Nearly 900 Texas children are waitlisted for a mental health program billed as an alternative to foster care

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Nidia Heston always had a plan for her son Quin but nothing could have prepared her when her son’s school wouldn’t enroll him in the eighth grade until his mental health was thoroughly evaluated.

At Dell’s Children’s Medical Center, doctors told Heston that Quin’s suicidal ideations were so severe that he would need to be admitted into a state hospital or a residential treatment center. To add to the heart-wrench, entering those facilities would require her to give up parental custody and care to the state for an extended amount of time.

Not wanting to say goodbye to her son, Heston quickly applied for an intensive state mental health program that would allow Quin to receive outpatient treatment at home or in offices. After a month of waiting and sleeping on the couch with Quin to make sure he didn’t hurt himself, she was approved for the program.

“I could finally surrender myself to help,” Heston said.

Heston and her son, who was diagnosed with bipolar disorder, autism and ADHD, is among thousands of families who have received treatment from the Youth Empowerment Services (YES) Waiver, an intensive mental health service program for families who cannot afford long-term psychiatric inpatient care or who would rather see their child receive treatment in their own community.

The program, which serves about 2,200 children, is currently in desperate need of additional funding as providers leave the program due to low Medicaid reimbursement rates. The waitlist for this mental health service is nearly 900 families on a given day.

Started in 2015, the program provides a family with a team of specialists within the community who provide various behavioral health services and nontraditional services, such as adaptive support, specialized therapies, and minor home modifications. The program is in high demand because it allows kids to go to school, play on their sports teams, and stay with their families. Often, families who cannot access acute mental health services give full or partial custody to the state to obtain treatment, which taxes the state’s already overburdened foster care system.

In 2023, 3,109 children inquired about being assessed for YES, a 53% increase from 2019. Despite the increased inquiries over the last five years, the number of youth served has steadily declined, with 2,227 youth enrolled in 2023 compared to 2,826 in 2019 — a 21% decrease.

Because of stagnant Medicaid reimbursement rates that are at times one-half of what providers are paid in the private sector, the program lost 386 YES providers between 2020 and 2023, according to a Texas Statewide Behavioral Health Coordinating Council report on youth health.

This has led to wait times for the YES program that vary by county, with rural parts of the state most affected.

“HHSC continues to work … to expand the provider base and maximize utilization of existing YES Waiver slots as a statewide service,” said Jennifer Ruffcorn, Texas Health and Human Services Commission spokesperson.

A lack of providers  

Monica Reyes, a certified family partner and mental health peer specialist in Travis County, has helped more than 100 families get approved for the YES program. She said the program's effectiveness is undisputed, with the state saving an estimated $12,500 per child served.

In 2023, 2,575 children were served in the YES program, and 95% of children who aged out of the program transitioned to other services or graduated with a transition plan for ongoing care. The YES Waiver is available statewide through all 39 local mental health and behavioral health authorities and two comprehensive waiver providers.

The demand for services has never been higher, but the system can’t handle the need, Reyes said.

“Our providers are making much more money not using Medicaid,” she said.

In Texas, Medicaid pays between $60 and $122 for a 50-minute session with a therapist who can charge $180 or more for that visit.

Since many therapists would rather accept privately insured or self-paying clients, few providers are left to treat Medicaid patients.

“Now the ones that do accept Medicaid, which are very few, are already booked and never have availability because the need is so high,” Reyes said.

Reyes said the YES program in Travis County has about two providers for nontraditional therapy services like art and music and eight providers for classic therapy services. The YES waitlist is at least six months.

“By then, our kiddos and families have already forgotten about it, and they have potentially fallen through the cracks,” she said.

Research shows a sharp increase in sadness, hopelessness, suicidal ideation and suicide attempts each year for Texas youth.

From 2005 to 2023, the number of Texas high school students reporting suicide attempts rose by 31%. Twenty-three percent of parents surveyed during the 2021-2022 school year by Texans Care for Children reported their child had one or more mental, emotional, developmental, or behavioral problems.

“It’s getting worse for sure,” Reyes said. “We’re seeing more aggression than ever before in our young people. We are seeing more cases of assaults on family members and assaults against school staff. Something is happening.”

The foster care problem 

For families going through severe mental health episodes, insufficient access to care can often force them to relinquish or share custody of their children with the state to secure necessary services.

In 2023, 108 Texas children entered foster care due to unavailable mental health or intellectual or developmental disability services, according to the Texas Department of Family and Protective Services database. Additionally, 461 children were placed in foster care due to “refusal to accept parental responsibility,” which are often linked to a child’s mental health or behavioral challenges. Typically, these cases involve a child who was in a psychiatric hospital or juvenile justice facility, and their parents didn’t pick them up, possibly for fear of not being able to support their child or concerns about the safety of others in the home.

There are also cases in which the parents agree to share custody of their child with the state to access mental health services. During the first eight months of the 2023 fiscal year, there were 1,493 of such cases. About 15% of these youth had unmet mental health needs.

“Many of these families don’t have a choice,” Reyes said. “The caregivers are losing their jobs because they must pick up their kids from school after every incident. Or they have to go to some court hearing for truancy. I worked with a family for a year and a half, and the mom lost three jobs during that time because of her kid's high needs.”

Many of these children still face significant barriers to receiving the services even once they enter foster care. They can be sent to unregulated, temporary placements such as hotels or churches, which can worsen their mental health challenges. It can also be hard for families to get their children back after giving them up for a certain amount of time.

The YES program was explicitly designed to stop this.

“We need more providers, and to get more, Medicaid will need to pay more,” Reyes said.

Funding request

Life for Quin Heston before being accepted into the YES program in January 2016 was one filled with pain and confusion that he had a hard time expressing. He felt isolated at school after he was placed in special education and was having a hard time with staff. He just wanted to run away, and often he did from the school.

That all changed once he started getting intensive treatment from the YES program. Through art therapy, he could express the emotions he had felt for years to his parents. He also learned to manage his emotions through a new therapist, and his team set him on a routine schedule for treatment and appointments. Almost a year later, when he moved to a different program that would cover his services for life, he felt like a new person.

“I think the one thing I regret is not noticing it,” said Quin Heston, now 22. “Obviously, I was younger…but now that I look back, I should have told my mother and father that there was something incredibly wrong. I didn’t feel right. I didn’t feel safe. But now I do.”

Quin Heston now works at Greenleaf Neurodiversity Community Center to help people with autism and other neurodivergent conditions develop friendships, social skills, workplace readiness, and a sense of belonging. Because of his work and life experience, he also has become an advocate for expanding the YES program and other state programs for those with disabilities and mental illness.

“I think lawmakers should recognize that this is becoming a growing need and that this isn’t something that will go away. Programs like the YES Waiver won’t solve the mental illness, but it helps,” he said. “It needs funding.”

Despite bipartisan support for a proposed increase to provider rates in the YES program in the 2023 legislative session, the proposal died.

Since then, the urgency for this service has only increased, and multiple advocacy groups and health organizations have voiced support for improving the YES program.

The National Alliance on Mental Illness in Texas, Texans Care for Children and the Statewide Behavioral Health Coordinating Council have asked lawmakers to approve the appropriations request in the state budget, which would provide a total of $61.9 million in 2026 and 2027 to expand critical services, including the YES program and other children’s health programs. It’s not clear whether the state agency will use any funding to the YES program to increase reimbursement rates for providers.

Another solution to help improve access to mental health services for youth is to make crisis services, intensive outpatient programs, partial hospitalization, and home-based services reimbursable through Medicaid.

“I think plenty of families want this kind of support. They just don’t know where to start,” Quin Heston said. “(My mother) told me, and I could see how terrible navigating the mental health system was. I think more families need to be made aware that there is service out there not just for children with developmental issues, but also mental health issues.”

Disclosure: Texans Care for Children has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.