Cover: Medicaid Enrollment for Individuals Leaving Jail or Prison

Medicaid Enrollment for Individuals Leaving Jail or Prison

Published Dec 20, 2023

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Research Brief

Requires that correctional personnel initiate Medicaid applications or assist with Medicaid application information for individuals nearing release from incarceration or that Medicaid managed care entities collaborate with correctional personnel to coordinate the discharge and transition of enrollees following release from a correctional facility.

A panel of experts rated how they expect this type of policy to affect four outcomes: opioid use disorder (OUD) treatment engagement, OUD treatment retention, OUD remission, and OUD overdose mortality. Another panel of experts rated the policy on four decisionmaking criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
OUD Treatment Engagement
No
No
Yes
OUD Treatment Retention
No
No
Yes
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
No
Yes
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect the policy to improve treatment engagement and retention because insurance coverage and financial factors are important treatment barriers for this population.
  • Experts do not expect reduced OUD remission at the population level; they anticipate reduced mortality because the policy targets a high-risk period for overdoses.
  • Experts rated this policy as highly implementable across all four criteria.
  • Experts think the public generally supports improving health care access.
  • Experts view real-world examples and existing systems for this policy as evidence for its feasibility and its cost-effectiveness as making it affordable.
  • Experts believe that the policy is equitable: It focuses on a societally vulnerable and oppressed population experiencing disparities in morbidity and mortality.

Outcome Summaries

OUD Treatment Engagement

Percentage of people meeting the criteria for an OUD diagnosis who receive two or more OUD treatment services (including medication for OUD) within 34 days of initiating treatment.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
Addressing an important barrier to initiating treatment for a priority population. “Given the extremely high risk of [overdose] following release and the challenges of access to treatment following incarceration, notably from lack of insurance, this intervention is likely to promote initiation and engagement in treatment following release”
Little-to-no Paperwork/processes to activate coverage can take too long, and coverage has limited impact without coordinated linkages to timely treatment. “Unfortunately, even when a patient/client has enrollment paperwork done prior to leaving jail, it is often not in effect quickly enough for medication to be covered the day they leave. Often the processes to reactivate Medicaid are not followed appropriately, which also causes gaps in care. Even 1–2 days of a gap in care can result in a person returning to use”
Harmful N/A N/A

OUD Treatment Retention

Percentage of people meeting the criteria for an OUD diagnosis who remain continuously enrolled in OUD treatment services for at least six months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
Coverage and financial factors are barriers to retention in treatment. “Insurance/ability to pay are big factors for people remaining in care”
Little-to-no Coverage alone is necessary but not sufficient, and this is a difficult population to retain in treatment. “I believe that Medicaid coverage alone is not sufficient. Treatment while people are incarcerated—including medication—will have a greater impact”
Harmful N/A N/A

OUD Remission

Percentage of people meeting the criteria for an OUD diagnosis who do not experience OUD symptoms (other than craving/desire/urge for opioid) for at least 12 months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Greater continuity of care translates into improved health outcomes. “Having access to healthcare and being able to address all of their physical and mental well-being needs will greatly increase the number of folks who do not experience OUD symptoms over time”
Little-to-no
(selected)
Depends on additional factors (e.g., finding treatment that accepts Medicaid in a timely manner) “Assuming that patients leaving jail or prison can find timely treatment that accepts Medicaid, then this would lead to an increase in treatment and OUD remission”
Harmful N/A N/A

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
Greater continuity of care translates into improved health outcomes, especially for overdoses during the high-risk period of transition back to the community. “Mortality immediately following release from incarceration is so unbelievably high, and lack of insurance is a key barrier to receiving addiction care. Perhaps mortality per capita will only have a modest improvement here, but for some individuals, this would be a lifesaving intervention”
Little-to-no Need to provide explicit linkages to treatment in addition to Medicaid coverage in order to see meaningful effects. “Medicaid coverage alone is not enough for most people. Greater support getting people directly into treatment is necessary”
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Public generally supportive of improving healthcare access, especially if effective in addressing overdose epidemic. “Not sure how much the general public knows about this, but to the extent that it ensures healthcare access for people, I think it's relatively non-controversial”
Moderate Depends on the status quo in the state (e.g., political climate, Medicaid expansion). “This is highly variable in terms of the state context, community, political climate, etc.”
Low Negative public attitudes towards people in and spending on the criminal-legal system. “I think people would have a hard time about this because it would be viewed as wasting more money on those in the [criminal-justice] system”

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Demonstrated to be feasible by real-world examples and existing systems for this policy. “This practice is increasingly being recognized for its low burden of implementation. Additionally, corrections and other agency officials are recognizing that recidivism of people with untreated morbidities is high and ultimately very costly to treat during incarceration period and that facilitating coverage and therefore healthcare access, including [substance use disorder] treatment, in the community can contribute to lower costs ultimately”
Moderate Several barriers to implementation exist (e.g., burdens associated with Medicaid enrollment, information technology, workforce issues, coordination across agencies from both the criminal-legal and healthcare systems). “There are barriers to an effective implementation: workforce, IT, availability of staff and of inmates for often complex application processes”
Low Potential political pushback. “I think conservative legislators would not like it. I think progressive leaders would. It would also require a waiver, which could have a hard time getting approved”

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Cost-effective policy given positive impacts on morbidity and mortality. “I would expect that this would be cost-saving as it would address the substantial costs faced due to gaps in care upon release from incarceration settings”
Moderate Depends on status quo in state (e.g., sources of funding available, size of affected/uninsured population). “May be somewhat expensive if a large proportion would otherwise be uninsured”
Low Expensive to implement. “Could be expensive for the state and the feds”

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Inherently targets an important at-risk period (release from incarceration) and barrier (access to healthcare) for a societally vulnerable and oppressed population experiencing disparities in morbidity and mortality. “Focusing policies explicitly on disadvantaged groups is an important approach to reduce disparities. The justice-involved population is not only vulnerable itself, but comprised largely of other disadvantaged groups (i.e., minority race/ethnicity, low-[income])”
Moderate Depends on how the policy is implemented and availability of providers who accept Medicaid. “Depends on how it is implemented and the equity in which people of color are afforded the same support as majority populations”
Low Risks compounding structural racism that currently exists in the criminal-legal and healthcare systems. “There is so much racism in the criminal legal system and health care systems, the two working together will only create equitable entry and outcomes with deep work and community involvement”

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