Public Release: 

Children in foster care may be underaccounted for in the Medicaid program

Study: Many foster children are not receiving needed health care

Children's Hospital of Philadelphia

The currently accepted statistics for numbers of children who live in foster care and are eligible for Medicaid may seriously underestimate the actual figure, according to a new analysis by pediatric researchers at The Children's Hospital of Philadelphia. The study also reinforces previous findings that significant numbers of children in foster care are failing to receive needed health care services.

Medicaid, the federal health care program for low-income families and many children with disabilities, also insures most children living in foster care. As a result, "most prior studies that estimated health service use by children in foster care used Medicaid records as their source of information," said the study's lead author, David Rubin, M.D., M.S.C.E., director of Research and Policy for Safe Place: The Center for Child Protection and Health at The Children's Hospital of Philadelphia. "The problem we found is that Medicaid records fail to identify many foster care children, especially those who may not have been receiving medical services they needed."

The study appeared in the May-June issue of Ambulatory Pediatrics.

The research team studied Medicaid eligibility files for a sample of 5,683 children who entered foster care in Philadelphia during 1994 and 1995. They found that the Medicaid system failed to identify 28 percent of the children as residing in foster care. "We found a systematic sampling bias," said Dr. Rubin. "Children were more likely to be identified correctly as foster children if they had a greater number of foster care placements or used more services, such as hospital emergency departments or mental health programs."

"However, we found that nearly 40 percent of the children in our sample never visited an outpatient health care or mental health provider during the year after they were placed in foster care," added Dr. Rubin. "Many of these children were among those not identified by Medicaid as living in foster care. The concern is that these children may be falling through the cracks, because other studies have shown that the majority of children in foster care have chronic unmet medical or mental health needs."

Noting that the proposed new federal budget contains some $10 billion in cutbacks to Medicaid, Dr. Rubin believes his group's findings of sampling bias have particular relevance to the current debate about the level of public funding for Medicaid. He adds, "Although our findings were based on data from the mid-1990s, there's no reason to suspect those findings would be different today. As such, policymakers risk underestimating the burden of needs and service use among children in foster care. They may also underestimate potential implications for foster care children from large rollbacks in the Medicaid program."


Dr. Rubin's co-authors, all from The Children's Hospital of Philadelphia, were Susmita Pati, M.D., M.P.H., and Evaline A. Alessandrini, M.D, M.S.C.E., from the Pediatric Generalist Research Group, and Xianqun Luan, M.S., from the Division of Biostatistics. Drs. Rubin, Pati and Alessandrini are also in the Center for Clinical Epidemiology and Biostatistics of the University of Pennsylvania, and Drs. Pati and Alessandrini are senior fellows at the University's Leonard Davis Institute of Health Economics.

Dr. Rubin was supported by a University Research Foundation Grant from the University of Pennsylvania. Dr. Alessandrini was supported by a grant from the National Institute of Child Health and Development.

The Children's Hospital of Philadelphia was founded in 1855 as the nation's first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking second in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 430-bed hospital recognition as a leading advocate for children and adolescents. For more information, visit

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