BILL ANALYSIS                                                                                                                                                                                                    

                                                                    SB 1466

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          Date of Hearing:   June 28, 2016


                                Susan Bonilla, Chair

          1466 (Mitchell) - As Amended May 31, 2016

          SENATE VOTE:  39-0

          SUBJECT:  Early and Periodic Screening, Diagnosis, and Treatment  
          Program:  trauma screening

          SUMMARY:  Requires Early and Periodic Screening, Diagnosis, and  
          Treatment (EPSDT) screening services to include screening for  
          trauma, as defined, and requires children removed from the  
          custody or care of their parents or guardians, as specified, to  
          be assessed for specialty mental health services.

          Specifically, this bill:  

          1)Defines "trauma" to mean any physiological response to an  
            event or events or set of circumstances that is experienced by  
            an individual as harmful or life-threatening and that has  
            lasting adverse effects, as specified.

          2)Requires, consistent with federal law, screening services for  
            the EPSDT benefit, as specified, to include at all screenings  
            a screening for trauma.


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          3)Requires a child who is removed from the custody or care of  
            his or her parent(s) or legal guardian(s), as specified, to be  
            assessed by the county mental health plan for specialty mental  
            health services.

          EXISTING LAW:   

          1)Permits the juvenile court to adjudge a child a dependent of  
            the court for specified reasons, including, but not limited  
            to, if a child has suffered or is at substantial risk of  
            suffering serious physical harm, emotional damage, or sexual  
            abuse, as specified.  (WIC 300)

          2)States that the purpose of foster care law is to provide  
            maximum safety and protection for children who are currently  
            being physically, sexually, or emotionally abused, neglected,  
            or exploited, and to ensure the safety, protection, and  
            physical and emotional well-being of children who are at risk  
            of harm.  (WIC 300.2)

          3)Declares the intent of the Legislature to, whenever possible,  
            preserve and strengthen a child's family ties and, when a  
            child must be removed from the physical custody of his or her  
            parents, to give preferential consideration to placement with  
            relatives.  States the intent of the Legislature to reaffirm  
            its commitment to children who are in out-of-home placement to  
            live in the least restrictive family setting and as close to  
            the child's family as possible, as specified.  Further states  
            the intent of the Legislature that all children live with a  
            committed, permanent, nurturing family and states that  
            services and supports should be tailored to meet the specific  
            needs of the individual child and family being served, as  
            specified.  (WIC 16000)


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          4)Authorizes the juvenile court to make any reasonable orders  
            for the care, supervision, custody, conduct, maintenance, and  
            support of a minor or nonminor ward of the court, including  
            medical treatment, subject to further order of the court, as  
            specified.  (WIC 727)

          5)Establishes rights of foster children, including the right to  
            receive medical, dental, vision, and mental health services.   
            (WIC 16001.9)

          6)Establishes the federal Medicaid program to provide health  
            benefits to low-income individuals.  (42 U.S.C. Section 1396  
            et seq.) 

          7)Establishes California's Medicaid program, Medi-Cal, through  
            which eligible low-income individuals receive health care  
            services.  (WIC 14000 et seq.)

          8)Establishes the federal Early and Periodic Screening,  
            Diagnosis, and Treatment (EPSDT) program to provide  
            comprehensive and preventive health services, including  
            preventive, dental, mental health, and developmental, and  
            specialty services, to Medicaid beneficiaries under the age of  
            21.  Requires states to administer EPSDT as a condition of  
            receiving federal Medicaid funds.  (42 USC Section 1396)

          9)Requires county mental health departments that receive full  
            system of care funding, as specified, to provide children  
            served by county social services and probation departments  
            mental health screening, assessment, participation in  
            multidisciplinary placement teams and specialty mental health  
            treatment services for children placed out of home in group  


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            care, for those children who meet the definition of medical  
            necessity, to the extent resources are necessary.  (WIC  

          10)Requires each local mental health plan to establish a  
            procedure to ensure access to outpatient specialty mental  
            health services, as required by EPSDT program standards, for  
            any child in foster care who has been placed outside his or  
            her county of adjudication.  (WIC 14716)

          FISCAL EFFECT:  According to the Senate Appropriations Committee  
          analysis on May 27, 2016, this bill may result in the following  

          1)Increased costs in the low millions of dollars per year for  
            additional screening provided to Medi-Cal eligible children  
            (General Fund and federal funds).  Under current federal and  
            state law, children enrolled in Medi-Cal are eligible for the  
            EPSDT benefit.  This benefit covers screening for both  
            physical and mental health issues.  By specifically requiring  
            screening for trauma, the bill is likely to increase the costs  
            to provide screening services due to additional time spent by  
            providers with eligible children.  It is not clear to what  
            extent children are already being screened for trauma.  It is  
            likely that the specific requirement in the bill will lead to  
            increased focus on trauma during screening.  For example, if  
            the cost to provide trauma screening increased the overall  
            cost of screening under EPSDT by 5%, the cost would be about  
            $2 million per year.

          2)Increased costs of $5 million to $10 million per year to  
            provide assessments for specialty mental health services by  
            county mental health plans (General Fund and federal funds).   
            The bill would require all children who have been removed from  
            the home to be assessed by a county mental health plan for  


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            specialty mental health services.  There are about 15,000 new  
            foster care placements per year in the state.  The cost to  
            provide an assessment for specialty mental health services is  
            around $500. 

          3)Likely increase in specialty mental health services in the  
            hundreds of millions per year (General Fund and federal  
            funds).  Under the bill, about 6.5 million children are likely  
            to get additional screening for trauma.  Currently, there is a  
            very low rate of utilization of specialty mental health  
            services by Medi-Cal eligible children.  It is likely that the  
            requirement for additional screening in the bill will result  
            in a significant number of children receiving being referred  
            for specialty mental health services who are not currently  
            receiving those services.  Currently, 4.4% of children receive  
            specialty mental health services, at an average annual cost of  
            $6,000.  If 5% of the children who are likely to be found to  
            have experienced trauma under the bill are subsequently found  
            to be eligible for specialty mental health services, the cost  
            would be about $500 million per year.

          4)Unknown potential future costs savings for Medi-Cal services  
            (General Fund, federal funds, local funds).  Under the bill,  
            it is likely that a significant number of Medi-Cal children  
            will be determined to have experienced trauma and to be in  
            need of mental health services - over and above those who are  
            currently being identified.  By identifying those children, it  
            is possible that early mental health interventions could  
            improve those children's long-term prognoses and reduce future  
            costs, such as psychiatric hospitalizations and other health  
            care costs associated with trauma (for example health care  
            services related to alcohol or substance abuse).  The extent  
            to which those would occur is unknown.



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          Child Welfare Services:  The purpose of California's Child  
          Welfare Services (CWS) system is to protect children from abuse  
          and neglect and provide for their health and safety.  When  
          children are identified as being at risk of abuse, neglect or  
          abandonment, county juvenile courts hold legal jurisdiction and  
          children are served by the CWS system through the appointment of  
          a social worker.  Through this system, there are multiple  
          opportunities for the custody of the child, or his or her  
          placement outside of the home, to be evaluated, reviewed and  
          determined by the judicial system, in consultation with the  
          child's social worker, to help provide the best possible  
          services to the child.  The CWS system seeks to help children  
          who have been removed from their homes reunify with their  
          parents or guardians, whenever appropriate, or unite them with  
          other individuals they consider to be family.  As of January 1,  
          2016, there were 62,148 children in California's child welfare  

          Childhood trauma:  According to the Jim Casey Youth  
          Opportunities Initiative, "When a child experiences stress, the  
          body's stress response system is activated and produces  
          physiological changes in the body and the brain.  Some forms of  
          stress are positive or tolerable and contribute to children's  
          ability to develop coping skills throughout their lifetimes.   
          When a young child's stress response systems are activated  
          within an environment of supportive relationships with adults,  
          these physiological effects are buffered and brought back down  
          to baseline.  Traumatic events can cause stress levels to move  
          past a tolerable level and become toxic, potentially causing  
          physical and long lasting damage to the developing brain.   
          Responsive relationships with caring adults can mediate toxic  
          stress exposure; otherwise, the stress can lead to physical and  
          mental health problems that could last well into the adult  


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          Maltreatment, removal from the home, foster care placement, and  
          detention in the juvenile justice system have been shown to  
          contribute to high proportions of dependents and wards of the  
          court experiencing trauma.  Kaiser Permanente's Department of  
          Preventive Medicine and the Centers for Disease Control and  
          Prevention (CDC) have conducted one of the largest studies of  
          childhood abuse and neglect and their impacts on health and  
          well-being later in life.  This investigation, the Adverse  
          Childhood Experiences (ACE) Study, began in 1995 with two waves  
          of data collection where over 17,000 Health Maintenance  
          Organization members in Southern California filled out  
          confidential surveys regarding their childhood experiences and  
          current health status and behaviors.  Today, the CDC continues  
          ongoing monitoring of ACEs.

          The ACE Study found that traumatic experiences such as physical  
          abuse, sexual abuse, neglect, and exposure to domestic violence  
          during childhood were correlated health problems as adults; that  
          is, emotional experiences as a child can impact one's physical  
          and mental health as an adult.  The Jim Casey Youth  
          Opportunities Initiative observes that, "the findings of the ACE  
          Study regarding early traumatic experiences in children's lives  
          have important implications for young people in foster care,  
          including the vital importance of trauma-informed services that  
          promote current and future well-being."

          EPSDT and specialty mental health services:  State mental health  
          services are delivered through local county mental health  
          authorities to Medi-Cal beneficiaries and others with  
          significant mental health needs.  Children and youth under the  
          age of 21, including foster youth, are eligible for EPSDT  
          Rehabilitation and Specialty Mental Health Services if they  
          receive Medi-Cal and meet medical necessity criteria.  Federal  
          Medicaid law defines EPSDT services broadly, to include  
          preventive, diagnostic, and treatment services such as case  


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          management, crisis intervention, outpatient mental health  
          services, and many others.  States must provide coverage for  
          certain services when they are determined to be medically  
          necessary for a child.  For children under 21, Medi-Cal managed  
          care plans cover screening, preventive, and diagnostic treatment  
          services for youth with mild to moderate mental health needs.   
          Screening services under EPSDT must include a minimum set of  
          factors, and periodic assessments must take place according to  
          state guidelines for screening frequency based on a child's age  
          and nature of the screening.  

          County mental health plans, under the Medi-Cal Specialty Mental  
          Health Services Waiver, generally provide mental health services  
          to Medi-Cal beneficiaries with severe mental health issues.   
          These specialty mental health services are an entitlement under  
          Medi-Cal for children and adults who meet medical necessity  
          criteria, including having a specific covered diagnosis,  
          functional impairment, and who meet intervention criteria.  

          Need for this bill:  According to a report from the Department  
          of Health Care Services' and the Department of Social Service's  
          guide, Pathways to Mental Health Services - Core Practice Model  

            "In any given year, over 30,000 children come into the care of  
            California's Child Welfare System.  Most are victims of abuse  
            or neglect and live with caregivers who are impaired, and/or  
            deal with school and community violence as a fact of life.  In  
            addition, many of the families that come to the attention of  
            the child welfare system have experienced multigenerational or  


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            historical trauma- collective emotional and psychological  
            injury both over the individual lifespan and across  
            generations, resulting from massive group trauma experiences.   
            Identifying these traumas, preventing further trauma and  
            providing interventions are crucial to assisting children  
            traumatized by maltreatment and other stressors.   
            Understanding the impact of trauma on individuals is essential  
            in meeting the needs of children, youth and their families in  
            the child welfare system?Trauma experiences affect brain  
            function, the attainment of developmental milestones, social  
            perceptions and relationships, health, emotion and behavior."

          According to the author: 

            "Children in foster care have suffered from abuse, neglect or  
            exploitation, and have suffered secondary trauma as a result  
            of being removed from their parents.  [This bill] is needed to  
            ensure that distressed children are appropriately screened for  
            trauma without delay.  Under California law, the treatments of  
            children's mental health needs are determined by the severity  
            of the diagnosis.  Because we do not currently screen under  
            EPSDT for trauma, we run the risk of delaying treatment to  
            this vulnerable population because of this complicated  
            delivery model.  By requiring trauma screening by a designated  
            agency on the front-end, we minimize possible delays in  
            critically-needed treatment."


          SB 1291 (Beall), 2016, would require, among other things, each  
          mental health plan to submit a foster care mental health service  
          plan to the Department of Health Care Services that details the  
          services available to Medi-Cal eligible children and youth under  
          the jurisdiction of the juvenile court and their families.  This  
          bill has been referred to the Assembly Appropriations Committee.


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          SB 1220 (McGuire), 2016, would require that a summary or copy of  
          a treatment plan be included in the case plan of a child who is  
          within the jurisdiction of the child welfare system and who has  
          been assessed as needing behavioral health services, as  
          specified.  This bill will be heard in the Assembly  
          Appropriations Committee on June 29, 2016.

           SECOND COMMITTEE OF REFERENCE  .  This bill was previously heard  
          in the Assembly Health Committee on June 14, 2016 and was  
          approved on a 15-0 vote.



          Alameda County Board of Supervisors 
          Alliance for Children's Rights 
          CA Youth Connection (co-sponsor) 
          California Alliance of Child and Family Services 
          Californians for Safety & Justice (co-sponsor) 
          California School Employees Association 
          Children NOW 
          California Pan-Ethnic Health Network (CPEHN) 
          Children's Defense Fund 
          County Welfare Directors Association (CWDA) 
          FIGHT CRIME: Invest in Kids, CA 
          Futures Without Violence 
          Health Access California 
          National Health Law Program (NHeLP) 


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          San Luis Obispo County Department of Social Services 
          Trinity County Health and Human Services 
          Western Center on Law and Poverty 
          Youth Law Center (co-sponsor) 


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          California Right to Life Committee, Inc. 

          Analysis Prepared by:Daphne Hunt / HUM. S. / (916)