Responsibility for providing care and services to foster children is shared by federal, state, and county governments, with HHS having responsibility for oversight of federal foster care programs. The Administration for Children and Families (ACF) within HHS helps the states to develop plans required under title IV-B of the Social Security Act; reviews and approves those plans; conducts audits to certify states’ compliance with the safeguards for foster children, thereby making states eligible for additional federal funds; and allocates funds to states, among other duties. The Social Security Act of 1935 was amended twice to include safeguards for foster children. The Adoption Assistance and Child Welfare Act of 1980 (P.L. 96-272) added most of these safeguards—such as requirements that the case file contain a plan for appropriate care and services, as determined by state and local foster care policies; periodic court or administrative reviews; and a reunification program to return children to their parents. This act also authorized HHS to provide technical assistance to aid states in developing programs to meet the requirements of the law. Furthermore, the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239) added other safeguards to the Social Security Act, including a requirement to maintain health records for foster children. A combination of federal, state, and county funds may be used to provide services to young foster children. States may participate in federal programs authorized by the Social Security Act such as title IV-B, matching grants for various child welfare services; title IV-E, an uncapped entitlement for a portion of the maintenance of foster children who are eligible under the Aid to Families With Dependent Children (AFDC) program; title XIX, Medicaid, an entitlement for a portion of medical services; or title XX, block grants for a wide array of social services for children. In addition, the Education of the Handicapped Act, part H, authorizes grants to states for early intervention programs for handicapped infants and toddlers. Except for federal title IV-E expenditures, data were unavailable to estimate federal, state, and county expenditures for services for foster children. In the last 10 years, federal title IV-E expenditures for the administration and maintenance of AFDC-eligible foster children increased from about $546 million in 1985 to an estimated $2.9 billion in 1995. When foster children do not meet title IV-E eligibility for federal funding, states must bear the full cost for maintaining these children. However, some states pass at least a portion of these costs to their counties. All young children need routine, comprehensive medical monitoring, treatment for minor illnesses, and immunizations to grow up healthy. In the three locations reviewed, state and county regulations require that children in foster care receive periodic medical examinations and treatment. Research indicates that children at risk for serious health problems as a result of prenatal drug exposure often need additional assessments and specialized care. Child development experts generally agree that health care is particularly important during the first 36 months of life as language, motor, psychological, and social skills develop. Conditions left untreated during the first 3 years of life can influence functioning into adulthood. Some young foster children in the locations we reviewed did not receive even the most basic health service—required routine care. In addition, many children had identified health-related needs that were not met, including the need for specialized services. Foster care agencies refer foster parents to community-based programs and practitioners, rather than providing the services directly. Foster children in the locations reviewed are eligible for Medicaid to cover the cost of these health-related community-based services. Despite state and county foster care regulations, comprehensive routine health care for young foster children may not be ensured. Specifically, an estimated 12 percent of the children received no routine health care, and 34 percent received no immunizations in the three locations reviewed. Furthermore, case files at all three locations did not reflect the exact nature or extent of what services were provided in many cases. Thus, children we noted as having received routine medical care may have received as little care as one visit with a physician for treatment of a minor illness rather than comprehensive or ongoing medical care. (See table II.1 in app. II.) While Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services are one way to ensure that children receive comprehensive medical examinations, only an estimated 1 percent of the young foster children in the locations reviewed received EPSDT services. EPSDT services are specific, comprehensive medical examinations and follow-up treatment that states must offer to Medicaid-eligible children. EPSDT examinations can serve as an effective safeguard of a child’s overall health and development and as a gateway to other health-related services. (See table II.1 in app. II.) Children with no known health problems were less likely to receive routine care than children who were at risk for or had serious health problems. For the locations reviewed, an estimated 28 percent of the children with no known serious health problems did not receive any health-related services. By comparison, only 6 percent of children who were at high risk for serious health problems because of prenatal drug exposure and 2 percent of children with serious physical health problems did not receive any health-related services. Without routine health care, children with no known health problems are not monitored to identify and treat health and developmental problems as they occur. (See table II.2 in app. II.) In addition to routine health care, young foster children need many specialized health-related services. As we previously reported, an estimated 58 percent of young foster children in the three locations reviewed had serious physical health problems, and 62 percent were at high risk for serious health problems as a result of prenatal drug exposure. Many of these children may need health-related services and treatment beyond those needed by the average child. (See fig. 1 and table II.3 in app. II.) Although young foster children received a wide variety of services from health care providers, many children had identified health-related needs that were not met. Based on information collected from case files, we matched the health-related needs identified and the services received for each child and estimated that one-third of the children in the locations reviewed had some identified needs that were not met. These unmet needs included pulmonary and speech therapy; psychotherapy; developmental assessments; infant stimulation services; cardiological, urological, and neurological examinations; and testing for sickle cell anemia, syphilis, and HIV. (See fig. 2 and table II.4 in app. II.) Of those children with no identified health-related needs, about one-half in each location received no routine health care, and less than one-half received a toxicology screen at birth to detect recent prenatal drug exposure. Thus, many of these children may have had health-related needs that were not identified and, consequently, were not met. One particularly critical health need of young foster children is HIV risk assessment because most young children in the locations reviewed are at risk for the infection as a result of parental drug abuse. Without risk assessment, a child’s HIV status may not be determined early because HIV-infected children can remain asymptomatic or exhibit only minimal signs of infection for years. Recent medical advances in early identification and treatment can enhance and prolong the lives of these children. Early identification is also critical because HIV-infected children should receive modified immunizations to prevent adverse reactions, and their exposure to infectious illnesses such as measles or chicken pox—which are particularly hazardous to these children—should be minimized. While state laws, and the county policies based on them, do not prohibit HIV testing or the disclosure of test results, some can hamper HIV testing and disclosure. State laws and county foster care policies, where they exist, vary widely. In some locations, including the three reviewed, these laws and policies impede HIV testing and disclosure by specifying the risk factors that must be present in order to request HIV testing; who has the authority to consent to testing; and to whom HIV test results can be disclosed. For example, for the 36 states with HIV testing policies as of 1992, one-half of the foster care agencies in the states with testing policies may not have authority to consent to an HIV test for a child, even when the child was identified by the agency as being at high risk for HIV. Foster care agencies in the locations reviewed do not know the full extent of their caseloads that is at high risk for HIV since no mechanism exists to ensure that all young foster children are assessed for HIV risk. While two of the three locations we reviewed currently have some HIV risk assessment requirements, one location did not require risk assessments for all foster children until recently, and the other has not implemented clear assessment procedures. HIV risk has long been associated with intravenous drug use, but more recent research has established an equally strong link between HIV risk and the lifestyle of nonintravenous cocaine and crack users. Using New York City’s current HIV risk factors, which include nonintravenous drug use, we assessed our 1991 population of young foster children on the basis of one risk factor, parental drug abuse. Accordingly, we estimated that at least 78 percent of the children in the three locations reviewed were at high risk for HIV. We estimated that only 9 percent of the young foster children in the locations reviewed were actually tested for HIV, despite the large proportion at high risk and statistics indicating that these are locations with a high incidence of HIV. The American Academy of Pediatrics Task Force on Pediatric AIDS recommends HIV testing for all foster children with high-risk factors or in areas with a high incidence of HIV to facilitate appropriate medical treatment and follow-up. We estimated the HIV infection rate for children born in 1993 and found that the three states reviewed ranked 2nd, 14th, and 26th, based on national data from the Centers for Disease Control and Prevention (CDC) on blind HIV testing of newborns. (See table II.5 in app. II.)