Medicaid Waiver Adoption for Youth With Complex Behavioral Health Care Needs: An Analysis of State Decision-Making

Many states have enacted Home- and Community-Based Services (HCBS) Medicaid waivers, which waive or expand Medicaid means tests to increase access to community-based public mental health services for youth with Serious Emotional Disturbance (SED). This study sought to understand key factors in State Mental Health Authorities and Medicaid Agency decision-making in adopting Medicaid waivers for youth with SED. Using purposive sampling to collect data through semi-structured interviews with officials from 37 state mental health systems, interviews focused on fiscal, historical, and political reasons for states' adoption or rejection of Medicaid waivers to serve youth with SED. Results suggest that decisions around waiver adoption relate to the size and flexibility of state budgets, the sufficiency of existing public HCBS funding and services, political prioritization of children and families, states' desire to move away from a reliance on residential care, and ideology related to the role of the state in providing for the welfare of children and families. Advocacy efforts promoting state waiver adoption can address apprehensions about budget constraints and providing financial assistance to non-poor families by emphasizing potential cost savings from residential diversion and ethical imperatives to keep children in their homes and communities.