Information Hub / BlogA Closer Look AtLOSER LOOK AT “Realignment”

Much in the child welfare system calls for swift action — children who are in dangerous or neglectful situations must be removed quickly. But other situations, such as the implementation of policies that will affect thousands of children for many years, call for deliberation and reflection. Angie Schwartz makes a compelling case for taking time to carefully consider the impact of “realignment” on California’s foster youth in this guest blog for the John Burton Foundation for Children Without Homes, re-posted below.


By guest blogger Angie Schwartz, Alliance for Children’s Rights California is in the midst of a grand experiment regarding the funding structure of programs designed to protect vulnerable children.  In July 2011, the California Legislature adopted “realignment,” a fiscal policy that shifts a portion of the state sales tax, along with seven functions from the state level to the county level, including the core programs of California’s child welfare system.  These core programs include Foster Care, Child Welfare Services, Adoptions and Adoptions Assistance, and Early Periodic Screening, Diagnosis and Treatment (EPSDT) mental health program. While realignment of programs aimed at providing support and protection to vulnerable children is problematic, the realignment of EPSDT is particularly troubling and will likely result in lasting harm to our state’s most fragile citizens.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), is part of the federal Medicaid program, known as Medi-Cal in California. EPSDT provides comprehensive medical benefits, including mental health services, for low-income children from birth and up until age 21.  The mental health services that are required under EPSDT are especially critical for children in foster care. Research has shown that up to 80% of youth involved with the child welfare system experience emotional and behavioral problems that indicate a need for mental health treatment.

Prior to realignment, counties paid a small portion of the cost of EPSDT mental health services, just 5%. The rest was paid by the federal government (50%) and the state (45%).  Under realignment, the amount paid by counties will now increase from 5% to a full 50%; the federal government will continue to pay its 50%; the state will pay nothing.


Photo Courtesy of “MadamPsych”

Even before increasing the county share of cost tenfold, California was doing a bad job of providing medically necessary mental health services to children in foster care.  According to a report, from the state’s own California Department of Health Care Services, just 60% of youth who required mental health services received them. That’s right – only 60%!  Why?  Because that relatively small share of cost was still a cost to counties – and one they felt they could contain by controlling the services offered and access to those services.

Realignment will exacerbate the problem of access to critical mental health services by creating a greater fiscal incentive for counties to reduce or curtail access to medically necessary mental health services for children.  Under realignment, counties will be responsible for a full 50% of the cost of EPSDT services, with no guarantee that the level of realigned revenues will be adequate.

What is a predictable response for a county in this position? Manage costs by controlling caseload. This notion that caseloads can – or should – be controlled is completely contrary to the legislative intent and mandate of EPSDT.  EPSDT is not intended to be limited or capped based on arbitrary fiscal allocations.  Rather, it is supposed to provide each child the care he or she needs to thrive.

In addition, the capped allocation makes little sense given pending policy changes that will greatly expand the population of youth eligible for EPSDT.  Over the next couple of years, an additional 878,000 new children will enter the Medi-Cal program due to the elimination of the Healthy Families program. In addition, thousands more children will be newly covered by Medi-Cal due to implementation of the federal Affordable Care Act.  Finally, the recent settlement in Katie A. v. Bonta will require that specialized clusters of EPSDT mental health services be provided for youth at risk of group home placement.

However, the legislature is in the process of establishing the fiscal base line for EPSDT when we have no idea how much counties will require to serve these newly eligible children. The combination of these three policy changes create a perfect storm that, without careful deliberation and planning, will likely leave many needy children without critical care and supports.

The Governor’s approach to realignment of EPSDT should be reconsidered. The Legislature should slow down the process and ensure that adequate time and attention is paid to ensuring that our EPSDT mental health system will meet the needs of children and families. Rather then proceeding full steam ahead with all of these changes at once, I believe the Legislature should establish a statewide working group tasked with developing a plan to improve the service delivery system, ensure equity of access between counties, increase accountability, develop outcome measures, determine if EPSDT should be realigned ongoing, and if so, ensure adequate funding for the program in the realigned system.

This Thursday, April 12th, the Senate Budget Subcommittee will hold a hearing on EPSDT realignment starting at 9:30 a.m. in Room 4203. Please join me in encouraging the legislature to press the pause button on the realignment of EPSDT to provide more time for careful deliberation and planning. Yes, the state budget is in a crisis. That is no excuse for proceeding recklessly with the lives of abused and neglected children.

By Toni Heineman