Early School Medicaid Expansions and Health Services for Children With Parental Opioid Use Disorder.

Importance: Children experiencing parental opioid use disorder are a growing population at heightened risk of physical and mental health issues over the life course. Yet these children are less likely to receive comprehensive, ongoing health care and their parents are more likely to report barriers to access health care for their children. School-based health services have potential to overcome some of these health care access barriers, including parental burden, transportation, time, costs, and health care discontinuity. In 2014, Medicaid revoked its longstanding free care rule, expanding the scope of school-based health services eligible for Medicaid reimbursement. Subsequently, some states began to expand their school Medicaid programs to benefit from the new federal rule.

Objective: To estimate the early effects of state school Medicaid expansions on the receipt of Medicaid-funded school-based health services among children who have experienced parental opioid use disorder.

Design, setting, and participants: This cohort study using nationwide Medicaid claims data included Medicaid-enrolled children aged 5 to 18 years who experienced parental opioid use disorder at any point before age 19 years. A difference-in-differences design that exploits the staggered implementation of school Medicaid expansions between 2014 and 2019 was used. Data were analyzed between January 2023 and January 2025.

Exposures: Children living in states implementing (treatment group) and not implementing (comparison group) school Medicaid expansions, before and after state-specific expansion dates.

Main outcomes and measures: Binary measures indicating receipt of school-based health services, primary care, prevention, rehabilitative, dental, and mental health services, emergency department visits, and inpatient hospital stays.

Results: The sample comprised 6 628 404 person-years from 1 700 304 children. The mean (SD) age was 10.5 (3.9) years and 3 371 918 (51%) were male. School Medicaid expansions increased the receipt of Medicaid-funded school-based health services by 8.9 percentage points (pp; P = .01). Growth was primarily driven by school claims for nursing services (difference, 7.4 pp; P = .02) and for Early and Periodic Screening, Diagnostic and Treatment services (difference, 8.6 pp; P = .04). Reductions in emergency department visits among children aged 5 to 11 years were also documented (difference, -1.8 pp; P = .02).

Conclusions and relevance: This cohort study found that, given the complex health and health care needs of children growing up amid the opioid crisis, integrating health care into schools may offer a promising policy solution.