Despite the child welfare system’s recent focus on keeping families together and preventing out-of-home placement, 187,000 children entered foster care and a total of 369,000 children were living in foster care in 2022. While child maltreatment includes both abuse and neglect, most placements in foster care are precipitated by reports of neglect rather than abuse. Health care providers, teachers, child care workers, and other professionals who work with children are considered mandatory reporters and, as such, must report cases of suspected child maltreatment to Child Protective Services (CPS). Given the impact of systemic racism on poverty and substance use, as well as racial biases and discrimination more broadly, Black and Indigenous families continue to be overrepresented in foster care.
Primary care providers and Medicaid agencies can play a critical role in preventing child welfare system involvement. These roles are an important complement to broader, community-based approaches and cross-system strategies to address inequities in the child welfare system.
The Center for Health Care Strategies spoke with Kimá Joy Taylor, MD, nonresident fellow at the Urban Institute’s Health Policy Center, and founder of Anka Consulting. Dr. Taylor shared her perspective on inequities in the child welfare system and approaches that can support prevention, including strategies that can be implemented through primary care and within Medicaid.
Q. What do inequities within the child welfare system look like?
A. Inequities include who gets reported, who gets their children taken away, and outcomes for children and families involved in the system. These inequities are driven by racism and other forms of discrimination, including bias against LGBTQ+ families and people with disabilities. For example, structural racism causes families of color to be disproportionally impacted by poverty, which is often inappropriately conflated with neglect.
Individual biases also impact which families get reported to CPS and how families are treated once they are involved in child welfare. For instance, biases among health care providers may result in more Black and Indigenous parents than white parents being subject to drug tests, the results of which are often inappropriately used to justify CPS reporting. There is a long history in the U.S. of systems’ biases guiding determinations of who is and isn’t a good parent, and often, that’s based on melanin, from Black children being taken away from their parents during slavery to the forced removal of Native American children from their families.
Low-income families are also disproportionately impacted. A family might be told that their parental rights will be terminated unless they meet a set of requirements, such as participating in substance use testing, engaging in services or treatment, and making repairs to their home. These requirements are more difficult to meet for families that don’t have insurance, transportation, or job flexibility than it would be for families with financial means.
There are not enough culturally and linguistically effective services available for families, and there is often the perception that the child welfare system will have access to systems and services that don’t exist. In this way, the child welfare system is set up for failure, too. Health care providers sometimes refer to child welfare because we don’t know what else to do or because we’re overwhelmed and exhausted, and our biases can come into play.
Q. What changes can be made to reduce inequities and improve support for families?
A. First, mandatory reporters need to have a better understanding of the requirements for reporting and what happens when families become involved with the child welfare system. If you asked 20 mandatory reporters what the regulations are, they’d all say something different. Additionally, for child welfare referrals, providers generally don’t or can’t follow up on outcomes. When a primary care provider (PCP) refers an individual to a cardiologist, they are expected to follow up with the specialist or patient so that they can provide holistic follow-up care. Child welfare referrals should be treated the same way. If a referral is warranted, it is important for PCPs to find out whether evidence-informed, culturally and linguistically effective services were provided so that they can advocate for appropriate care.
Second, mandatory reporters — including PCPs — should support a system that prioritizes family preservation. What would it look like to keep families together? Focusing on family preservation can help families address their needs in the community. PCPs shouldn’t have to do it all, but their team can learn how to access culturally and linguistically effective, non-punitive resources in the community through partnerships, such as with community-based organizations and government agencies, to address societal determinants of health.*
The third piece is advocacy to build up needed community-based, culturally and linguistically effective services and supports, such as supportive housing, education, and job opportunities, and expanding programs like the supplemental nutrition assistance program. Having more resources in place will allow providers to help address underlying needs of families and by having appropriate resources in place, providers will feel less compelled to report families to CPS when its unwarranted. Right now, PCPs can connect families to housing lists, but affordable housing is too often not available.
Q. Can you describe the concept of “mandated supporting,” and how it differs from mandated reporting?
A. Often, people default to reporting certain families (e.g., due to race, ethnicity, class) rather than connecting them to support in the community. In reality, all families need support, it’s just that some families have the means to get access to these supports outside of public systems and do not face societal barriers and stigma to access what they need.
Mandated support asks, “What are some of the things that people need to thrive, and are you required to provide them?” This requires individual and systems-level advocacy. If an individual needs housing, advocate to get them housing. If an individual needs access to WIC but can’t get to the office, provide access to transportation. No one system can do this on its own, so it also requires working with community-based organizations and government agencies to ensure sufficient services are available and that all services can be provided in a culturally and linguistically effective way.
Q. What are some of the strategies that child and family-serving systems, including primary care, can implement to better support families and achieve more equitable outcomes?
A. Providers, policymakers, and advocates need to rethink the health care system. Providers need more time — they have 15 minutes for an appointment which is not enough time to get to know a child and their family. The health care system needs team-based care, inclusive of behavioral health services, not just for folks with behavioral health concerns. There is also a need for more culturally and linguistically effective care, which is different than cultural competence. An individual can’t become culturally competent across all cultures and communities. Culturally and linguistically effective care is working in partnership with the individual to improve their well-being. Instead of providing someone with a list of foods they should eat, ask what they eat and work with them to suggest alternatives. This type of partnership with patients is needed to support physical and emotional well-being, and better understand the pressures that people are facing every day.
Additionally, everyone in a primary care practice, not just providers, needs to be educated on and rethink their role in the child welfare system. One example of this is a curriculum developed by researchers at the University of California and the Friends Research Institute that educates providers on the history of the child welfare system, racial disparities in child welfare involvement, the impact of child welfare reporting, and how to avoid over-reporting. Other resources to help educate providers on supporting family preservation include Movement for Family Power.
Provider organizations need to create a culture of humility where providers can learn from their mistakes, while also holding people accountable. Data collection needs to be disaggregated and analyzed. When someone is reported to CPS, who is being reported? Is the rate disproportionate by race, ethnicity, sexual orientation, age — and if so, why? This can enable provider organizations to improve their practices and protocols.
Q. How can state Medicaid programs support these efforts?
A. Medicaid programs can engage parents to better understand their families’ needs and work with providers to develop approaches to better support these identified needs. Providers also need more time with families, but they’re often limited by the 15-minute visit because of current payment structures. Many practices conduct screenings for societal determinants of health, but if providers can’t or don’t act on the results, it’s just a piece of paper. Medicaid can play a role in implementing value-based payment that is equitable and outcomes-based, not just for clinical metrics but also metrics related to child welfare involvement. Such payment models should enable team-based care so that providers have the time to get to know and support families. This requires paying more for improved quality, outcomes, and partnerships — not just focusing on cost savings.
Medicaid could also collect and use disaggregated data to analyze and understand the story of families’ involvement with the child welfare system, such as which children enter the foster system and when and which families are preserved and why. This data can be collected in partnership with community-based providers and be used to tie payment to outcomes and improve funding for community-based organizations that provide culturally and linguistically effective services to support family preservation. Medicaid could also help ensure that providers understand and are appropriately following (i.e., not overreaching) the legal requirements related to mandated reporting.
Finally, even though there are gaps in service capacity, Medicaid can help identify and fill those gaps. This includes increasing the supply of culturally and linguistically effective services, behavioral health services, and specialist services. Medicaid can be intentional about supporting family preservation and making sure that families receive services so that they are as healthy as possible physically, socially, and emotionally.
*“Societal determinants of health” include “social determinants of health” as well as broader social and environmental structures that influence health (e.g., social institutions, norms, beliefs, built environment, etc.). Dr. Taylor specifically uses the term “societal determinants of health” to emphasize that it is not individuals’ mistakes that have led to poor outcomes, such as lack of access to food, housing, or transportation. Rather, society’s priorities and choices, such as continuing to uphold racist policies and institutions, have led to these outcomes.
