Lantsman J. The COVID-19 stimulus bill: inclusion of the Medicaid Reentry Act is critical to justice-involved individuals. Harvard Public Health Review. 2021; 27.

At the start of the COVID-19 pandemic, legislators had the opportunity to either double-down, by reinforcing the inhumane conditions of confinement or to employ public health systems to intervene in mass incarceration. The direction legislators chose is made clear by the 392,493 cases of coronavirus across prisons, as of April 8th.

After months of advocates demanding justice-involved individuals and correctional facilities receive assistance in the COVID-19 stimulus bill, the newly revised House bill included language from the bipartisan Medicaid Reentry Act. While this inclusion does not take federal action to protect individuals from COVID-19 while incarcerated, it takes a large step to improving public health systems’ ability to intercept reentering individuals. This is also the first time Congress has voted to recognize the opportunity for Medicaid to operate in the correctional environment. In recognizing this opportunity, Congress inadvertently is commenting on the issue of directing Medicaid funding to the criminal legal system – `currently a very divisive issue.

Historically, policy debates to improve the continuity of care between prison and community focused on preventing Medicaid termination upon incarceration and, instead, having states temporarily suspend Medicaid for the duration of the individual’s sentence. This is guided by regulations that restrict Medicaid funding from being used in correctional environments. More recently, advocates have raised concerns over the utility of using Medicaid funds in prison, instead of making more funds available to community-based programs. Various organizations have reservations over using healthcare dollars to further buttress the revenue of correctional facilities.

Medicaid Reentry Act Helps Public Health Systems Intercept Re-Entering Populations

The inclusion of the Medicaid Reentry Act in H.R.925 can be found in Section 107 of the bill. This is an immense opportunity for public health to improve the success of reentry by expanding access to healthcare for justice-involved individuals facing chronic illness and behavioral health conditions. The Medicaid Reentry Act in its original form intended to allow states to restart Medicaid coverage for eligible incarcerated individuals up to 30 days before their release from jail or prison. Starting Medicaid 30 days prior to re-entry is expected to help connect justice-involved individuals to health care systems in communities, given previous findings from New York and Colorado that reveal a high proportion of justice-involved individuals are Medicaid eligible upon release. Connecting recently returned individuals to health care is critical given the high rates of drug relapse, overdose, and even death faced by this community.

New York state, which expanded Medicaid under the Affordable Care Act, determined that 80 percent of individuals incarcerated in state prisons were eligible for Medicaid. Similarly, Colorado identified that 90 percent of individuals incarcerated in state prisons were eligible for Medicaid.

Section 107 of the COVID-19 stimulus bill retains the following components of the Medicaid Reentry Act:

  1. Individuals residing in public correctional institutions, who are up for release may receive medical assistance under Medicaid during the 30-day period, prior to re-entry.
  2. Requests that the Medicaid and CHIP Payment and Access Commission track and report information on a number of incarcerated individuals eligible to enroll for medical assistance under State plan, report the access to health care experienced by incarcerated individuals, and identify current discharge practices, including how corrections collaborates with State Medicaid agencies.

While these clauses minimally meet the long list of demands made by advocates to improve the quality of care inside prisons and post-release, if the language on Medicaid reentry survives Senate negotiations, justice-involved individuals can benefit.

Especially Important During the COVID-19 Pandemic

While the issue of discontinuity of care between incarceration and release is not new – as reflected by the 80 percent of released individuals without health insurance upon reentry into the community – the characteristics of individuals re-entering amid COVID-19 make access to health care especially critical.

Historically, research demonstrates that upon re-entry justice-involved individuals experienced problems with at least one of the following three health areas, physical health, mental health, or substance use disorder. Failure to intervene in these chronic conditions upon re-entry can result in death. Research in Washington state reveals that two leading causes of death among returned individuals were cardiovascular disease and drug overdose, with the largest proportion of death taking place 1-2 weeks after release.

Why is this relevant – firstly, among justice-involved individuals death from cardiovascular disease was determined to be most common among individuals that are 45 years and older. During the COVID-19 pandemic, many states’ release strategy focused policy on elderly individuals. States like California, New York, Ohio, Maryland, Texas, Oregon, and Michigan decided to focus release efforts on elderly individuals because of high risk of COVID-19 complications and low-risk for recidivism. Without proper medical planning before release, to establish a plan to receive healthcare upon return, formerly incarcerated elderly individuals with pre-existing conditions are especially at risk for poor outcomes if contracted COVID-19 given heart disease is deemed an underlying medical condition (CDC).

Further, when extrapolating rates of mortality among recently re-entered populations, findings reveal that formerly incarcerated individuals with substance use disorder are at exponential risk for overdose and death. The source of this problem is multidimensional, ranging from challenges connecting to harm-reduction treatment access in the community, lack of screening and failed diagnosis during incarceration, and overdose due to reduced tolerance for high doses during incarcerated. Expanding Medicaid by 30-days prior to an individual’s return to society has the potential to confront each dimension of this problem. By connecting with a provider via telemedicine, an individual can receive a diagnosis, a prescription for medication-assisted treatment (MAT) for re-entry and/or referral to a more permanent provider that can prescribe MAT. This would be a prime opportunity for prisons to become involved in harm-reduction treatment, an approach common across jails. Various states have implemented statewide policies with variations in available drugs to treat substance use disorder. For example, Rhode Island, Pennsylvania, New Jersey, Connecticut, Vermont, and Massachusetts have established MAT programs with all three drug options – naltrexone, methadone, and buprenorphine. Since 2018, Denver, Colorado initiated a jail program to provide buprenorphine three-day detoxification for individuals experiencing withdrawal and continued access to buprenorphine to individuals with drug prescriptions.

Improving access to harm-reduction treatment is especially pertinent given that the population of individuals returning amid COVID-19 are disproportionately older and have a history of limited treatment access. Research identified that older incarcerated individuals with mental illness, specifically with substance use disorder, experienced under diagnosis and lower rates of treatment while in prison. Reaching this population before re-entry is a prime opportunity for the public health system to reach an underserved population before it enters a health care landscape experiencing obstacles maintaining systems of care for individuals with substance use disorder.

Why Federal Involvement is Necessary

Various states have indicated an interest in extending Medicaid access by 30-days prior to release, however, very few states have attempted to use existing opportunities to reform Medicaid to create early eligibility. Among states interested in extending health insurance to justice-involved individuals, New York submitted Medicaid 1115 waivers for approval by the Centers for Medicare and Medicaid Services (CMS), which are intended to provide a narrow set of services to justice-involved individuals 30 days prior to release. Maryland is also seeking approval for a Medicaid 1115 waiver to enroll re-entering individuals into Medicaid under presumptive eligibility, to improve continuity and access to care in the community. The state of Ohio provides currently incarcerated individuals a clinical review 15 to 30 days prior to release and video conferencing with health care providers 7 to 14 days prior to release. While state efforts are commendable, expecting states to follow the standard, lengthy process of CMS approval during a pandemic that has placed a strain on agency capacity, is insufficient given unprecedented levels of expedited re-entry facing states across the country. Federal passage of the Medicaid Reentry Act is a more efficient avenue to allowing states to extend health care to justice-involved individuals, which were historically underserved by the public health system.

Implications of Medicaid Funding for the Criminal Legal System

In the United States, the COVID-19 pandemic was coupled with a nationwide movement to reallocate city and state budgets away from law and order and towards evidence-informed public health programming. Many localities explicitly called for divestment and instead funded education. States focused efforts on law enforcement accountability and the development of task forces’ intended for experts to evaluate and tailor investments to community needs. Lawmakers that chose to increase funding for law enforcement were met with public outrage. Current policies intended to improve wellness and health in the correctional environment are operating within this political landscape. While enacting legislation to expand Medicaid into prisons supports successful re-entry and release, concerns over the political suitability of health care dollars in correctional facilities need to be addressed.

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