Case: DOJ Investigation of Alaska's Behavioral Health System for Children

This was an investigation into potential American with Disabilities Act (ADA) violations via the institutionalization of children with behavioral health disabilities in Alaska. On December 17, 2020, the U.S. Department of Justice (DOJ) notified Alaska of its intent to investigate whether the state had unnecessarily institutionalized children with behavioral health disabilities in violation of Title II of the Americans with Disabilities Act (ADA). Legal frameworks like the ADA and the Medicaid Act's Early Periodic Screening Diagnostic and Treatment Services (EPSDT) mandate that states provide necessary health services in the most integrated setting appropriate. In a report released on December 15, 2022, the DOJ concluded that Alaska had violated the ADA by forcing many children, including a substantial number of Alaska Native children, to endure unnecessary and unduly prolonged admissions in psychiatric hospitals and residential treatment facilities.

The investigation found that children in Alaska, including a significant number of Alaska Native children, were institutionalized at high rates and for long periods due to the lack of community-based services. Despite efforts by Alaska to bolster its community-based behavioral health services through initiatives like the Section 1115 Medicaid demonstration waiver, which is granted to enable states to carry out experimental, pilot, or demonstration projects that promote innovation, the care system remained heavily biased toward institutionalization. Notably, the State spent over $56 million in 2020 on treatment for children in psychiatric hospitals and an additional $14.5 million for acute psychiatric care in general hospitals. By comparison, Medicaid claims for all community-based behavioral health services for children, excluding those provided in residential settings, totaled under $32 million. This situation forced many children who could otherwise receive community-based services to endure unnecessary admissions to psychiatric hospitals and residential treatment facilities, contravening the ADA's requirements.

The DOJ's investigation included outreach to service providers across Alaska, interviews with state officials and tribal organizations, and reviews of medical records for children receiving state-funded behavioral health services. This comprehensive approach revealed a consistent pattern: children were often placed in institutions far from their homes and communities because the necessary community-based services were unavailable or inaccessible.

To rectify these issues and align with federal legal standards, the DOJ recommended a series of reasonable modifications to Alaska's behavioral health service system. Recommendations included ensuring the availability and accessibility of community-based services with sufficient intensity to prevent unnecessary institutionalization and coordinating with local providers, tribal stakeholders, and governments to ensure culturally appropriate service delivery. Additionally, leveraging schools as venues for providing behavioral health services and developing robust protocols for identifying and addressing the needs of children at risk of unnecessary institutionalization were recommended as critical steps toward compliance with the ADA.

The DOJ investigation concluded with an expression of a desire to work with the State toward a solution but warned of possible legal action if an agreement could not be reached.