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

## TL;DR

Expanding Medicaid in schools increased health service access for children of parents with opioid use disorder, especially for nursing and screening services.

## Contribution

This study provides empirical evidence that early school Medicaid expansions improved access to school-based health services for children affected by parental opioid use disorder.

## Key findings

- School Medicaid expansions led to an 8.9 percentage point increase in Medicaid-funded school-based health services.
- Nursing services and Early and Periodic Screening, Diagnostic and Treatment services drove the increase.
- Emergency department visits decreased by 1.8 percentage points among younger children.

## Abstract

What is the early impact of state school Medicaid expansions on the receipt of Medicaid-funded school-based health services among children who ever experienced parental opioid use disorder?

In this cohort study including 6.6 million person-years from 1.7 million children, early state school Medicaid expansions were associated with an 8.9–percentage point increase in the receipt of Medicaid-funded school-based health services. This growth was primarily driven by school claims for nursing services and for Early and Periodic Screening, Diagnostic and Treatment services.

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.

This cohort study estimates 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.

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.

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.

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.

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

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.

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).

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.