Healthcare Access Barriers and Facilitators Among Youth Leaving Foster Care: A Scoping Review

Background & Purpose: Youth within the child welfare system are a medically complex population. Roughly 9 of every 10 children entering the child welfare system reports at least one physical health condition, while approximately half experience an emotional or behavioral condition. Given the extraordinary medical need within this population, access to healthcare is critical. Challenges around healthcare access are more pressing for older youth in foster care. Older youth experience myriad challenges upon leaving foster care, including early parenting, substance misuse, joblessness, and homelessness—outcomes that may be exacerbated by inadequate healthcare, while also imposing additional barriers to healthcare access. Despite ACA extension of Medicaid eligibility through age 26 for care leavers, concerns around healthcare access persist due to low Medicaid reimbursement rates, stigma around seeking services, and other potential psychosocial barriers to access.

Healthcare access is a critical component of wellbeing among youth leaving foster care, yet no reviews specifically address the issue. This scoping review seeks to answer the following question: What personal, social, and structural factors facilitate or hinder healthcare access for young adults (including emancipated youth) ages 14-35 transitioning out of the US foster care system?

Methods: Using the JBI Scoping Review Protocol, the authors searched EBSCO, Child Development & Adolescent Studies, PubMed, JBI, and Social Services Abstracts databases and engaged in reference harvesting. The search strategy employed a combination of keywords related to former foster youth, healthcare access, barriers, and facilitators. Studies were included if they focused on the foster youth population, including emancipated youth, ages 14-35, explored factors affecting their access to healthcare, were published between 2013-2023, and conducted in the US. Reviews, grey literature, and non-empirical studies were excluded. Data extraction was conducted by four researchers to enhance reliability and included barriers, facilitators, recommendations, and limitations.

Results: Of the 12,549 initial articles, 297 were assessed for eligibility, and 31 met the eligibility criteria. Twenty studies were qualitative, seven were mixed-methods, and four were quantitative. Most of the articles reported barriers and facilitators on mental health (n=18), followed by substance use (n=8), sexual/reproductive health (n=4), physical health (n=4), oral/dental health (n=1), and eye care (n=1). Barriers to access, described across 26 of 31 studies, included lacking knowledge, experience, and guidance; concerns with confidentiality and trust; treatment accessibility, availability, options, and coverage; stigma and judgment; housing and community instability; provider and intervention-specific characteristics. Facilitators to access, described across 25 of 31 studies, included necessity; support and encouragement from providers and other stakeholders; relationships; quality and legitimacy of services; alternative interventions; youth experiences; finances; and health insurance.

Conclusion & Implications:

This scoping review highlights multiple systemic, social, and personal factors that help or hinder access to healthcare for youth leaving foster care. Recommendations flowing from these noted barriers and facilitators are discussed with respect to individual-, social-, and system-level determinants of healthcare access and include policy-level interventions (e.g., facilitation of Medicaid reenrollment after 18), practice-level interventions (e.g., empathy education/training for healthcare providers), and guidance for future research (e.g., rigorous evaluation of novel interventions to facilitate access).