States Try New Approaches to Connecting Formerly Incarcerated Individuals With Healthcare

Prior to the Affordable Care Act, many adults leaving jail or prison were ineligible for Medicaid because coverage was not available to most adults without children. However, by mid 2018, 33 states and the District of Columbia had expanded Medicaid eligibility to include all adults with incomes below 138% of the federal poverty level, which has made Medicaid available to more individuals upon their release.

However, coverage for this population is only one step; delivering care to individuals once they leave the prison system is a larger challenge, and a new report from The Commonwealth Fund shows that states are undertaking innovative approaches to making sure that individuals are not just insured, but also connected with comprehensive care upon release.

Formerly incarcerated individuals have a pressing need for healthcare; The Commonwealth Fund estimates that 80% of this population has a long-term health need, such as a substance use disorder, a chronic medical condition, or a psychiatric condition. Those who have been incarcerated also have rates of active tuberculosis, hepatitis C, and HIV that are many times that of the general population. However, upon release, many people’s most pressing concerns relate to finding housing and social supports, and seeking healthcare coverage may take a backseat to addressing these urgent needs.

One way to make sure that individuals have access to care as soon as they are released is to suspend—rather than terminate—Medicaid coverage when a person enters prison or jail. Federal law carries an exclusion that bans incarcerated people from receiving Medicaid, but states are finding that 80% to 90% of people are eligible for Medicaid upon release, so pausing coverage allows for coverage to resume immediately when a person is released. In cases in which individuals are not already covered by Medicaid, they can be enrolled at any time prior to release, including at intake or as part of the release-planning process.

Once individuals are enrolled in Medicaid, data exchange systems may be part of the equation of delivering post-release care; in New York City, the correctional health service notifies health homes when individuals are released so that they can conduct outreach—such as home visits—to begin care planning. In other states, such as Florida, through “in-reach” program, clinicians may be sent into a jail or prison to meet with an individual to plan for postrelease care.

Medicaid plans and health homes can also play a role in addressing formerly incarcerated people’s need for housing; New York’s Brooklyn Health Home, for example, uses community-based care mangers who work with clients to find housing and address other pressing social and economic issues that can impact health outcomes.

Another important feature of addressing social determinants of health can involve support specialists; the Transitions Clinic Network, for one, which operates in multiple states, employs community health workers with a history of incarceration to identify patients who would be well served by the clinic. These workers identify patients through outreach to emergency departments (ED), faith-based organizations, homeless encampments, and other locations, and also help individuals adhere to the conditions of their release. In a 2-year study, the clinic’s clients had 50% fewer ED visits during their first program year compared with individuals who were part of a control group.

“Medicaid expansion has provided states with a powerful tool to address the health care needs of justice-involved individuals,” write the report’s authors, but added, “The challenge going forward is to solidify coverage upon discharge, maintain it, and connect people leaving the prison system with the comprehensive health care, social supports, and care management they need.” The authors say that promising programs, like the use of in-reach and support specialists, could potentially become requirements for Medicaid managed care plans or provided as part of health homes.