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On a reporting trip in Indiana some years ago, I met a man who had shot and killed his 2-year-old daughter while he was in the throes of a psychotic break. Re-enacting the biblical story of Abraham’s sacrifice of Isaac, he thought God would intervene to save her.
He was found guilty of the child’s murder and sent to state prison, where he was stable on psychiatric medications for 25 years. Then he got out and spent weeks scrambling to enroll in Medicaid, the government health insurance program, before his medication ran out. “I have a serious mental disorder, which is what caused me to commit my crime in the first place,” he told me then.
In the last decade, more states have recognized the importance of providing health insurance to those leaving prisons and jails. Recently, states and the federal government have gone even further, proposing to enroll people in Medicaid before they set foot in the free world again.
People in prisons and jails tend to be sicker than the general population, and after release, are more likely to rely on expensive, stopgap health care from emergency rooms. In the two weeks after their release, formerly incarcerated people are almost 13 times more likely to die than anyone else, most commonly from drug overdoses, heart disease, homicides and suicides.
But for years, they couldn’t get Medicaid — first because the original 1965 Medicaid law excluded anyone in prisons and jails (as well as large inpatient psychiatric hospitals and drug rehabilitation centers). And second, because Medicaid mainly covered children, pregnant people and disabled adults. The demographic of mostly young, able-bodied men swept up by mass incarceration did not qualify.
That changed in 2010, when Congress passed the Affordable Care Act. The new rules, which apply in the 40 states that took advantage of the law’s new coverage, meant that anyone with zero or very low income — which is almost all incarcerated people — qualified for free or heavily subsidized government health insurance.
States and counties worked to streamline their Medicaid procedures so incarcerated people could enroll as soon as eligible, which was the moment they were released. Some states and counties set up workshops to help people fill out paperwork while they were locked up. Others tried to link corrections and health department data to merge release dates and names of eligible enrollees. But government bureaucracies are slow and inefficient, and waiting until someone was released to activate their Medicaid frequently caused delays and mishaps.
For the man I met in Indiana, that meant he had to begin his Medicaid application from scratch when he got home. He made increasingly frantic calls to the program and scrambled to find his birth certificate and other paperwork as his antipsychotic medication dwindled. “Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he told me at the time.
The COVID-19 pandemic, when officials released many people — often with no doctor to follow up with and no health care plan in place — exposed the wide gap between the nation’s lockups and the health care system. This had grave implications both for prisoners and for the society they returned to.
So policymakers looked to a provision in Medicaid law that allows pilot projects that would otherwise run afoul of the rules. Four states have now been approved by the Centers for Medicare and Medicaid Services for “reentry waivers,” which allow people in prisons and jails to receive Medicaid coverage up to 90 days before release. At least 18 more states have asked for a waiver, and several others have applications in the works, according to Gabrielle de la Guéronnière of the Legal Action Center, a nonprofit that advocates changes in criminal justice policy.
The idea is not only to get people health coverage before they leave prison, but to also get case managers and health care providers into the facilities to create health care plans that can be implemented when people get out. Grant-funded nonprofit organizations have been doing this on a small scale in several states. The ability to bill Medicaid will make these services more widely available.
The Transitions Clinic Network is one of those groups. Their executive director, Shira Shavit, a physician based at the University of California, San Francisco, recalled a patient her team met before his release. He had serious kidney disease, so they arranged for him to receive dialysis in San Diego, where he was set to be released. A case manager helped set up housing and transportation to his medical appointments.
But days before his release, his parole officer placed him in San Francisco instead, Shavit said. “Because we were tracking his case, we found out about it, and we were able to pivot — make an appointment in San Francisco, get him seen in my clinic, and get him into dialysis without him missing a day,” she said. Without the connection they made before his release, “he would have just missed his appointment in San Diego. And no one would have known where he went.”
Last year, California became the first state to be granted a waiver to allow incarcerated people to enroll in Medicaid 90 days before their release. Soon, federal Medicaid authorities advised other states to do the same. The agency quickly approved waiver applications from Washington, Montana and most recently, Massachusetts. Applications from 18 additional states are pending.
A bipartisan proposal in Congress would make Medicaid coverage available 30 days before release as a national policy, eliminating the need for states to apply.
And federal officials are experimenting with broader waivers that would allow Medicaid to cover “health-related social needs,” like housing and food. These have emerged as “part of a much broader discourse [that recognizes] poverty really makes people unhealthy,” said Dan Mistak, an attorney with Community Oriented Correctional Health Services, a policy outfit that has been advocating reentry waivers for years.
These efforts have some critics. States are required to design their waiver programs so they are not spending more money than they would have otherwise, but fiscal conservatives have argued that is not happening. The Manhattan Institute, a conservative think tank, recently called them “a one-way ratchet for increased Medicaid costs.”
But many in the criminal justice system have enthusiastically embraced the proposed changes, including sheriffs, who run the more than 3,000 county jails across the country. Because the average length of stay in jail is less than a month, almost all health care in jail would be covered by Medicaid rather than by the counties. “It’s a big win!” a Massachusetts sheriff’s department posted on Facebook.
Jail administrators also hope that having most people under the Medicaid system would help them maintain the same care they had before they came in, through the time they’re released. That “will literally lower crime and save lives,” said Peter J. Koutoujian, sheriff of Middlesex County near Boston. Koutoujian is a member of the Major County Sheriffs of America, which has advocated allowing people in jail to receive Medicaid.
The new efforts could also help lower the rate of people who return to prison. Data that Shavit and her colleagues have collected from their clinics show that people who meet with a case manager before release — especially case managers who have been incarcerated — had lower chances of ending up back in prison for parole violations. They also found that fewer people relied on the emergency room for care, and the system saved money.
But no Medicaid dollars have gone to prisons or jails yet. It’s an enormous bureaucratic lift to get the health care system and sheriffs’ and corrections departments to work together. All four states with approved waivers are still working to clear those administrative hurdles before the money can start flowing. California plans for its system to begin operating this fall.
