State Actions to Prevent and Mitigate Adverse Childhood Experiences (ACEs)
This brief highlights the recent work of nine states (Alaska, California, Delaware, Maryland, New Jersey, Pennsylvania, Tennessee, Virginia, Wyoming) to prevent and mitigate adverse childhood experiences (ACEs) and to implement trauma-informed practices at the state level. Experiencing adversity in early life can affect a person’s health, well-being, and success into adulthood. COVID-19 has brought additional attention to the impact of ACEs and trauma across the lifespan, which may be exacerbated by disruption in the lives of families; increased family stressors; income, food, and housing insecurity; social isolation; and school closures. ACEs are common across sociodemographic groups; however, they do not impact all sociodemographic subgroups equally – elevating ACEs as an important locus for states to address health equity. To mount an effective response to ACEs, states are implementing holistic approaches to promoting resilience for children and their families and adopting approaches that combine universal training, access to screening and treatment, improved data collection and reporting, and a commitment to transformative, cross-agency cultural change.
Previous case studies:
Maryland’s Family Recovery Courts: Successfully Reuniting Families with the Help of Customized Substance Use Disorder Treatment
To reduce substance use as a key cause of children removed from their homes, Maryland implemented a Family Recovery Court program in 2004 that connects parents to intensive treatment for substance use disorder (SUD) and provides case management and incentives. Over a one-year period, program evaluations show the program produced a 25 percent higher reunification rate, reduced days that children spend in non-kinship foster care (252 vs. 346), and produced more than $1 million in savings for the state’s child protective system due to reduced foster care utilization.
Background
Substance use is a major contributing factor in child removals. The rate of removals associated with substance use rose nearly 20 percent between 2000 and 2016 and peaked at 36 percent in 2018 before falling slightly to 34 percent in 2019. To address substance use as a driver of children entering foster care, Maryland uses a Family Recovery Court (FRC) model that connects parents to intensive services, case management, and incentives – all emphasizing SUD treatment as an opportunity to support family reunification.
FRC is a civil court proceeding that works closely with the state’s child welfare/child protection system. Individuals are referred to the FRC when they interact with the judicial system because their abilities to parent have been impaired as a result of SUD. Parents participating in FRCs have an underlying child welfare case in civil family court, where they often face the threat of losing custody following allegations of neglect. Maryland’s FRCs recognize the chronic nature of SUD and that without support and treatment, parents with SUD may continue to struggle. Maryland’s successful model is centered around services and engagement that incentivize the safety, health, and stability of families.
Establishing Family Recovery Courts
Maryland’s Code and Court Rules established a formal process for creating “problem-solving courts” that include FRCs. An administrative order from the Chief Judge of the Court of Appeals details the court’s process.
- A county circuit court or district court judge is required to lead its development, which includes consulting with and receiving commitments from other government agencies that are willing to participate as partners in the problem-solving court.
- Planning must establish community need indicated by SUD rates, child abuse/neglect cases related to parental SUD, rates of SUD treatment retention. The leaders outline program goals, protocols, and an estimated budget.
Maryland established its first FRC in Harford County in 2004, followed by Baltimore City in 2005. Today, the state operates five such courts across the state. To standardize best practices and requirements across jurisdictions, the Maryland Office of Problem Solving Courts released Guidelines for Planning and Implementing Family/Dependency Drug Treatment Court Programs in 2017. These guidelines spell out the process of establishing a FRC, including programming details, target populations, the role of the judiciary, policy issues, and funding strategies.
Eligibility:Parents who participate in Maryland’s FRC programs do so voluntarily, understanding that family reunification is the goal of the program. Eligible participants include:
- Parents of infants with positive screens for substances;
- Parents with reported neglect;
- Parents who maintain custody, but neglect is indicated through a petition; and
- Parents who maintain custody following a court’s disposition.
Parents may be referred into the program by child protective services, public defenders, magistrates, and social workers.
Services: Parents participating in a Maryland FRC are provided with an immediate assessment followed by comprehensive SUD treatment services and intensive supports to stabilize the family unit. “The range of services available are so rich and so focused on getting at the source of the medical issue that is driving their use disorder,” noted one Maryland state official. “[The goal is] not to simply achieve a period of negative urine analysis screenings, but to get to the core causes that will bring them to that ‘I’m done’ day.” All parents undergo extensive intake by internal court case managers who develop personalized treatment plans. Plans are closely monitored by the court, which convenes weekly to review open cases and participant progress.
Through the FRC, parents can access:
- Psycho-social supports, including counseling, as well as medication for opioid use disorder (MOUD) when clinically indicated;
- Peer support;
- Assistance in applying for Medicaid;
- Linkages to housing and transportation;
- Life skills training; and
- Continued access to the staff and resources of the FRC to gain continued parenting and SUD support.
FRCs take an incentives-based approach that embraces the reality that SUD is a chronic relapsing disorder – it does not terminate parents from the program solely on the grounds of their return to substance use.
Funding/State Support: Maryland utilizes several funding sources to operate its FRCs. State grant funds from the Office of Problem-Solving Courts, within Maryland’s Administrative Office of the Court, are the primary source of financial support. These grants cover administrative, staffing, training, and drug testing costs, and some ancillary services. In recent years, the state legislature has reduced the judiciary’s budget, but exempted problem-solving courts from any reductions. In 2017, the state’s Heroin and Opioid Prevention Effort (HOPE) and Treatment Act included an ongoing, mandated an appropriation to fund drug courts, including FRCs. FRCs and the Office of Problem-Solving Courts also partner with the Department of Behavioral Health, Department of Social Services, and other agencies to fund and navigate services such as transportation and housing supports. Finally, health care services, such as in- and outpatient treatment, psycho-social therapy, and MOUD are covered by Maryland Medicaid for eligible participants.
Outcomes:While the core goal of this court model is to achieve residential permanency for children, Maryland’s FRCs seek to achieve the often more difficult goal of family reunification by emphasizing holistic rehabilitation. In addition to treatment adherence, parental skill development and engaged participation are critical to the program’s success, and meeting the requirements for graduation from the program can be challenging. As part of annual reporting, the Administrative Office of the Courts routinely reviews all problem-solving courts, including FRCs. The 2020 Annual Report to the legislature indicated that, after adjusting for participants who left for administrative reasons, an average of 19 percent of participants graduated across FRCs in the state; Baltimore County had the highest graduation rate at 34.5 percent.
An external evaluation covering one year in 2008 also showed:
- A reunification rate of 70 percent for families participating in FRCs, as opposed to a 45 percent reunification rate among families who did not participate;
- Fewer days spent in non-kinship foster care placement (252 days vs. 346 days)
- A net savings of over $1 million for the state’s child protection system due to decreased utilization of the foster care; and
- A treatment completion rate by participating parents of 64 percent, compared to 36 percent of non-FRP parents.
Further, one FRC in a small jurisdiction was closed as the result of positive outcomes that led to a lack of subsequent need in the community.
Key Takeaways
To establish an FRC in a state, Maryland officials recommend policymakers:
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- Seek judicial leadership. Maryland’s Problem-Solving Courts are championed, developed, and supported by leadership within the judiciary, included judges across the state and from various levels of the state’s court system. Critical administrative funding, guidance, and enabling regulation flows from and is overseen by the judicial system, contributing to the program’s overall sustainability and success.
- Frontload a diverse and intensive array of services, and then maintain connections. State officials credit the program’s wraparound approach as an integral part of its success. Maryland’s FRCs provide case management services, short- and long-term family housing and transportation assistance, and employment preparation and life skills development. State leaders view the FRC as a lifelong program. FRCs employ parent locators who seek out FRC alumni and either re-engage them in treatment or encourage their participation in the program as peer support specialists. Parents may continue to receive services in the community after program completion.
- Encourage cross-agency collaboration. Maryland’s FRCs and adult drug courts are administered by the Office of Problem-Solving Courts and share an oversight committee, which provides an opportunity for collaboration across criminal and civil dockets. This approach also requires coordination among systems and agencies – the courts work with social services, health and behavioral health/SUD providers, and housing and transportation services to align resources and policies to ensure that the necessary supports are in place to help parents and families remain unified, healthy, and safe.
The National Academy for State Health Policy is providing this fact sheet with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. The authors would also like to thank Richard Abbott, Director, Juvenile and Family Services, Gray Barton, Director, Problem Solving Courts, Lou Gieszl, Assistant State Court Administrator for Programs, and the Hon. Robert Kershaw, Associate Judge, Baltimore Circuit Court, for contributing their expertise and state experiences to this report.
States Take Diverse Approaches to Drug Affordability Boards
As states take important steps to lower prescription drug costs, at least six have implemented prescription drug affordability review initiatives, although approaches vary across states. The National Academy for State Health Policy (NASHP)’s new chart, Comparison of State Prescription Drug Affordability Review Initiatives, provides a road map of the diverse efforts taken by Maryland, Maine, New Hampshire, New York, Massachusetts, and Ohio.
NASHP’s Prescription Drug Affordability Board (PDAB) model legislation, first released in 2017, defines a PDAB as an entity comparable to a public utility commission, with the ability to establish upper payment limits when a state’s PDAB determines a drug is otherwise unaffordable for state health care purchasers and consumers.
Maryland’s PDAB Phased-in Approach
Maryland’s PDAB, enacted in 2019, was based on the NASHP model but initially limits the board’s ability to set upper payment limits to only public purchasers, pending approval by the state legislature. The landmark Maryland law also includes a phased-in approach that could eventually establish upper payment limits for all payers in the state, including the commercial market. The start-up cost for the Maryland PDAB is roughly $750,000 and covers five full-time employees. The funding mechanism for Maryland’s board was vetoed by Gov. Larry Hogan, however the General Assembly recently overrode the veto.
In determining whether a drug is unaffordable, the Maryland board can consider a variety of factors, including:
- The wholesale acquisition cost (manufacturers’ list price) or another relevant drug cost index;
- Average rebates provided to health plans, pharmacies, and pharmacy benefit managers;
- Net drug prices; and
- Average patient copay.
In its early meetings, the board began to outline a list of potential drug pricing data sources it will need to access in order to determine an appropriate upper payment limit.
State Approaches that Leverage Purchasing Power
Maine and New Hampshire have also enacted laws creating their own unique PDABs. While these boards are called PDABs, it is important to note that, unlike Maryland, they do not have the authority to set payment limits, but are instead focused on leveraging public purchasing power to lower drug costs.
To accomplish that mission, Maine and New Hampshire’s boards are charged with recommending strategies for public purchasers to lower the cost of prescription drugs in order to meet drug spending targets that will be established by the boards. Ohio enacted a law creating a Prescription Drug Transparency and Affordability Council, but the law does not aim to set upper payment limits. Instead, it established a group of stakeholders to provide recommendations to the governor and legislature on actions that could lower drug costs in Ohio.
Medicaid Models
In addition to the models described above, New York and Massachusetts are engaged in affordability review initiatives that focus on drugs purchased by their states’ Medicaid agencies. As NASHP’s new chart shows, New York and Massachusetts use affordability reviews and direct negotiations with drug manufacturers to attain supplemental rebates on high-cost drugs.
Using Canadian Prices to Set Upper Payment Limits
NASHP’s model legislation’s key strategy was to set enforceable upper payment limits for prescription drugs in order to rein in drug prices. However, particularly with COVID-19’s impact on state budgets, not every state has the resources and capacity to establish a new entity to oversee the robust review of drug costs necessary to establish upper payment limits through a PDAB. During the 2020 legislative session, Washington Gov. Jay Inslee vetoed a number of bills based on cost concerns, including a measure that would have established a PDAB.
In the current 2021 legislative session, four states have introduced bills to establish a PDAB but others have refrained due to budget constraints. To support states facing those budget pressures, NASHP has also released a less costly, alternative approach to setting an upper payment limit – NASHP’s international reference rate model.
Using Canadian drug prices, the model allows a state insurance department to set an upper payment limit for up to 250 high-cost drugs (determined by drug price times utilization). A state could revise the model and use an affordability board structure as well. Canadian prices, which are established with reference to prices in various comparable countries, offer a less costly and labor-intensive process of determining upper payment limits.
Lawmakers in five states (HI, ME, OK, ND, and RI) have introduced or pre-filed bills based on the NASHP’s international reference rate model legislation and more bills are expected to be filed. To learn more about NASHP’s legislative models to curb drug costs and estimated savings from each of them, please contact Jennifer Reck.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
