Medicaid during incarceration: a step toward health equity

As a physician caring for chronically ill individuals recently released from incarceration, I’ve become accustomed to working as a detective of sorts, trying to piece together the care they received while incarcerated in an attempt to recreate their medical histories and treatment plans.

Since they are often released without medical records, prescriptions, and other lifesaving information, I ask questions like, “Do you remember your doctor’s name? Was the ride from the prison to the hospital long or short? When you looked out the window, was the ocean on your left or right?” So much of my early work with a new patient feels like getting to the starting line, the place where we can begin providing care.

Help for the patients in the Transitions Clinic Network, the national program I lead, and millions of people across the country may be on the horizon in the form of a Section 1115 Waiver to Medicaid’s Inmate Exclusion Policy. The waiver allows Medicaid to be activated for eligible youths and adults in jails and prisons up to 90 days before they are released.

California is the first state to receive this type of approval from the Centers for Medicare and Medicaid Services, but a dozen other states have waiver applications in the works.

Activating Medicaid for an individual before leaving incarceration is a first and critical step toward reducing systemic barriers that create gaps in care between the carceral and community health systems and exacerbate health inequalities.

Each year in the U.S., about 650,000 people are released from prison and 9 million return to their communities from jail, often with multiple chronic conditions, few medical records or medications, and no insurance or continuum of care. As a result, they face a risk of death in the two weeks after release that is 12 times higher than that of the general population; the risk for overdose death is a staggering 129 times higher.

It is no secret that the U.S. criminal legal system disproportionately harms people of color. The traditional health care system has not only underserved the populations most affected by mass incarceration but has harmed them, and the issues of health, race, poverty, and incarceration are deeply intertwined. Incarceration exacerbates health and economic disparities, a vicious cycle in which poor health impedes employability, preventing financial gain and housing stability, and increasing the risk of recidivism.

Trying to rebuild a life after incarceration is challenging. Trying to do so while dealing with health issues and all basic needs up in the air at the same time — housing, food, transportation, employment, and more — takes herculean effort, particularly when coming back from decades of incarceration to a changed world dependent on unfamiliar technologies. Many of my patients return home to no one, their relatives gone, their friends moved away.

People released from incarceration have so many hurdles and hoops to jump through just to get to the starting line, and then the race they must run is harder and longer, with more barriers and fewer supports to make it to the end. The clinicians and staff at Transitions Clinic Network try to be their support system by providing wraparound social support in the form of community health workers with lived experience of incarceration. If I’m a doctor and detective, community health workers are social workers, cheerleaders, career counselors, and friends.

I hope it will become standard operating procedure throughout the U.S. for individuals to leave incarceration at least at the starting line, the pieces in place for community providers to begin providing care: their Medicaid active, in possession of sufficient medication, appointments set up and records transferred. If the last portion of incarceration becomes focused on comprehensive transitional release planning, individuals will leave incarceration not just with information for who their new provider is but already engaged and in contact with them.

Health equity is not only about providing more care. It is about providing better care: trauma-informed and culturally appropriate care that individuals returning from the dehumanizing experience of incarceration want to engage with. I credit community involvement with the success of Transitions Clinic Network’s model, which trains and employs formerly incarcerated individuals as community health workers to provide support and engage patients in care. This community-led model has been found to reduce emergency department use and hospitalization, decrease reincarceration, and save states money. We developed it in collaboration with directly affected community members, asking what they wanted, and then delivering it, in partnership with them.

The Medicaid waiver expands access to health care for people leaving incarceration. But for it to be effective, those most in need of care must be engaged. This means connecting them to community-based care provided by health workers who understand the experience of incarceration. The Medicaid waiver opens the door to care. Now it’s time to provide care that individuals harmed by the legal system and its numerous collateral consequences will want to — and choose to — walk through to receive it.

Shira Shavit is a physician and clinical professor of family and community medicine at the University of California, San Francisco, and the executive director of the national Transitions Clinic Network.