Sherri and Thomas Croom of Tallahassee, Florida, have fostered 27 children in the past decade. They’re pictured with four adopted children, two 18-year-old former foster daughters and those daughters’ sons.

Photograph courtesy of the Croom family

Sherri and Thomas Croom have been foster parents to 27 children — from newborns to teenagers — during the past decade.

That has meant visits to dozens of doctors and dentists for issues ranging from a tonsillectomy to depression.

Although foster parenting has innumerable challenges, healthcare coverage for the children isn’t one of them. Medicaid, the U.S. federal-state health insurance program for the poor, picks up the tab for nearly all children in foster care in the United States and often continues to cover them if they are adopted, regardless of their parents’ income. And as a result of the 2010 Affordable Care Act, foster children who have Medicaid at 18 can retain the coverage until they turn 26.

“We would not be able to foster without Medicaid,” says Sherri Croom, 41, of Tallahassee, Florida. “It pays for everything.”

Yet Croom and other foster parents say that even with the coverage they struggle to meet the extraordinary health needs of their children. Part of the trouble is too few doctors accept Medicaid, most notably mental health specialists.

Families also face the challenge of coordinating treatment decisions between government welfare agencies and foster children’s biological parents.

‘Medicaid nation’:

Although foster care children make up only a tiny portion of the 74 million Americans who receive Medicaid, this population faces significantly more health needs than most enrollees. These children often have experienced abuse, neglect, violence and parental substance abuse. About half of them have been diagnosed with mental health disorders, according to the Medicaid and CHIP Payment and Access Commission.

Medicaid is the nation’s largest health program, yet its broad reach beyond traditional populations of low-income children and parents and people with disabilities is less known. Kaiser Health News is examining how the U.S. has evolved into a ‘Medicaid Nation,’ where millions of Americans rely on the program, directly and indirectly.

A 2016 study in the journal Pediatrics found that children in foster care are twice as likely as others to have learning disabilities and developmental delays, five times as likely to have anxiety, six times as likely to have behavioral problems and seven times as likely to have depression.

And the number of these enrollees has increased in recent years, largely as the opioid epidemic has devastated many families. Between 2012 and 2016, children in foster care nationally rose from roughly 397,000 to 437,500, according to federal data.

Foster children’s health problems frequently demand specialized and consistent care, yet these children’s often unstable lives make it difficult for doctors or other health specialists to care for them, says Moira Szilagyi, a pediatrician based in Los Angeles. The children often move between foster homes or from foster homes back and forth to their families.

“Every time they change providers, some information is lost and leads to some duplication of services, or children fall out of treatment,” she says.

Lasting consequences:

Melanie Stimmell, a foster parent currently to a dozen children in Winter Garden, Florida, says nearly all the children she and her husband have taken in have had some mental health issues. She recalls it took months to find a nearby, Medicaid-friendly therapist for an 11-year-old who is bipolar and had been hospitalized before coming to her home.

Delays in getting these children care has lasting consequences, she says.

“The issues snowball into other issues,” she says. “It affects their performance in school, which hurts their ability to make friends, which hurts their self-esteem, and then they fall behind in classes and get held back and it affects everything in their life.”

In addition, some experts warn that children who have aged out of foster care at age 18 may delay care because they don’t know that they still have access to Medicaid until they turn 26.

“We are concerned that there are thousands of kids who should be getting Medicaid but aren’t because they are not plugged in to the system,” says Irene Clements, executive director of the National Foster Parent Association.

State performance varies widely on signing up former foster children through age 25. For example, according to state officials, Florida has signed up about 7,900 of them; Iowa, about 700; Colorado, more than 21,000; and Indiana, 1,685.

Separate plans:

A few states, including Florida, Georgia and Texas, have started to test an idea that might improve foster children’s access to care.

They are placing foster children in their own Medicaid health plan — separate from the coverage offered to most Medicaid families.

These plans are typically run by private, mostly for-profit Medicaid managed care companies, including Centene, Amerigroup and United Healthcare.

Supporters say these plans can be designed to meet the higher health needs — particularly for mental health services — of foster children.

For instance, Florida’s child welfare plan is required to have more primary care doctors and mental health specialists available than traditional Medicaid health plans. It also offers extra benefits such as nutrition counseling, art therapy and a $25 monthly allowance for over-the-counter items such as cough syrup and vitamins. About 34,000 foster children are in the plan managed by Centene Corp.

“This is a promising model,” says Roxann McNeish, research assistant professor of child and family studies at the University of South Florida.

She says having health plans with administrators and physicians trained to address the unique needs of foster children has helped better coordinate care to them. But more study is needed to see if children’s health has improved care compared with traditional health plans, she cautions.

These plans can also allow children to remain under the same coverage if they move to different parts of the same state.

No silver bullet:

Szilagyi says getting care to foster children is often difficult because responsibilities vary between state agencies, birth parents and guardians. “Obtaining consent from parents to provide health to the child can be challenging,” she says.

Ali Caliendo says Medicaid coverage has been invaluable since she and her husband, Terry, became Anthony’s foster parents more than four years ago.

Photograph courtesy of Ali Caliendo.

The foster-care-only plans try to improve this because they are trained to work with state foster care caseworkers to speed care to children.

But a 2016 study conducted by researchers at the University of South Florida for the state Agency for Health Care gave the plan mixed results. It found that parents often complained about lack of access to doctors. On the other hand, child welfare agencies reported having more input in health decisions for children. This is important because those agencies are responsible for recruiting and supporting foster parents and coordinating health services for the children.

The report did not examine whether the children in the plan had better outcomes.

Glen Casel, chief executive officer of Community Based Care of Central Florida, a foster care agency that contracts with the state to provide child welfare services, says these specialized plans have limited benefit. “I don’t think a foster-care-only plan is a silver bullet,” he says.

His nonprofit has worked with Centene to get more mental health providers in the network, particularly in communities that typically don’t have large numbers of Medicaid enrollees but have foster parents.

“It’s a daily fight for us,” he says.

Supporting parents:

Despite the challenges, foster parents do recount success stories.

Ali and Terry Caliendo, of Las Vegas, say Medicaid has been invaluable since they became foster parents to 7-month-old Anthony in 2013. He had bronchitis and pneumonia his first year and later was repeatedly sent home from daycare for being too aggressive toward other children.

“He was so sick as a baby, and then socially and emotionally he really struggled with violent rages and attachment issues,” Ali Caliendo says.

Medicaid paid for him to see psychiatrists, psychologists and physical and occupational therapists.

“Having the support through Medicaid made it an easier decision to be foster parents,” Caliendo says.

The Caliendos adopted Anthony at 18 months and were able to keep his Medicaid coverage. This fall, he begins kindergarten.

“Because we were able to intervene early, he is on a good trajectory, and we are really pleased,” she says.

Kaiser Health News’ coverage of children’s healthcare issues is supported in part by the Heising-Simons Foundation. This story originally appeared on Kaiser Health News. It has been slightly modified to reflect Spectrum’s style.