Why and How States Adopt School Medicaid Expansion

Child mental health concerns have grown over the last ten years, with four in ten adolescents reporting that they feel persistently sad or hopeless (Centers for Disease Control and Prevention, 2024). Schools have become a primary place of healthcare because they are where children spend most of their day. One promising policy for improving funding and access to health services is school Medicaid expansion, which provides Medicaid reimbursement funding for delivering eligible school-based health services. To date, 27 states have adopted this expansion. Although school Medicaid expansion offers substantial and sustainable financing of school-based health services, state decisions to adopt and select school-based health services are not well understood. This study aims to understand why and how states adopted this policy. To understand state decisions, I conducted 32 semi-structured interviews over Zoom with State Medicaid and State Education Agency staff responsible for school-based health services. This study used a case study design and used thematic analysis to analyze interviews (Braun and Clarke, 2022). I also employed a novel policy coding approach using state policy documents to understand why and how states adopt this expansion. Despite widespread and bipartisan adoption, there is widespread variation in policy design across states. Adoption is motivated by the opportunity to increase child access to health services and improve federal funding for these services and policy design is shaped by state politics. Democratic states are more likely to adopt comprehensive designs that cover a wide range of services while Republican states are more likely to pursue select service designs. This study uncovers how partisanship drives service design comprehensiveness across states.This study presents early evidence on school Medicaid expansion, a policy innovation with the potential to improve access to health services and to address longstanding health inequities for millions of children.