Earlier this year, the Arizona Health Care Cost Containment System (AHCCCS) wrote to the Centers for Medicare & Medicaid Services (CMS) requesting an amendment to the state’s Medicaid 1115 Research and Demonstration Waiver. AHCCCS seeks to waive eligibility conditions and automatically renew Medicaid coverage for individuals who were in the state’s foster care system as youth until they reach the age of 26 years.
The request is in alignment with House Bill 2622, which requires organizations or advocates that mandate or offer healthcare coverage, and institutions that would restrict the amount of cost sharing applied to health plans benefits issued by insurers, hospitals, medical, dental, or optometric corporations to submit a report to address the social and financial impacts of the change to coverage or cost-sharing restriction.
The waiver amendment would allow the Young Adult Transitional Insurance population to be automatically renewed in Medicaid without requiring additional information from that individual until they reach 26 years. AHCCCS hopes to implement this upon CMS approval and completion of operational system modifications.
Under current AHCCCS policy, former foster youth may be removed from coverage if they are no longer a state resident, they die, or AHCCCS determines their eligibility was false due to agency error, fraud abuse, or perjury. If CMS approves, AHCCCS will create policy revisions, implement staff training on policy changes, and develop and deploy a communication plan.
AHCCCS closed their public comment period for the waiver amendment in May, during which three organizations spoke out in support of the possible change. In his public comments, Bruce Lesley, president of First Focus on Children, a bipartisan advocacy organization that works on Medicaid policy for children and families, issued a statement explaining how former foster youth have greater rates of physical and behavioral health needs when compared to their peers, oftentimes the result of trauma they suffered from abuse and neglect.
“It is important that this population have stable, comprehensive healthcare coverage. Medicaid plays a vital role in providing comprehensive coverage, especially for former foster youth transitioning to adulthood, reducing health and social disparities.”
— Lesley
Lesley said the organization supports Arizona’s proposal to automatically renew Medicaid coverage for foster youth who have aged out of the system, but that they would like CMS to encourage the state to extend the proposal to apply to any foster youth, not just those who have aged out of the system.
Rachel Dolan, senior director of policy for the Pharmaceutical Research and Manufacturers of America, commented that if approved, the waiver request will provide much-needed continuous healthcare coverage to improve health outcomes for hard-to-reach populations. Dolan highlighted how Black and Native/Indigenous children are disproportionately represented in the Department of Child Safety, and that delaying or foregoing medical care or treatments not only strains the healthcare system, but also has negative impacts to patient health.
“The Partnership to Fight Chronic Disease finds that Arizona could save $62 billion in medical costs and advance health equity among residents with better management and adherence to medicines for chronic conditions, many of which affect former foster youth, due to improved social determinants of health or healthcare access.”
— Dolan
Dolan said the recent public health emergency showed the impacts that gaps in access to healthcare have on minority populations, and that those gaps are more impactful among newly emancipated foster youth. According to the National Foster Youth Institute, many children who enter the foster care system have complicated and severe medical, mental, oral, and psychosocial health issues, and that medical and mental health issues are compounded by inaccessible and inadequate health services.
Further data suggests that about 33% of former foster youth have no health insurance, and that about 50% of emancipated foster youth have chronic health conditions, including visual and auditory impairments, malnutrition, asthma, and dental decay. Additionally, former foster youth experience greater rates of unemployment, homelessness, and lower educational attainment.
The Affordable Care Act allowed for young adults who were in foster care at 18 years or older to remain eligible for free healthcare in each state until they reach the age of 26. Due to increased rates of becoming unhoused, former foster youth can be a difficult-to-reach population, underscoring the need for interventions like this waiver.
“Ensuring continuous Medicaid coverage up to the age of 26 for individuals formerly in foster care is particularly important since those formerly in foster care have higher rates of pregnancy and parenthood at young ages, and unemployment.”
— Lisa Satterfield, senior director of Health Economics & Practice Management at the American College of Obstetricians and Gynecologists (ACOG)
ACOG represents over 636 practicing obstetrician-gynecologists in Arizona, and cited the Center for Disease Control and Prevention’s consideration of insurance coverage disruptions being one of many factors that lead to high rates of maternal mortality among those who are Medicaid-eligible.
Satterfield said half of all uninsured new mothers reported losing Medicaid post-pregnancy as a reason they’ve become uninsured, and that coverage disruptions disproportionately impact women of color. Almost half of all non-Hispanic Black women lost insurance from pre-pregnancy to postpartum, while half of all Hispanic Spanish speaking women became uninsured during their postpartum period.
“Without automatic renewal, Former Foster Youth are at a particularly high risk of losing coverage during the Medicaid unwinding period. During the early years of adulthood, over one in four Former Foster Youth report experiencing homelessness, a number which jumps to 43 percent among American Indian populations.”
— Satterfield
Satterfield noted that without stable housing, former foster youth are at high risk of having renewal paperwork returned to AHCCCS, and may create failures to comply with the procedural requirements to keep coverage. According to her, not only will the automatic renewal of coverage for this population reduce the number of terminations during the Medicaid unwinding period, it will ensure continuous coverage and care for this population, and further reduce administrative burden for AHCCCS.
“Further, this waiver amendment should be approved because it will support the Biden administration’s efforts to improve health equity. In 2018, Black children made [up] five percent of the state’s population, but 16 percent of its foster care population. Because foster care youth are at higher risk for poor health outcomes, extending the Medicaid coverage age eligibility for former foster care youth will help with eliminating racial and ethnic disparities in healthcare outcomes.”
— Satterfield
If the waiver gets approved, it would be in place for five years. Additional details about the waiver amendment’s timeline have yet to be released.