BILL ANALYSIS Ó SB 1466 Page 1 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. SB 1466 Page 2 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) SB 1466 Page 3 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 SB 1466 Page 4 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 SB 1466 Page 5 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: SB 1466 Page 6 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." SB 1466 Page 7 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 SB 1466 Page 8 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 SB 1466 Page 9 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. SB 1466 Page 10 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) SB 1466 Page 11 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) SB 1466 Page 12 Opposition California Right to Life Committee, Inc. Analysis Prepared by:Daphne Hunt / HUM. S. / (916) 319-2089