COVID-19 Pandemic-related Changes in the Child Tax Credit and Effects on Behavioral Health for Medicaid-enrolled Adolescents

ABSTRACT Adolescent behavioral health was already in crisis prior to the COVID-19 pandemic and has only worsened. Pandemic-related changes to the 2021 Child Tax Credit (CTC) offered financial relief to disadvantaged families. The changes were historic; the amount of refundable credit per child more than doubled, families with no or very low income were no longer excluded, and half the credit was paid through advance monthly payments (July-December 2021). Increased household income is a modifiable social determinant of health that could improve adolescent mental health through reduced household stressors. We hypothesize that compared to adolescents who were not age-eligible for the CTC, the additional CTC advance payments for age-eligible adolescents will lower their risk for adverse behavioral health events. We also expect that the CTC provided enabling resources for vulnerable adolescents with major depressive disorders (MDD) to continue treatment. The goals of the proposed study are to examine the effects of the CTC advance payments on adolescent behavioral health and treatment engagement through an innovative, quasi-experimental design (difference-in- differences, DID) and concurrent mixed-methods approach. For Aim 1, DID will compare effects before, during, and after the CTC advance payment period (1/2021-6/2021, 7/2021-12/2021, and 1/2022-9/2022) for two age groups: 1) adolescents who turned 18 fourth quarter of 2021 (not eligible for 2021 CTC advance payment), and 2) adolescents who turned 18 first quarter of 2022 (eligible). We will use two data sources to conduct these analyses from a state and national perspective: 1) Ohio Medicaid ACO (n=10,521), and 2) national Medicaid T-MSIS Analytic Files (n=972,000). Our Aim 1 outcomes include a) adverse behavioral health events (deliberate self-harm, psychiatric crisis, alcohol/drug poisoning) in emergency department/inpatient setting, and mortality (suicide, all-cause); and b) outpatient treatment and pharmacotherapy continuation (among adolescents with MDD). For Aim 2, we will recruit adolescents with a diagnosis of MDD and their caregivers using purposive sampling with quantitative Ohio Medicaid claims data for qualitative interviews (n=90). Interviews will explore the influence of the CTC on family financial distress, household resources, adolescent behavioral health and treatment engagement from diverse perspectives (racial/ethnic minorities and rural residents). Finally, Aim 3 will explore heterogeneity of the CTC treatment effects for racial/ethnic minorities and rural residents. The validity of our findings will be strengthened by using multiple data sources and a concurrent mixed-methods approach, including diverse perspectives from qualitative interviews and input from our stakeholder advisory group of national and state policy experts, community-based service providers, adolescent behavioral health providers, and families with lived experience. Impact. Our findings will have important implications for the effects of anti-poverty policies on mental health among vulnerable adolescents and could point to solutions for a growing mental health crisis.