Why states should change Medicaid rules to cover people leaving prison

People leaving prison have sky-high mortality rates. Most are likely Medicaid-eligible. Making sure they are covered upon release from prison would save lives and reduce recidivism.

by Emily Widra, November 28, 2022

The gap in healthcare coverage following incarceration leads to high rates of death just after release: During just the first two weeks after release from prison, people leaving custody face a risk of death more than 12 times higher than that of the general U.S. population, with disproportionately high rates of deaths from drug overdose and illness. A huge contributing factor to this astronomically high death rate following release is the healthcare coverage gap: People lose health insurance coverage while in jail or prison and their lack of coverage continues post-release, leaving many without access to adequate, timely, and appropriate health care in those critical first weeks of reentry.

Fortunately, we have a way to address this healthcare coverage gap, and to improve the health and safety of our communities in general: Medicaid. Research shows that expanding access to healthcare through Medicaid saves lives and reduces crime and arrest rates — along with state spending — making this a reform strategy whose time has come.

 

How Medicaid’s “inmate exclusion policy” leaves formerly incarcerated people without healthcare

When Medicaid was authorized in 1965, the “inmate exclusion policy” was established to prevent state and local governments from receiving matching federal funds to cover the healthcare costs of people in state prisons and local jails. This policy leaves state and local governments solely responsible for financing the healthcare of incarcerated people,¹ even when those people were covered by Medicaid prior to their incarceration. This means that in most states, Medicaid coverage is terminated when someone is incarcerated.²

The Center for Medicare and Medicaid Services (the federal agency responsible for Medicare and Medicaid) has advocated that people be returned to the Medicaid eligibility rolls “immediately upon release from a correctional facility,” and has even provided resources to correctional systems, probation officers, and parole officers to help make this happen. Nevertheless, as things stand now – despite most people being financially eligible for Medicaid upon release – connecting with appropriate healthcare providers and reapplying for Medicaid is no easy feat for people going through reentry, leaving too many medically vulnerable and disconnected from healthcare services in the community.

 

Most incarcerated and formerly incarcerated people are probably eligible for Medicaid

In all states, Medicaid provides health coverage for low-income people who qualify based on income, household size, disability status, and a handful of other factors. Most people in contact with the criminal legal system are likely eligible for Medicaid: People in prisons and jails are among the poorest in the country and have high rates of disabilities, making them likely eligible for Medicaid in almost every state. People in contact with the criminal legal system have drastically lower pre-incarceration incomes than people who are never incarcerated. In fact, 32% of people in state prisons in 2016 who had insurance at the time of their arrest were covered by Medicaid (compared to about 19% of insured people nationwide). As an additional indicator of need among this population, 50% of people in state prisons were uninsured at the time of arrest.

 

See our 2022 report, Chronic Punishment, for methodology details.

Formerly incarcerated people face low incomes and high rates of unemployment, meaning that they too are likely to be eligible for Medicaid, especially in states where Medicaid eligibility is based solely on income. After incarceration, people experience unemployment at high rates and report low incomes. Formerly incarcerated people are unemployed at a rate of over 27%, which is higher than the total U.S. employment rate during any historical period, including the Great Depression. When formerly incarcerated people do land jobs, they are often the most insecure and lowest-paying positions: the majority of employed people recently released from prison receive an income that puts them well below the poverty line.

 

Excluding justice-involved people from Medicaid can be lethal

People in prison have higher rates of certain chronic conditions and infectious diseases, disabilities, and face exceptionally high rates of mental illness compared to the general U.S. population, but medical and mental health care in prisons and jails are grossly inadequate.³ As a result of such inadequate healthcare, many people in prison end up worse off upon release. Subpar healthcare behind bars and the post-release healthcare coverage gap are pivotal factors in the heightened risk of death after release.

The risk of death is particularly high in the first two weeks following release from prison (12 times higher than the general population), but the lethal consequences of incarceration continue beyond these first two weeks. A 2021 study found that high county jail incarceration rates are associated with high mortality rates, but most acutely with deaths by infectious disease, respiratory disease, drug overdose, suicide, and heart disease. In 2019, a study of people released from North Carolina prisons found that people who spent any time in solitary confinement⁴ were 24% more likely to die in the first year after release (with an extraordinarily high risk of death from opioid overdose in the first two weeks after release). Another study found that people in their sample who were released from prison were twice as likely to die within 30 days and 90 days of release than those who were not incarcerated.

Many of these deaths following release are preventable with appropriate medical, mental health, and substance use interventions, which usually require health insurance. But because people are released from prisons and jails without insurance, they are less likely to receive the necessary interventions upon release. Uninsured people are less likely to seek medical care (because of the financial costs), and when they do seek out care, the care is likely of poor quality or too late, resulting in worse health outcomes and higher rates of death when compared to insured people.

 

How states can reform Medicaid to cover people leaving prison

A number of states have utilized Medicaid to start to bridge the healthcare coverage gap, and there are encouraging results. Given that some of the predominant healthcare-related concerns among recently-released people include lack of insurance and difficulty accessing care and medication, bridging this gap is a crucial step to mitigating the harms caused by barriers to healthcare services.

Reduce barriers to Medicaid eligibility

In a handful of states, Medicaid coverage is expanded to allow people to qualify based solely on finances (with an income below 133% of the federal poverty line). In these states, there are now fewer barriers to Medicaid eligibility, and therefore more people receiving Medicaid. While this reform does not exclusively target people leaving prison, it benefits them: Following Medicaid expansion in New York and Colorado, state officials estimated that 80-90% of people in state prisons would now be eligible for Medicaid coverage upon release (based on their pre-incarceration incomes).

Enroll people in Medicaid before their release from prison

Oklahoma began a program in 2007 to help people in prison with severe mental illness apply for Medicaid benefits during their final months in prison. This program had quick results: after one year, the share of people who were enrolled in Medicaid on their day of release increased by 28 percentage points.

A 2022 study of Louisiana’s Prerelease Medicaid Enrollment Program found that there was a 34.3 percentage point increase in Medicaid enrollment, and of those who were successfully enrolled before release, 98.6% had attended at least one outpatient visit within the first 6 months of release. These findings – along with similar programs in other states – suggest that pre-release Medicaid enrollment programs are a relatively simple way to connect people to necessary healthcare services and bridge the healthcare coverage gap.

In Connecticut and Massachusetts, there are statewide programs that enroll all Medicaid-eligible people who are being released from prison to parole. While incarcerated and waiting for their release date, incarcerated people work with “discharge planners” in correctional facilities to complete and submit Medicaid applications that are then held by the state’s Medicaid agency until they are released on parole. In Massachusetts, the state reports that 90% of people released to parole are covered by Medicaid upon their release.

Suspend – rather than terminating – Medicaid coverage for incarcerated people

In twelve states,⁵ Medicaid coverage is suspended – rather than terminated – when someone is incarcerated in state prison, which makes the process of reinstating Medicaid coverage upon release much simpler and avoids the need for “discharge planners” to help with applications or make other arrangements. In Maricopa County, Arizona, an agreement with the state Medicaid agency allows Medicaid eligibility to be suspended – not terminated – upon jail incarceration in the county.

Request federal Medicaid waivers

States can petition the U.S. Department of Health and Human Services to waive federal guidelines⁶ to allow states to trial new approaches and pilot new policies.⁷ At least nine states – Arizona, California, Kentucky, Massachusetts, Montana, New Jersey, Oregon, Utah, and Vermont – have submitted requests for waivers to modify the “inmate exclusion policy” and allow for coverage of certain health services provided pre-release. The proposals vary in what incarcerated populations they are seeking eligibility for, what services they would like to be Medicaid-eligible prior to release, and when coverage would be offered. Some states are seeking eligibility for a specific group of incarcerated people, such as four behavioral health case management visits for those with behavioral health diagnoses (New Jersey) or specific substance use disorder treatment services for incarcerated people with substance use disorders (Kentucky). Other states are seeking the full set of Medicaid benefits for incarcerated people with chronic conditions (Massachusetts) or for all incarcerated people (Utah). As of March 2022, the Center for Medicare and Medicaid Services (CMS) had not yet issued decisions on any of these proposals.

 

A bill in Congress would allow Medicaid coverage for people leaving prison or jail

In 2021, members of the House of Representatives introduced the Medicaid Reentry Act. This bill would allow Medicaid coverage to begin 30 days before people are released from prisons or jails, allowing medical services during that time period to be covered by Medicaid and for people to be insured the moment they are released from the facility. Legislation like this would vastly expand access to healthcare after incarceration, closing the dangerous healthcare coverage gap and thereby reducing the preventable deaths and health problems that occur in the immediate post-release period.

 

Other benefits of closing the healthcare coverage gap

The effects of bridging the healthcare coverage gap are far more expansive than one might expect. Increasing access to healthcare appears to have significant effects on reducing arrests, crime rates, criminal-legal system involvement, recidivism, and state expenditures.

Reducing arrests and lowering crime rates

In states with Medicaid expansion (i.e., where eligibility is based solely on income), there have been correlated reductions in crime rates and arrests. Compared to counties in states that had not implemented expanded Medicaid coverage, counties in states with Medicaid expansion saw a 25% decrease in drug arrests, a 19% decrease in “violent offense” arrests, and a 24% decrease in “low-level” offense arrests.⁸ Looking at more specific types of crimes, researchers also found a 3.7% to 7.5% decrease in burglary, motor vehicle theft, robbery, and violent crime rates in counties with statewide Medicaid expansion.⁹

Preventing contact with the criminal-legal system

In 1990, the federal government expanded Medicaid to provide coverage for more children and families living below the federal poverty line. Research shows that the expanded Medicaid eligibility among youth actually reduced the incarceration rates in Florida: there was a 3.5% reduction in incarceration for each additional year of population-level Medicaid eligibility. These results suggest that by investing resources in healthcare and expanding Medicaid coverage to as many people as possible up front, we can actually begin to reduce our reliance on the carceral system.

Reducing recidivism

Increased access to healthcare through Medicaid coverage also reduces recidivism. Prior to the Affordable Care Act (ACA), there were eligibility requirements that restricted Medicaid eligibility for formerly incarcerated people, but with expanded Medicaid coverage, most previously incarcerated people who meet the necessary income criteria are eligible for Medicaid. A study published in 2022 found that expanded Medicaid coverage resulted in significant reductions in the rate of rearrest, with a 16% reduction in arrests for violent crime for two years following release.

Reducing state expenditures

The direct costs of incarceration are immense: it costs more than $225 to incarcerate someone in New York county jail for a single night and nationally, it costs an average $31,307 a year to incarcerate a single person in state prison. Meanwhile, 2019 estimates suggest that total annual Medicaid spending per person ranged from a low of $4,970 in South Carolina to a high of $12,580 in North Dakota, suggesting that even where Medicaid is spending the most per person, it is far less expensive than incarceration. While these are just rough estimates of the per capita costs of incarceration and Medicaid coverage, more in depth research implies substantial cost reductions by expanding Medicaid coverage to all Medicaid-eligible formerly incarcerated people. The estimated costs of expanded Medicaid coverage – by reducing the economic and social costs of victimization and the expenditures on multiple incarcerations – are significantly less than state and local governments are currently spending on arrest, jail, court, and imprisonment.

 

Conclusion

The healthcare coverage gap that threatens the lives of people recently released from prison is not inevitable. Incarcerated people and those released from incarceration face poverty, unemployment, and disproportionately high rates of disability, disease, and illness, but Medicaid is a tool we can use to expand healthcare coverage and reduce the number of preventable deaths after release. Evidence from states with these kinds of Medicaid programs in place suggests that hundreds of thousands of people being released across the country each year would benefit from such efforts. Expanding access to affordable, quality healthcare results in a myriad of benefits to public health, public safety, and public coffers. Perhaps most encouragingly, the drop in arrests and crime following expanded Medicaid coverage offers evidence that by ensuring people’s most basic needs are met, we can begin to reverse our nation’s reliance on mass incarceration.

 
 

In an election where every vote matters, Georgia officials should ensure registered voters in jails can cast their ballots

Sheriffs and local election officials must do everything in their power to ensure detained individuals can exercise their fundamental right to vote.

by Wanda Bertram and Naila Awan, November 18, 2022

With the upcoming Senate runoff election in Georgia likely coming down to a few thousand votes, an overlooked form of disenfranchisement deserves attention: The huge barriers to voting for people locked up in locally-run jails (which we explained in depth in our 2020 report Eligible, but Excluded).

Roughly 39,000 people are held in Georgia’s county jails on any given day (a number very close, coincidentally, to the 36,000-vote difference in the general election between Sen. Raphael Warnock and Herschel Walker at the moment). While it’s not known exactly how many of these people meet the qualifications to vote, the number is likely in the thousands because:

• Most people in county jails are there awaiting trial, and Georgia does not restrict voter eligibility for people charged with a crime (though people already on probation or parole are ineligible).
• Of the minority of people in Georgia jails who are serving a sentence, most are serving a misdemeanor sentence. Georgia does not restrict voter eligibility for people convicted of misdemeanors.

Any of these eligible voters who are already registered qualify to vote in the runoff election.

Incarcerated people’s diverse voices and opinions should be heard in our democracy, yet people in jail will likely be excluded from the close race for this pivotal Senate seat. But there are things sheriffs and local election officials can do to ensure that detainees can cast their votes:

• Make people in jail aware of their likely eligibility and the absentee ballot deadlines. One of the main reasons people in jail do not vote (despite being eligible) is because they think they’re not allowed to. Jail and election officials can coordinate to identify people who are incarcerated who are eligible to vote in the county and conduct affirmative outreach to them.
• Enable and assist people in requesting an absentee ballot by the November 28 deadline. Jail officials must make sure people have access to ID information, such as their driver’s license number, needed to complete an absentee ballot application. They should also facilitate people in jail being able to submit ballot applications not just by snail mail, but also via the state’s online portal, email, or fax.
• Allow incarcerated people to receive absentee ballots in time by ensuring election mail is processed in a timely way, and provided in its original, physical form. (Many jails currently ban postal mail; needless to say, these jails should make an exception for ballots.)
• Help incarcerated people submit absentee ballots on time by quickly mailing any absentee ballots cast by incarcerated voters and guaranteeing that commissary is available so people can purchase stamps (or better yet, the jail can provide stamps for free).
• Ensure that people in jail have contact information for their local board of elections, can track the status of their ballot, and are able to fix any deficiencies with their absentee ballot.

Barring people in jails from voting “is a social injustice and a civic indignity,” wrote Rev. Jesse Jackson in a 2020 Chicago Sun-Times op-ed. “Not surprisingly,” Jackson noted, “it disproportionately impacts African Americans, Latinos, and the poor.” People in jail are citizens who stand to be affected by laws around things like housing, healthcare, and of course, criminal justice. In Georgia — and everywhere people in jails are effectively disenfranchised — sheriffs and election officials must do everything in their power to ensure these individuals can exercise their basic right to vote.

Mail scanning: A harsh and exploitative new trend in prisons

In at least 14 states, people in state prisons are falling victim to a scan: Prisons are replacing physical mail with scanned copies, a policy that benefits private companies.

by Leah Wang, November 17, 2022

The appendix table was updated on December 1, 2022 to reflect new information about South Dakota.

In recent years, many prison systems have either tried or fully implemented a policy that interferes with incarcerated people’s mail in a way we haven’t seen in our many years fighting to protect family communication behind bars: Prisons are increasingly taking incoming letters, greeting cards, and artwork, making photocopies or digital scans of them, and delivering those inferior versions to recipients. This practice of mail scanning, either performed at the prison itself or off-site using a third-party vendor, strips away the privacy and the sentimentality of mail, which is often the least expensive and most-used form of communication between incarcerated people and their loved ones.

Prison administrators claim that delivering scanned copies of mail correspondence will stem the flow of contraband — primarily, drugs — into their facilities, but there’s no solid evidence to date that mail scanning has this intended effect. (In fact, some jurisdictions have found the opposite effect with respect to drugs.) We did a policy and media scan of all 50 state prison systems and the federal prison system, and found that mail scanning is quickly becoming widespread, despite the enormous benefits of genuine mail.

Table 1: States scanning mail at all state prisons

Data was gathered via a survey of correctional departments’ websites. See the appendix table at the end of this briefing for more details.

	When did mail scanning begin?	Vendor doing mail scanning, if any
Arkansas	August 2017	Unknown
West Virginia	2017	Pigeonly
Virginia1	April 2018	None (internal)
Pennsylvania	September 2018	Smart Communications
Indiana	July 2020	None (internal)
Michigan	October 2020	Unknown
North Dakota	July 2021	Securus
North Carolina	October 2021	TextBehind
Nebraska	December 2021	Unknown
Wisconsin	December 2021	TextBehind
Ohio	February 2022	None (internal)
New Mexico	February 2022	Securus
Missouri	July 2022	Securus
New York	August 2022	None (internal)

We found 14 state prison systems that are scanning all incoming mail, but we’re confident that this number is an undercount, because we couldn’t verify the status of mail scanning in some other states.² Several more states are trialing mail scanning practices in just a few of their facilities, or have correctional policies that allow mail scanning to begin at any facility, at any time.³ Many more states are likely to be scanning mail before long: Even during the course of our research, one state (Minnesota) implemented a six-month alternative mail delivery pilot — which includes mail scanning — in some of its facilities. (For details about every state’s prison mail scanning practices, see the appendix table at the bottom of this briefing.)

Mail scanning happens in locally-run jails, too; in our state-level research, we stumbled upon 15 jails⁴ that have banned incoming mail in favor of digitized copies. While most of the local jails we read about implemented mail scanning in 2021 or 2022, we’ve been receiving reports of jails scanning mail since 2017, and we suspect that dozens more jails across the U.S. have done away with delivering real mail.

How does mail scanning work?

As the table above shows, some prisons pay a vendor to scan mail and deliver copies to incarcerated people, while others manage the process internally.

There are two primary methods for delivering scanned mail. Some prison systems deliver printed copies of mail, often including copies of the envelope. (If there’s a limit on the number of pages that can be copied and delivered, the envelope may count toward that limit, as it does in Arkansas.) Other prison systems scan mail and upload it into a digital database, where it’s then viewable on a tablet or a shared kiosk inside a prison. Most states and third-party vendors hold onto original letters and cards for a period of time — several states have a 45-day holding period, for example — but eventually dispose of or destroy them.

The four biggest problems with scanning mail

1. Prisons and jails often switch to scanning mail not out of any concern for safety, but at the encouragement of the same private companies that dominate the prison technology industry. For years, these companies’ strategy for securing contracts has been to offer facilities multiple services “bundled” together, such as phone calls, tablet computers, and mail scanning. Scanning mail pushes incarcerated people to use other, paid communications services provided by the companies: Compared to mail that’s delayed due to scanning procedures, or scanned incorrectly, incarcerated people and their loved ones often understandably switch to electronic messaging (which requires the purchase of digital stamps), phone calls, or video calls.
   

   A number of prison vendors currently bundle mail scanning with other exploitative communications “services”:

We found four third-party vendors scanning incoming mail for state prisons. These companies all offer other services as well as mail scanning, often bundled into one contract. Not listed here, prison telecom giant ViaPath Technologies (formerly Global Tel*Link, or GTL), offers a mail scanning service branded as “GettingOut,” but we didn’t find evidence of a prison system using it.

	Vendor	Services offered to prisons other than mail scanning
	Securus5	Electronic messaging and greeting cards, video calling, other financial services
	Smart Communications	Electronic messaging, video calling, phone calls, “MailGuard Tracker” (for senders to track mail delivery), tablets and/or kiosks with educational materials, simplified commissary ordering
	Pigeonly	Electronic messaging and greeting cards, phone calls, other financial services
	TextBehind	Electronic messaging and greeting cards, electronic kids’ drawings

2. Physical mail carries great sentimental value for incarcerated people, which translates into a more hopeful experience behind bars. In one incarcerated person’s words, “Under the new policy of digitizing mail [in Florida], [we] are losing the visceral experience of touching a letter or smelling perfume on an envelope.” Taking that away has real, measurable consequences for mental health, behavior, and even recidivism after release. Incarcerated people return to their mail over and over to be reminded of their support networks; scanned mail, on the other hand, is often low-quality or incomplete, lacking the same meaning. Even if contraband occasionally enters prisons through the mail, the practice of scanning all mail senselessly punishes all incarcerated people and their families for a few infractions.

3. This extreme interference with mail will have a chilling effect on correspondence, reducing the overall volume of mail sent into prisons. People who send mail to prisons don’t want their letters and artwork scanned into a searchable database and/or destroyed, two common features of mail scanning. Scanning is a needlessly complicated and costly practice that violates privacy and stifles communication, as we learned when many jails started postcard-only policies. (This effect may be desirable for prison administrators and correctional staff.)
4. Finally, mail scanning doesn’t work to make prisons safer. In fact, early analyses in Pennsylvania⁶ and Missouri⁷ suggest that mail scanning is having little to no effect on the frequency of overdoses and drug use, the type of issues that prisons claim mail scanning will address. “Security” measures like mail scanning (as well as banning in-person visitation) distract from the reality that correctional staff are a major source of contraband in prisons, as a correctional labor union leader himself acknowledged (and as we found in a 2018 survey). Considering half of people in state prisons meet the criteria for a substance use disorder, prisons would be wise to center their budgets and efforts around drug treatment rather than cutting off a lifeline for everyone.

Mail between incarcerated people and their loved ones has long been surveilled by prison staff, but it remains one of the last bastions of communication that is not intercepted and monetized by private telecom companies. As the organization Just Detention International concluded in their 2021 letter to Attorney General Merrick Garland expressing outrage at the federal prison system’s mail scanning pilot: “Banning physical mail harms the well-being of incarcerated people, while offering no meaningful benefits.” Prisons and jails shouldn’t make families work even harder to maintain bonds; like other policies that quash communication, the recent trend toward mail scanning must end.

 

 

31 criminal justice reforms ripe for victory in 2023 legislative sessions

New Winnable Criminal Justice Reforms report provides state lawmakers with resources and information to secure victory on these important reforms.

by Naila Awan and Mike Wessler, November 16, 2022

Despite millions of dollars in TV advertisements and countless hours of hyperbolic news coverage, last week, voters across the country rejected fearmongering about efforts to overhaul the nation’s broken criminal legal system. They made clear they are interested in solutions and that the scare tactics that have been a staple of American politics for generations no longer resonate as they once did.

With that in mind, today, we released our annual guide to winnable state legislative criminal justice reforms ripe for victory in 2023. These 31 reforms will shrink the carceral system, mitigate its harms, and remove deeply entrenched financial incentives from the system.

The reforms focus on nine areas:

• Expanding alternatives to criminal justice system responses to social problems;
• Reducing the number of people entering the “revolving doors” of jail and prison;
• Improving sentencing structures and release processes to encourage timely and successful releases from prison;
• Reducing the footprint of probation and parole systems and supporting success on supervision;
• Protecting incarcerated people and families from exploitation by private contractors;
• Promoting physical and mental health among incarcerated and formerly incarcerated people;
• Giving all communities equal voice in how our justice system works;
• Setting people up to succeed upon release; and
• Eliminating relics of the harmful and racist “war on drugs.”

Each reform explains the problem it seeks to solve, points to in-depth research on the topic, and highlights solutions or legislation introduced or passed in states. While this list is not intended to be a comprehensive platform, we’ve curated it to offer policymakers and advocates straightforward solutions that would have a significant impact without further investments in the carceral system and point to policy reforms that have gained momentum in the past year. We have focused especially on those reforms that would reduce the number of people needlessly confined in prisons and jails. We made a conscious choice not to include critical reforms unique to just a few states or important reforms for which we don’t yet have enough useful resources to be helpful to most states.

We sent this guide to hundreds of lawmakers across the country — from all parties — who have shown interest in fixing the criminal legal system in their state. As they put together their legislative agendas for the upcoming session, legislators can use this guide to develop solutions to make their state’s criminal legal system more just, equitable, and fair.