In just a few weeks, the major provisions of the Family First Prevention Services Act will take effect in all 50 states, more than two years after former President Donald Trump signed it into law. Most states took a two-year delay on implementing the restriction in Family First, which meant they also had to pass on most of the new federal money it makes available.
So where do things stand as Family First goes nationwide? Following is a basic breakdown of things based on what Youth Services Insider knows.
First, for those who aren’t familiar: the Family First Act aims to help states prevent the need for foster care in some child welfare cases, reduce the use of congregate care (group homes, residential centers, shelters and institutions), and either develop or strengthen kinship navigator programs. It accomplishes this by updating the Title IV-E entitlement, which heretofore has been focused mostly on helping to pay for foster care placements and adoption subsidies.
You can click here for our comprehensive guide to the particulars.
IV-E Foster Care Prevention
As mentioned, states can now draw in IV-E dollars to help pay for services aimed at preventing the need to place children into foster care in some cases where abuse or neglect has been investigated. It is not primary prevention money to help families before abuse or neglect is reported; rather, this new funding can be seen as support for the federal requirement that states make reasonable efforts to prevent the removal of children into foster care.
Only services and program models approved by a newly formed clearinghouse are fundable through this change; more on that process later. Unlike IV-E foster care, there are no conditions or eligibility rules around which kids the prevention money can be spent on.
But states cannot just start billing the feds for reimbursement willy-nilly for the prevention services. They must submit a five-year plan that outlines what services they intended to use, how they define eligibility for the services, and more. Until that plan is approved, no IV-E foster care prevention funds will flow, which means that as of October 1, any state without an approved plan is facing the funding restrictions of Family First without availing themselves of the incentives.
Alright, so where do states stand with these plans? Here’s how it shakes out as of Monday, September 13:
Have submitted and been approved: 14 states, the District of Columbia, and one tribe
States: Arkansas, D.C., Hawaii, Iowa, Kansas, Kentucky, Maine, Maryland, Nebraska, North Dakota, Oregon, Utah, Washington, Virginia, West Virginia
Tribe: Eastern Band of Cherokee Indians, North Carolina
Have submitted, awaiting decision: 17 states, three tribes
States: Alaska, Arizona, California, Colorado, Connecticut, Indiana, Illinois, Maine, Michigan, Missouri, Montana, Nevada, New Hampshire, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee
Tribes: Aleut Community of St. Paul Island, Alaska; Keweenaw Bay Indian Community, Michigan; Salt River Pima Maricopa Indian Community, Arizona
Have not submitted: 19 states, seven tribes, two territories
States: Alabama, Delaware, Florida, Georgia, Idaho, Louisiana, Massachusetts, Minnesota, Mississippi, New Jersey, New Mexico, New York, North Carolina, Rhode Island, South Dakota, Texas, Vermont, Wisconsin, Wyoming
Tribes: Cherokee Nation, Oklahoma; Mashpee Wampanoag Tribe, Massachusetts; Navajo Nation Window Rock, Arizona; Pascua Yaqui Tribe, Arizona; Penobscot Indian Nation, Maine; Port Gamble S’Klallam Tribe, Washington; Tolowa Dee-Ni’ Nation, California
Territories: U.S. Virgin Islands, Puerto Rico
So in all likelihood, unless the Children’s Bureau cranks out a lot of approvals in these next two weeks, the congregate care limits will hit states without any new funding available for front-end work on family preservation. Two-thirds of the submitted proposals that have not been acted on were submitted before June, so there is some chance that we see 20 states get cleared for prevention services by October.
As mentioned, there is a IV-E Prevention Services Clearinghouse created to determine which services and programs met the evidence-based threshold for funding under Family First. There has been frustration with the pace of the review process and its opaque nature, and the Trump administration even proposed that states be allowed to use child welfare services approved by existing clearinghouses – not a ringing endorsement of the need for this new entity.
After a slow start, the clearinghouse has signed off on 36 fundable services, rejected another 24 (two are under re-review) and have about 30 up for consideration now. You can search the list of programs by clicking here.
Two observations on the list thus far. First: The most glaring hole is the absence of any approved kinship navigator program, which is significant because while the front end of Family First incentivizes better efforts at preventing foster care, it anticipates that relatives would need to informally step in and care for kids in some cases. Some might view that as the first real recognition by the federal government of what is referred to as “hidden foster care,” where the physical custody of a child changes due to child welfare investigations but the legal custody does not.
The kinship care community was excited for the first chance at predictable federal funds every year to expand the universe of navigators, which serve as one-stop shops to help relatives connect to benefits and resources, respite care, support groups and more. But nearly three years later, not a single existing model has been anointed as “evidence-based.” The clearinghouse is currently re-reviewing Ohio’s navigator program, so that could change soon.
Second observation: Family First became law at a time when Congress was compelled to fight the opioid epidemic that continues to rage in America. While some notable service models associated with substance abuse treatment have been approved, the list of eligible programs is far more rooted in parenting supports like home visiting and mental health interventions (which, in fairness, can certainly help people in recovery).
The real surprise to Youth Services Insider continues to be how many of the services reviewed by the clearinghouse have little to do with parental behavior at all: many of the mental health services are focused squarely on the behavioral issues of children.
And that speaks to a less-talked about aspect of child welfare and foster care: the number of children who end up removed from home not because of abuse or neglect, but because a parent or parents are struggling to keep them safe from themselves. Last year, The Imprint Weekly Podcast featured an interview with Ohio’s Medicaid director, Maureen Corcoran, talking about this very issue.
A handful of states have had their prevention plans approved for a year or more, able to draw down IV-E funds for the newly approved services. But how much was actually going out the door? Youth Services Insider looked at public spending records from the Department of Health and Human Services to see.
Those records suggest that prevention services funding was pretty paltry through May, then picked up quite a bit. Just $36.3 million had gone out of the door as of June 2; by the last day of June, the money going out to states had jumped to $60.5 million. The biggest users thus far have been Kansas ($16.6 million) and Kentucky ($28.1 million).
It’s worth noting that since the passage of the December coronavirus stimulus package, the feds have paid full boat for the Family First services; these approved states have been able to draw 100% of the funds down with no state match required. That probably has a lot to do with the late surge in funds headed out the door.
We still have plenty as Family First begins to take effect in all states. Here are a few:
How big a hit are the congregate care funding limits? It isn’t clear from state to state how much of the group home and institutional placements are paid for in part with federal IV-E foster care dollars. It is probably a question plenty of states have tried to answer internally in the past year or so.
What will emerge as the most-used foster care prevention services? Our guess would be Motivational Interviewing, which can be added as a component for lots of different programs, and some of the big names in home visiting such as Nurse-Family Partnership and Healthy Families America. There is already an annual federal grant for states to spend on home visiting, so lots of systems already have the infrastructure in place and can use Family First to augment.
Youth Services Insider will be most interested in pickup on some of the substance abuse-specific items, such as Methadone Maintenance Therapy and the Sobriety Treatment And Recovery Teams (START) model, which puts parents in recovery together with dedicated peer support caseworkers.
Will Congress expand use of Medicaid in congregate care? A bipartisan bill was recently introduced in the Senate that would make qualified residential treatment programs — an exception in Family First as congregate care placements that could continue to draw federal funds past the two-week mark — an exception to the rules forbidding Medicaid funds for institutions. As of right now, only psychiatric residential treatment facilities and psychiatric hospital wings are exempted in regard to using Medicaid to serve youth and young adults up to age 21.
How different will definitions be? Each state was left to decide for themselves what children and families would be candidates for the foster care prevention services. These services are intended for children at “imminent risk” of entering foster care, but the states will define what it means to be at imminent risk.
Note: On the day this article was published, Maine's prevention services plan was approved by the U.S. Children's Bureau. We have updated the section on state statuses accordingly.