Preventing Institutionalization of California’s Foster Youth
Katie A. v. Bonta, a federal class action lawsuit filed on behalf of California foster youth and children at risk of out-of-home placement, was filed in July 2002. The lawsuit sought to improve access to intensive home and community-based mental health services offered through Medi-Cal, California’s Medicaid program. After a decade of litigation and negotiation, the parties reached a landmark settlement in September 2011. When fully realized, an estimated 35,000 youth in California may receive intensive mental health services in their own homes and communities. Young Minds’ President, Patrick Gardner, served as co-counsel from 2003.
When the Katie A.* lawsuit was filed, Katie was 14 years old and had been in foster care for 10 years. She was removed from her home at the age of four due to neglect; her mother was living on the street and her father was incarcerated. By age five, Katie’s assessments indicated she was a victim of trauma and in need of treatment. Despite pleas to the Department of Child and Family Services (DCFS) by her caregiver, Katie never received the mental health treatment she needed. Instead DCFS shuffled Katie from one inappropriate placement to another—37 placements in all—including psychiatric facilities and group homes. Needless to say, the instability and lack of adequate treatment was devastating.
Unfortunately, Katie’s story is not so unusual. Children placed outside the home due to abuse or neglect disproportionately suffer mental health disorders. Adolescents living with foster parents or in group homes have about four times the rate of serious mental health needs than those living with their own families. Institutional or group care may be necessary for some youth with extremely high level needs, but for others it is unnecessary—even harmful. Indeed, separating children from their homes and families may add to their distress. To make matters worse, children in state custody often do not receive needed appropriate mental health treatment. According to the Surgeon General, although three out of every five children in out-of-home care have moderate to severe mental health problems, fewer than one in three receive any mental health treatment.
Under the children’s provisions of the Medicaid Act, known as Early and Periodic Screening Diagnostic and Treatment (EPSDT), federal law requires states to provide children and youth with a broad array of mental health services and supports, including intensive home and community-based services. Providing these services helps prevent costly – and frequently ineffective – residential placements. Further, by providing intensive mental health treatment in the home before behaviors escalate beyond the family’s ability to cope, fewer children will enter foster care. Unfortunately, intensive home-based services are often not available, and until recently, the State of California did not acknowledge that Medicaid-eligible children and families were entitled to these services.
The Katie A. v. Bonta lawsuit was filed in July 2002 as a federal class action lawsuit on behalf of California foster youth and children at risk of out-of-home placement. The suit named as defendants the former California Department of Health Services (now the Department of Health Care Services (DHCS)), the California Department of Social Services (CDSS) and Los Angeles County’s Department of Children and Family Services. The suit was brought to remedy violations of federal and state law, including the Medicaid Act, the Fourteenth Amendment’s Due Process Clause, the Americans with Disabilities Act, and the Rehabilitation Act.
Los Angeles County quickly reached a settlement in March 2003. The County committed to making comprehensive reforms and expanding intensive home and community-based mental health services. More than ten years later, implementation of the settlement agreement is ongoing, and intensive services are now more accessible for children in Los Angeles County. Los Angeles County is the largest child welfare system in the country and about 40 percent of California’s foster youth reside there.
Litigation against the state defendants continued for several years. In March 2006, the District Court judge granted plaintiffs’ motion for a preliminary injunction and ordered California to provide home and community-based wraparound services and therapeutic foster care statewide. A year later, the Ninth Circuit Court of Appeals reversed the District Court’s order, while affirming the broad and deep EPSDT entitlement to mental health services. After additional proceedings, the plaintiffs’ filed a renewed motion for a preliminary injunction in January 2008. The District Court then ordered the parties to negotiate, appointed a Special Master to oversee the process, and in September 2011, the parties reached a settlement agreement.
In the settlement agreement, California agreed to make two types of mental health services, “Intensive Home-Based Services” and “Intensive Care Coordination,” available to Medi-Cal eligible children in foster care or at risk of out of home placement. These services include intensive mental health treatments such as educating parents on their child’s strengths and needs, intensive case management, in-home mental health aides, etc., and must be provided using a wraparound approach called the Core Practice Model. The State also agreed to determine what parts of Therapeutic Foster Care services are covered under the Medicaid Act, and make those services available, as well.
The Katie A. settlement agreement limited the federal District Court’s oversight of implementation to three years. Accordingly, the court’s enforcement jurisdiction over the State settlement concluded in December 2014.
Although the Court’s oversight role of the state defendants has ended, California remains obligated to provide Katie A. services to all eligible youth for whom these services are medically necessary. In October 2014, the State issued an All County Letter confirming that counties will “continue with implementation activities and practices on an ongoing basis so that all eligible children and youth receive [Specialty Mental Health Services], including [Intensive Care Coordination] and [Intensive Home-Based Services], as medically necessary.” The letter reaffirmed that Katie A. services were a federal entitlement and emphasized the need for county mental health plans and local child welfare agencies to work together to deliver Katie A. services. to children and youth.
Young Minds continues to closely monitor the rollout of services statewide. Enrollment and other information is available here and on the state CDSS and DHCS websites.
*Katie A. is not the plaintiff’s real name. The Courts use a pseudonym to protect the child’s true identity.
Our co-counsel included the National Health Law Program, Western Center on Law and Poverty, Bazelon Center for Mental Health Law, Disability Rights California, National Center for Youth Law, and ACLU of Southern California.