From the Baltimore Banner to the Department of Legislative Services, serious issues might be ahead for children in need of both social and behavioral services as Maryland begins the 2023 General Assembly.

This article is part of MACo’s Policy Deep Dive series, where expert policy analysts explore and explain the top county policy issues of the day. A new article is added each week – read all of MACo’s Policy Deep Dives.

It has been widely reported this month, and in years before, that Maryland hospital wait times are the worst in the country according to data from the Centers for Medicare and Medicaid Services that recently released a study showing the average time at 228 minutes. A recent Baltimore Banner article by Hallie Miller and Liz Bowie accounted for nearly 70 percent of all “ER boarding” days being attributed to behavioral health issues but only accounted for a quarter of hospital admissions. The article went on to highlight that a major reason for the back-up is children who are in need of behavioral health services, including foster children. Due to a shortage of options, hospital beds have become a last resort, similar to jails being a known last resort for adults with mental and behavioral issues. This alludes to a disheartening pattern and pathway for young adults with limited means.

From the article, a representative at Johns Hopkins Hospital:

30% of the beds are not being used because staff have been diverted to help care for children who shouldn’t be there. “We’d have the capacity if we had the ability to get the kids in and out,” she said.

There is general agreement that an accessible continuum of care needs to be created for youth behavioral health services. This essentially means the development of a system that can meet any patient where they are and adapt to their evolving needs as they progress through the treatment options, whether they are getting better or worse. Advocates agree that both public and private funds and resources could be woven together to create the fabric of this system within the communities where children in need live. Types of care range from community-based efforts on the less intense end, such as at-home aides, to the more intensive options, such as a long-term residential centers. Efforts have yet to synchronize around this mission in a meaningful way according to the many experts cited in the Banner article and will likely be top-of-mind going in to the January start of the Maryland General Assembly.

Children in the foster care and or social services system can account for a significant portion of the population in need of behavioral health services in addition to housing. According to a recent 2023 legislative preview by the Department of Legislative Services, the bad situation the state is in might be getting worse as they noted the child maltreatment and child welfare caseloads are anticipated to increase toward pre-pandemic levels in the coming year. Additionally, child welfare placement costs will be impacted in fiscal 2023 by substantial provider rate increases as well as greater demand for subsidized adoptions and subsidized guardianships. The report claimed these two placement types are anticipated to increase during the remainder of fiscal 2023 as courts continue to move more children into permanency options. This climate would likely put further strain on human service resources both at the state and county levels.

With psychiatric beds in Maryland continually at capacity and long waitlists, families with the means could still opt to send kids out of state, which is not as viable an option for economically insecure families and children involved in the social services system. Even in the instance when private and public residential facilities have space there is a significant funding disparity in the cost verses coverage offered by the state to handle those fees. While inpatient psychiatric care can cost thousands of dollars per day, Medicaid reimbursements are often only several hundred dollars. When care is insufficient or unavailable it compounds equity concerns around those populations most likely to face resource scarcity and or discriminatory practices.

A lack of community-based services for care is an issue for some but is further exacerbated for individuals who, additionally, need an actual place to live. A Banner report, again by Miller and Bowie, back in September of this year, further highlighted the lack of appropriate placements for children in foster care with a focus on the practice of housing foster children in hotels and downtown office buildings.  Practitioners could potentially put their medical license in jeopardy if found to be providing care in an unapproved facilities leading to risky and questionable practices and outcomes for incredibly vulnerable individuals. A hospital setting, under the circumstances, might seem like a better option in he short-term but is not without its challenges. In one instance a Banner article, again by Miller and Bowie, cited a situation where the Maryland Public Defender’s office, received reports that the Maryland Department of Social Services, “refused to pick up foster children ready for hospital discharge because they had no place to take them. When forced to pick them up, social workers would take them to another hospital emergency room.”

These issues are coming to a head just as help from the federal government is also being pulled back. At the federal level, the loss of expanded child tax credits and a looming rollback of pandemic aid threatens to destabilize parents that are just managing to stay afloat amidst continued record inflation. With the 2023 legislative session just around the corner and a new administration transitioning into the Governor’s Office, advocates will be ready to demand policy solutions to the current gap in behavioral health access for vulnerable youth populations in Maryland.

All Maryland counties and Baltimore City operate foster programs and work to coordinate resources for care. With much of the agreed solutions to the behavioral needs of at-risk youth being focused on community-based programs, counties will certainly have a voice and role to play in navigating the myriad of challenges these issue represent.  Numerous pieces of legislation have been proposed over the past couple years with more state level implications than county based initiatives, at home, where the problems often start and could stand to be prevented, especially through the lens of the situation outlined in this article. With a renewed focus on the need and community-based care options, MACo will be keeping an eye on how these priorities come together from a policy perspective in 2023.