Medicaid should cover the incarcerated

Correctional facilities have become primary care facilities

THERE IS AN UNSPOKEN and growing public health crisis in our country.

For millions of Americans with serious health care needs, their treatment is not being provided at a hospital or clinic, but at the county jail. Many outside of this field do not know that the social determinants of becoming involved in the justice system are identical to the social determinants of health: neighborhood quality, personal and family economic stability, social connections, education, and access to quality health care.

As a result, jails like the one I oversee in Middlesex County have become de facto treatment centers for individuals who are otherwise forgotten in our health care system, and too often in society at large. The largest mental health treatment facilities in our country are all jails. And while many of us in law enforcement are proud of the quality treatment and programming we provide to this high-need population, we can all agree that you should not have to come to jail to get good health care.

Consider this: 40 percent of state prisoners and 33 percent of individuals in federal correctional facilities have a chronic health condition. At my county facility, 65 percent of individuals are being treated for a chronic disease, ranging from asthma and cancer to psychological disorders. If we saw those numbers in our local community, we would rightly label it a public health crisis.

These are longstanding problems in our criminal justice and behavioral health systems, and they have only worsened during the COVID-19 pandemic. At my facility, where we use data and specialized programming to drive our treatment, we have seen it firsthand. In 2019, about 11 percent of our population had a diagnosed mental health disorder. Today, it’s approximately 44 percent.

This is why I’ve been working closely with both state and national leaders to eliminate the Medicaid Inmate Exclusion Policy, a little-known, antiquated section of federal law that bars any eligible incarcerated person from accessing their Medicaid services – even if they have yet to be found guilty of a crime.

Currently, an individual’s access to Medicaid is shut off as soon as they enter jail – and remains so until they leave. The appropriations bill recently signed by President Biden made an important first step by allowing access to Medicaid benefits for certain incarcerated individuals under certain circumstances. But the truth is, there should be no interruption to any individual’s health care coverage just because they are incarcerated.

A group of us on the Council on Criminal Justice Health and Reentry Project are pushing for  state waivers from Medicaid rules for just that reason. Fully eliminating the inmate exclusion policy would do two key things. First, it would enhance continuity of care by creating a stronger bridge to community-based services as individuals return to society. Second, greater coordination between correctional and community providers will help lower crime, with a 2019 study finding that “increased access to health care through Medicaid coverage reduces recidivism.”

The stakes are literally life and death. Studies show that in the period immediately following release, formerly incarcerated people are 12 times more likely to die than the general population. The causes range from heart disease to homicide, suicide, and ALS. The rates of death from overdoses are particularly alarming as we grapple with another co-occurring public health epidemic in opioid use. The Massachusetts Department of Public Health found that opioid-related overdose deaths are 120 times higher for people released from state prisons and jails compared to the rest of the adult population. How many of these deaths could have prevented with access to health care?

When Medicaid was created in the mid-1960s, few could have imagined that correctional facilities would become primary care facilities for so many who were eligible for it. Our jails and prisons were not designed or built for this purpose, but we have become experts in providing exceptional care. We need all the tools possible to help improve the health and criminal justice outcomes for this population. Avoiding gaps in Medicaid coverage upon release and facilitating connections to care can provide individuals the opportunity to remain in the community and hopefully avoid future law enforcement interactions.

The time has come for a seismic shift in how we provide health care to incarcerated individuals – to improve public health outcomes, enhance public safety, and strengthen communities as well. The overwhelming majority of the 1.8 million people incarcerated in this country will eventually be released, and we have an obligation to return them home healthy and whole to their families.

We cannot allow more people, rehabilitated and ready for reentry, to lose their health care and potentially their lives because of an outdated, counterproductive policy. Let’s eliminate it now.

Peter J. Koutoujian is sheriff of Middlesex County. He is a former public defender, prosecutor, and state legislator, and serves on the advisory committee of the Council on Criminal Justice Health and Reentry Project.