The United States’ adolescent mental-health crisis is unfolding inside a health-insurance system that has changed dramatically over the past two decades. Medicaid covers roughly half of the nation’s children, making it one of the most important sources of mental-health care for young people. Yet an increasing share of that care is now organized by a small group of national corporations, raising new questions about how corporate ownership may influence the treatment children receive.
A study led by researchers at Oregon Health & Science University found that millions of Medicaid-enrolled youths were covered in 2022 by managed care organizations owned by one of five major national firms: Centene, Elevance Health, UnitedHealth Group, Molina Healthcare, and CVS Health. The analysis, published in Health Affairs, compared behavioral-health care patterns in plans controlled by these companies with patterns in other Medicaid managed care organizations. The researchers found consistent differences in screening, medication use, and acute-care utilization.
Managed care organizations, or MCOs, receive public Medicaid funding and assume responsibility for arranging or paying for members’ medical services. States generally use these organizations to control costs, coordinate treatment, and manage provider networks. The model has become the dominant way Medicaid services are delivered, but ownership has become increasingly concentrated. In 2006, most Medicaid managed care enrollees were covered by locally governed plans. By 2022, the five national firms examined in the study accounted for approximately half of the managed care market.
The researchers analyzed Medicaid claims data covering millions of young people during 2022, the most recent year available for the study. Claims data record services billed to an insurance plan, including preventive screenings, prescriptions, psychotherapy visits, emergency-department encounters, and psychiatric hospitalizations. Although such records cannot fully capture a child’s symptoms, family circumstances, or unmet needs, they allow scientists to identify large-scale patterns in how care is delivered across health plans.
One of the clearest findings involved screening. Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit requires states to provide regular assessments designed to identify physical, developmental, and behavioral-health problems in children. These screenings function as an entry point into care: they can reveal depression, anxiety, attention-deficit/hyperactivity disorder, substance use, suicidal thoughts, or other concerns before a crisis develops. The study found that screening rates were consistently lower among MCOs owned by large private insurance companies than among other organizations.
“That front door to care” matters because untreated behavioral-health problems can become more difficult and expensive to manage as they worsen, said lead author John McConnell, director of OHSU’s Center for Health Systems Effectiveness. A lower screening rate does not by itself prove that a plan denied needed treatment, and the researchers cannot determine from claims alone why screening differed. Possible explanations include variations in provider networks, administrative practices, documentation, patient access, or the way plans incentivize preventive services. Still, the consistency of the pattern prompted the authors to call for closer examination.
The analysis also found that young people enrolled in plans owned by four of the five firms were more likely to receive a psychotropic medication without a recorded psychotherapy visit. Psychotropic drugs include medications that affect mood, behavior, attention, or other mental processes. Some children may appropriately receive medication alone, particularly in cases such as uncomplicated attention-deficit/hyperactivity disorder. However, clinical guidelines often recommend psychosocial interventions, monitoring, or family support alongside medication, depending on the diagnosis and the child’s circumstances. A prescription without a corresponding therapy claim may therefore indicate limited access to counseling rather than inappropriate prescribing.
The researchers observed another concerning pattern: for most of the firms, enrollees had higher rates of emergency-department visits for mental-health conditions and were more likely to experience psychiatric inpatient admission. Emergency departments and hospitals are essential when children face immediate danger, severe symptoms, or suicidal behavior, but they are not designed to replace sustained outpatient treatment. Higher acute-care use could reflect poorer access to routine therapy, more severe underlying illness, differences in local provider availability, or other factors unrelated to corporate ownership. The study identifies an association, not proof that a particular company caused the outcome.
That uncertainty is especially important amid a nationwide shortage of youth mental-health services. OHSU researchers previously reported that children in psychiatric crisis can remain in emergency departments for days while waiting for an appropriate placement, a practice known as psychiatric boarding. When outpatient clinicians, crisis programs, and inpatient beds are scarce, families may rely on emergency services as the only available point of entry. The new findings suggest that managed care plans may be operating within that broader capacity crisis, while also raising the question of whether their network design and payment policies are helping solve the problem or reinforcing it.
The study’s authors argue that Medicaid’s growing dependence on a small number of for-profit firms deserves greater public scrutiny. A separate policy report from the same OHSU research group concluded that some administrative functions performed by MCOs could potentially be handled through more transparent, standardized systems and at lower administrative cost. Co-author Stephan Lindner said that because Medicaid is a public program, policymakers should examine whether the current structure provides sufficient value for the public money it administers. The findings do not establish that every national plan performs poorly, nor do they show that local plans always deliver better care. They do, however, show that corporate consolidation has coincided with measurable differences in how Medicaid-enrolled adolescents enter and move through the mental-health system. As the youth crisis intensifies, those differences could affect millions of children.
Subject of Research: People
Article Title: Corporate Consolidation And The Youth Mental Health Crisis: Evidence From Medicaid Managed Care In 2022
Web References: https://www.healthaffairs.org/doi/10.1377/hlthaff.2025.01619 ; https://news.ohsu.edu/2025/08/15/thousands-of-kids-in-mental-health-crisis-are-stuck-for-days-in-hospital-emergency-rooms-study-finds ; https://www.milbank.org/publications/managed-care-as-medicaids-administrative-architecture-does-it-still-provide-value-to-states/
References: Health Affairs, DOI: 10.1377/hlthaff.2025.01619
Keywords: adolescent mental health, Medicaid, managed care, health insurance, behavioral health, psychotherapy, psychotropic medication, emergency departments, psychiatric hospitalization, corporate consolidation
