Has Family First Congregate Care Reform Made a Difference?

Federal law requires children to be placed in the most family-like setting,¹ yet 9% of youth in foster care live in a group setting² referred to as “congregate care.” Pediatricians³ have expressed concerns about the inadequacies and risks of congregate care, recognizing that children fare best when living within a family. Their advocacy propelled federal policymakers to pass the Family First Prevention Services Act of 2018 (FFPSA). This legislation incentivized family-based placement and sought to ensure that residential services were of high quality, used only when therapeutically necessary, and focused on successful return to family. The mandate for change was federally driven; however, the implementation for change, which began in 2021, is at the state level.

In this issue of Pediatrics, Keefe et al⁴ provide a landmark overview of the successes and challenges of implementation of FFPSA congregate care reforms in the past 2 years. Of...