State Medicaid Waivers and Youth Mental Health Service System Outcomes

Background: Obstacles to accessing mental health care for children are numerous.  The multiple pathways to services and disjointed funding streams make mental health systems difficult for families to navigate.  The system of care approach has been developed to address problems of fragmentation in mental health services and to provide a philosophy and value system for how comprehensive mental health care should be provided for SED children and their families (Stroul & Friedman, 1989).  A barrier to accessing such a system of care exists for families who do not qualify for Medicaid or other financial aid (Frank et al, 2003).  Some states attempt to reduce income-level access barriers to mental health care through the use of a Medicaid waiver—which waives the means tests for parents’ income, and bases eligibility for Medicaid on the child’s clinical severity of symptoms and functional impairment.  Types of Medicaid waivers include HCBS waivers, TEFRA waivers and Section 1115 waivers. The present study aims to discover if the use of particular Medicaid waivers yields increased state child mental health service system penetration rates, consumer satisfaction or functional outcomes for families. 

Methods: Analysis examined the following outcomes: state mental health service penetration rates, state-level consumer-reported changes in parental socialization and youth functioning, and families’ satisfaction with services, as captured by the Youth Services Survey for Families (YSS-F). Data was gathered from multiple secondary sources including the U.S. Census, SAMHSA’s URS data, and the Centers for Medicare and Medicaid Services. Random intercept linear regression models were created, controlling for a variety of state demographic and fiscal variables, to determine if relationships between Medicaid waivers and state level outcomes could be observed.

Results: Findings indicate that 4.2 to 6.1 additional individuals (per 1,000) are served in states with HCBS waivers than in states with no Medicaid waivers. However, when compared with states that have no waivers, states with Medicaid waivers have reduced reports of improved parent social connectedness or increased client functioning as a result of services (-3.8% to -5.4%). States that have TEFRA waivers (but do not extend it to youth with mental health disabilities) have significantly lower penetration rates (-9.4 to -15.8 per 1000 youth) than states that offer no Medicaid waiver at all. No other Medicaid waivers were found to be positively related to penetration rates. 

Conclusions: Variance across states in children’s mental health service use and unmet need exceeds discrepancies across racial or income groups (Strum, Ringel and Andreyeva, 2003). Given these state-level disparities, it is imperative that policies more effective in creating access to quality care be identified.  This study suggests that states offering HCBS Medicaid waivers may yield greater access to services, but does not ensure that the services accessed are effective or consumer-focused. Further study of the policies, interventions and programs that comprise a state’s mental health system of care— and examination of the effects of these on youth, families, communities and organizations —may help to identify specific components in these systems that could be strengthened through greater scrutiny.