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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 the age of 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.

Lapses that lead back to jail

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 disorder, 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.

A challenge for states, building on a Trump 1.0 law

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 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.

Busà Photography/Moment RF/Getty Images

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.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

Chances are you haven’t heard the term “manifest destiny” since high school history class. That is until President Trump’s inaugural address last month, when he used it to call for America to “plant the Stars and Stripes on the planet Mars.”

The 19th century term describes a belief in American exceptionalism and a divine right to expand into lands in North America where indigenous people and Mexicans lived. “It’s fascinating to see this term come back, because the whole concept of expanding the country, of course, is at the core of the American experience,” Michael O’Hanlon, a senior fellow at the Brookings Institution, says.

When Trump discusses the U.S. acquiring Greenland, making Canada the “51st state,” threatens to “take back” the Panama Canal and most recently suggested the U.S. would take over Gaza, he wipes the dust off other notions of American imperialism that haven’t been an overt part of U.S. aims since the days of Teddy Roosevelt.

Trump, O’Hanlon says, “has a long historical tradition to build upon.”

What is the origin of the term “manifest destiny”?

James K. Polk won the presidency in 1845 on an explicitly expansionist platform: acquire California and other land in the Southwest, annex the then-independent Republic of Texas and settle a dispute with Britain for control of the Oregon Territory. (Another Polk promise, by the way: reducing import tariffs).

James Knox Polk, eleventh President of the United States serving from 1845 to 1849.

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National Archives/Getty Images/Hulton Archive

The term manifest destiny was coined by journalist John O’Sullivan that year in an essay praising the annexation of Texas and looking ahead to California — then part of Mexico — as being the next.

More generally, the term was a form of American exceptionalism that came to mean the inevitable east-to-west occupation of the North American continent, often expressed in messianic terms.

Although the term was created in the 19th century, it hearkens back to the first European settlers who believed their quest was divinely inspired, according to the Smithsonian American Art Museum.

“Manifest Destiny was meant as this notion that America was destined to control all of this territory… we have to have all of this land because we were exceptional,” said Susan D. Page, the first U.S. ambassador to South Sudan, who’s now a professor at the University of Michigan Law School.

Does the term describe Trump’s brand of diplomacy?

In part. “There are some surface-level parallels,” says Will Freeman, fellow for Latin America Studies at the Council on Foreign Relations. “It seems Trump and those around him are fairly serious about making this a time of U.S. territorial expansion.”

But when Trump talks about Canada, Greenland and Panama, he also taps into manifest destiny’s source code — the Monroe Doctrine, first espoused by President James Monroe in 1823 as a warning to European powers against interfering in the affairs of the Western Hemisphere. As Stewart Patrick, a senior fellow at the Carnegie Endowment for International Peace notes, Polk invoked the Monroe Doctrine as a justification first for annexing Texas — to prevent it from becoming “an ally or dependency of some foreign nation more powerful than [the United States],” in Polk’s words — and later for war with Mexico (1846-1848). In 1867, President Andrew Johnson similarly cited it as a rationale for purchasing Alaska.

“The Monroe Doctrine historically has been the United States’ way of relating to its own sphere … although it’s changed meaning over time,” Freeman says.

By the end of the 19th century, the Monroe Doctrine took on a more robust implication, Patrick notes. It was “understood to imply that the entire Western Hemisphere was an American preserve,” he writes.

Another historical parallel can be drawn with Trump’s aggressive use of tariffs and threats of them and the arrival in 1853 of a flotilla of U.S. warships in Tokyo Bay. The ships were meant to bully Japan into opening its ports to U.S. trade. The tactic came to be known as “gunboat diplomacy” and it would be reshaped by President Theodore Roosevelt into his “big stick” maxim of persuasion coupled with the threat of force to achieve goals on the international stage.

Theodore Roosevelt, the 26th President of the United States of America (1901-1909), in the uniform of a Lieutenant-Colonel of the Rough Riders, a volunteer cavalry unit which he led during the Spanish-American war.

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“Trump seems to be reinventing ‘big stick diplomacy’ in the Americas for the 21st century, only without the ‘speak softly’ part,” says Freeman.

But in doing so, he says, Trump “will face constraints.”

“The United States does not have the unrivalled power in the hemisphere it was beginning to gain in the days of Teddy Roosevelt,” Freeman says. “Now there is China to compete with, and in most of South America, China’s economic weight is decisive.

“His ‘big stick’ will be most effective, ironically, in the countries he needs it least — those north of Panama which are already for the most part tightly integrated into the United States’ orbit,” he says.

It’s also worth noting that Trump has also long espoused isolationist rhetoric, calling for the U.S. to remove itself from world conflicts and accusing American military allies of not paying their fair share.

What would it mean if Trump followed through?

If Trump follows through on his expansionist rhetoric, the U.S. “would essentially become an international pariah,” O’Hanlon, of Brookings, says.

“If we use military force to seize the Panama Canal or Greenland… it would [put] us in the same category… as Vladimir Putin,” he says.

But having made the comments, backing off of them could also be difficult, Freeman says. When Trump says he’s going to slap 25% tariffs on Colombia, but then settles for a resumption of deportation flights, for example, “it’s kind of the boy who cried wolf,” Freeman says. “So I think that maybe what he’s able to get out of each of these, what he’s able to leverage out of each of these threats is going to probably decrease as leaders realize, ‘well, he doesn’t really mean what he says,’ but, you know, he’s also quite unpredictable.”

Being unpredictable can be its own long-term problem, according to Page, the former ambassador. As an example, she points to the North American Free Trade Agreement (NAFTA), and its successor, the United States-Mexico-Canada Agreement (USMCA) negotiated and signed during Trump’s first term.

“How can you threaten your two other partners with tariffs when you have a trade agreement with them?” she wonders. If Trump can do it, “that means that the next administration can then go against whatever those previous policies and agreements were.”

Republicans in Congress are working to finalize competing plans to advance some of President Trump’s top policy priorities.

House Speaker Mike Johnson, R-La., and other GOP leaders met late into the evening on Thursday following a roughly five-hour meeting at the White House that at times included Trump in hopes of releasing a broad budget framework on Friday. Republicans have been under intense pressure to move quickly on a legislative agenda but have so far been unable to agree on how to get that done.

Rep. Lisa McClain, R-Mich., told reporters lawmakers discussed options to include in the budget plan: an extension of the federal borrowing limit, an extension of tax cuts passed in 2017 under the first Trump administration and campaign promises like addressing the U.S.-Mexico border and eliminating taxes on tips.

“Tick, tock, we’re running out of time,” McClain said. “We’ve talked about this for how long?”

Republicans hope to use an element of the budget process, known as reconciliation, to pass policy priorities without the threat of a filibuster from Democrats in the Senate. Reconciliation rules require lawmakers to pass a budget resolution that includes budget-related impacts to be addressed.

McClain and others who attended the White House meeting returned to the Capitol on Thursday night to finalize that topline figure and framework.

McClain stopped short of describing many of those details, deferring to Johnson and Trump after the plans are finalized.

White House press secretary Karoline Leavitt, however, told reporters at the White House on Thursday that House Republicans were also discussing ideas like eliminating taxes on senior Social Security and overtime pay, adjusting the State and Local Tax deduction, eliminating special tax breaks for “billionaire sports team owners,” and closing the carried-interest tax deduction loophole and tax cuts for Made-in-America products.

“They’re talking about the budget and priorities from this administration — tax priorities,” she said.

Even if GOP House leaders are able to reach an agreement amongst themselves, the path to passing the bill will not be easy. Republicans have an extremely narrow House majority, meaning they will need virtually every Republican on board in order to pass a plan.

House Republicans may also face a competing proposal from their GOP counterparts in the Senate.

Senate Budget Committee Chairman Lindsay Graham, R-S.C., is expected to introduce a separate budget measure next week.

Sen. John Barrasso, R-Wyo, the number-two Republican in the Senate, told reporters Thursday evening that the Senate bill will include provisions covering energy, border and the military.

Barrasso will travel with a group of senators to meet with Trump in Florida on Friday.

“We want to go with urgency,” Barrasso said. “We want to make sure we get something done.”

NPR’s Elena Moore contributed to this report.