Individuals entering jail are sometimes coming into custody directly off the street, and at times in the throes of withdrawing from a substance. People in jails have a high level of acute health needs (Bureau of Justice Statistics, 2016; Bureau of Justice Statistics, 2017; Bureau of Justice Statistics, 2017), including:

• High blood pressure—26.3% of people in jail
• Hepatitis—6.5% of people in jail
• Mental health conditions—26.4% of people in jail
• Substance use disorder—63% of people in jail

Front line staff often find themselves taking on the duties of clinicians or social workers. Corrections professionals have few supports for these duties, which has a negative impact on the wellness of the workforce as well as recruitment and retention. More often than not, this system fails correctional staff, the individuals in custody, and our communities. Promoting the health needs of individuals during the carceral period, coupled with providing a bridge to services in the community, will not only benefit those receiving the care but enhance the safety and security of staff and facilities as well.

Historically, one barrier to creating greater continuity of care between corrections and community has been the lack of access to Medicaid behind the wall. Many people in the justice system are eligible for Medicaid, especially in the 41 states that have expanded Medicaid coverage to low-income adults. Since 1965, a federal law known as the Medicaid Inmate Exclusion Policy has barred Medicaid from covering services when individuals are in custody, even if they are enrolled in Medicaid. This challenges effective reentry service provision and leaves state and local governments to shoulder the financial burden of providing care. Active Medicaid coverage upon reentry coupled with greater care coordination between corrections and community settings holds potential to improve both health and safety outcomes.

Without access to Medicaid at reentry, local jails struggle to set follow-up appointments for individuals being released because community-based healthcare providers are reluctant to book appointments for patients who lack insurance coverage. Oftentimes, this results in people returning home without access to health care or medication, a situation that is perilous for many and tragic for some. Insurance coverage and a warm handoff to services in the community at reentry is critical because research shows:

• People are 12 times more likely to die in the 2 weeks following release than the general population (Bingswanger, 2007; Mallik-Kane & Visher, 2007).
• Overdose death rates are 40—129 times higher in the 2 weeks after release than the general population (Bingswanger, 2007; Ranapurwala, 2018).
• People who have been incarcerated are nearly 10 times more likely to be homeless upon release than people who have not (Augustine & Kushel, 2022).
• Suicide risk is 2 times higher than the general population for the 3 years after release, with the highest risk time being the 2 weeks post release (Fitch et al., 2024).

Meeting the Moment

This is a public safety issue and jail administrators must be at the table for discussions with state Medicaid partners regarding the implementation of these new changes, for them to be successful, the most pressing of which are the requirements to provide Medicaid-covered services to sentenced juveniles. The need to implement these provisions is an immediate and pressing priority. Health care and correctional officials must work closely together to navigate complex implementation challenges such as building systems that share information, meeting a community standard of care, and mapping out changes in workflow. In particular, the insight from practitioners with experience working with the pretrial population will be critical to tackling the complexity of developing reentry plans for individuals who have short stays and unpredictable release dates while awaiting trial. The expertise of correctional leaders, command staff, and front-line officers will be essential to lift up key operational and security concerns in order to identify potential pain points.

To that end, the call to action for our corrections professionals is two-fold:

• First, reach out to your state office of Medicaid to inquire about the status of discussions regarding the implementation of the new federal law requiring Medicaid covered services for incarcerated juveniles ages 18—21. Also, facilities could begin to review census data for this cohort, identify Medicaid enrollment practices, and understand the screening & assessment tools used for medical, behavioral health, etc.
• Second, ask whether your state has submitted an 1115 demonstration waiver, and if so begin discussions regarding the implementation of the proposed changes.

Acting on these unprecedented opportunities now can save lives, improve safety, and make the jobs of local law enforcement and correctional staff easier. We’re optimistic that Medicaid coverage and connections to care upon reentry will improve health outcomes and enhance public safety by returning individuals back home healthy and whole. Jails have a critical role to play in seizing the potential but the work must begin today.

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David Ryan is Senior Director of Criminal Justice Initiatives at the Health and Reentry Project (HARP). David has over fifteen years of experience working on policy issues at the intersection of health and justice. Prior to joining HARP, David spent over a decade at the Middlesex Sheriff’s Office leading policy priorities to advance changes to the Medicaid Inmate Exclusion Policy (MIEP). He also spent five years working as a legislative aide in the U.S. Senate. For more information, he can be contacted at DRyan@HealthandReentryProject.org.

Dr. Marc Stern, MD, MPH is a general internist and former Assistant Secretary for Health Care at the Washington Department of Corrections. He is currently Affiliate Assistant Professor University of Washington School of Public Health in Seattle, Washington. Dr. Stern also serves as Medical Advisor on the AJA Board of Directors. For more information, he can be contacted at marcstern@live.com.