Expert: Medicaid Waivers Should Be Leveraged to Improve Care for the Incarcerated

Oct. 19, 2023
Can correctional healthcare be improved on a systemic level? One healthcare policy expert thinks that it can—and must—be improved systemically—and that the Medicaid waivers process could leveraged to accomplish that goal

Can correctional healthcare be improved on a systemic level? One healthcare policy expert thinks that it can—and must—be improved systemically—and that the Medicaid waivers process could leveraged to accomplish that goal.

Writing in the Perspectives section of The New England Journal of Medicine in an article published online on Oct. 19 and entitled “A Chance to Modernize Health Care behind Bars — Section 1115 Medicaid Inmate Exclusion Waivers,” Brendan Saloner, Ph.D., a Johns Hopkins University professor with dual appointments in the Department of Health Policy and Management, and Mental Health, argues that policy leaders need to rethink healthcare delivery for those who are incarcerated.

Saloner notes that, “In 2023, California and Washington became the first states to receive waivers from the Centers for Medicare and Medicaid Services (CMS) regarding the Medicaid Inmate Exclusion Policy, a federal provision that generally prohibits Medicaid from paying for health care for people who are incarcerated. Roughly 2 million Americans were incarcerated on any given day in 2020 and 2021. People who are incarcerated are disproportionately poor and members of marginalized racial or ethnic groups, and they have elevated rates of mental illness, substance use disorders, and other chronic diseases. Engaging members of this population in better-coordinated care as they leave jail or prison could improve postrelease use of preventive and chronic-disease care at safety-net clinics and support improved health outcomes.”

Now, Saloner notes, waivers provided under Section 1115 of the Social Security Act could offer the opportunity for state governments to modernize carceral healthcare. As he notes, “The California waiver, for example, covers various reentry-related health services for an estimated 200,000 people per year during the 90 days before release from jail or prison. At least 13 additional states are seeking Inmate Exclusion waivers,” he adds.

Meanwhile, Saloner goes on to write, “Providing coverage in a new context is a complicated undertaking for states. To support applications for such waivers, CMS released guidance in April 2023 outlining broad programmatic goals, including increased continuity of coverage and services, improved care coordination, and reduced hospital use and mortality in the postrelease period. The guidance lays out three required benefits: comprehensive case management, prerelease provision of medication for substance use disorder (referred to by CMS as medication-assisted treatment [MAT]), and provision of a 30-day supply of all prescribed medications to people at the time of release (see table).1 It also defines operational expectations related to data sharing, monitoring, and evaluation. All of this will be complex, Saloner writes, as CMS’s guidelines for these waivers are somewhat vague and lacking in details. States that receive these waivers will have a very large amount of flexibility in how to administer medications for substance abuse disorders, for example.

Importantly, Saloner believes, “Ensuring that carceral health care is independently financed and operated would be one step toward modernizing care delivery. Health care contracts and budgets are generally overseen by security officials, many of whom have limited expertise in and experience with health care provision. Such officials often outsource care delivery to for-profit vendors that compete for contracts by underbidding their competitors and ultimately skimp on services. Medicaid funding has the potential to disrupt this model.” He notes importantly that, in other high-income countries, carceral healthcare is most often administered by health agencies instead of corrections departments. As a result, carceral providers will always have to be involved with corrections officials. What’s more, he recommends that state governments always require ongoing, transparent surveillance and quality measurement as a condition of Medicaid funding, given that “People who are incarcerated are currently excluded from all major national population-based health and health care surveys and statistics.4 States receiving Inmate Exclusion waivers will be required to compile data on Medicaid-funded services rendered under the waiver but aren’t slated to engage in broader, systematic data collection. A bolder approach would be to require states and localities to compile health care claims data sets that meet reporting standards used by CMS programs outside of carceral facilities.” And, he recommends that, over the long term, clinicians working in jails and prisons be included in value-based payment programs now widespread in Medicaid.

“The recent Inmate Exclusion waivers granted to California and Washington represent a meaningful step toward greater care integration for people who are incarcerated,” Saloner writes. “Although the waivers cover only a limited prerelease period, they could be a stepping stone to the partial or complete repeal of the Medicaid Inmate Exclusion Policy — a proposal with bipartisan support that is under serious consideration in Congress.” Ultimately, he believes, Medicaid officials “could use the leverage associated with federal funding to improve the conditions under which health care is delivered in jails and prisons. Doing so could support the health of millions of Americans and the communities to which most of them will return.”

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