ISSUE BRIEF
NOVEMBER 2020

Medicaid’s Evolving Role in
Advancing the Health of People
Involved in the Justice System
Natasha Camhi

Dan Mistak

Vikki Wachino

Research Analyst
Community Oriented
Correctional Health Services

Director of Health Care Initiatives for
Justice-Involved Individuals
Community Oriented
Correctional Health Services

CEO
Community Oriented
Correctional Health Services

ABSTRACT

TOPLINES

ISSUE: Individuals who are incarcerated or otherwise involved with the
criminal justice system (justice-involved people) face significant health
challenges, including high rates of COVID-19.

►	Medicaid plays a key role in

GOAL: To describe the health needs of justice-involved populations,
explain how Medicaid meets those needs, and identify policy changes that
could strengthen Medicaid’s role as a tool to improve health outcomes in
this population.
KEY FINDINGS: State and local governments are developing new
Medicaid approaches to meet the health needs of justice-involved people,
particularly as they are leaving incarceration. However, siloes between
correctional and community health care providers disrupt care coordination
and create gaps in treatment and health services that can be life-threatening.
Medicaid policy contributes to these siloes because Medicaid cannot cover
services provided to incarcerated people. New policies are being considered
to allow Medicaid coverage of some services provided during incarceration
to improve coordination, access, and health outcomes.

providing coverage for lowincome people who are involved
in the criminal justice system.

►	State and local governments

are increasingly strengthening
enrollment processes and care
delivery for justice-involved
people, particularly at reentry
into the community.

CONCLUSIONS: The concurrent COVID-19, substance abuse, and mental
health crises, as well as growing awareness of racial inequities, are prompting
state and federal interest in examining the role of public programs, such as
Medicaid, in meeting the needs of the justice-involved population.

The
Commonwealth

Fund

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

2

INTRODUCTION
Several factors are driving efforts to strengthen health care for people who spend
time in jails and prisons or are otherwise involved with the criminal justice
system. These include the impact of COVID-19 behind bars, the need to address the
country’s mental health and substance use crises, and interest in helping people
successfully rejoin their families and communities after they are released from
prison or jail.
In general, justice-involved individuals have extremely complex health care needs.
They experience chronic and infectious diseases, including COVID-19, as well as
serious mental illness and substance use disorders at higher rates relative to the
general population. Improving health services for justice-involved people can
improve the health of populations and communities, keep state and local health
care spending down, and advance public safety goals like successful reentry and
reduced recidivism. Many individuals currently in the criminal justice system
are eligible for Medicaid, especially in states that have taken up the Affordable
Care Act’s expansion of eligibility for low-income adults. Medicaid plays a central
role in supporting these individuals. Because people who are incarcerated are
disproportionately poor and of color, strengthening health care approaches for the
justice-involved can advance the goals of health and racial equity.
This issue brief describes the health care needs of people involved in the justice
system, how Medicaid’s role in providing coverage for this population has evolved
to address those needs, and new policy changes that states and the federal
government are advancing.

OVERVIEW OF THE JUSTICE-INVOLVED POPULATION
The United States has the highest incarceration rate of any nation. Jails and prisons
function differently within the criminal justice system, although they are often
talked about together. On any given day in 2020, about 2.3 million individuals are
held in prisons and jails in the U.S.1 Just over 600,000 people enter prison annually. In
December 2018, almost 1.5 million individuals were in state or federal prisons.2 Despite
how large these numbers are, they pale in comparison to the jail population. There are
10.6 million admissions to jail each year.3 In 2018, the weekly jail inmate turnover
rate was 55 percent, and the average jail stay was 25 days.4 The U.S. Department of
Justice (DOJ) estimates that the annual cost of corrections to U.S. taxpayers is just
over $80 billion, although many experts believe that to be an underestimate.5
Jails and prisons are responsible for providing health care services to people when
they are incarcerated. Many facilities contract with vendors to provide services
under the oversight of state correctional administrators and local officials, who
generally determine the level of services made available. Health care spending,
services, and staffing vary from institution to institution and depend on what is
available in the community.6

commonwealthfund.org

INCARCERATION
AND THE CRIMINAL
JUSTICE SYSTEM:
A QUICK OVERVIEW
In most states, jails and
their health care services
are the responsibility
of counties under
the oversight of an
independently elected
sheriff. There are 3,000
U.S. counties, and most
of the individuals held in
their jails are detained
pretrial, or serving a
sentence of less than a
year. Prisons, on the other
hand, hold individuals
sentenced for more
than a year and are run
by states or the federal
government. Prisons
generally fall under
the jurisdiction and
financial responsibility
of a state-appointed
director of corrections
or the federal Bureau
of Prisons. The reach
of the criminal justice
system extends beyond
jails and prisons; millions
more people are under
probation, parole, pretrial
supervision, and specialty
court supervision, as
well as under other
local alternatives to
incarceration.

Issue Brief, November 2020

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

The incarcerated population is disproportionately poor
and made up of people of color. According to the Prison
Policy Initiative, incarcerated prisoners had a median
annual income of $19,185 prior to their incarceration,
41 percent less than what comparable nonincarcerated
people earned (Exhibit 1).7
In addition, people of color are more likely to be
incarcerated than whites. In 2018 approximately 431 per

Exhibit 1

3

100,000 U.S. residents were in prison (state or federal)
(Exhibit 2). But the imprisonment rate for Black residents
(1,134 per 100,000) was much higher than the rate for
white residents (218 per 100,000). The imprisonment rate
for Hispanic residents was also high (549 per 100,000). 8
Similar racial disparities exist in jails (Exhibit 2).9
Disparities also exist across gender and other racial
and ethnic groups.

People Who Are Incarcerated Are Disproportionately Low-Income
Exhibit 1. People Who Are Incarcerated Are Disproportionately Low-Income
Median annual incomes for incarcerated people prior to incarceration
and nonincarcerated people ages 27–42, by race, ethnicity, and gender, 2014
Incarcerated people
(prior to incarceration)

Nonincarcerated people

Men

Women

Men

Women

All

$19,650

$13,890

$41,250

$23,745

Black

$17,625

$12,735

$31,245

$24,255

Hispanic

$19,740

$11,820

$30,000

$15,000

$21,975

$15,480

$47,505

$26,130

Exhibit 2

White

People Who Are Incarcerated Are Disproportionately Black

Data: Prison Policy Institute.

Exhibit 2. People Who Are Incarcerated Are Disproportionately Black
Jail incarceration rates by race, 2018
Data: Prison Policy Institute.(per 100,000 U.S. residents)

Prison incarceration rates by race, 2018
(per 100,000 U.S. residents)

Source: Natasha Camhi, Dan Mistak, and Vikki Wachino, Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System
(Commonwealth Fund, Nov. 2020).
1,134

592

Black

549

- 187

182

226

White

Hispanic

Total

431

218
Black

White

Hispanic

Total

Data: Bureau of Justice Statistics, Jail Inmates in 2018; Bureau of Justice Statistics, Prisoners in 2018.

commonwealthfund.org

Issue Brief, November 2020

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

4

COVID-19’S IMPACT

make it difficult to control the spread of COVID-19

COVID-19 is taking a heavy toll on people who live

behind bars.14 Resources for treatment available within
correctional facilities vary, and many are not equipped

or work in the nation’s prisons and jails and on the

to treat acute COVID complications or coordinate with

communities that are overrepresented in the justice
system. As of October 2020, there were a reported 146,472
cases of COVID-19 among incarcerated people and 30,178
cases among correctional staff, although inconsistent
state and local reporting means the actual case rate is not
known. In late April, over 70 percent of tested inmates
10

in federal prisons had COVID-19.11 The high rates of
comorbidities among people who are incarcerated place

community providers as people enter the correctional
setting or are released. Because correctional staff
return home to their communities each day, and many
jail stays are brief, these facilities are a leading source
of community transmission in the U.S.15 Researchers
estimated that one in six cases of COVID-19 in Illinois
could be traced back to the Cook County jail.16

them at risk of dangerous COVID complications. In some
state prisons, three out of every four inmates have tested
positive.12 This spring, the rate of infection for prisoners
was 5.5 times higher than that of the general public, and
the COVID-19 death rate was three times higher.13 Because
people of color, and particularly Black people, are much
more likely to be incarcerated than white people, high
COVID-19 rates in correctional settings contribute to racial
disparities in COVID’s impact.

PEOPLE INVOLVED IN THE JUSTICE SYSTEM
HAVE COMPLEX HEALTH ISSUES
COVID-19 is having a severe impact on many people who
are incarcerated. Incarcerated individuals — including
people in prisons and jails — are much more likely to
suffer from chronic health conditions and infectious
diseases (such as hypertension, tuberculosis, diabetes,
and hepatitis), which elevate their risk of serious COVID

Correctional facilities face serious challenges in

complications, than nonincarcerated individuals

mitigating
virus transmission. Close, shared spaces
Exhibit 3

(Exhibit 3).17

People in the Justice System Have High Rates of Chronic and Infectious Diseases
Exhibit 3. People in the Justice System Have High Rates of Chronic and Infectious Diseases
Rates of disease among
prison and jail inmates
■

Chronic condition
51%

Rates among state and federal prisoners vs.
the overall population
■ State and federal prisoners

■ Infectious disease

■ General population

50%

30.2%
22%
18.1%
14%

-6.0%

Prisoners

Jail inmates

High blood
pressure

0.5%

Turberculosis

10.9%
1.1%

1.3%

Hepatitis

0.4%

HIV/AIDS

Data: Bureau of Justice Statistics, Medical Problems of Prison and Jail Inmates, 2011–12. Data reflect numbers of inmates who report ever having had
a chronic condition.
Data: Bureau of Justice Statistics, Medical Problems of Prison and Jail Inmates, 2011–12. Data reflect numbers of inmates who report ever having had a chronic condition.

commonwealthfund.org

Issue Brief, November 2020

Source: Natasha Camhi, Dan Mistak, and Vikki Wachino, Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

5

Justice-involved people also experience high rates of
substance use disorders and have more severe mental
health needs. In 2009, an estimated 58 percent of state
prisoners and 63 percent of sentenced jail inmates met the
criteria for drug dependence or abuse, in comparison to
just 5 percent of the total general population over age 18
(Exhibit 4).18 In general, prison and jail inmates are threeto-five times more likely to meet the threshold for serious
psychological distress than adults in the nonincarcerated
U.S. population.19

particularly strong role in providing coverage to justice-

When people leave prison or jail, they are also more
likely to use hospital services and experience adverse
health events, including death. In the first two weeks post
reentry, the mortality rate for individuals leaving prison is
12 times higher than that of the general public.20

Congress first authorized Medicaid, to prevent cost-

involved people. Over the past several years, states and
providers have strengthened Medicaid coverage and
services for people who are involved in the justice system.
However, Medicaid’s role for people who are incarcerated
is limited. By law, Medicaid cannot cover services
provided to people while they are in jail or prison, with
the exception of inpatient hospital stays provided outside
of carceral settings. This prohibition, known as the
inmate exclusion policy, was established in 1965, when
shifting from state and local governments to the federal
government. As a result, states and local governments are
solely responsible for financing health care delivered to
incarcerated people who qualified for Medicaid before
they were in prison or jail. The services provided to people

MEDICAID’S ROLE FOR JUSTICE-INVOLVED
INDIVIDUALS

who are incarcerated reflect the variability of state and
local resources and practices; consistent standards do not
apply and there is substantial variation in the amounts

Because many people who are incarcerated are poor,
most of them are eligible for Medicaid. States that
Exhibit
4
have
expanded
Medicaid to low-income adults play a

spent, the type and quantity of services provided, and the
quality of services.

Justice-Involved Populations Face High Rates of Substance Use Disorder and
Mental
Health Conditions
Exhibit
4. Justice-Involved
Populations Face High Rates of Substance Use Disorder and Mental Health
Conditions
Mental health status of prisoners and jail inmates
by type, 2011–2012
■

Jail inmates

■ Prisoners

Meets clinical criteria for drug dependence
or abuse, 2007–2009
■

50%

Sentenced in jail
63%

■

Prison

58%

43%
37%

36%

27%
14%

Serious psychological
distress

History of mental
health problem

No indication of a
mental health
problem

State and federal prisons

Data: Bureau of Justice Statistics, National Inmate Survey, 2011–12; Bureau of Justice Statistics, Drug Use, Dependence and Abuse Among State Prisoners and
Jail Inmates, 2007–2009.
Data: Bureau of Justice Statistics, National Inmate Survey, 2011–12; Bureau of Justice Statistics, Drug Use, Dependence and Abuse Among State Prisoners and Jail Inmates, 2007–2009.

commonwealthfund.org

Issue Brief, November 2020
Source: Natasha Camhi, Dan Mistak, and Vikki Wachino, Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System
(Commonwealth Fund, Nov. 2020).

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

The inmate exclusion policy thus creates discontinuities
in care for Medicaid beneficiaries as they move from
Medicaid coverage preincarceration to the correctional
system, which is largely locally driven, and back to the
Medicaid system upon release. Insufficient coordination
between corrections providers and community providers
frequently interrupt the services, medications, and
treatments that individuals were receiving prior to
detention. It also creates disruptions at release that make
it difficult for people to obtain services that can support
successful reentry and reduce recidivism.
States and local jurisdictions have begun developing
approaches to better meet the health needs of Medicaid
beneficiaries who are incarcerated. Historically, many
states responded to the inmate exclusion policy by
terminating individuals’ Medicaid eligibility when they
became incarcerated, which means that people leave
incarceration without Medicaid eligibility and must
reapply. Increasingly, however, states are recognizing the
value of maintaining continuous Medicaid coverage for
this population. Instead of terminating coverage, many
states are suspending Medicaid benefits for incarcerated
people. As of 2019, 43 states had implemented suspension
policies for some prisons, while 42 had done so for some
jails.21 Leveraging data exchange between information
systems can help ensure suspensions are coordinated
between state Medicaid agencies and prisons and jails.
States also are developing approaches to strengthen
services and coordination for people during and after
incarceration. Strategies include:
•

conducting in-reach by encouraging community
providers and health plans to begin communication
and coordination before release

•

deploying peer support specialists who have lived
experience with incarceration and/or behavioral
health issues

•

training primary care providers to be culturally
competent and understand the unique and complex
health needs of justice-involved individuals

•

addressing housing instability and other social
determinants of health.22

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6

DATA EXCHANGE IN ARIZONA
Arizona operates a data-exchange pilot program.
Through this program, participating jails correspond
daily with the state Medicaid agency to provide
information on everyone who was either booked
or released that day. Arizona’s system uses data
transfer to automate the suspension of Medicaid
eligibility for incarcerated individuals and reinstate
coverage when they are released. Arizona also uses
this information to provide notices to managed care
organizations and community providers about who
is enrolled.
As of 2017, this program operated in most of the
state’s counties and covered more than 90 percent
of the state’s jail population.23

These approaches are much more common in Medicaid
expansion states, where the share of the low-income
population that Medicaid covers is substantially larger and
is supported with a favorable 90 percent federal matching
rate, making systems and programmatic investments for
this population more viable.24
Another strategy being used by some states is the
establishment of “health homes,” created by the Affordable
Care Act as an option for Medicaid beneficiaries with
chronic conditions. Beneficiaries are eligible for health
homes if they have two or more chronic conditions
(including mental health disorders, substance use disorders,
asthma, diabetes, heart disease, and obesity), have one
chronic condition and are at risk for a second, or have
one serious and persistent mental health condition. The
model is designed to coordinate and integrate all primary
care, hospital care, mental health services, substance use
disorder services, and ongoing social services and supports.

Issue Brief, November 2020

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

7

The reform also would facilitate access to pre- and

HEALTH HOMES IN NEW YORK AND
RHODE ISLAND

Both New York and Rhode Island have implemented
variations of the health home model, an optional
state plan benefit designed specifically to serve
Medicaid beneficiaries with chronic health
conditions on their reentry into the community.
As of 2017, New York had developed seven criminal
justice health home pilots, while Rhode Island had
three health homes, each focused on a different
group of individuals based on their chronic disease
profiles. One of these three — the opioid treatment
program — was specifically designed to assist the
reentry population.25
The authorization of Medicaid health homes has
encouraged collaboration across the criminal
justice and community health boundary in some
states, a development that should improve the care
provided to the justice-involved population and
result in better health outcomes.

postrelease services for individuals with COVID-19 and
other complex health conditions, including substance
use disorders and mental health conditions. And it could
address the concerns of local government and public
safety officials who argue that the inmate exclusion policy
leads to worse health outcomes, creates service gaps at
reentry that drive recidivism, and poses a financial and
administrative burden for local governments.28 Other
recent legislative proposals would repeal the inmate
exclusion policy altogether.29
The Medicaid Reentry Act follows the passage of another
piece of legislation focused on similar policy goals,
the SUPPORT (Substance Use Disorder Prevention
that Promotes Opioid Treatment for Patients and
Communities) Act. The law requires the Centers for
Medicare and Medicaid Services (CMS) to issue policy
guidance to states to help them improve health care
transitions for incarcerated people at reentry, including
providing services in the 30-day period prior to release,
through a Medicaid Section 1115 demonstration waiver.
This guidance has not yet been issued.30

State Policy Changes

RECENT PROPOSALS TO CHANGE MEDICAID’S
INMATE EXCLUSION POLICY
Policy proposals are emerging to allow Medicaid to cover
services for people who are incarcerated.

At the same time, some states are proposing to provide
Medicaid services to people when they are incarcerated.
States are seeking federal authority to waive the inmate
exclusion policy. 31 Specifically:
•

As part of broader COVID-19 response 1115 waiver
proposals, California and Illinois have asked for

Federal Policy Changes

authority for Medicaid coverage for COVID-19 testing

In May, the U.S. House of Representatives included the

and treatment for Medicaid beneficiaries who are
incarcerated.32

Medicaid Reentry Act in the COVID relief package it passed
(the HEROES Act, which awaits action by the Senate).26
The Medicaid Reentry Act would allow Medicaid to cover
services for beneficiaries who are incarcerated during
the 30 days preceding their release from prison or jail.27

•

Utah recently submitted an 1115 waiver proposal to
CMS seeking authority to cover services for people
who are preparing to leave incarceration and return
to their communities. Utah proposes to provide

This would close part of the gap in care that beneficiaries

comprehensive services to people with complex

experience when they are incarcerated and could improve

health needs in the 30 days prior to release from

the health of those involved in the justice system.

prison or jail.33 CMS has not yet acted on this proposal.

commonwealthfund.org

Issue Brief, November 2020

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

•

Last year, the District of Columbia proposed to
provide transition planning services for people leaving
incarceration, among other settings.34 In 2017, Illinois
proposed to provide behavioral health services to
Medicaid beneficiaries leaving Cook County jail. The
federal government did not approve these proposals
to cover services for people leaving incarceration.

In permitting Medicaid coverage of these services, all
these proposals, whether undertaken statutorily or
administratively, would recalibrate the historical coverage
and financing responsibilities assigned to local, state, and
federal governments for health care for people who are
incarcerated. These proposals also create the potential
for greater coordination of care and services by reducing
the policy barrier that separates the correctional health
system from the community health system. Implementing
these proposals would require overcoming service
delivery differences between correctional and community
health, including differing systems of accreditation,
quality, and health care decision-making. It also would
necessitate developing relationships between correctional
and community providers, as well as an enhanced focus
on ensuring that people involved in the justice system
have access to community services.

commonwealthfund.org

8

CONCLUSION
Medicaid plays a key role in providing coverage for
low-income people who are involved in the criminal
justice system. The program is propelling health
care advances that have the potential to address
disproportionately high rates of COVID-19, substance
use disorders, and mental health issues among this
population, as well as to facilitate successful reentry. State
and local governments are increasingly strengthening
enrollment processes and care delivery for justiceinvolved people, particularly at reentry.
A number of issues are bringing Medicaid’s inmate
exclusion policy into sharper focus, including the need for
expanded, continuous access to substance use disorder
and mental health treatment, the COVID-19 crisis in
prisons and jails, and a desire to address serious racial
inequities in health and criminal justice. As a result, there
is growing state and congressional interest in broadening
Medicaid’s role for people who experience incarceration.

Issue Brief, November 2020

COVID-19’s
Impact on Older
Workers:
Employment,
Income, and
Medicare
Spending
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High Is America’s
Health
Care
Cost Burden?

9

9

GLOSSARY
Inmate exclusion policy
Section 1905(a) of the Social Security Act prohibits federal
Medicaid funds, known as federal financial participation,
from being used to pay for services for inmates of public
institutions, even if they are otherwise eligible for
Medicaid. This is known as the Medicaid inmate exclusion
policy. The Code of Federal Regulations defines an “inmate
of a public institution” as an individual who is living in a
public institution, except if he or she is in an institution
for “a temporary period pending other arrangements
appropriate to his needs.” Public institutions are defined as
those that are “the responsibility of a governmental unit or
over which a governmental unit exercises administrative
control,” including jails and prisons (42 CFR Section
435.1010). Despite the inmate exclusion, Medicaid can
reimburse a provider for services delivered to an inmate
sent to a noncorrectional medical facility if the inmate is
an inpatient in that facility for greater than 24 hours. The
Affordable Care Act did not make any changes to these
long-standing federal Medicaid policies.

Pretrial supervision
Strategy often used to ensure that an individual who
has been accused of committing a crime will appear
for a court hearing without having to post a bond, thus
avoiding pretrial incarceration. This supervision can take
many forms, including, but not limited to, check-ins with a
designated case manager, court date reminders, and drug
and alcohol testing.

Jail vs. Prison
Jails are typically county or city institutions that house
individuals awaiting local trial (detainees) and individuals
convicted of misdemeanors (inmates) who are serving
short sentences, generally less than one year. Prisons, on
the other hand, are state or federal facilities that usually
incarcerate convicted felons (frequently referred to as
inmates or prisoners) serving sentences longer than one
year. At any time, a jail inmate may be released on bail or
charges could be dropped. By contrast, prison inmates
are usually stable on admission and have relatively fixed
release dates that depend on their sentences.

Recidivism
Generally speaking, the phenomenon in which an
individual who was once detained or incarcerated ends up
back in a correctional facility. There are various ways that
this can happen. For instance, a previously incarcerated
individual could commit another crime or violate the
terms of his or her probation or parole. Thus, there are
many ways to define recidivism.

Justice-involved
Refers to any individual — or the population of individuals —
that come into direct contact with the U.S. criminal justice
system. This includes those in jails and prisons, but also those
under probation, parole, pretrial supervision, specialty court
supervision, and other alternatives to incarceration. The term
encourages a more holistic, and realistic, recognition of our
criminal justice system.
Pretrial
Refers to the processes and events that occur at the front
end of the criminal justice system — from initial contact
with a law enforcement officer through final adjudication
of charges — as well as to the period during which those
processes and events occur. In general, defendants are
either held in jail or released into the community during
the pretrial period.

commonwealthfund.org

Probation vs. Parole
Two forms of community supervision by the criminal
justice system. An offender may be sentenced to probation
in lieu of serving jail or prison time. Probation sentences
usually involve strict guidelines to which offenders must
adhere; violating conditions of probation can result in
incarceration. Parole is a conditional release from prison.
Parolees are individuals who have already served time
in prison and are granted an early release, dependent on
certain conditions that must be met for the offender to
avoid reincarceration.

Reentry
The transition period between custody in jail or prison
and the community. Although individuals making
this transition are sometimes given assistance through
discharge planning, the resources available are typically
very limited.
Serious psychological distress
Serious psychological distress is determined through
questions based on the Kessler 6 (K6), a six-question tool
developed to screen for serious mental illness among
adults age 18 and older in the general U.S. population.
People taking the K6 are asked how often in the past 30
days they have felt:
•
•
•
•
•
•

nervous
hopeless
restless or fidgety
so depressed that nothing could cheer them up
like everything was an effort
worthless.

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10

NOTES
1.

Wendy Sawyer and Peter Wagner, “Mass
Incarceration: The Whole Pie 2020,” press release,
Prison Policy Initiative, Mar. 24, 2020.

2.

E. Ann Carson, Prisoners in 2018 (Bureau of Justice
Statistics, Apr. 2020).

3.

Sawyer and Wagner, “Mass Incarceration,” 2020.

4.

Zhen Zeng, Jail Inmates in 2018 (Bureau of Justice
Statistics, Mar. 2020).

5.

U.S. Department of Justice, Smart on Crime: Reforming
the Criminal Justice System for the 21st Century
(DOJ, Aug. 2013); and Michael McLaughlin et al.,
The Economic Burden of Incarceration in the U.S.
(Concordance Institute for Advancing Social Justice,
July 2016).

6.

Pew Charitable Trusts, Jails: Inadvertent Health Care
Providers (Pew, Jan. 2018).

7.

In 2014 dollars. Bernadette Rabuy and Daniel Kopf,
“Prisons of Poverty: Uncovering the Pre-incarceration
Incomes of the Imprisoned,” press release, Prison
Policy Initiative, July 9, 2015.

8.

Carson, Prisoners in 2018, 2020.

9.

Zeng, Jail Inmates in 2018, 2020.

10. Sharon Dolovich and Aaron Littman, “UCLA Law
COVID-19 Behind Bars Data Project,” (UCLA School of
Law, Aug. 14, 2020).
11. Michael Balsamo, “Over 70% of Tested Inmates in
Federal Prisons Have COVID-19,” AP News, Apr. 29,
2020.
12. Bill Chappell and Paige Pfleger, “73% of Inmates at an
Ohio Prison Test Positive for Coronavirus,” National
Public Radio, Apr. 20, 2020.

commonwealthfund.org

13. Brendan Saloner, Kalind Parish, and Julie A. Ward,
“COVID-19 Cases and Deaths in Federal and State
Prisons,” Journal of the American Medical Association
324, no. 6 (July 8, 2020): 602–3.
14. James Hamblin, “Mass Incarceration Is Making
Infectious Diseases Worse,” The Atlantic, July 18, 2016.
15. The Marshall Project, “A State-by-State Look at
Coronavirus in Prisons,” July 2020.
16. Eric Reinhart and Daniel L. Chen, “Incarceration and
Its Disseminations: COVID-19 Pandemic Lessons from
Chicago’s Cook County Jail,” Health Affairs 39, no. 8
(June 2020): 1412–18.
17. Laura M. Maruschak, Marcus Berzofsky, and Jennifer
Unangst, Medical Problems of State and Federal
Prisoners and Jail Inmates, 2011–2012 (Bureau of
Justice Statistics, Feb. 2015).
18. Jennifer Bronson et al., Drug Use, Dependence,
and Abuse Among State Prisoners and Jail Inmates,
2007–2009 (Bureau of Justice Statistics, June 2017).
19. Jennifer Bronson and Marcus Berzofsky, Indicators of
Mental Health Problems Reported by Prisoners and
Jail Inmates (Bureau of Justice Statistics, June 2017).
20. Ingrid A. Binswanger et al., “Release from Prison — A
High Risk of Death for Former Inmates,” New England
Journal of Medicine 356, no. 2 (Jan. 11, 2007): 157–65;
Erlyana Erlyana et al., “Emergency Room Use After
Being Released from Incarceration,” Health Justice 2,
no. 5 (Mar. 2014).
21. Kathleen Gifford et al., A View from the States: Key
Medicaid Policy Changes—Results from a 50-State
Medicaid Budget Survey for State Fiscal Years 2019
and 2020 (Henry J. Kaiser Family Foundation, Oct.
2019). In addition, in 2018 the federal government
prohibited states from terminating eligibility for
people who are under age 18.

Issue Brief, November 2020

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

22. 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).
23. Jesse Jannetta et al., Strategies for Connecting JusticeInvolved Populations to Health Coverage and Care
(Urban Institute, Mar. 2018).
24. Jocelyn Guyer, Deborah Bachrach, and Naomi Shine,
Medicaid Expansion and Criminal Justice Costs:
Pre-Expansion Studies and Emerging Practices Point
Toward Opportunities for States (State Health Reform
Assistance Network, Nov. 2015).
25. Brenda Spillman et al., Connecting Justice-Involved
Individuals with Health Homes at Reentry: New York
and Rhode Island (Urban Institute, Jan. 2017).

11

32. In addition, South Carolina submitted an 1115 waiver
application to use federal matching funds to pay
for inpatient care provided to Medicaid-eligible
individuals in jail or prison, rather than in a hospital
setting.
33. Utah Department of Health, Utah 1115 Primary Care
Network Demonstration Waiver Amendment Request:
Medicaid Coverage for Justice-Involved Populations
(UDOH, June 2020).
34. Government of the District of Columbia, Department
of Health Care Finance, District of Columbia Section
1115 Medicaid Behavioral Health: Transformation
Demonstration Program (DHCF, June 2019).

26. Medicaid Reentry Act, H.R. 1329, 116th Cong. (2019).
27. Medicaid Reentry Act, 2019.
28. National Association of Counties, Federal Policy
Impacts on County Jail Inmate Healthcare &
Recidivism (NACo, Mar. 2019); and National
Association of Counties–National Sheriffs’
Association Joint Taskforce, Addressing the Federal
Medicaid Inmate Exclusion Policy (NACo–NSA, Feb.
2020).
29. See, for example, Anne McLane Kuster,
“Congresswoman Kuster, Senator Booker Introduce
Legislation to End Outdated Policy That Prevents
Incarcerated Individuals from Accessing Medicaid,”
press release, Aug. 2, 2019.
30. MaryBeth Musumeci and Jennifer Tolbert, Federal
Legislation to Address the Opioid Crisis: Medicaid
Provisions in the SUPPORT Act (Henry J. Kaiser Family
Foundation, Oct. 2018).
31. Elizabeth Hinton et al., Section 1115 Medicaid
Demonstration Waivers: The Current Landscape
of Approved and Pending Waivers (Henry J. Kaiser
Family Foundation, Feb. 2019).

commonwealthfund.org

Issue Brief, November 2020

Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System

12

ABOUT THE AUTHORS
Natasha Camhi, M.P.P., a research analyst for Community
Oriented Correctional Health Services (COCHS), provides
rigorous research and writing support for a wide range
of projects. Formerly a professional gilder, she began
her policy career with the Brennan Center’s Justice
Program, analyzing federal criminal justice policy, as
well as helping to direct the program’s communications,
media, and operational strategy. Ms. Camhi is particularly
interested in how criminal justice intersects with
housing and health care and recently coauthored a
paper (forthcoming) examining how Washington, D.C.,
landlords’ understanding of local “pro-tenant” housing
policies impacts voucher holders’ ability to secure housing.
She received her master of public policy degree from the
McCourt School of Public Policy at Georgetown University.
Dan Mistak, M.S., M.A., J.D., director of Health Care
Initiatives for Justice-Involved Individuals at Community
Oriented Correctional Health Services, aims to connect
community systems of care to improved health care
behind the walls of the jail. In addition to working to
change long-standing inequities by improving health and
justice policy, he has been a trial attorney and worked
with justice-involved individuals regarding the collateral
consequences of their justice involvement. Mr. Mistak
established the first medical–legal partnership for victims
of crime and justice-involved individuals in the U.S. He
holds a juris doctorate from the UC Berkeley School of
Law and master’s degrees in genetics/cell biology and
philosophy from Washington State University. He is
admitted to practice law in California and Hawaii.

commonwealthfund.org

Vikki Wachino, CEO of Community Oriented
Correctional Health Services, has worked for more than
25 years to advance stronger health care systems for
low-income people in the U.S. She is the former deputy
administrator of the Centers for Medicare and Medicaid
Services, for which she oversaw all policy and operations
for Medicaid and the Children’s Health Insurance Program
and led historic efforts to expand Medicaid coverage,
reduce the nation’s uninsured rate, and strengthen state
health care delivery systems. Ms. Wachino is the author of
many publications on Medicaid coverage and financing
and speaks frequently on these topics, including in
testimony before Congress.

...................................................................................................................
Editorial support was provided by Maggie Van Dyke.

For more information about this brief, please contact:
Dan Mistak, M.S., M.A., J.D.
Director of Health Care Initiatives for Justice-Involved
Individuals
Community Oriented Correctional Health Services
dmistak@cochs.org

Issue Brief, November 2020

.. ·.

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•
•
• • •

The
Commonwealth

Fund

Affordable, quality health care. For everyone.
About the Commonwealth Fund
The mission of the Commonwealth Fund is to
promote a high-performing health care system
that achieves better access, improved quality, and
greater efficiency, particularly for society’s most
vulnerable, including low-income people, the
uninsured, and people of color. Support for this
research was provided by the Commonwealth Fund.
The views presented here are those of the authors
and not necessarily those of the Commonwealth
Fund or its directors, officers, or staff.