School Medicaid Expansion: Examining Child Access to Mental Health Services

Over the last ten years, mental health concerns have increased among school-age children in the United States, with four in ten children reporting they have felt persistently sad or hopeless (Centers for Disease Control and Prevention, 2024). Schools are critical providers of mental health services and millions of students receive school-based mental health services each year. Despite the critical role of schools to address child mental health concerns, securing sustainable funding remains a significant barrier to increasing school-based mental health service provision. One critical but underexplored area of federal funding to pay for school-based mental health services is Medicaid.

This dissertation examines the policy of school Medicaid expansion. Since 1988, school districts have been able to receive Medicaid funding for the Medicaid eligible special education services they provide to Medicaid enrolled students. In 2014, the Centers for Medicare and Medicaid Services amended this policy to allow school districts to receive Medicaid funding for all Medicaid eligible school-based services they provide to Medicaid enrolled students. Although this expansion presents a significant opportunity for school districts to fund a wider array of school-based health services, the process of expansion requires that both states and school districts adopt and implement this policy in the context of complex federal and state education and health laws. This dissertation contributes empirical evidence on this policy at the state and local levels as more states and school districts continue to expand.

This three-paper dissertation examines: (1) how and why states adopt school Medicaid expansion, (2) mental health service use among students in the years pre- and post-school Medicaid expansion, and (3) how street level bureaucracies manage policy growth and negotiate the complex web of policy layering. Paper 1 focuses on state adoption and policy design through interviews with most (22 of 28) current school Medicaid expansion states. This paper found that although adoption of the policy was bipartisan and states across the political party spectrum were motivated to leverage federal funding to improve student access to health services, the comprehensiveness of a state’s policy design was driven by state partisanship. To examine policy adoption, this paper developed the diffusion of adoption framework to examine how state policy trajectory and learning shaped adoption. To examine policy design, this paper developed a policy coding approach to standardize service categories across each state’s expansion policy design.

Paper 2 focuses on student mental health service use among K-12 students in Chicago Public Schools in the years pre- and post-school Medicaid expansion in the school district. When examining service use among all students, service use increased in the two consecutive years post-school Medicaid expansion relative to the year preceding expansion. When mental health service use results were disaggregated by disability identification, this paper found that service use increased among students identified with disabilities but did not increase among students without identified disabilities in the two consecutive years following expansion compared to the year preceding expansion. These findings underscore the role of disability identification in student use of school-based mental health services.

Paper 3 focuses on how street level bureaucracies manage an accumulating number of policies, including school Medicaid expansion, in the context of service delivery and resource constraints. This paper presents the new theory of policy hierarchy and new concept of policy disjuncture to attune to the special role of entitlement policy in policy implementation. This paper illustrates how points of policy disjuncture between existing policy mandates and new policies, and between local characteristics and new policies, shape service delivery and present a critical implementation challenge for street level bureaucracies in expanding service delivery.