Medicaid’s Broken Promise to Children

In the United States, poor children’s access to necessary healthcare is determined more by geography than medical need. This variation is not the result of thoughtful local tailoring but of excessive state autonomy and passive federal oversight. The result is a fragmented and unequal system that obscures accountability and fails the Nation’s most vulnerable children. Building on scholarship showing how decentralized implementation of federal social programs can erode America’s social safety net, this Article examines how one of Congress’s most ambitious entitlements for children—Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit has been quietly undermined.

In light of formidable political and legal obstacles to wide-scale reform, this Article contends that bottom-up strategies, through state-based litigation and grassroots legislative advocacy, offer the most viable path forward. Using EPSDT as a case study, this Article reveals both the structural perils of cooperative federalism and the possibilities of restoring children’s healthcare rights from the ground up.