Record-breaking overdose deaths and increasing mental health challenges highlight the urgent need for stronger behavioral health policies and systems. Policymakers are trying new approaches, including the 988 suicide and crisis lifeline launched this year and new mobile crisis services under Medicaid.
Recognizing that the justice system has become a default mental health provider, policymakers should also look to proposals to improve health care continuity as people leave prison and jail, including allowing Medicaid to cover services prior to release. Current law prohibits Medicaid from covering most health care for incarcerated individuals. Providing continuous coverage has the potential to improve behavioral health outcomes and make it less likely that people return to prison and jail. These approaches have bipartisan support and have advanced at the federal and state levels. They are driven by failings in the current system and are supported by an unlikely coalition of health care providers, patient advocates, law enforcement, and criminal justice reformers.
The proposals that amend Medicaid’s longstanding inmate exclusion have advanced along two pathways:
- Federal legislation. Several bipartisan proposals are under consideration by Congress, most notably the Medicaid Reentry Act (S. 285; H.R. 955). This bill would allow Medicaid to cover health care services in the 30 days preceding release from prison or jail. The Medicaid Reentry Act has passed the House as part of several different legislative packages but has not passed the Senate.
- Medicaid waivers. Nine states have submitted requests for waivers to the federal government under Medicaid’s demonstration authority, Section 1115. Each of the nine waivers would modify (or waive entirely) Medicaid’s inmate exclusion to allow for coverage of certain health services provided to incarcerated people pre-release. The specifics of these proposals, including the coverage period, available services, and eligibility categories, vary by state. Congress has required the Centers for Medicare and Medicaid Services to issue guidance on how states can use 1115 waivers to strengthen reentry transitions.
Making these reentry policies a reality will require bridging gaps between the health and criminal justice systems. To inform policy and potential implementation, the Health and Reentry Project (HARP)1 convened government officials, key stakeholders, and people who have been incarcerated. The full findings from this project are available online and summarized here.
Reentry’s North Star: Building a New Health Care Model to Meet People’s Needs
Stakeholders convened by HARP expressed strong support for efforts to allow Medicaid to cover prerelease services, which they believe will improve continuity of care and equity, and support people in successfully returning to communities.
They set a “north star” to guide the way in which potential Medicaid policy changes are carried out: a reentry health care model that helps people return to communities “healthy and whole.” It should include:
- Enhanced primary care and connections to behavioral health. Primary care that facilitates access to mental health and substance use services can reduce barriers to treatment, improve outcomes, and promote care coordination.
- A commitment to active patient engagement. Understanding and supporting patients’ needs through direct, patient-centered engagement can help build trust, which is an essential but largely missing element for people who have experienced incarceration. Health care models that build trust between patients and providers can help people access services and meet their health care needs. The Transitions Clinic Network, which operates in 14 states and Puerto Rico, is one such model.
- Service coordination and navigation. Health professionals, such as community health workers, and correctional officials, such as probation officers, can support individuals in navigating reentry. Professionals and paraprofessionals who have been incarcerated themselves may be particularly effective in supporting people leaving prisons and jails.
- Trauma-informed approaches. Trauma-informed care can be an important service for some people post-incarceration, mitigating the effect of past trauma on individual functioning and health.
- Integrated social and health supports. Smooth connections to services like housing, nutrition, and transportation can improve the health of people post-release.
The Nuts and Bolts of Reentry: Operational and Policy Considerations
To carry out new policies, connections between the health and criminal justice systems must be strengthened. One key challenge will be making sure that the requirements and standards of care that apply to Medicaid-covered services in the community are effectively translated into the correctional setting. Establishing the cross-sector collaboration will require financial investments in infrastructure. Policy and operations will need to accommodate differences between prisons and jails. Continuing to expand access to community behavioral health services will promote access to services after people are released and can make it less likely that people become incarcerated in the first place. Finally, evaluation will be needed to measure the impact of new policies on health and public safety and fine tune them, if necessary.
The Path Forward
Expanding Medicaid’s role at reentry can be a powerful lever to help address national mental health and substance use challenges and improve public safety. Potential policy changes create an opportunity to build reentry services that support people’s health and success in rejoining their families and communities. Cross-sector collaboration, stakeholder engagement, and prioritizing the input of people with lived experience can help realize the full potential of these changes.
