Medicaid Enrollment Assistance for People Released From Prison—One Step on a Long Road

More than 1.2 million people, disproportionately racial and ethnic minority individuals, are incarcerated in US prisons. More people are being released from prisons and jails because of the risk of COVID-19¹ alongside calls for decarceration from the Black Lives Matter movement. Given the dramatically increased risk of death immediately after release, primarily from opioid overdose,² there is an urgent need to understand how to best support the growing population of released individuals in the transition to community-based health care.

Burns and colleagues³ address this prison-to-community transition. They examine the association between Medicaid enrollment assistance prior to release and health care use in the 30 days after release from prison among people in Wisconsin with probable substance use disorder (SUD). Using a retrospective cohort design, the authors compare Medicaid-reimbursed health care between people released prior to and those released after the Wisconsin Department of Corrections implemented prerelease Medicaid enrollment assistance. They found that people who had Medicaid enrollment assistance were more likely to attend any outpatient visit, opioid use disorder (OUD) visit, and general SUD visit or to have an inpatient hospitalization within 30 days of release. They saw no difference in use of the emergency department. Overall access to care, however, remained low, particularly for SUD services. Among those released after the implementation of enrollment assistance, only 24.4% attended any outpatient visit, 3.8% attended an SUD-associated visit, and 0.7% received medication for OUD (MOUD), such as buprenorphine or methadone.

This timely and well-designed study from Burns et al³ shows us that Medicaid enrollment assistance may be necessary, but is not sufficient, for supporting people releasing from prison to link with community-based health care services. Further work is needed to develop and scale interventions that facilitate access to community care and examine whether access improves health outcomes and reduces postrelease mortality. As Burns et al³ have done with their focus on health insurance, it is paramount that research and implementation efforts consider the social and structural determinants of health that recently released patients face. These include homelessness, poverty, racism, and discrimination due to criminal history, all of which can be barriers to accessing care and may contribute to poor health outcomes.

One strength of the study by Burns and colleagues³ is that it evaluates an intervention that occurred owing to a policy change and while people were still incarcerated, in contrast to many prior studies, which have evaluated postrelease interventions.⁴ As Burns et al³ highlight in their discussion, there is a growing body of literature on promising community-based interventions for recently released people, such as transitional care clinics and use of patient navigators. A focus on community-based interventions, however, places insufficient burden on (1) correctional institutions and (2) policy makers to address gaps in care for people being released from prison. These are areas where conducting research is often more complex than in community settings but is nevertheless necessary to establish an evidence base to guide practice.

Prisons can and should play a role in supporting people with SUD to link with care after release through, for instance, universal screening for SUDs, including alcohol use, with validated screening tools intended for clinical care. COMPAS (Correctional Offender Management Profiling for Alternative Sanctions), one of the tools Burns et al³ used to identify patients with SUD, is designed for corrections case management, not clinical care. It provides inexact information for both clinical decision-making and research into SUD treatment in prison and after release. Many prisons provide opt-out screening for infectious diseases, such as HIV and hepatitis C virus, which are similarly prevalent in this population and can similarly be treated while people are incarcerated.⁵ Screening for SUDs is not only in line with community-based standards of care, per the US Preventive Services Task Force, but would also help identify people who need treatment for SUDs while incarcerated and on release.

Some prisons are beginning to use MOUD, an evidence-based treatment for OUD, which can be initiated or continued while patients are incarcerated and allows patients to be on a stable dose of methadone, buprenorphine, or naltrexone at the time of release. Such programs have been shown to have positive associations with both opioid use and health care engagement outcomes.⁶ Lack of specific attention to initiating MOUD may help explain why emergency department visits for overdoses did not decrease after implementation of Medicaid enrollment assistance, an additional finding of the study by Burns et al.³ More broadly, adequate management of both mental health and SUDs while incarcerated is essential because people with decompensated mental illness or addiction can experience disorganization and other behavioral symptoms that are barriers to attending follow-up care.

There is also a role for policy change in facilitating linkage to community-based care. As Burns et al³ highlight, the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act spurred the initiation of Medicaid enrollment assistance in Wisconsin. Policy changes may be needed for new programs, such as Medicaid enrollment assistance, to be implemented at scale. Policy could, for instance, mandate prisons to develop MOUD programs or medical records sharing with community-based clinicians, both of which could facilitate connections to community-based care. One particularly relevant policy is whether states terminate or suspend Medicaid coverage while people are incarcerated. Wisconsin is 1 of only 8 states that terminate Medicaid coverage while people are in prison.⁷ If coverage is terminated, incarcerated people must reenroll prior to release, whereas if coverage is suspended, benefits can be automatically reinstated for certain eligible patients. Federal law bars Medicaid from covering health care while someone is incarcerated, except some inpatient stays at community-based facilities, but suspending, rather than terminating, coverage places less burden on patients after being released.¹ Wisconsin is one of a minority of states that terminate Medicaid coverage, raising questions about the generalizability of the findings of Burns et al³ to states that suspend coverage and, consequently, can automatically reenroll a portion of patients being released. This is an area that warrants further investigation.

In conclusion, the study by Burns and colleagues³ evaluates a promising policy and practice change to support people being released from prison. It also sheds light on the ongoing gaps in care that these patients face, particularly in access to evidence-based OUD treatment. Collaboration between community-based clinicians, correctional facilities, policy makers, and the research community will be essential for continuing to develop and evaluate interventions to reduce postrelease morbidity and mortality in this vulnerable population.

Published: January 7, 2022. doi:10.1001/jamanetworkopen.2021.42695

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Jack HE. JAMA Network Open.

Corresponding Author: Helen E. Jack, MD, Division of General Internal Medicine, Department of Medicine, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359780, Seattle, WA 98104 (hjack@uw.edu).

Conflict of Interest Disclosures: None reported.