Association for Public Policy Analysis & Management

Objectives: Between 2012 and 2016, the number of children in foster care increased by 10 percent nationally, ending more than a decade of sustained decline. Over the same period, opioid-involved overdose death rates increased by 80 percent, and may be contributing to increases in foster care placements. For example, areas with high rates of drug overdose deaths and drug-related hospitalizations are more likely to have high rates of child abuse and neglect reports and foster care placements. There are evidence-based treatments for substance use disorder (SUD) that might prevent or reduce the amount of time that children spend in the child welfare system. Previous research found that parents separated from their children due to SUD and completing SUD treatment were more likely to experience family reunification. Medication-Assisted Treatment (MAT) is an effective approach for the treatment of opioid use disorder (OUD), a type of SUD. Since 2013, all states have covered buprenorphine for MAT for all Medicaid beneficiaries, making it a viable and affordable OUD treatment option for many low-income adults. In addition, methadone for MAT is covered by 31 states as of 2015.

This study aimed to understand the potential for MAT to prevent child maltreatment and subsequent foster care placement. This association was explored by examining state-by-state variation in Medicaid expansion and the availability of methadone used in MAT. The early expansion of Medicaid, beginning in April 2010, and the 2014 Medicaid expansion, elected by 32 states as of December 2016, increased Medicaid eligibility for low-income adults, improving access to MAT. We focused on evaluating the impact of Medicaid expansion and MAT coverage on first-time foster care placements.

Method: Data from 2000-2016 Adoption and Foster Care Analysis and Reporting System (AFCARS) was used. We focused our analyses on children aged 17 or younger who entered foster care for the first time (N=3,776,985), as re-entries into care may systematically differ between states. We further focused on those who entered the foster care system with “parental drug abuse” as one of the reasons for removal (N=919,833). The number of entries per year was aggregated at the state level. We used the differences-in-differences method to exploit variations between states on Medicaid expansion and coverage in methadone. We examined the effect of state Medicaid expansion and MAT service coverage on first-time foster care entries due to parental drug abuse.

Results: Preliminary results show that first time foster care entries due to parental drug abuse decreased by 22% (p = 0.004) in states that expanded Medicaid and covered methadone compared with Medicaid expansion states not covering methadone in their Medicaid programs. Falsification tests were conducted to examine whether Medicaid expansion and methadone coverage have the same impact on first-time foster care entries due to sexual abuse, alcoholic parents, child disability, and child behavior problems, but no significant effects were found.

Conclusions: Improving access to OUD treatment such as methadone may reduce foster care entries due to parental drug abuse. Further analyses aimed at understanding these associations are warranted.