P2.093: Medicaid Reform and Juvenile Justice: A New Era of Healthcare Access for Incarcerated Youth

Background: Over 30,000 children are incarcerated in the United States on any given day. The 1965 Medicaid Inmate Exclusion Policy (MIEP) barred federal Medicaid funds from covering healthcare for individuals in custody, including youth, preventing states from using Medicaid and CHIP to fund care for detained minors. A significant shift came with the 2023 Consolidated Appropriations Act (CAA), which reversed MIEP and mandated coverage for youth in detention. Additionally, 1115 waivers allow states to expand pre-release Medicaid coverage further. These reforms changed the treatment landscape for our communities’ most vulnerable youth.

Project Description: Starting January, 2025, the 2023 CAA requires Medicaid and CHIP to cover medically necessary screenings (including medical, dental, and behavioral health), diagnostic services, and case management for all eligible youth (under age 21 and former foster care youth under 26) in public institutions (including state prisons, local jails, and all juvenile detention and youth correctional facilities) 30 days before release. States must continue to provide case management services for at least 30 days post-release. This offers a profound opportunity for pediatricians to advocate for system-involved youth. Some states additionally use 1115 Medicaid waivers to provide pre-release services to incarcerated youth up to 90 days before release. The 2023 CAA also allows states to provide Medicaid or CHIP services to eligible youth in detention pending disposition of charges (i.e., awaiting the proceedings) and offers additional funding to school-based health centers for continuity. Unfortunately, few youth advocates shaped these policies, leading to many challenges in implementation.

Discussion: The CAA presents an opportunity to improve healthcare continuity for incarcerated youth. Effective implementation requires coordination among juvenile justice agencies, community health providers, and policymakers to ensure vital services—such as substance use treatment and chronic disease management—are initiated pre-release and maintained post-release. With poor implementation, vulnerable youth face heightened risks. Pediatricians can advocate by knowing what services are available in their community, whether their state has applied for or obtained a 1115 waiver, pressuring policymakers to consider the needs of youth in implementation, and familiarizing themselves with local organizations supporting this critical initiative.

Conclusion: Expanding Medicaid and CHIP coverage under the CAA of 2023 and related 1115 waivers transforms healthcare access for juvenile-legal-involved youth. By providing 30 to 90 days of pre-release coverage and structured case management, states can help break cycles of violence, recidivism, and relapse. However, these initiatives remain vulnerable to shifting federal policy priorities, and essential data on effectiveness is still emerging. Policymakers, pediatricians, and juvenile justice agencies must work collaboratively to ensure the full implementation of these reforms, leveraging available funding mechanisms and assistance programs. By addressing immediate healthcare needs and long-term support systems, these policies can provide justice-involved youth with a better chance at rehabilitation, stability, and improved health outcomes.