A new policy that allows states to provide Medicaid health care coverage to incarcerated people at least a month prior to their release has drawn bipartisan interest and a slew of state applications.
Federal policy has long prohibited Medicaid spending on people who are incarcerated in jails or prisons, except for hospitalization. As a result, when people are released, they typically don’t have health insurance and many struggle to find health care providers and get needed treatment. In a population that is disproportionately likely to have chronic conditions such as heart disease and substance use disorders, that can be deadly.
Some states terminate residents’ Medicaid coverage when they’re incarcerated, while others just suspend it. Either approach can cause delays in seeking health care for people recently released from incarceration, with sometimes disastrous outcomes: A seminal 2007 study found that former prisoners in Washington state were 12 times more likely to die from all causes within two weeks of release, compared with the general population. The leading causes were drug overdoses, cardiovascular disease, homicide and suicide.
Because a disproportionate number of Black, Native and Hispanic people are incarcerated, lowering their death risk after release might reduce racial health disparities in the overall population.
In 2022, about 448,400 people were released from prison, according to the federal Bureau of Justice Statistics.
Under federal guidance released a year ago, states can connect prisoners with case managers 30-90 days before they are released to develop plans based on their health needs. The case manager can help the person make post-release appointments with primary care doctors, mental health counselors, substance use programs, and housing and food assistance.
States that want to extend Medicaid coverage to people in prison or jail must request a federal waiver to do so. At a minimum, participating states must provide case management, medication-assisted treatment for people with substance use disorders and a month’s supply of medication upon release, though states are free to do more.
The Health and Reentry Project, a policy analysis organization focused on health care for former prisoners, called the new policy “ groundbreaking.”
“What these waivers enable states to do is build a bridge to access to health care — a bridge that starts before someone’s released and continues after their release,” said Vikki Wachino, executive director of the Health and Reentry Project and a former deputy director of the Centers for Medicare & Medicaid Services.
“It’s about starting the process before they leave prisons and jails, so that they can have stronger connections to health care providers and treatment providers after they leave prison and jail.”
As of last month, federal officials had approved waiver applications from four states — California, Massachusetts, Montana and Washington. Nearly 20 other states are waiting for approval, according to health research organization KFF.
Jack Rollins, director of federal policy at the National Association of Medicaid Directors, said states that want to participate are focusing on different incarcerated populations and medical conditions. Some would start with jails, others with state prisons or youth detention facilities. Some states would provide coverage to all inmates, others just to those with a substance use disorder.
Washington, for example, will cover people incarcerated in jails, prisons and youth correctional facilities beginning three months before they are released, an estimated 4,000 people each year. It will connect them to community health workers, bring in doctors and counselors for consultations, and provide lab services and X-rays.
Montana will limit its program to people in state prisons who have a substance use disorder or mental illness and will provide services beginning a month before release. It did not give an estimate of how many people would receive help each year.
California, where an estimated 200,000 people will be covered each year, also included community health workers in its plan. Dr. Shira Shavit, executive director of the Transitions Clinic Network, a California-based national network of clinics focused on formerly incarcerated people, said ex-prisoners are especially well suited for that role.
Shavit said her group consults them on where to locate new clinics and on strategies to reach recently released inmates, because the workers are adept at “knowing where people are when they come out into the community and finding them there.”
Research suggests that connecting recently released people with others who know what it’s like to be incarcerated makes it less likely that they will end up in the emergency room.
“They know how to connect with people, and people trust them, and will follow them to come to clinic and feel comfortable coming,” Shavit said.
Alfonso Apu, director of behavioral health services at Community Medical Centers Inc., a California network of neighborhood health centers that serves patients in San Joaquin, Solano and Yolo counties, said it’s easy to “lose” people once they are released.
“The complexity of these patients is so intense that they are going to need three, four, five hours of encounters with primary care every month, at least,” Apu said.
“Imagine if we had three months to prepare,” he said. “Having a plan of action and even having appointments already scheduled for their needs — it’s going to be game changing.”
Dr. Evan Ashkin is a physician who founded the Formerly Incarcerated Transition Program at the University of North Carolina, a network of community health centers that works with local health departments, clinics and community health workers to connect former inmates with health care. He agreed that employing community health workers who share the experience of previous incarceration is essential.
“I’m hoping we’ll be able to expand this workforce,” Ashkin said. “In our state, North Carolina, there’s not a lot of folks focusing on access to health care for people post-release.”
North Carolina is awaiting word on its application.
Ashkin added that “racial equity issues are really important.”
“We have to have our eyes wide open on the type of services we provide, that they are set up to bring in the communities most impacted,” he said.
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