Compared to most other countries, the United States has high rates of incarceration. From July 2020 to June 2021, 6.9 million people were admitted to local jails, and as of the end of 2021, approximately 1.2 million people were held in state or federal prisons. People who are incarcerated face higher levels of many health challenges, including chronic health conditions, infectious disease, and mental health/substance use conditions. The re-entry period – or the time when a person is leaving incarceration and coming back to their community – is a particularly vulnerable time, with research showing a dramatically increased risk of negative health outcomes.
Historically, Medicaid has not been able to provide coverage for people who are incarcerated (with the exception of limited inpatient hospital services) due to the Social Security Act’s “inmate exclusion” policy. In April 2023, however, CMS released groundbreaking guidance allowing Medicaid agencies to apply for 1115 waiver authority to cover certain services in the 90 days before an individual’s release. And in December 2023, Congress enacted national changes to the inmate exclusion by requiring Medicaid agencies to provide certain services to incarcerated young people beginning in January 2025.
These changes have enormous potential. Most individuals leaving jail and prison face significant gaps in coverage and care, fueling high rates of overdose, emergency room visits, and mortality. By providing care both before and after release, Medicaid can help bridge this gap, increasing access to health care services like prescription medications, primary care, and behavioral health care and social services like housing supports. Research shows that when people have access to Medicaid during the re-entry period, they are more likely to find employment, more likely to utilize health care services, and less likely to go back to jail or prison.
However, implementing these policy changes is much easier said than done. At the 2023 NAMD Fall Conference, DeAnna Hoskins, CEO of JustLeadershipUSA, Autumn Boylan, Deputy Director for California Medicaid, Jennifer Strohecker, Medicaid Director in Utah, and Vikki Wachino, Executive Director of the Health and Reentry Project and former Deputy Administrator for Medicaid and CHIP Services at CMS, provided key insights into Medicaid’s changing role in the re-entry process.
The impact of these policy changes will only be as strong as their implementation.
Recent policy changes represent seismic shifts in how Medicaid agencies and jails/prisons interact. Most jails and prisons are not set up to enroll people in Medicaid, submit claims for Medicaid-covered services, and document care in electronic health record systems. And, conversely, many Medicaid agencies don’t have a clear line of sight into how health care services are currently delivered within jails and prisons. “We’re finding that the systems themselves are not built to support this type of care,” said Jennifer. “For us, there [needs to be] significant investment in the design of the system itself to develop the care plan that the case manager can then use to work with external providers.” Successfully implementing 1115 waivers and the Consolidated Appropriations Act policies will require years of thoughtful work to build out processes to screen individuals for Medicaid eligibility in jails and prisons, develop systems to share data across Medicaid and jails/prisons, and enroll networks of providers. “As part of our waiver, we got approval for $410 million dollars which we are providing to correctional facility partners… to lift up the infrastructure that’s necessary [to implement pre-release coverage],” said Autumn. “And it’s still not enough.”
People with lived experience must be at the center.
It is crucial to include people who have been impacted by incarceration in every step of the policy design and implementation process. When policymakers fail to center the voices of people with lived expertise, they risk designing policies that look good on paper but don’t work in practice. “[Formerly incarcerated people] have expertise that you can’t learn from a book. We know what the correctional healthcare system looks like. We know about lack of access to healthcare upon release,” said DeAnna. “We’re bringing firsthand experience of a system… To not include community is a failure in implementation.” Giving people with firsthand experience of jails and prisons – including formerly incarcerated people and corrections staff – real power in the policy design and implementation process also helps ensure that health care services will be utilized. “You can build the best system in the world, but if trust hasn’t been built with the population, [incarcerated people] are not going to access services,” said DeAnna. “If we’re going to build this, who are the partners that we need at the table? Who are the credible messengers?”
Partnership is the first (and second, and third) step.
Historically, Medicaid programs and jails/prisons have not worked closely together. “We’re a health care system telling a correctional system how to provide health care services and that’s not how things have worked on the corrections side,” said Autumn. “We can write a 200-page policy guide, but that means nothing if it’s not translated into the language of our correctional facility and implementation partners.” Medicaid agencies, Departments of Corrections, and local jails will need to work together to address a range of technical challenges, including building out data systems, provider networks, and processes to enroll individuals in Medicaid. But they’ll also need to work together to develop a shared vision and lead their organizations through change. “This is complicated for us, but it’s even more complicated for the correctional facilities,” said Jennifer. “It’s been really important to slow down and walk through what we’re hoping to accomplish… I can’t overemphasize the importance of working towards a common outcome.”