The unique health, legal, and social status of children in foster care* poses particular problems for the designers of any kind of health plan. Because many children in out-of-home care are highly mobile, moving from family to family, and from one geographic locale to another, the context of their lives challenges the assumptions that health insurance is based upon. This article attempts to highlight current access to health care services for this group of children, how the President's proposed Health Security Act would affect the delivery of health care services, and what special considerations are necessary to meet the needs of this particular group of children. We have focused on the President's plan partially because it provides the greatest amount of detail, and partially because it has the greatest likelihood of doing the most to improve the availability of appropriate health care services for children in general, and children in foster care in particular.** The analysis printed here is based upon the version of the American Health Security Act that was introduced in Congress by members of the House and Senate on November 22, 1993 (H.R. 3600/S. 1757). This most recent version of the Health Security Act has incorporated changes that greatly improve the extent of coverage and other considerations for children in foster care compared to earlier drafts of the plan.
Studies have documented that while children in foster care experience high rates of serious health problems, they also face significant obstacles in their access to essential health care services. Although professional organizations such as the American Academy of Pediatrics and the Child Welfare League of America have developed excellent standards for health care services for children in foster care, the actual delivery of health care services to this needy population falls far short of these standards. The reasons for this failure relate to both the financing of services and the organization of care. President Clinton's proposed American Health Security Act of 1993 would have a major impact on the accessibility of health care services for children in foster care. In a number of important respects, the proposed plan would improve access, but in other critical areas it would limit essential care.
HEALTH CARE ACCESS UNDER CURRENT LAW FOR CHILDREN IN FOSTER CARE
WHO ARE THE CHILDREN IN FOSTER CARE?
The population of children in foster care is growing rapidly. There were an estimated 460,000 children in foster care at the end of fiscal year 1993, with more than 659,000 served by the system during that year. In the wake of escalating and persistent poverty, family violence, mental illness, and the drug epidemic, the number of children in foster care has been increasing nationwide since 1985. It is projected that 500,000 to 600,000 children will be in foster care by 1995. The vast majority of these children live in family foster homes (70%); the remainder are in group homes, residential treatment centers, or institutional settings.
WHAT ARE THE HEALTH CARE NEEDS OF CHILDREN IN FOSTER CARE?
Children in foster care have high rates of serious health problems. Several studies have documented that children in foster care have high rates of chronic medical problems that require ongoing treatment. Approximately 60% of children in foster care have moderate to severe mental health problems. Children in foster care also experience high rates (40%) of physical health problems (e.g., asthma, growth disorders, neurological abnormalities). The high frequency of health and mental health problems is a result of the children's poor health prior to placement, the effects of abuse and neglect, the effects of separation and frequent moves, and the lack of access to appropriate health and mental health services. A particular concern is the increasing number of infants entering care with multiple health and developmental needs due in large part to maternal drug use and prenatal exposure to drugs. …