Significant Medical and Behavioral Health Needs Among Individuals with a History of Incarceration

• An estimated 80 percent of individuals released from prison in the United States each year have a substance use disorder, or chronic medical or psychiatric condition.⁴
• Incarcerated individuals have four times the rate of active tuberculosis compared to the general population, nine to 10 times the rate of hepatitis C, and eight to nine times the rate of HIV infection.⁵
• Correctional facilities in Los Angeles County, New York City, and Cook County, Illinois, have become the three largest mental health care providers in the country.^.6

This issue brief first discusses the impact of Medicaid expansion on coverage and then describes the latest developments in comprehensive primary care delivery models for people leaving jail or prison and the role that Medicaid can play in financing and supporting such models. The models are designed to improve health outcomes and reduce unnecessary costs associated with people cycling in and out of hospitals, homelessness, and jails. Often they are part of broader efforts in Medicaid to better manage the cost of high-cost, high-risk individuals. The opioid epidemic has added urgency to this work, spurring states to design better care delivery for people with substance use disorders. The work varies among states, but the comprehensive primary care models routinely include the following key elements:

• Data exchange to promptly identify when someone is leaving jail or prison so that a plan or provider is prepared for them when released to the community.
• Jail or prison “in-reach” to help inmates, even before release, establish a relationship with a primary care provider, identify health conditions, transition medical records, and set up community-based care.
• Strategies for addressing housing issues and other social determinants of health in the days and weeks after release; these are the major concern of many leaving jail or prison regardless of the severity of their health conditions.
• Use of a peer support specialist who has been incarcerated to help the beneficiary navigate health care and related social service resources.
• Primary care providers and specialists with training and expertise working with individuals who have been incarcerated, including behavioral health staff who can address mental health issues and substance use disorders.

Medicaid Coverage for People Leaving Jail or Prison

Under a provision of federal law known as the “inmate exclusion,” Medicaid is banned from financing the care of anyone committed to a jail, prison, detention center, or other penal facility unless an inmate is treated in a medical institution outside the prison or jail for 24 hours or more.⁷ Medicaid can finance the cost of services provided to eligible individuals after release. Expansion states are finding that the vast majority of those incarcerated are eligible for Medicaid. New York and Colorado, for example, estimate that 80 percent and 90 percent of their prison populations, respectively, are likely eligible for Medicaid upon release.⁸States are deploying a range of tools to ensure that individuals have Medicaid coverage immediately upon release from jail or prison (Exhibit 3).

Data: Laura M. Maruschak, Marcus Berzofsky, and Jennifer Unangst, Medical Problems of State and Federal Prisoners and Jail Inmates, 2011–12 (U.S. Department of Justice, Bureau of Justice Statistics, Feb. 2015, revised Oct. 4, 2016).

Source: Jocelyn Guyer et al., State Strategies for Establishing Connections to Health Care for Justice-Involved Populations: The Central Role of Medicaid (Commonwealth Fund, Jan. 2019).

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