CHILD WELFARE: Navigating a Fractured System, Part 2

By Robyn Murray, KVNO News

January 13th, 2012

Omaha, NE – We continue our special report on child welfare in Nebraska today. In part one of our series, Child Welfare: Navigating a Fractured System, we talked to families whose children have been removed from the home, and are fighting to get them back. Today, we’ll talk to families whose children need help outside the home. In both cases, critics of the child welfare system say the state is making the wrong choice – one that’s more expensive for Nebraska and more traumatic for families.

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“When I found out he was going to be here in Omaha, I put my two week’s notice in, and drove him out here.” Shayla Alex is a young mom who moved from Scottsbluff to Omaha five years ago – to get help for her son.

He was severely aggressive, and had been diagnosed with an “alphabet” of ailments. Between the ages of five and six, he was hospitalized six times. Five years ago, he spent eight months in Boys Town, a residential treatment center, and Alex said his behavior became much more manageable. Then, he hit puberty and his aggression got out of control.

“My son has beat me to a living pulp,” Alex said. “I’ve had black eyes, broken lips. And I’m not a small person. When he goes into a rage, even though he’s 12, he goes into a rage and there’s nothing that can stop him.”

Alex is trying to get her son back into Boys Town. But Nebraska’s Medicaid office said he no longer qualifies.

“And that is the most frustrating feeling in the world,” Alex said. “When there’s services that your child could benefit from, has proven to benefit from, but Medicaid just refuses to pay for them.”

“The decision to deny is done by psychiatrists who … have practices here in Nebraska,” said Vivianne Chaumont, the director of the Division of Medicaid and Long-Term Care at Nebraska’s Department of Health and Human Services. “And you can have the care,” she said. “What we decide is whether or not we’re going to pay for it. And that’s pretty standard practice.”

Two years ago, Medicaid may have paid for Alex’s care. But Chaumont said the state was notified by the federal government that it was out of compliance. She said it was covering too many out-of-home services for children who shouldn’t qualify. Chaumont said the state developed a case plan to move into compliance, and that included a more restrictive definition of who qualifies for high-level treatment.

“It’s very complicated,” said Carolyn Rooker, the Executive Director of Voices for Children in Nebraska. “It’s very difficult to understand what is really the (federal government) saying that you can and can’t fund with Medicaid, and what the states are choosing not to, in terms of trying to save money.”

Rooker said the state is deliberately applying a narrow interpretation of federal guidelines to save money. “The interesting part of that,” she said, “is if they don’t fund those things, it ends up going to the child welfare system, and it costs more.”

If the state denies a child services through Medicaid, their family is often left with the option of turning the child over to state custody in order to receive those services. That costs the state more because it loses the federal match that’s provided through Medicaid.

While there are some community-based services available to children, the residential treatment that Shayla Alex wants to see available to her son, is typically not covered by any other program.

Sarah Forrest, a policy coordinator for Voices for Children in Nebraska, says Nebraska has never invested enough in strong, in-home, community-based supports. And while residential treatment should be a last-resort option, she says, it’s sometimes the only option for families who have not received help, while their child’s behavioral problems worsen.

Part of this gap in services came to light in the headline-grabbing “safe haven” debacle in Nebraska in 2008. At that time, the state’s safe haven laws were expanded to allow parents to drop off their children at local hospitals, and hand them over to state custody, no questions asked. States typically apply “safe haven” laws to newborn babies, in an attempt to prevent children being abandoned.

A resulting series of drop-offs of teen children with behavioral and mental health problems led the state to begin a massive reform effort to overhaul the child welfare system. The goal of reform was to lower the number of children in state custody – across the system. That meant providing more options for families struggling with children with behavioral health problems, so that turning them over to state custody would not be necessary; as well as improving in-home assistance for families living in poverty to reduce incidents of “neglect” that lead the state to intervene and remove children from their homes. (This issue is detailed in our first report in this series).

Senator Kathy Campbell, who chairs the Legislature’s Health and Human Services Committee, said when it comes to children with behavioral health issues, she’s concerned the state has not expanded and improved in-home and community-based services, before reducing other options like residential treatment. “We have to make sure services are there before we make changes,” she said.

Vicki Maca is an administrator with the Department of Health and Human Services, and heads the child welfare reform efforts. She said part of the problem of reforming the system to make more sense for families, and make better choices, is coordinating the multiple agencies involved, and the multiple payers. “I think it is a challenge for us to coordinate and integrate services as much as possible,” she said. “And I think we get better at that each year and each month. And we still have work to do in that area, there’s no doubt about it.”

Part of that coordination is also necessary to paint a clearer picture of where DHHS is spending money on child welfare, and where it could be saving. A recent audit of DHHS showed millions of dollars had been spent – unaccounted for – since reforms to the system began in 2009.

“I think that’s where the legislature has had some frustration in the last couple of years,” said Sen. Campbell. “Because we have not really been able to have a handle on what is the budget for child welfare – all the components to it, and what is being spent.”

Campbell’s committee released a comprehensive report in December that detailed some of those complaints, and made recommendations to help make the system more accountable. The report also made other recommendations, including returning duties like case management from private contractors to the state. Governor Dave Heineman has expressed some concern about those recommendations – and how much they will cost the state, although he said he’s open to discussion.

“A lot of this has been about money,” Maca said. “And I’ll just be very honest with you. That’s been a hard one for me as a social worker. A lot of the attention has been on the dollars and the funding and while that’s very, very important, I don’t want people to lose sight about what this is all about.”

“This is about keeping the most vulnerable population in our state, kids, safe.”

Child welfare is set to be one of the main priorities for Nebraska lawmakers at the Capitol this year. Legislation has already been introduced to roll back more planned cuts to Medicaid and increase oversight of the child welfare system. Vivianne Chaumont in the Medicaid office also said she is taking another look at some of those restrictions to see if there’s some flexibility there.

Shayla Alex will have to wait to see if any of those changes will affect her son. And in the meantime, she said she’ll to continue to ignore those voices telling her to give up her child. “Every time I turn around, people are coming to me saying just sign him over, sign him over to the state, just make him a state ward,” she said. “Why would I want to place him with people who don’t know him, don’t understand him?”

“I would never walk away from my son,” she said. “I will always love him, regardless of battle scars or not. I know deep inside that he would never want to do that to me.”

“He just doesn’t know what else to do right now.”