Data Surprise: Children with Mental Health Needs in Foster Care More Likely to Receive Therapy and Medication

Plus MACPAC deep dive, and MS infant mortality and child welfare

Zach Laris

Aug 25, 2025

Curated by Founder Zach Laris, with contributions from the Wonk Team.

From the Founder’s Desk

Welcome, Wonks.

This week we’ve got a focus on mental health for you:

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Strategic Snippet

Premium Wonk Data Drop

Children with Mental Health Needs in Foster Care More Likely to Receive Therapy and Medication, Though Gaps Remain

Our recent analysis looked at the higher prevalence of mental health disorders among children in foster care.

This piece turns to a natural follow-up: treatment access.

What it finds is counter-intuitive to conventional wisdom. Compared to children not in foster care, children in foster care are:

More likely to have both therapy and medication treatment;
Less likely to have only medication treatment; and
More likely to have only therapy without medication.

Large gaps also remain: nearly a quarter of both groups still get no treatment at all.

This matters now more than ever, as states face Medicaid cuts that could erode the relatively higher access for children in foster care.

What We Found: All Children Face Similar Treatment Gaps, Those in Foster Care Are More Likely to Receive Therapy Along with Medication

“Whether in or outside of foster care, children with mental health needs face substantial barriers to accessing care. Here’s what the data show:
23 percent of children in foster care with a mental health diagnosis did not get any mental health treatment.
This is comparable to their counterparts not in the foster care system; the difference is not statistically significant.
Nearly half (49 percent) of foster care children with a mental health diagnosis received both prescription medication and therapy.
This is substantially higher than non-foster care children at 31 percent.
Children not in foster care were far more likely to only receive prescription medication, with no therapy (30 percent vs 12 percent for children in foster care).
17 percent of foster care children received therapy only, higher than the 13% of non-foster care children who do so.
General clinical guidance for children’s mental health prefers combining therapy with medication, overmedication alone.”

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Weekly Wonk Deep Dive

The Medicaid Brain Trust Child Welfare Needs to Know

By Laura Radel, Senior Contributor, Child Welfare Wonk

Medicaid covers virtually all children in foster care — but the policy shop Congress created to shape Medicaid and CHIP rarely shows up in child welfare conversations.

That’s a gap with consequences.

For folks interested in learning more about the funding, access, and service delivery side of the foster care equation, MACPAC’s work is a lever hiding in plain sight.

What MACPAC Is

MACPAC is a small, non-partisan, legislative branch agency established by Congress to analyze and advise Congress and the Department of Health and Human Services (HHS) on issues related to Medicaid and the Children’s Health Insurance Program (CHIP).

Medicaid and CHIP cover virtually all children in foster care and those who have adoption assistance agreements, as well as many other children who interact with the child welfare system.

Congress requires MACPAC to explore a wide range of Medicaid and CHIP issues–including payment, eligibility, enrollment and retention, coverage, access to care, and quality of care.

While it is well known in the health community, MACPAC as a resource and point of strategic engagement is under-utilized by child welfare professionals.

The Overlap We Don’t Talk About

Children associated with the child welfare system, particularly children in the title IV-E Medicaid eligibility category, are among the highest-cost, highest-need Medicaid users.

That means MACPAC’s deep dives on service utilization, behavioral health, and care coordination overlap greatly with the kids in the child welfare system– even if they’re never labeled that way.

Analyses Worth Your Time, and Key Findings

MACPAC produces a range of analytical products, including reports, data briefs, and presentations to its commissioners.

Below are some recent relevant analyses that can power your work, including key findings.

Health Care Access for Children in Foster Care (April 2025).
- What it Is: In this presentation to the Commission, staff presented findings from a study of health care access for children in foster care.
- What it Looked At: The analysis examined policies, approaches and experiences of seven state agencies. Key findings include:
  - There’s no federal requirement for Medicaid–child welfare coordination which leaves collaboration to voluntary efforts, producing wide state variation.
  - Interagency data sharing isn’t mandated — and legal, technical, and financial barriers stall progress.
  - Workforce shortages in both agencies and provider networks choke timely behavioral health access.
  - Specialized managed care plans for foster youth reduce state administrative burden and enable population-specific quality tracking.
  - Mobile crisis and therapeutic foster care models braiding Medicaid and child welfare funds are promising tools for prevention and placement stability.
  - How to Use It: These findings can frame discussions about care quality and cost efficiency at the state and national level.
Annual Report Chapter on Access to Residential Treatment for Behavioral Health Needs.
- What it Is: A review of access to care for residential behavioral health services.
- What it Looked At: While not specifically focused on youth in foster care, children involved with the child welfare system are particularly high users of residential treatment services. Key findings include:
  - Residential care is rare — but disproportionately used by foster youth.
    - In North Carolina, for example, they’re under 1% of the child population but up to 42% of PRTF placements, depending on the year.
  - The in-state bed hunt is brutal — and pushes kids out of state.
    - States report making dozens of calls to find an in-state PRTF willing to take a child, with denials based on diagnosis, behaviors, or co-occurring conditions.
    - Bed shortages, lack of specialty expertise, and higher payment rates for out of state patients contribute to access problems.
  - Data and workforce shortfalls keep the problem in the shadows.
    - There’s no national data set tracking who gets residential care, who’s denied, or who’s stuck waiting.
    - Meanwhile, facilities across states report closing beds or shutting down entirely because they can’t recruit and retain qualified staff — especially for kids with autism, I/DD, or complex co-occurring needs.
- How to Use It: This is a resource for anyone working on policy issues related to residential care, community-based services, mental health, and permanency.
Issue Brief on Behavioral Health Services for Youth in Foster Care.
- What it Is: This analysis, published in 2021, looks at the prevalence of certain behavioral conditions among youth who spent time in foster care as well as their Medicaid/CHIP coverage and access to services.
- What it Looked At: Key findings include:
  - Nearly two-thirds of youth with foster care experience are on Medicaid or CHIP and receive behavioral health care at higher rates than their peers outside of foster care
  - Access to non-specialty mental health treatment was high and Medicaid and CHIP beneficiaries generally received mental health services at similar rates as their peers with private coverage.
- How to Use It: This background can inform deliberations about mental health needs and access for youth in care.
Report on Therapeutic Foster Care.
- What it Is: In 2019, MACPAC published a major report on Therapeutic Foster Care (TFC) services.
- What it Looked At: Congress required the report to focus on whether a uniform definition of such services could improve care and treatment.
  - MACPAC concluded that a single federal definition of therapeutic foster care could backfire by limiting state flexibility.
  - MACPAC urged joint CMS–ACF guidance instead.
- How to Use It: TFC continues to be an issue of interest for maximizing family-based placement, and this is a key element of those discussions.

What’s Coming

MACPAC’s pipeline includes work on:

The safety and quality of residential treatment services,
The use of managed care for children in foster care,
Transitions from pediatric to adult care for children and youth with special health care needs,
Collaboration and data sharing between state Medicaid and child welfare agencies.

If your professional portfolio relates to the physical or behavioral health needs of children in foster care and beyond, it is worth keeping an eye out for MACPAC’s work, including public meetings.

Wonkatizer

Signals to watch, distilled down for you

Mississippi’s Infant Mortality & Foster Care Connection

Mississippi has declared a public health emergency in response to rising infant mortality rates.

What’s not getting headlines is the parallel in foster care data that points to common connections.

Why it Matters for Child Welfare

Infant mortality is closely tied to child maltreatment and child welfare system involvement; they share key social and family factors.

At the same time that Mississippi saw rising infant mortality rates, it saw rising infant placements into foster care, as you can see here:

Worth Tracking

Mississippi’s infant foster care rate is much higher than other age groups. That by itself isn’t unusual.

What sticks out is that while national foster care rates declined, Mississippi's rose every year starting in 2020, with infant rates exceeding national averages even when they fell.

Strategic Implications

Marshaling a public health response alone without also tapping child welfare expertise could miss the common factors driving both.