Child Welfare: States Use Flexible Federal Funds, But Struggle to Meet Service Needs
Published: 2013-01-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In fiscal year 2011, over 675,000 children were found to be victims of abuse or neglect. To help ensure that such children have safe and permanent homes, state and local child welfare agencies secure child welfare services, such as parenting classes and substance abuse treatment. Title IV-B of the Social Security Act is the primary source of federal funding designated for child welfare services that is available to states. In fiscal year 2012, Congress appropriated $730 million under Title IV-B. Although states augment these funds with state, local, and other federal funds, some children and families may not receive the services they need. Congress mandated that GAO provide information about the funding and provision of child welfare services. This report addresses: (1) how selected states use funds provided under Title IV-B, (2) what alternative sources of federal funding states use to fund child welfare services and other activities covered under Title IV-B, and (3) what services, if any, child welfare agencies have difficulty securing for children and their families. To answer these questions, GAO reviewed relevant laws, regulations, guidance, and reports; analyzed HHS expenditure data and program evaluations; and interviewed HHS officials, child welfare experts, and state and local child welfare officials in 4 states and 13 localities selected to illustrate a variety of approaches to financing and delivering services. GAO also reviewed state fiscal year 2011 expenditure data from selected states and administered a data collection instrument to selected localities.
section_title: What GAO Found
paragraphs: The four states GAO selected used funds provided under Title IV-B of the Social Security Act for a variety of child welfare services and other activities, and had different strategies for spending these funds. For instance, in fiscal year 2011 Virginia provided funding to all local child welfare agencies to spend on their own priorities, such as parenting classes. New Mexico targeted certain counties for services, such as intensive in-home services for families at risk of foster care.
States nationwide also use other federal funds, such as Temporary Assistance for Needy Families (TANF) and Social Services Block Grant (SSBG) funds, as well as Medicaid, for purposes covered under Title IV-B. In the spring of 2011, 31 states reported spending TANF funds, and in fiscal year 2010, 44 states reported spending SSBG funds on these purposes. Some states also claim federal Medicaid reimbursement for activities covered under Title IV-B. One selected state, Minnesota, claimed reimbursement for case management for children at risk of foster care placement in 2011. Funds authorized under Title IV-E of the Social Security Act make up the large majority of federal child welfare funds, but are designated for purposes such as providing room and board payments for children in foster care and subsidies to adoptive parents, and generally cannot be used for child welfare services. However, 14 states have waivers allowing them to use these funds more flexibly to improve child and family outcomes. Among GAO's selected states, Florida had a waiver allowing it to use some Title IV-E funds for in-home services designed to prevent foster care placement.
Many services, including substance abuse treatment and assistance with material needs, such as housing, are difficult for child welfare agencies to secure due to a variety of challenges. A 2008-2009 U.S. Department of Health and Human Services (HHS) survey that sampled children and families in the child welfare system found that many did not receive needed services. For example, an estimated 58 percent of children age 10 and under at risk of emotional, behavioral, or substance abuse problems had not received related services in the past year. Local child welfare officials in four selected states reported service gaps in multiple areas. Service gaps may harm child wellbeing and make it more difficult to preserve or reunite families. For example, officials from one locality noted 2- to 3-month wait times for substance abuse services. Due to the chronic nature of the disease, delays in receiving services may make it more difficult to reunify families within mandated deadlines. Officials cited factors contributing to service gaps that included provider shortages and lack of transportation. Additionally, officials noted difficulty securing services from partner agencies, such as housing authorities. State fiscal constraints, which affect both child welfare and partner agencies, contribute to such difficulties.

section_title: Letter
paragraphs: In fiscal year 2011, states reported that over 675,000 children were  victims of maltreatment, often abused or neglected by their parents. To  help ensure that children affected by abuse and neglect have safe and  permanent homes, the federal government provides states with funding to  assist them in carrying out state and local child welfare programs.  Services designed to ensure that children live in safe and permanent  homes, either with their parents or with other caregivers, are commonly  referred to as child welfare services. Such services may include parenting  classes, mental health counseling, and substance abuse treatment. In  many cases, services aim to improve how a family functions so that  children can remain safely at home or return home from foster care.
Funds provided under Title IV-B of the Social Security Act (Title IV-B) are  the chief source of federal support explicitly targeted at child welfare  services. In fiscal year 2012, Congress appropriated $730 million under  Title IV-B. The Administration for Children and Families (ACF) within the  U.S. Department of Health and Human Services (HHS) distributes Title  IV-B funding to state child welfare agencies. In addition to Title IV-B  funds, states may also use state, local, and other federal funds to support  services to children and families. Some of these other federal funds are  not specifically designated for child welfare, but states are allowed to use  them to fund some services to children and families in the child welfare  system. For instance, Social Services Block Grant (SSBG) goals include  preventing or remedying child abuse; a wide variety of services, including  parent education and training, may be supported with these funds. While  other federal funding sources like SSBG may be used for purposes  similar to those of Title IV-B, the service needs of children and families  are complex, and agencies may face difficulty meeting them.
Congress mandated in the Child and Family Services Improvement and  Innovation Act of 2011 (which extended funding authorization for Title IV- B) that GAO explore issues related to federal funding sources for child  welfare services and family service needs. This report addresses: (1)  how selected states use funds provided under Title IV-B, (2) what  alternative sources of federal funding states use to fund child welfare  services and other activities covered under Title IV-B, and (3) what  services, if any, child welfare agencies have difficulty securing for children  and their families.
DeVooght et al., Federal, State, and Local Spending to Address Child Abuse and Neglect  in SFYs 2008 and 2010 (Washington, D.C.: Annie E. Casey Foundation and Casey Family  Programs, June 2012). on service needs and service receipt from ACF’s National Survey of Child  and Adolescent Well-Being (NSCAW) and analyzed findings on the  availability of services from an aggregate ACF report on its Child and  Family Services Reviews. Further, we used data from a survey funded  by Casey Family Programs to describe waiting lists for various types of  child welfare prevention services reported by states. We determined  through interviews with knowledgeable officials and reviewing existing  information about the data that the data sources cited above were  sufficiently reliable for our purposes. Lastly, in response to our  Congressional mandate, we reviewed academic studies that explored the  impact of substance abuse treatment on family reunification outcomes.
States vary in how they fund and organize their child welfare programs. The majority of  states administer their child welfare programs centrally, but some supervise child welfare  programs that are administered by localities. them to be sufficiently reliable for our purposes. We used these data to  identify expenditures of federal funds that appeared to be for purposes  covered under Title IV-B. We excluded foster care maintenance  payments and adoption subsidies from the scope of our review, because  they are typically not covered under Title IV-B. Due to their similarity to  foster care maintenance payments and adoption subsidies, we also  excluded maintenance payments made to relative caregivers of children  in foster care and subsidies to relatives who become legal guardians of  children leaving foster care. We interviewed ACF officials and various  child welfare experts who had published reports on topics relevant to our  research questions. We also conducted a discussion group with officials  from seven state child welfare agencies at ACF’s 18th National  Conference on Child Abuse and Neglect. We assembled officials for the  discussion group with the help of the American Public Human Services  Association and the National Association of Social Workers.
We conducted this performance audit from January 2012 through January  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: In 2011, an estimated 6.2 million children were referred to child welfare  agencies by sources including educators, law enforcement officials, and  relatives because they were allegedly maltreated. After an initial  screening process, agencies conducted abuse or neglect investigations  and assessments on behalf of more than half of these children. Over  675,000 children were found to be the victims of abuse or neglect. Many  of the children (both victims and non-victims) who were referred to child  welfare agencies, as well as their caregivers and families, received some  child welfare services, such as in-home services and counseling or other  mental health services. Child welfare agencies also conduct activities  referred to in the report as non-service related. These non-service-related  activities include investigating allegations of abuse or neglect (known as  child protective investigations), providing case management for children  at home or in foster care, training staff, and administering programs.  Further, child welfare agencies make payments to caregivers of children  in foster care (maintenance payments) and to adoptive parents of former  foster children and other eligible children with special needs (adoption  subsidies).
subsections: section_title: Child Welfare Services
paragraphs: Children referred to child welfare agencies as well as their families may  need a variety of services. Families may need services to prevent child  abuse or neglect, or to help stabilize the family if abuse or neglect has  occurred so that the child can safely remain at home. If it is not in a child’s  best interest to remain at home, the child may be placed in foster care. In  these cases, services may be offered to help the family reunite. If  reunification is not possible, services may be needed to encourage  adoption and support adoptive families. Some common types of child  welfare services are listed in table 1, below.
Child welfare agencies secure services in a variety of ways. Child welfare  agency staff may provide some services directly in addition to carrying out  typical case management duties. Child welfare agencies may also rely on  contractors, also called purchased service providers. Another way child  welfare agencies secure services is by relying on partner agencies, such  as behavioral health agencies and public housing authorities. These  agencies serve families in the child welfare system in addition to clients  who are not in the child welfare system. Child welfare agencies also refer  individuals for medical services. Medical services may be supported in a  variety of ways, including through Medicaid or private health insurance.
Figure 1, below, is an example of how a child welfare agency might  meet—using various providers and funding sources—a hypothetical  family’s diverse service needs.
States are chiefly responsible for funding and administering child welfare  programs. Most states administer their child welfare programs centrally.  However, in some states, local agencies administer their own child  welfare programs, with supervision from the state. To varying degrees,  these agencies use a combination of state, local, and federal funds to  support their programs. According to a survey of states funded by the  Annie E. Casey Foundation and Casey Family Programs, in state fiscal  year 2010, 46 percent of all child welfare expenditures were from federal  sources, while 43 percent and 11 percent were from state and local  funds, respectively. Among federal funds used for child welfare  purposes, states use a combination of funding designated solely for child  welfare purposes and other sources of funding with broader aims.
section_title: Federal Funds Dedicated to Child Welfare
paragraphs: Title IV-B is the primary source of federal child welfare funding available  for child welfare services, representing about 9 percent of dedicated  federal child welfare appropriations ($730 million of $8 billion) in fiscal  year 2012. In addition to child welfare services, Title IV-B funding may  also be used for a variety of other activities, such as child protective  investigations and case management. Child welfare agencies may spend  Title IV-B funds on behalf of any child or family. They receive these funds  primarily though two formula grant programs: the Stephanie Tubbs Jones  Child Welfare Services program (CWS) under Subpart I of Title IV-B, and  the Promoting Safe and Stable Families child and family services  program (PSSF) under Subpart II. About $281 million in CWS funds and  $328 million in PSSF funds were provided to states, territories, and tribes  in fiscal year 2012.streams are similar, as seen in table 2, below, although CWS funds may  be used for a broader array of activities. States may spend CWS funds on  any service or activity that meets the program’s broad goals, which  include protecting and promoting the welfare of all children. Ninety  percent of PSSF funds must be spent within four required categories:   The purposes of Title IV-B’s two main funding  family support, family preservation, time-limited family reunification, and  adoption promotion and support.
Funds authorized under Title IV-E of the Social Security Act make up the  large majority of federal funding dedicated to child welfare, with funds  chiefly available for specific foster care and adoption expenses, but not for  services. Congress appropriated $7.1 billion under Title IV-E in fiscal year  2012 (89 percent of federal child welfare appropriations), in general to  partially reimburse states for expenditures on behalf of eligible children and  youth who are in foster care, have left care for adoption or guardianship, or  are aging out of care without adoptive homes. Title IV-E funds may be  used to reimburse states for a portion of room and board (maintenance)  expenses for eligible children in foster care, and for the costs of subsidies  to parents who adopt eligible children with special needs (adoption  assistance). States participating in the Guardianship Assistance Program  may also receive Title IV-E reimbursement for a portion of assistance  payments provided to relatives who become guardians (known as kinship  guardians) of eligible children in foster care. States may also use Title IV- E funds to support case planning for eligible children in foster care, and for  administration and training costs associated with eligible foster children and  children adopted out of foster care. Additionally, states may use Title IV-E  funds available through the Chafee Foster Care Independence Program  and Education and Training Vouchers to support youth who are  transitioning out of foster care without a permanent home, youth who have  been adopted out of foster care after age 16, and youth who have entered  into kinship guardianships after age 16.
The funds provided under Title IV-E serve as an open-ended entitlement  to support the costs of caring for eligible children in foster care. However,  there is no similar entitlement to preventive services for children at risk of  entering into foster care. Experts and policymakers have expressed  concerns that the federal funding structure for child welfare encourages  reliance on foster care and does not grant states flexibility to support  services designed to reduce the need for foster care. However, Congress  authorized HHS to waive certain Title IV-E funding restrictions so that  states with approved demonstration projects may spend those funds  more flexibly. In order to be granted a waiver, states must demonstrate  that their projects are cost-neutral to the federal government, among  other requirements. States must also conduct an evaluation (carried out  by an independent contractor) of project success in improving child and  family outcomes. HHS’ authority to issue these waivers lapsed in 2006  but was renewed by Congress in 2011.
Congress also appropriated $189 million in fiscal year 2012 (2 percent of  federal child welfare appropriations) under the Child Abuse Prevention  and Treatment Act (CAPTA) and a variety of other programs and  initiatives, much of which was not directed explicitly to child welfare  agencies and could be available to partner agencies and community- based organizations as well. These programs and initiatives included  competitive grants for purposes including eliminating barriers to adoption  and providing services to abandoned children.
section_title: Selected States Used Title IV-B Funds to Support a Wide Array of Services, and Strategies for Using These Funds Varied
paragraphs: Officials from the four states we studied reported spending Title IV-B  CWS funds in state fiscal year 2011 to support a variety of services and  other activities, and they told us they largely spent PSSF funds for  services in the program’s four required expenditure categories. With  respect to CWS, Virginia used these funds for case management costs  for children in foster care who were not eligible for Title IV-E funding.  Florida allocated over two thirds of CWS funds for case management  costs for children living at home, out of the home, or with adoptive  families. Florida spent almost one third of CWS funds on children’s legal  services, and limited funds on administration and training. Minnesota  officials reported spending CWS funds on licensing staff, other state level  expenses, quality assurance, and program administration. New Mexico  largely spent CWS funds on foster care maintenance payments, which is  permitted in limited circumstances. States report annually to ACF on how  they plan to spend Title IV-B funds within specific categories. For fiscal  year 2012, states nationwide planned to spend 32 percent of CWS funds  on child protective investigations and related activities. Other common  planned expenditure categories were family preservation services (18  percent), family support services (13 percent), time-limited family  reunification services (11 percent), and foster care maintenance  payments (10 percent).
States reported spending 93 percent of PSSF funds in these categories for fiscal year  2009. States are not required to report actual expenditures for the CWS program. material supports, such as emergency rent assistance. For instance, one  Virginia locality reported spending PSSF family support funds for a home  visiting program designed to reduce the risk of abuse and neglect by first- time mothers, and a parenting academy for individuals ordered by the  court to attend parenting classes and others found to have neglected or  abused their children.
Minnesota distributed some PSSF funds to localities through competitive  matching grants targeted at two service areas, and additional funds to all  localities for differential response initiatives. The first of these areas  focused on family group decision-making practices designed to increase  family involvement in decisions about their children’s care needs. The  second of these areas focused on services to “screened out” families, or  families who would not otherwise qualify for ongoing case management  or services due to relatively low abuse or neglect risk levels. Some funds  were also distributed to localities to support their differential response  practices. Minnesota officials said the state began encouraging localities  to implement differential response in the early 2000s, and PSSF funds  played an integral role in these efforts. State officials said that because  Minnesota localities administer and largely fund their own child welfare  programs, they had to find creative ways to develop incentives for  localities to adopt a differential response model. They decided to leverage  PSSF funds along with funding from a private donor to initiate a 4-year  pilot project that established differential response in 20 counties.
New Mexico officials told us their next round of family support contracts would be  targeted at services to birth families, but services would also be available to foster  families. develop this strategy to improve its performance. The state’s family  preservation contracts covered up to 4 months of intensive in-home  services designed to prevent the need to remove children to foster care in  families with high levels of safety and risk concerns in eight counties. In  addition, time-limited family reunification contracts covered intensive  services designed to enable families in 11 counties to reunite with  children in foster care within 4 months of referral. New Mexico used PSSF  adoption promotion and support funds statewide for activities including  home studies, parent training, and a social networking site for adoptive  parents.
section_title: Most States Rely on Flexible Federal Funding to Provide Additional Support for Child Welfare Services
subsections: section_title: States Use TANF, SSBG, and Medicaid to Fund Services Also Covered by Title IV-B
paragraphs: Nationally, most states supplement Title IV-B funds with other federal  funding that is not dedicated to child welfare, according to expenditure  data states reported to ACF. States use widely varying approaches and  make different choices about how to spend the federal dollars they  receive due to a variety of competing demands. As seen in figure 2  below, our selected states each used different combinations of federal  funds not dedicated to child welfare to support services and other  activities covered under Title IV-B in state fiscal year 2011. These funding  sources were chiefly TANF, SSBG, and Medicaid. Officials in these states  told us that they first used the most restrictive federal sources for  activities that meet funding criteria and, after those costs were covered,  they used more flexible sources to support services and other activities as  needed.
Most states across the country, including two of our selected states,  chose to use TANF funding for child welfare services and other activities  covered by Title IV-B. TANF is a federal block grant that supports four  overarching goals, one of which is to provide assistance to needy families  so that children can live in their homes or the homes of relatives.  Because TANF funds can be spent on essentially any service for eligible  families that aims to achieve one of the program’s four goals, it offers  states flexible funding that can be used to support child welfare activities.  According to national data reported by states to ACF, in the spring of  2011, 31 states spent TANF funds, including state maintenance of effort  funds, for purposes covered by Title IV-B. For fiscal year 2011, we  estimate these expenditures to have been at least $1.5 billion.  Moreover, nationally states reported spending these funds for a variety of  purposes. For example, 16 states reported using TANF funds for in-home  services, family preservation services, or both. Another 9 states  reported using TANF for child protective investigations and related  activities. Among the four states we studied, Virginia spent TANF funds  on family support and family preservation programs. Florida used TANF  for a number of different purposes including case management, child  protective investigations, and a state-sponsored home visiting program.  New Mexico and Minnesota, in contrast, did not use TANF for child  welfare. New Mexico officials said that their state had a relatively high  poverty rate and spent most of its TANF funds on cash assistance.result, New Mexico officials said they had few TANF funds available for  other purposes—including child welfare.
Most states, including all four of our selected states, also used SSBG  funds for child welfare services and other activities. SSBG is a federal  block grant under which states are provided funding to support a diverse  set of policy goals. abuse and neglect, preventing or reducing inappropriate institutional care,  and achieving or maintaining self-sufficiency. In addition to their annual  SSBG allotments, states are permitted to transfer up to 10 percent of their  TANF block grant to SSBG. According to ACF data, 44 states including  the District of Columbia spent fiscal year 2010 SSBG funding (including  TANF transfer funds) in three reporting categories covered by Title IV-B.  (Fiscal year 2010 was the most recent year for which national SSBG  expenditure data were available.) Specifically, 35 states reported  spending $377 million for services to children in foster care and other  related activities, which accounted for 13 percent of total SSBG  expenditures. Covered activities included, but were not limited to,  counseling, referral to services, case management, and recruiting foster  parents. Thirty-nine states also reported using $290 million in SSBG  funds (10 percent) for child protective investigations and related activities,  such as emergency shelter, initiating legal action (if needed), case  management, and referral to service providers. Twenty-two states  reported spending $31 million on adoption services and other activities,  such as counseling, training, and recruiting adoptive parents.
For fiscal year 2012, Congress appropriated $1.7 billion in SSBG funds. the states we selected to study used SSBG for services and other  activities covered by Title IV-B. In state fiscal year 2011, New Mexico  used SSBG for purposes including administrative costs associated with  child protective investigations, foster care, and adoptions. In that same  year, Florida spent SSBG funds on purposes including child protective  investigations, child legal services, and the state’s hotline for reporting  abuse and neglect.
Nationwide, some child welfare agencies also claimed federal Medicaid  reimbursement for services they provide to Medicaid beneficiaries. The  amount of federal Medicaid reimbursement claimed by child welfare  agencies is unknown. Under the Medicaid targeted case management  benefit, child welfare agencies can be reimbursed for case management  activities designed to assist targeted beneficiaries in gaining access to  needed medical, social, educational, and other services. One of our  selected states, Minnesota, claimed $24 million in federal reimbursement  for Medicaid targeted case management for children at risk of placement  in foster care and their families in calendar year 2011. Another selected  state, Virginia, reported claiming $1.9 million in federal Medicaid  reimbursement for targeted case management activities related to  children in foster care in state fiscal year 2011. Child welfare agencies  may also obtain federal reimbursement for services they provide to  Medicaid beneficiaries covered under home and community-based  service waivers. Under these waivers, states may cover a wide range of  services and other activities to allow targeted individuals, such as children  with developmental disabilities or serious emotional disturbances who  would otherwise require institutional care, to remain at home or live in a  community setting. Among our selected states, Minnesota claimed $1.8  million in federal reimbursement for services to children with disabilities  under a home and community-based services waiver in calendar year  2011. Child welfare agencies can also claim federal Medicaid  reimbursement for administrative case management activities, including  making Medicaid eligibility determinations. Two of our selected states— Florida and New Mexico—claimed federal Medicaid reimbursement for  administrative costs associated with case management activities. For  example, Florida claimed $1.3 million in federal reimbursement for  activities that included applying for Medicaid benefits and arranging  appointments.
Child welfare agencies nationwide also accessed other federal funding  sources dedicated to child welfare to support services and other activities.  These other dedicated federal funding sources included CAPTA and ACF  discretionary grants. CAPTA funds can be used for a wide variety of  purposes. For example, among our four selected states, New Mexico  used a $136,000 CAPTA state grant for purposes including training,  investigations, and case management in state fiscal year 2011. Florida  spent about $1.4 million in CBCAP funds to support its chapter of a child  abuse prevention organization, parent leadership and support groups, a  child abuse prevention month campaign, and fatherhood initiatives.
Other government entities whose missions intersect with those of child  welfare agencies may also use federal funds for purposes covered under  Title IV-B for children and families they serve. These entities, such as  behavioral health agencies, housing authorities, and the courts, typically  serve a broader population than children and families affected by abuse  or neglect. However, some serve children and families who are also in the  child welfare system. These entities may access a variety of federal funds  to benefit these children and families. For example:
Behavioral health agencies that oversee home visiting programs may  use Maternal, Infant, and Early Childhood Home Visiting Program  funds to provide home visiting services to families at risk of abuse or  neglect. They may also access Substance Abuse Prevention and  Treatment Block Grant funds for substance abuse treatment for  individuals in the child welfare system, including pregnant women and  women with dependent children.
Housing authorities that participate in the U.S. Department of Housing  and Urban Development’s (HUD’s) Family Unification Program may  provide housing vouchers to families at risk of losing their children to  foster care or who face difficulty achieving family reunification due to  inadequate housing.
Courts receive Court Improvement Program formula grants to improve  the handling of child abuse and neglect cases.
section_title: Some States Have Waivers that Permit Them to Use Title IV-E Funding for Services Covered under Title IV-B
paragraphs: Although states are generally prohibited from funding services, such as  parenting classes and substance abuse treatment, with Title IV-E funds,  ACF has granted waivers permitting some states to do so. As of October  2012, 14 states had implemented or were approved to initiate Title IV-E  waiver demonstration projects that allow them to use those funds for  services covered by Title IV-B. These projects were designed to test new  financing and service delivery approaches that may result in lower foster  care costs and increased available funding for new or expanded services.  States with waivers are required to ensure that their Title IV-E expenditures  under the waiver do not exceed what they would have spent without a  waiver. These states would be solely responsible for covering additional  costs incurred if the number of children in foster care, or costs of caring for  such children, exceeded state estimates. States with active and recently  approved waivers have used various methods to determine that their  projects were cost neutral. First, states with flexible funding waivers agree  to receive a capped (or fixed) amount of Title IV-E funding in exchange for  flexibility to use those funds for an expanded array of services, similar to a  block grant. In other states, the amount of funding received for children  participating in the waiver project is determined by the average amount of  funding received for children in a control group who are not receiving  waiver services, ensuring that funding for the waiver group is comparable  to what it would have been without the waiver.
The goals of each Title IV-E waiver project vary and include: (1) reducing  the time children and youth spend in foster care and promoting successful  transition to adulthood for older youth, (2) improving child and family  outcomes, and (3) preventing child abuse and neglect, and the re-entry of  children and youth into foster care. ACF encouraged states to develop  projects that included evidence-based and evidence-informed practices to  promote children’s social and emotional well-being and to collaborate with  state Medicaid agencies when possible. Approved waiver projects  reflect these priorities in a variety of ways (see figure 3). For instance,  Illinois plans to provide specialized training to parents and other  caregivers of very young children in Cook County who exhibit effects of  trauma, using a control- and treatment-group design. Wisconsin plans to  implement post-reunification support services, including evidence-based  therapies designed to address trauma (trauma-informed care), for families  reunified after foster care.
Among the four states we studied, only Florida had an active Title IV-E  demonstration waiver project. Florida’s waiver demonstration project was  implemented in 2006 as part of a statewide reform effort that included  transferring management of child welfare cases to community-based lead  agencies that work with a network of purchased service providers after  the state has concluded its initial child protective investigation. Florida’s  demonstration waiver goals are to: (1) improve child and family outcomes,  (2) expand the array of community-based services and increase the  number of children eligible for services, and (3) reduce administrative  costs related to service provision.
Vargo et al., IV-E Waiver Demonstration Evaluation Final Evaluation Report SFY 11-12,  a Title IV-E waiver evaluation submitted to the Florida Department of Children and  Families, March 15, 2012. these placement expenditures.funding restrictions such as these seem misaligned with federal policy  principles and fail to create incentives for states to invest in services  designed to prevent foster care placement. In New Mexico, a state official  said that increased Title IV-E flexibility would allow them to expand  investments in services that prevent foster care placement. At the same  time, another state official said that Title IV-E funds were an important  source of guaranteed support for children in foster care, and cautioned  that New Mexico may have difficulty ensuring that adequate resources  are devoted to those children if Title IV-E funds are used for different  purposes. Some experts and policymakers have also suggested reforms  to how child welfare services are funded and have put forth proposals that  would change the way states can use Title IV-E funding. These proposals  include instituting various mechanisms for allowing states to increase  their focus on services that aim to keep families together while also  preserving adequate funding for those children who must be placed in  foster care.
section_title: Child Welfare Agencies Have Difficulty Securing Many Services Due to a Variety of Challenges
subsections: section_title: Gaps in Child Welfare Services Include Substance Abuse and Mental Health Services
paragraphs: Data from a national survey conducted by ACF indicate that not all  children and families in the child welfare system receive the services they  need. The survey included interviews with a sample of over 5,000  children and caregivers with child protective investigations closed  between February 2008 and April 2009. Many of these children and  caregivers reported that they had not received services for which they  had a demonstrated need in the 12 months prior to being interviewed.  For instance, an estimated 91 percent of caregivers who needed  substance abuse services had not received them (see table 3).  Additionally, an estimated 58 percent of younger children and 48 percent  of adolescents at risk for behavioral, emotional, or substance abuse  problems had not received any behavioral health services during this  same time period.
ACF reviews of state child welfare systems also suggest that children and  families may not receive the services they need. ACF’s most recent Child  and Family Services Reviews, conducted from fiscal years 2007 to 2010,  showed that 20 of 52 states did not have an appropriate range of services  to adequately identify and address the needs of children and families.  ACF defined an appropriate range of services as those that help create a  safe home environment and enable children to remain at home when  reasonable, and help find other permanent homes for foster and adopted  children. ACF officials told us that, while the reviews do not include formal  data on the availability of specific services, their reports on individual  states indicate that the most commonly unavailable services included:  behavioral health services, including child psychologists and psychiatrists;  substance abuse treatment for adults and youth; housing; and domestic  violence services. In a survey funded by Casey Family Programs, 25 out  of 41 of state child welfare agencies responding reported waiting lists for  at least one service provided by child welfare agencies or their purchased  service providers. (This survey did not ask states about the length of  time a child or family remained on the waiting list before receiving  services.) These services included in-home services, home visiting  services, and substance abuse assessment and treatment. The absence  of a waiting list, however, does not necessarily indicate that services are  available. A service provider may not maintain a waiting list even if there  are families waiting to be served.
Officials from our 13 selected localities echoed these concerns. In  response to a GAO data collection instrument, most of these localities  reported key service gaps in the areas of substance abuse assessment  and treatment services; assistance with material needs, such as housing  and transportation; and in-home services (see figure 4).
Service gaps can negatively affect outcomes for children and their  families. Specifically, according to officials in our 13 selected localities,  previous GAO work, and some research, service gaps can complicate  efforts to prevent placement in foster care, hinder chances of reunification  after foster care, and harm child well-being.
Officials in our selected localities reported that difficulty securing high- quality, timely treatment for families with parental substance abuse  problems can decrease the likelihood of recovery and reunification. In 6  of 13 selected localities, officials reported waiting lists for substance  abuse treatment services. Officials in one of these localities noted that  clients often wait 2 to 3 months for these services. Further, officials in  five localities said that available inpatient services were of poor quality or  too short in duration to meet client needs. New Mexico officials told us  their state’s behavioral health entity covered a maximum of 30 days of  inpatient substance abuse treatment, which they said is insufficient for  long-term addicts.
Some research corroborates the views of local officials that lack of access  to timely, intensive treatment may negatively affect a family’s chances of  reunification. A 2007 study of nearly 2,000 women in Oregon who were  substance abusers and had children in foster care found that mothers  were more likely to be reunited with their children if they entered  treatment quickly and spent more time in treatment. Similarly, in California, a study of more than a thousand mothers who participated in a  drug treatment program in 2000 found that mothers who completed or  spent at least 90 days in treatment were about twice as likely to reunify  with their children as those who spent less time in treatment. GAO  previously reported on family-centered residential drug treatment  programs, which can last up to 24 months and may allow women to bring  their children with them. These programs help women address issues  underlying their substance abuse, build coping strategies, and enhance  parenting skills, which can reduce chances that children will need to be  removed to foster care. The Substance Abuse and Mental Health  Services Administration (SAMHSA) evaluated performance data from  residential treatment programs for mothers and found that 6 months after  treatment ended, fewer children of participating women were living in  foster care and most children who accompanied their mothers to  treatment were still living with them.
Officials in several of our selected localities also said it could be difficult  for families experiencing substance abuse to achieve reunification within   Delays in receiving treatment can make it difficult  mandated deadlines. for treatment to be completed within these deadlines. In addition, a  previous GAO report found that mandated reunification deadlines can  conflict with the amount of time required to successfully address the  needs of these families.high-quality, evidence-based treatment is essential to achieving  reunification within mandated timelines. Officials in one selected locality  said they frequently terminate parental rights due to parents’ inability to  establish sobriety within limited time frames. However, officials in another  locality reported that judges are sympathetic to substance-abusing   One ACF official told us that timely access to  parents’ efforts to engage in services, and frequently extend their  permanency deadlines.
According to past GAO work and officials in selected localities, lack of  affordable housing may also contribute to children’s removal into foster  care or may prevent families from reunifying. In 2007, GAO surveyed 48  state child welfare directors about African American children in foster  care. Officials from 25 states cited a lack of affordable housing options as  one factor that contributed to disproportionately high rates of foster care  placement among African American children in the child welfare system.  This report found that affordable public housing is a critical support that  can help low-income families stay together. 13 selected localities told us that a parent’s inability to obtain housing  could prevent family reunification even if all other reunification criteria had  been met. However, officials in one locality said they work with families  to find them appropriate housing and would not keep a child from his or  her parents based solely on the family’s housing situation.
Similarly, officials in 3 of our  GAO previously reported that failure to provide services to address the  trauma of abuse or neglect may negatively affect children’s well-being in  both the short and long term. GAO reported that children may experience  traumatic stress as a result of maltreatment, which significantly increases  their risk of mental health problems, difficulties with social relationships  and behavior, physical illness, and poor school performance. Early  detection and treatment of childhood mental health conditions can  improve children’s symptoms and reduce the likelihood of negative future  outcomes, such as dropping out of school or becoming involved in the   ACF has also made the social and emotional  juvenile justice system.
GAO, African American Children in Foster Care: Additional HHS Assistance Needed to  Help States Reduce the Proportion in Care, GAO-07-816 (Washington, D.C.: July 11,  2007). well-being of children receiving child welfare services an agency priority,  and is encouraging child welfare agencies to focus on improving  behavioral and social-emotional outcomes for the children they serve.
section_title: In Our Selected Localities, Service Gaps Were Caused by Factors Including Provider Shortages and Challenges Accessing Services of Partner Agencies
subsections: section_title: Provider Shortages
paragraphs: Officials from 8 of our 13 selected localities reported a shortage of  substance abuse treatment providers. Some officials cited a shortage of  treatment in general, while others discussed shortages of specific kinds of  treatment. For instance, officials from six localities reported an inadequate  number of inpatient treatment providers. Officials from two selected  localities also reported particular difficulty finding providers that offered  appropriate substance abuse treatment services for adolescents. In one  Virginia locality with extremely high rates of substance abuse, officials  said that in order to address this shortage, their local behavioral health  agency had hired a counselor dedicated to treating youth with substance  abuse problems. However, this counselor served five counties and had  difficulty keeping up with demand.
Officials from nine selected localities as well as three state officials from  our discussion group reported a shortage of mental health service  providers. Officials from six localities and three state officials from our  discussion group also noted shortages of certain types of specialists. For  example, officials from multiple localities in three out of four selected  states reported acute shortages of child psychiatrists. One state official  who participated in our discussion group also reported particular difficulty  finding mental health providers who offered evidence-based therapies  specifically designed to address trauma in children. Officials in one  Florida locality said that service providers in their community were  interested in becoming trained in certain evidence-based practices, but  found it too costly to do so. To address mental health provider shortages,  Minnesota’s Department of Human Services contracted with the Mayo  Clinic to provide phone-based psychiatric consultation services to primary  care doctors across the state. Officials said the initiative would improve  the quality of psychiatric care for children, including children in the child  welfare system.
Officials in several localities across three states and from one state in our  discussion group reported a shortage of mental health, substance abuse,  and/or other service providers who accept Medicaid. GAO has previously  reported on this issue. In a recent survey of states, GAO found that 17  states reported challenges ensuring enough mental health and substance  abuse providers for Medicaid beneficiaries. Additionally, GAO found in  2011 that more than three times as many primary care physicians  reported difficulty referring children enrolled in Medicaid or the Children’s  Health Insurance Program (CHIP) to specialists as compared with  privately-insured children.
Finally, provider shortages were cited as particularly challenging in rural  areas. Officials in localities across all four selected states and two state  officials from our discussion group reported provider shortages in rural  areas. Officials from some rural localities described difficulty attracting  and retaining service providers. A local Florida official said that one of his  agency’s behavioral health purchased service providers had been  advertising a child psychiatrist position for 5 years without success. In  several localities, officials said provider shortages often result in families  traveling long distances to receive services in more urban areas.
Inadequate health coverage among some children and families in the  child welfare system also contributes to service gaps. In 6 of 13 localities,  officials cited lack of health insurance as a factor contributing to difficulty  securing medical services for families. Officials from selected localities  reported that in some cases services were more difficult to obtain for  parents than for their children, due to lack of health insurance. In  addition, undocumented immigrants are not eligible for Medicaid and may  lack private health insurance as well. Officials in several localities  described particular difficulty obtaining services for these families. There  are, however, a variety of approaches local officials reported using in  order to obtain services for families. In some cases, agencies were able  to turn to behavioral health agencies. And in one locality, officials said a  local non-profit sometimes funded mental health assessments for clients  without insurance. In other cases, officials said their agencies paid for  these services with their own funds. Additionally, fewer parents in the  child welfare system may lack health insurance after January 1, 2014,  when states may expand eligibility for Medicaid coverage to non-elderly  non-pregnant adults with incomes at or below 133 percent of the federal  poverty level, as provided for under the Patient Protection and Affordable  Care Act.
Lack of transportation is also a widespread impediment to obtaining  services, especially in rural areas. Officials in all selected agencies that  served rural areas reported difficulty with transportation for rural clients,  and discussion group participants from two additional states reported  similar difficulties. A number of local officials said that providing services  in the home could help mitigate transportation challenges, as well as  allow providers to better assess and address challenges in the home  environment. Some officials noted that in-home services are typically  more expensive than office-based services. However, officials in one  Florida locality reported that they had made in-home services a budgetary  priority due to transportation challenges in their area.
While state child welfare agencies receive reimbursement under Title IV- E for many costs related to children in foster care, funding for services  designed to prevent the need to remove children from their homes and  place them in foster care is more limited. State and local child welfare  agencies may face difficult decisions when determining which of these  prevention activities to prioritize and fund, particularly in light of the  ongoing fiscal challenges states face. For instance, local officials in New  Mexico described challenges in securing resources to provide services to  children and families at risk of foster care placement. New Mexico state  officials told us they contracted for services designed to avoid foster care  placement or reunite families after foster care entirely with Title IV-B  PSSF family preservation and reunification funds and did not allocate  state or other federal funds to support these contracts. Because Title IV-B  funds were limited, the state targeted services only to selected counties  with the highest need. Officials in one New Mexico county said that most  of their family preservation and reunification services were cut for fiscal  year 2013, in part because they had been successful in reducing the  number of children in foster care and were no longer considered a high  need county.
Fiscal challenges have also affected child welfare partner agencies. For  example, one ACF official we interviewed noted that most states have  experienced budget cuts in social services, which affect both child welfare  and substance abuse services. In addition, officials from SAMHSA told us  that since 2008, states have had more difficulty maintaining state funding  of behavioral health services.
Many localities experienced gaps in services provided by partner  agencies, in some cases due to the fiscal constraints of those agencies.  For example:
Officials in 7 of the 13 localities, as well as one state official from our  discussion group, said that their local housing authorities had long  waiting lists (in some cases up to 3 or 4 years) for Section 8 housing  vouchers. As a result, families referred to the housing authority often  did not receive assistance.
In a few localities, officials said that families with children in foster  care could not obtain approval for public housing units until they had  regained custody, which hindered efforts to reunite children with their  families. One ACF official said that, in response to GAO’s inquiry, the agency initiated discussions with HUD about improving outreach  to local housing authorities about this issue.
Officials in two localities in different states, as well as one state official  from our discussion group, noted that their state Medicaid programs  required diagnoses of mental health disorders to cover services, even  for very young children (ages 0 to 3 years). Officials stated that these  requirements could make obtaining needed services difficult in some  cases, and could result in inappropriate diagnoses in other cases.
States may place appropriate limits on accessing services based on medical necessity  or utilization control procedures. 42 C.F.R. § 440.230.
However, in some cases, selected child welfare agencies coordinated  with other service agencies to improve families’ access to services. For  example:
Three selected localities had coordinated with their local housing  authority to apply for a grant through the federal Family Unification  Program, which sets aside housing vouchers for families in the child  welfare system.
Two selected localities had Family Dependency Treatment Courts,  which coordinate court, treatment, and child welfare services for child  welfare cases in which parental substance abuse is a primary factor.
One Virginia locality collaborated with partner agencies to use funding  provided under the American Reinvestment and Recovery Act for  homelessness prevention and rapid re-housing to help families at risk  of eviction. As these funds were about to expire, they worked with  community partners to identify other sources of funding to allow this  homelessness prevention program to continue.
There are also other opportunities on the federal, state, and local level for  child welfare and partner agencies to coordinate to improve service  delivery for children and families in the child welfare system. For instance:
ACF awards regional partnership grants for projects designed to  increase the well-being of, and improve the permanency outcomes  for, children affected by substance abuse through interagency  collaboration and program and service integration. In 2012, ACF  awarded 17 new regional partnership grants and approved 2-year  extensions for 8 of 53 grants awarded in 2007.
In September 2012, ACF awarded five grants totaling $25 million for  collaborative partnerships between child welfare agencies and  housing/ shelter organizations. Grants were awarded to projects  focused on improving safety, family functioning, and child well-being  in families at risk of homelessness and child maltreatment.
Also in 2012, ACF awarded nine grants totaling almost $29 million  over 5 years for projects to improve the social and emotional well- being of children and youth in the child welfare system. The purposes  of these grants, which are in the form of cooperative agreements,  include improving adoption outcomes through interagency  collaboration and supporting child welfare agencies in assessing  children’s mental and behavioral health needs.
The Commissioner of ACF’s Administration on Children, Youth and  Families told us the agency is encouraging states to collaborate with  state Medicaid agencies to solve issues affecting families in the child  welfare system, including barriers to accessing Medicaid-funded  mental health services for infants. As an example, he said ACF’s most  recent Title IV-E waiver announcement encouraged state child welfare  agencies to submit proposals in conjunction with state Medicaid  agencies. According to the Commissioner, six out of nine approved  waiver proposals explicitly indicate a partnership with the state  Medicaid agency.
In fiscal year 2012, SAMHSA awarded 16 grants totaling almost $16  million to implement systems of care (which involve collaboration  across government and private agencies, providers, and families) for  children and youth with serious emotional disturbances. According to  agency officials, 14 grantees were coordinating with child welfare  agencies to address service development, funding, and access to  care for children and youth in the child welfare system and those at  risk of abuse or neglect.
section_title: Concluding Observations
paragraphs: Child welfare agencies, like other state agencies, operate in an  environment of ongoing fiscal constraint. They must make difficult choices  about how to allocate their limited resources to support services critical to  ensuring children’s safety and well-being. Despite their use of Title IV-B  funding in combination with other federal dollars to supplement their state  and local funds, these agencies continue to struggle to meet the complex  needs of children not in foster care and their families. Given current state  and federal fiscal constraints, they will likely continue to struggle. The  waivers HHS has granted to some states to use their Title IV-E funding  more flexibly may provide useful information about the effects of shifting  available resources from foster care costs to support services intended to  reduce the need for foster care without increasing funding overall.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Secretary of Health and Human  Services for review and comment. HHS indicated in its general  comments, reproduced in appendix I, that it agreed with GAO’s finding  that gaps exist in services to address the effects of child maltreatment,  and provided additional information about the agency’s emphasis on  trauma-informed care and its efforts to encourage child welfare agencies  to respond more effectively to trauma. The agency also agreed with  GAO’s concluding observations that ongoing fiscal constraints contribute  to challenges in meeting the needs of children and families, and offered  two steps child welfare agencies could take to more effectively use  available resources: (1) identify currently funded services that do not yield  desired results and shift resources toward evidence-based programs and  practices; and (2) use outcomes (specifically those related to child well- being), rather than services delivered, to measure program success. Our  report did not address the effectiveness of specific services; however we  agree that information about effective practices is an important tool that  child welfare agencies can use to determine how best to allocate  available funds. Additionally, our work has long shown that using  outcomes is an important component of measuring program success.
HHS also discussed the use of TANF funds for child welfare purposes in  its comments, and noted that in addition to the services described in our  report, TANF funds are spent on foster care maintenance payments and  adoption subsidies, as well as relative foster care maintenance payments  and guardianship subsidies. Because this report focuses on expenditures  for services typically covered under Title IV-B, we did not include  maintenance payments and adoption subsidies in the scope of our  review. We have clarified that, due to the similarity among these payment  types, we excluded relative maintenance payments and guardianship  subsidies as well. HHS also noted that states may spend federal TANF  funds on purposes authorized solely under prior law that do not meet a  TANF purpose, and that many of these expenditures are for child welfare  purposes. We have also clarified that our analysis includes these  expenditures, as appropriate. Finally, HHS described planned revisions to  its TANF expenditure reporting form to capture more detailed information  about how states spend TANF funds on child welfare payments and  services. We have not reviewed these plans; however, we recently  recommended that HHS develop a detailed plan and specific timelines to  help monitor its progress in revising these TANF reporting categories.
In addition to these general comments, HHS also provided us with  technical comments that we incorporated, as appropriate.
We are sending copies of this report to relevant congressional  committees, the Secretary of Health and Human Services, and other  interested parties. In addition, this report will be available at no charge on  GAO’s website at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7215 or brownke@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff that made key contributions to this  report are listed in appendix II.
section_title: Appendix I: Comments from the Department of Health and Human Services
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact name above, the following staff members made  key contributions to this report: Elizabeth Morrison, Assistant Director;  Lauren Gilbertson; James Lloyd; Erin McLaughlin; Ellen Phelps Ranen;  and Deborah Signer. Also contributing to this report were: Susan  Anthony, Jeff Arkin, Carl Barden, James Bennett, Jessica Botsford,   David Chrisinger, Kim Frankena, Ashley McCall, Phillip McIntyre, Jean  McSween, Almeta Spencer, Hemi Tewarson, James Rebbe, and   Carolyn L. Yocom.