It is well known that the crisis in behavioral health among young people worsened during the COVID-19 pandemic and that pandemic mitigation was particularly difficult for young people and people with low incomes. Medicaid funds health services for people with low incomes and is the largest single funder of health services for adolescents and young adults (youth). However, little detail exists about the prevalence and characteristics of youth Medicaid enrollees with behavioral health conditions—specifically substance use disorder (SUD) and mental health conditions from before, during, or after the pandemic.

In this brief, we synthesize results from five briefs about the prevalence and characteristics of Medicaid-enrolled youth with a behavioral health condition before the pandemic (2018) in California, Colorado, New Mexico, Massachusetts, and Washington, DC. We highlight similarities and differences across the states and discuss how these findings relate to the prevention and treatment of behavioral health conditions and to youth well-being.

Why This Matters

Behavioral health conditions vary over time, place, and populations. The behavioral health of youth Medicaid enrollees may have been especially impacted by the pandemic. Medicaid enrollees with behavioral health conditions may also have increased risks of negative consequences of these conditions because of structural disadvantages, including low family wealth and historically racist policies related to substance use. Many states are already innovating their Medicaid programs to improve behavioral health–related services, including services tailored to youth. But stakeholders—including youth and their families—need more information about prevalence and characteristics of youth with behavioral health issues in their states and communities to help shape approaches to prevention and treatment and to ensure that those approaches are culturally effective and align with how stakeholders define wellness. This information can help stakeholders better assess how these issues are evolving in their states and communities.

What We Found

• Across five state Medicaid programs in 2018, rates of behavioral health diagnoses ranged from about one in six youth enrolled in Medicaid to about one in four youth enrollees.
• The extent and types of behavioral health diagnoses varied across and within states.
• In each of the study states, adolescent and young adult enrollees had similar levels of any behavioral health diagnoses. However, young adults were more likely than adolescents to have a SUD diagnosis and less likely to only have a mental health diagnosis (i.e. without SUD).
• Anxiety disorders, depressive disorders, and marijuana use disorders were generally the most common diagnoses among youth with behavioral health diagnoses.
• Suicidality was a substantial issue, especially among youth with co-occurring SUD and mental health conditions, among whom suicidality rates ranged from about one in five (young adults in Washington, DC, and Colorado) to about one in three (adolescents in New Mexico).
• In all states, youth with behavioral health diagnoses were more likely to experience disability than other youth.
• Racial and ethnic and other demographic patterns in behavioral health diagnoses differed across states.
• Youth with a diagnosed SUD or mental health condition had high contact with health care providers in a variety of settings, including disproportionate contact in the emergency department (ED).
• Most adolescents with behavioral health conditions did not get health services in school during the year.

Based on these findings, we recommend several strategies:

• Increase investment in youth well-being, including implementing and bolstering programs and policies that promote social connectedness, address parent needs, support family relationships, and allow a more holistic approach to preventing and treating behavioral health conditions.
• Facilitate involvement of a diverse range of community stakeholders, including youth and families, in shaping approaches to prevention and treatment and in ensuring that these approaches are culturally effective in their communities and align with how community stakeholders define wellness.
• Increase stakeholder access to detailed statistics about youth and subpopulations of youth in states and local areas.
• Look to innovative initiatives that focus on adult ED patients with opioid use disorder for potential models for providing youth with recommended behavioral health services in the ED.
• Increase efforts to address behavioral health workforce shortages, including by potentially expanding reimbursement to peer specialists and community health workers.

How We Did It

The data for this study comes from claims and enrollment data from the 2018 Transformed-Medicaid Information System (T-MSIS) Analytical Files (TAFs) for California, Colorado, Massachusetts, New Mexico, and Washington, DC. We used the Urban Institute’s Behavioral Health Services Algorithm to identify SUD and mental health conditions recorded in claims. We computed and analyzed descriptive statistics showing the prevalence and characteristics of youth with co-occurring diagnoses of SUD and a mental health condition, a SUD diagnosis only (and no mental health condition), a mental health condition diagnosis only (and no SUD), and no SUD or mental health diagnosis.