Valentino Valdez was given his birth certificate, his Social Security card, a T-shirt, and khaki pants when he was released from a Texas prison in 2019 at age 21. But he didn’t have health insurance, mental health medications, or access to a doctor, he said.
Three years later, he landed in an inpatient hospital after expressing suicidal thoughts.
After more than a decade cycling through juvenile detention, foster care placements, and state prisons, Valdez realizes now that treatment for his mental health conditions would have made life on his own much easier.
“It’s not until you’re put in, like, everyday situations and you respond adversely and maladaptive,” he said, “you kind of realize that what you went through had an effect on you.”
“I was struggling with a lot of mental stuff,” said Valdez, now 27.
For years, people like Valdez have often been left to fend for themselves when seeking health care services after their release from jail, prison, or other carceral facilities. Despite this population’s high rate of mental health problems and substance use disorders, they often return to their communities with no coverage, which increases their chances of dying or suffering a lapse that sends them back behind bars.
A new federal law aims to better connect incarcerated children and young adults who are eligible for Medicaid or the Children’s Health Insurance Program to services before their release. The goal is to help prevent them from developing a health crisis or reoffending as they work to reestablish themselves.
“This could change the trajectory of their lives,” said Alycia Castillo, associate director of policy for the Texas Civil Rights Project. Without that treatment, she said, many young people leaving custody struggle to reintegrate into schools or jobs, become dysregulated, and end up cycling in and out of detention facilities.
Medicaid has historically been prohibited from paying for health services for incarcerated people. So jails, prisons, and detention centers across the country have their own systems for providing health care, often funded by state and local budgets and not integrated with a public or private health system.
The new law is the first change to that prohibition since the Medicare and Medicaid Act’s inception in 1965, and it came in a spending bill signed by President Joe Biden in 2022. It took effect Jan. 1 this year, and requires all states to provide medical and dental screenings to Medicaid- and CHIP-eligible youths 30 days before or immediately after they leave a correctional facility. Youths must continue to receive case management services for 30 days after their release.
More than 60% of young people who are incarcerated are eligible for Medicaid or CHIP, according to a September 2024 report from the Center for Health Care Strategies. The new law applies to children and young adults up to age 21, or 26 for those who, like Valdez, were in foster care.
Putting the law into practice, however, will require significant changes to how the country’s thousands of correctional facilities provide health care to people returning to communities, and it could take months or even years for the facilities to be fully in compliance.
“It’s not going to be flipping a switch,” said Vikki Wachino, founder and executive director of the Health and Reentry Project, which has been helping states implement the law. “These connection points have never been made before,” said Wachino, a former deputy administrator of the Centers for Medicare & Medicaid Services.
The federal CMS under the Biden administration did not respond to a question about how the agency planned to enforce the law.
It’s also unclear whether the Trump administration will force states to comply. In 2018, President Donald Trump signed legislation requiring states to enroll eligible youths in Medicaid when they leave incarceration, so they don’t experience a gap in health coverage. The law Biden signed built on that change by requiring facilities to provide health screenings and services to those youths, as well as ones eligible for CHIP.
Even though the number of juveniles incarcerated in the U.S. has dropped significantly over the past two decades, more than 64,000 children and young adults 20 and younger are incarcerated in state prisons, local and tribal jails, and juvenile facilities, according to estimates provided to KFF Health News by the Prison Policy Initiative, a nonprofit research organization that studies the harm of mass incarceration.
A ‘Neglected Part of the Health System’
The federal Bureau of Justice Statistics estimates that about a fifth of the country’s prison population spent time in foster care. Black youths are nearly five times as likely as white youths to be placed in juvenile facilities, according to the Sentencing Project, a nonprofit that advocates for reducing prison and jail populations.
Studies show that children who receive treatment for their health needs after release are less likely to reenter the juvenile justice system.
“Oftentimes what pulls kids and families into these systems is unmet needs,” said Joseph Ribsam, director of child welfare and juvenile justice policy at the Annie E. Casey Foundation and a former state youth services official. “It makes more sense for kids to have their health care tied to a health care system, not a carceral system.”
Yet many state and local facilities and state health agencies nationwide will have to make a lot of changes before incarcerated people can receive the services required in the law. The facilities and agencies must first create systems to identify eligible youths, find health care providers who accept Medicaid, bill the federal government, and share records and data, according to state Medicaid and corrections officials, as well as researchers following the changes.
In January, the federal government began handing out around $100 million in grants to help states implement the law, including to update technology.
Some state officials are flagging potential complications.
In Georgia, for example, the state juvenile justice system doesn’t have a way to bill Medicaid, said Michelle Staples-Horne, medical director for the Georgia Department of Juvenile Justice.
In South Dakota, suspending someone’s Medicaid or CHIP coverage while they are incarcerated instead of just ending it is a challenge, Kellie Wasko, the state’s secretary of corrections, said in a November webinar on the new law. That’s a technical change that’s difficult to operationalize, she said.
State Medicaid officials also acknowledged that they can’t force local officials to comply.
“We can build a ball field, but we can’t make people come and play ball,” said Patrick Beatty, deputy director and chief policy officer for the Ohio Department of Medicaid.
States should see the law as a way to address a “neglected part of the health system,” said Wachino, the former CMS official. By improving care for people transitioning out of incarceration, states may spend less money on emergency care and on corrections, she said.
“Any state that is dragging its feet is missing an opportunity here,” she said.
‘Our System Is Making People Worse’
The Texas Department of Family Services took custody of Valdez when he was 8 because his mother’s history of seizures made her unable to care for him, according to records. Valdez said he ran away from foster care placements because of abuse or neglect.
A few years later, he entered the Texas juvenile justice system for the first time. Officials there would not comment on his case. But Valdez said that while he was shuffled between facilities, his antidepressant and antipsychotic medications would be abruptly stopped and his records rarely transferred. He never received therapy or other support to cope with his childhood experiences, which included sexual abuse, according to his medical records.
Valdez said his mental health deteriorated while he was in custody, from being put in isolation for long periods of time, the rough treatment of officials, fears of violence from other children, and the lack of adequate health care.
“I felt like an animal,” Valdez said.
In August, the U.S. Department of Justice released a report that claims the state exposes children in custody to excessive force and prolonged isolation, fails to protect them from sexual abuse, and fails to provide adequate mental health services. The Texas Juvenile Justice Department has said it is taking steps to improve safety at its facilities.
In 2024, 100% of children in Texas Juvenile Justice Department facilities needed specialized treatment, including for problems with mental health, substance use, or violent behavior, according to the department.
Too often, “our system is making people worse and failing to provide them with the continuity of care they need,” said Elizabeth Henneke, founder and CEO of the Lone Star Justice Alliance, a nonprofit law firm in Texas.
Valdez said trauma from state custody shadowed his life after release. He was quick to anger and violence and often felt hopeless. He was incarcerated again before he had a breakdown that led to his hospitalization in 2022. He was diagnosed with post-traumatic stress disorder and put on medication, according to his medical records.
“It helped me understand that I wasn’t going crazy and that there was a reason,” he said. “Ever since then, I’m not going to say it’s been easy, but it’s definitely been a bit more manageable.”
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