoting Healthy Sexual Development supra n.8 at 174.
45Medicaid.gov, Early Periodic Screening, Diagnostic and Treatment, supra n. 41.
46See Bright Futures, Recommendations supra n. 18.
4742 U.S.C. § 1396a(a)(43); see also Medicaid.gov, supra n.34.
48Medicaid.gov, supra n.34.
49See Jina Dhillon & Jane Perkins, Addressing Adolescent Health: The Role of Medicaid, CHIP and the ACA, (National Health Law Program, Washington D.C.) November 5, 2012 at 7; Harriet B. Fox et al., supra n.20 at 2-3.
50See Harriet B. Fox, et al., supra n.20, at 4.
51See 42 C.F.R. § 441.56 (transportation and scheduling assistance); see also 42 C.F.R. §§ 440.170(a)(1), 440.170(a)(3), 441.62(b) (scheduling services); 42 U.S.C. § 1396a(a)(43)(A); see also U.S. Dep’t. of Health and Human Servs. EPSDT Family Supports (Health Resources & Servs. Admin., Maternal & Child Health) accessed at HYPERLINK “http://mchb.hrsa.gov/epsdt/familysupports.html”http://mchb.hrsa.gov/epsdt/familysupports.html on April 25, 2013.
5242 C.F.R. § 441.62; CMS State Medicaid Manual § 5121(c); see also Jina Dhillon & Jane Perkins, supra n. 48 at 9.
53See Science Says: Teen Childbearing in Rural America (The National Campaign to Prevent Teen Pregnancy, Washington D.C.) 2013 at 1 (finding the teen birth rate in rural counties to be one-third higher than the rest of the country). In 2010, teens in rural counties accounted for 20% of the teen births, but only 16% of the teen population. Id. at 3.
54See Bright Futures, supra n. 8 at xv.
55Medicaid.gov, Early and Periodic Screening, Diagnostic, and Treatment, (Centers for Medicare & Medicaid Services, Baltimore, Maryland (accessed at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-Periodic-Screening-Diagnosis-and-Treatment.html),
5742 U.S.C. § 1396d(a)(4)(C).
58See Rachel Benson Gold & Cory L. Richards, Medicaid Support for Family Planning in the Managed Care Era (The Alan Guttmacher Instit., New York) 2001.
59CMS, State Medicaid Manual § 4270B.
60See California Department of Health & Human Services, Medi-Cal Provider Manual, Chapter 2.