A slew of states are pursuing Medicaid coverage for incarcerated populations ahead of their release from prison as a means to address substance use disorders.
In Jan. of 2023, California received federal approval to provide people in correctional facilities with Medicaid services before their release.
One year later, a “groundswell” of other states seek to make similar strides in the hopes of reducing the rates of overdose-related death and other health care problems that are exacerbated in the weeks immediately after an incarcerated person’s release.
“There’s really a groundswell of state interest,” Vikki Wachino, founder and executive director of the Health and Reentry Project (HARP), told Addiction Treatment Business.
HARP is an initiative that seeks to advance policy and practices that improve the lives, health and safety of incarcerated people as they return to their communities.
“We see very poor health outcomes after people leave prison and jail,” she continued.
“We see it across a range of conditions … but the real standout is with respect to opioid overdoses, where the rate of opioid overdose deaths for people right after they leave prison or jail is significantly higher than it is for the population as a whole.”
More states are following the example set by California, which submitted an 1115 waiver petitioning the federal government to amend the federal law prohibiting Medicaid from covering most services when people are incarcerated.
Other states have followed suit. Washington’s waiver was already approved, and other states are awaiting CMS approval.
These waivers, or other legislature like them, will soon be all but universal, industry experts told Addiction Treatment Business.
“It’s about health care, but it’s also about giving people second chances and the difference that health care can make between life and death,” Wachino said.
The problem: heightened rates of overdose deaths
Mental illness and substance use disorders are disproportionately prevalent among incarcerated people.
Around 18% of the general population is estimated to have a mental illness, compared to 44% of people in jail and 37% of people in prison, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).
Among the general population, approximately 11% of people aged 18 to 25 have an SUD, as well as approximately 6% of people over 25 years old. The rates skyrocket among incarcerated people, with approximately 63% of people in jail and 58% of people in prison having an SUD.
“Because of the war on drugs, we’ve criminalized substance use,” Meghann Perry, a recovery coach professional educator and person with lived experience of substance addiction and incarceration, previously told Behavioral Health Business. “Therefore, the vast majority of people who are incarcerated, it’s related in some way to substance use.”
Incarceration can exacerbate symptoms of SUD and make it more challenging to get appropriate treatment. These problems, in turn, can lead to people staying incarcerated for more extended periods.
The transition from incarceration back into the general population can be perilous for those with SUD. People incarcerated in state prisons are 129 times more likely to die from an overdose compared to the general public, according to a study published in the New England Journal of Medicine.
The increased risk immediately post-release is due to the isolation of prison, according to Cooper Zelnick, chief revenue officer at Groups Recover Together.
“What we have observed, and we have data on this because we’ve been doing transitional care and reentry planning work with departments of corrections for years, is that if you can get an individual plugged into treatment within the first 24 to 48 hours after release,” Zelnick said, “you can massively reduce fatal overdose, relapse and recidivism, which of course has a significant benefit from a societal cost perspective.”
Woburn, Massachusetts-based Groups Recover Together provides SUD treatment using Suboxone, a brand name of buprenorphine, along with group therapy to promote members’ recovery through in-person or virtual care models.
“We’d be able to provide them much better medical care and behavioral health care while incarcerated, which would really support them doing much better when they transition back into the community and not have that gap,” Perry said.
“The primary barrier,” Zelnick added, “Is that most treatment providers won’t provide treatment unless they’re reimbursed for it.”
The solution: passing 1115 waivers for incarcerated people
One method of breaking down that barrier is through an 1115 waiver designed to provide incarcerated people with Medicaid access prior to their release.
“The waivers basically build a bridge to help people access services right after release,” Wachino said.
The “bridge” covers a targeted set of services while still incarcerated, creating connections to community services.
“We’d be able to provide them much better medical care and behavioral health care while incarcerated, which would really support them doing much better when they transition back into the community and not have that gap,” Perry said.
California was the first state to receive federal approval to provide people in prisons, jails and youth correctional facilities with some Medicaid and Children’s Health Insurance Program (CHIP) services through an 11115 waiver called the California Advancing and Innovating Medi-Cal (CalAIM).
California’s waiver “blazed the path with CMS,” and now other states are following suit.
Two states, California and Washington, have approved waivers, and 16 other states have currently pending proposals.
“It’s really notable that a number of those states, like New Hampshire and West Virginia, have a specific focus on substance use or mental health services as part of their waiver,” Wachino said. “What we see here is governors and legislators of both parties looking to reentry waivers as a tool to address some of the national challenges that we face with respect to substance use overdoses and mental health.”
According to industry experts, both sides of the political aisle are supportive of addressing substance use disorders and related issues.
New Hampshire’s waiver, called ”Substance Use Disorder Serious Mental Illness and Serious Emotional Disturbance Treatment Recovery and Access,” would provide a limited package of care coordination services to incarcerated people in state prisons who are receiving treatment for SUD, opioid use disorder (OUD), serious mental illness (SMI) or serious emotional disturbance (SED).
West Virginia, Montana and Kentucky are also among the states with waivers that mention SUD.
Even among states that have not yet proposed similar waivers, the impact of California’s progress has sparked change.
“The state of Maine has, since 2018, received grants to serve the uninsured that are primarily designed to bridge that gap between incarceration and Medicaid coverage,” Zelnick said. “I imagine that this will be a thing that happens everywhere.”
States are motivated to follow in California’s footsteps partly because of potential cost savings.
“If you can give people access to benefits, they are much more likely to pursue care,” Zelnick said. “That care is likely to have a positive impact on recidivism, which massively reduces the cost center that is our criminal justice system, and on top [of that, you get positive] health outcomes, so it’s win-win.”
The waivers attract little criticism but have garnered questions on how the policies will be implemented.
“I think that’s a very valid question,” Wachino said.
To properly implement 1115 waivers, states must “set a big table” for the conversations to come, Wachino said, with place settings for correctional officials, health care providers, law enforcement officials, managed care plans and people who have themselves been incarcerated.
As California and Washington both work on implementing their approved waivers, more states will follow their examples.
“I imagine that this will be a thing that happens everywhere,” Zelnick said. “It’s still really tricky for a whole bunch of reasons. But the trend is moving in the right direction here.”
The waivers have the potential to be “groundbreaking,” Wachino said.
“It is a real opportunity to connect people to services and strengthen their health and the health of the communities that they live in,” she said. “This is a very substantial step forward, both by state and federal leaders.”
