BILL ANALYSIS Ó
SB 1466
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Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Susan Bonilla, Chair
SB
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
5867.5)
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
costs:
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.
COMMENTS:
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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
system.
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
years."
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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
Guide:
"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."
RELATED LEGISLATION:
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.
REGISTERED SUPPORT / OPPOSITION:
Support
Aspiranet
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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Opposition
California Right to Life Committee, Inc.
Analysis Prepared by:Daphne Hunt / HUM. S. / (916)
319-2089