Bridging the Gap: Efforts to Address Medicaid Coverage Gaps and Reentry Issues After Incarceration
/Introduction
“Compared to age matched peers, recently incarcerated adults are 3.5x more likely to die in the 2 years after release, and over 12x more likely to die within 2 weeks of release.”
The US incarcerates more people per capita than almost any other country in the world. At any one time, about 2.2 million people are incarcerated in prisons or jails, and approximately 600,000 people are released from incarceration per year. [1,2] Currently, the medical care and expenditures incurred while one is incarcerated not including a hospital admission greater than 24 hours is paid for by the correctional system using government allocated funds. [3] For this reason, individuals entering the carceral system encounter suspensions or terminations of their health insurance during the time they are incarcerated. There are often delays or insufficient resources to assist people upon reentry to either apply for or reactivate their health insurance thus leading to gaps in health care coverage.[4]
In the immediate period after release, formerly incarcerated individuals are at high risk for morbidity and mortality, especially death from opioid overdose. [4,5] Compared to age matched peers, recently incarcerated adults are 3.5x more likely to die in the 2 years after release, and over 12x more likely to die within 2 weeks of release. [6] Approximately 80% of incarcerated adults report a substance use, behavioral health, or chronic medical condition. [7,8] Both ED utilization and hospitalization is higher in adults recently released on parole or recently arrested, and costs associated with this utilization account for over $5.2 billion in ED expenditures. [7] It is thought that disruptions in insurance coverage and insufficient linkage to care prerelease contribute independently to these utilization patterns and recidivism. [2] Without insurance, individuals encounter difficulties obtaining medications; establishing/continuing primary, specialty, and behavioral health care; and connecting to community resources in addition to issues with unemployment, housing, and transportation. [1,2] Gaps in insurance coverage for recently released individuals have raised concerns at local, state, and federal levels.
How Did We Get Here? The Medicaid Inmate Exclusion Policy
Enacted in 1965, Medicaid is a joint federal and state program that provides health insurance to eligible low income populations. [3] However, built into the creation of Medicaid was a stipulation known as the Inmate Exclusion Policy that stated Medicaid would not cover the healthcare costs of incarcerated inmates given that correctional systems use state and federal funds to pay for their care. [5,9] Because of the Exclusion Policy, many states began terminating individuals’ health insurance upon incarceration to prevent charging Medicaid for care provided. [9] Given that applying for and enrolling in health insurance is typically an arduous and lengthy process with considerable paperwork and administrative burden, it is no surprise that upon release, many formerly incarcerated persons were undergoing reentry without having their insurance reinstated even if they had insurance before their period of incarceration.[10]
Prior to the passage of the Affordable Care Act (ACA) in 2010 and the state option to expand Medicaid, many incarcerated adults did not meet eligibility criteria for Medicaid. [1] After the Medicaid expansion, whereby eligibility for Medicaid is solely income-based, it is estimated that approximately 80-90% of justice-involved adults are Medicaid eligible. [1,4,5] A cross sectional analysis found that uninsurance rates among justice-involved individuals decreased significantly by nearly 10% between 2008 and 2014 during which time these policy changes went into effect. [8] Now that 41 states and Washington DC have expanded Medicaid, the lack of attention to enrolling and/or reinstating a Medicaid eligible incarcerated person undergoing reentry can amount to coverage gaps for potentially hundreds of thousands of vulnerable people each year.
Suspension vs Termination
Initially, many correctional systems terminated people’s insurance plans upon incarceration to prevent federal payment of healthcare costs incurred during a period of incarceration. [10] Prior to the passage of the ACA and state Medicaid expansion option, this process had little effect on incarcerated individuals since most were not Medicaid eligible.
A troublesome aspect of suspending or terminating people’s insurance during incarceration is that re enrolling or lifting suspension of benefits requires planning and resources to be able to do so. Some state corrections systems will work with state Medicaid offices or have internal staff work as facilitators to help with reentry planning. However, inmates’ release dates can be unpredictable and occur with little notice, making reentry planning impossible or occur with insufficient time to address complex issues such as health insurance status. [11] One study assessed people in jail with severe mental illness and found that nearly half experienced unpredictable release dates and only about 20% of people had appropriate notice to receive adequate reentry planning. [11]
Now most incarcerated individuals are Medicaid eligible and it is far more cumbersome to enroll an individual in Medicaid rather than lift a suspension of benefits. As of 2019, 48 states suspend rather than terminate coverage for individuals entering prison, while 46 states suspend rather than terminate coverage for individuals entering jail.9 Certain states such as Massachusetts and New Hampshire automatically screen and enroll incarcerated persons in Medicaid if eligible during the period of their incarceration while states like Ohio and Arizona work with incarcerated individuals prerelease to coordinate both Medicaid enrollment and care management prerelease for individuals with complex health needs. [9] Under the Consolidated Appropriations Act of 2024, Congress will require all states to suspend rather than terminate benefits for incarcerated individuals as of January 2026. [12]
For people who are incarcerated that do not meet Medicaid eligibility, they are granted a Special Enrollment Period (SEP) to apply for marketplace plans outside of the open enrollment period within 60 days of release. [13]
Reentry Section 1115 Demonstration Waivers
In addition to efforts to suspend rather than terminate benefits for people during incarceration, states have utilized Section 1115 demonstration waivers as a way to pilot new ways of addressing reentry issues including pre release services and coverage gaps. Section 1115 of the Social Security Act allows the Secretary of the Department of Human and Health Services (HHS) to approve states’ experimental plans in an attempt to encourage innovation and improvements to Medicaid in real time. [14,15]
As of August 2024, 11 states have approved Section 1115 demonstration reentry waivers while 13 states have waiver applications pending. [16] While none of the waivers have been approved to fully lift the inmate exclusion policy, which many see as the ultimate key solution to this issue, [2,3,5] waivers have been used in various ways to facilitate expeditious enrollment or reinstatement of benefits through pre and post release enrollment programs, hiring facilitators, improving data and infrastructure to allow automation of these processes, and allowing Medicaid reinstatement 30-90 days prior to release. [2,9,12,15] While each individual waiver is unique to the state that created it, CMS specifies that each waiver must at least address the provision of case management services, medication assisted treatment for substance use disorder, and a 30 day supply of all prescription medication received during the incarceration period. [12] These waivers allow states a minimum 5 year period to trial these innovations and ideally move the needle forward while larger scale overarching policy changes and advocacy continues in the background.
The Bottom Line
95% of people who are incarcerated will be released, and most are Medicaid eligible. [17] It is imperative to eliminate coverage gaps and assist incarcerated people prior to reentry in obtaining or reinstating health insurance and provide reentry services including case management and substance use treatment/counseling. Though incarcerated individuals are at high risk for negative health outcomes and face many social and health barriers that are often exacerbated by a period of incarceration, addressing health needs and improving access to care prior to release can hopefully lead to reduced ED utilization and recidivism and sustainable post release care for this vulnerable population.
Post by Kate Gallen, MD
Dr. Gallen is a PGY-2 in Emergency Medicine at the University of Cincinnati
Peer review and editing by Kelli Jarrell, MD
Dr. Jarrell is an Assistant Professor in Emergency Medicine at the University of Cincinnati and Social EM Fellowship Director
References
Gates A, Artiga S, Published RR. Health Coverage and Care for the Adult Criminal Justice-Involved Population. KFF. September 5, 2014. Accessed January 9, 2025.
Albertson EM, Scannell C, Ashtari N, Barnert E. Eliminating Gaps in Medicaid Coverage During Reentry After Incarceration. Am J Public Health. 2020;110(3):317-321. doi:10.2105/AJPH.2019.305400
Barnert ES, Scannell C, Ashtari N, Albertson E. Policy Solutions to End Gaps in Medicaid Coverage during Reentry after Incarceration in the United States: Experts’ Recommendations. Z Gesundh Wiss. 2022;30(9):2201-2209. doi:10.1007/s10389-021-01483-4
Widra E. Initiative PP. Why states should change Medicaid rules to cover people leaving prison. Accessed January 13, 2025. https://www.prisonpolicy.org/blog/2022/11/28/medicaid/
Fiscella K, Beletsky L, Wakeman SE. The Inmate Exception and Reform of Correctional Health Care. Am J Public Health. 2017;107(3):384-385. doi:10.2105/AJPH.2016.303626
Binswanger IA, Stern MF, Deyo RA, et al. Release from Prison — A High Risk of Death for Former Inmates. N Engl J Med. 2007;356(2):157-165. doi:10.1056/NEJMsa064115
Frank JW, Linder JA, Becker WC, Fiellin DA, Wang EA. Increased Hospital and Emergency Department Utilization by Individuals with Recent Criminal Justice Involvement: Results of a National Survey. J Gen Intern Med. 2014;29(9):1226-1233. doi:10.1007/s11606-014-2877-y
Winkelman TNA, Kieffer EC, Goold SD, Morenoff JD, Cross K, Ayanian JZ. Health Insurance Trends and Access to Behavioral Healthcare Among Justice-Involved Individuals—United States, 2008–2014. J Gen Intern Med. 2016;31(12):1523-1529. doi:10.1007/s11606-016-3845-5
Connecting Recently Released Prisoners to Health Care—How to Leverage Medicaid. National Conference of State Legislatures. Updated January 16, 2023. Accessed January 7, 2025. https://www.ncsl.org/civil-and-criminal-justice/connecting-recently-released-prisoners-to-health-carehow-to-leverage-medicaid
Rosen DL, Dumont DM, Cislo AM, Brockmann BW, Traver A, Rich JD. Medicaid Policies and Practices in US State Prison Systems. Am J Public Health. 2014;104(3):418-420. doi:10.2105/AJPH.2013.301563
Draine J, Blank Wilson A, Metraux S, Hadley T, Evans AC. The Impact of Mental Illness Status on the Length of Jail Detention and the Legal Mechanism of Jail Release. PS. 2010;61(5):458-462. doi:10.1176/ps.2010.61.5.458
Costanza K, Valdez J, Severance-Medaris, C. New Opportunities for Medicaid Funding to Ease Reentry. National Conference of State Legislatures. Updated July 23, 2024. Accessed January 9, 2025. https://www.ncsl.org/health/new-opportunities-for-medicaid-funding-to-ease-reentry.
Incarcerated and Recently Released Consumers Job Aid. Department of Health and Human Services. January 2024. Accessed January 7, 2025. https://www.cms.gov/marketplace/technical-assistance-resources/incarcerated-and-recently-released-consumers.pdf
About Section 1115 Demonstrations. Medicaid. Accessed January 14, 2025. https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html
Opportunities to Test Transition-Related Strategies to Support Community Reentry and Improve Care Transitions for Individuals Who Are Incarcerated. Centers for Medicare & Medicaid Services. April 17, 2023. SMD23-003. Accessed January 7, 2025.https://www.medicaid.gov/sites/default/files/2023-12/smd23003.pdf
Hinton E, Pillai A, Published AD. Section 1115 Waiver Watch: Medicaid Pre-Release Services for People Who Are Incarcerated. KFF. August 19, 2024. Accessed February 2, 2025. https://www.kff.org/other/issue-brief/section-1115-waiver-watch-medicaid-pre-release-services-for-people-who-are-incarcerated/
Howard J, Solan M, Neptune J, Mellgren, L, Dubenitz, J, Avery, K. The Importance of Medicaid Coverage for Criminal Justice Involved Individuals Reentering Their Communities. Department of Health and Human Services. April 28, 2016. Accessed January 9, 2025. https://aspe.hhs.gov/sites/default/files/private/pdf/201476/MedicaidJustice.pdf
