The state and other people's children: The impact of state health policies on pathways to ambulatory mental health services for children in child welfare

Introduction. Children in the child welfare system have high mental health needs, and depend upon Medicaid to finance access to mental health care. The effects of Medicaid managed behavioral care on this population are unknown. This study examines how variations in Medicaid managed care policies affect use of ambulatory mental health services for children in child welfare.; Methods. The National Survey of Child and Adolescent Well-Being is a panel study that provides individual-level data for 6,231 children in the child welfare system. The Caring for Children in Child Welfare study uses key informant interviews to obtain county-level Medicaid policy information. We merged these data files with the Area Resource File, and analyzed relationships between county-level policies and children's mental health utilization using a three-stage nested logit model.; Results. Around 37% of all children had a clinical score on the Child Behavior Checklist. Less than a fifth saw a specialist mental health provider. Multiple logistic regression showed older age, out-of-home placement, higher physical and emotional morbidity, and having a college-educated caregiver to be associated with higher odds of receiving mental health care. Children living in counties with high concentrations of child psychiatrists had higher odds of mental health service use; their odds declined if they lived in counties with high concentrations of pediatricians. Children placed out-of-home in counties with behavioral carve-outs had higher odds of use of mental health care. Fee-for-service provider reimbursement was associated with higher odds of mental health services use. Children seen by non-mental health specialists had higher probabilities of use of psychotropic drugs than children seen by specialty providers. Child welfare worker referrals played an important role in determining use of services.; Discussion. Medicaid managed care policies have heterogeneous effects on child welfare populations, and tend to affect the publicly insured and out-of-home children more than those placed in-home. Behavioral carve-outs with fee-for-service provider reimbursement may best promote access to mental health care. Supply-side policies, such as investments in caseworker training and increasing numbers of active child psychiatrists, are likely to have robust effects in promoting use of mental health services among children in child welfare environments.