Outside The Safety Net: An Analysis of Medicaid Eligibility and School-Based Mental Health Service Use Among Immigrant Youth

Abstract

Access to mental health care among adolescents in the United States remains uneven, with immigrant youth facing persistent disparities in service utilization despite substantial levels of need. Schools are key access points for behavioral health services because they reduce barriers such as cost, transportation, and provider availability. However, less is known about how state Medicaid policies shape immigrant youths’ access to school-based mental health (SBMH) services. This thesis examines how SBMH utilization varies by nativity and across state Medicaid policy environments and investigates how policy shapes access to care. Drawing on prior research, this thesis hypothesizes that more inclusive state Medicaid policy environments are associated with higher SBMH utilization among immigrant youth. To evaluate this hypothesis, the study employs a mixed-methods approach. The quantitative analysis uses restricted-use National Survey on Drug Use and Health data from 2022–2023 to examine differences in mental health need and SBMH utilization by nativity, insurance status, and state Medicaid policy category using descriptive estimates and Wald chi-square tests. The qualitative component draws on interviews with stakeholders across state government, school systems, Medicaid programs, and immigrant-serving organizations in a selected group of states representing different Medicaid policy environments, in order to examine how policy contexts impact access in practice. The quantitative findings indicate that immigrant youth experience meaningful levels of mental health need but consistently report lower SBMH utilization than their U.S.-born peers. This disparity persists even among youth enrolled in Medicaid or CHIP, suggesting that coverage alone does not eliminate differences in access. Within the immigrant population, utilization varies by insurance type, with higher use among privately insured youth and lower use among uninsured youth, while Medicaid coverage is associated with modestly higher utilization relative to those without Medicaid. Contrary to expectations, more restrictive state policy environments are associated with slightly higher SBMH utilization among immigrant youth, although these differences are not statistically significant. The qualitative findings highlight that eligibility expansions alone are insufficient to ensure access. Administrative complexity, language barriers, cultural stigma, fear related to immigration enforcement, and variation in school-based capacity determine whether eligible youth receive services. This thesis concludes that while Medicaid policy influences access through eligibility rules, expanding coverage is necessary but not sufficient to improve school-based mental health service use among immigrant youth. Policy efforts must also reduce administrative barriers, strengthen school-based capacity, and support culturally and linguistically appropriate care.