The relationship between health and the criminal legal system is complex. Poor health and limited health care access contribute to incarceration, and involvement with law enforcement, courts, and correctional facilities often worsens individuals’ health. Even brief jail stays can disrupt stability and disconnect people from important care. The criminal legal system disproportionately affects historically marginalized communities. For men born in 2001, one in five Black men will be incarcerated, compared to only one in 20 white men.
Medicaid agencies are critical partners in criminal legal system reform. They can play an important role in both preventing involvement in the system and ensuring effective care upon reentry. Historically, Medicaid agencies have operated outside the criminal legal system due to the inmate exclusion policy, which has precluded federal Medicaid dollars from being used for people who are incarcerated. However, new policy opportunities have significantly broadened Medicaid’s ability to provide coverage for individuals at risk of incarceration and those reentering their communities.
The criminal legal system — law enforcement, courts, and corrections — now has new opportunities to work with state Medicaid agencies toward the common goal of addressing the needs of people with criminal legal system involvement. Following are five ways Medicaid can contribute to improved outcomes for this critical population.
To Improve Outcomes for People at Risk or Involved in the Criminal Legal System
1. Support Prevention and Diversion Efforts
One of the most important things Medicaid can do to reduce the impact of criminal legal system involvement is help prevent and divert involvement in the first place. People with behavioral health needs and significant health related social needs, such as substance use disorder and homelessness, are disproportionately arrested, less likely to be diverted, more likely to be held in jails and prisons, and stay incarcerated for longer.
Medicaid agencies can work with behavioral health and housing agencies, as well as local law enforcement, to reduce barriers to accessing behavioral health services and evidence-based housing options, including supportive housing. Investing in these resources reduces overreliance on law enforcement and more effectively addresses the underlying reasons for some arrests.
The 2021 American Rescue Plan Act (ARPA) expanded the role that Medicaid agencies can play in funding crisis response systems, which can provide more immediate services for people in a behavioral health crisis and reduce the burden on law enforcement. Twenty states have received ARPA planning grants for state plan amendments that cover crisis response services, and 38 states’ Medicaid programs cover some form of community-based crisis response systems. Crisis response is also a critical component of community responder programs, which position health care professionals to serve as emergency first responders rather than police. Medicaid agencies can also partner with court systems, including specialty courts, to ensure that people who are eligible for Medicaid continue to be enrolled in and have access to behavioral health care services.
2. Leverage New Youth Requirements to Advance Prevention Goals
Many leaders in departments of corrections, behavioral health, child welfare, and juvenile justice agencies have already committed to reducing the total number of people in prisons, jails, and detention — especially young people. As state agencies work collaboratively — along with youth, families, and community providers — to implement new requirements and support youth returning to the community from incarceration, they can continue to build resources and partnerships that advance broader prevention and diversion goals for all ages.
Recent federal requirements under the Consolidated Appropriations Act of 2023 expand Medicaid and CHIP coverage for eligible youth, cover screening and assessment, and require targeted case management services to better connect youth who are incarcerated with services and supports. Both adult and youth facilities where eligible youth reside will need to implement these federal requirements. States working on implementation are taking steps to activate Medicaid and CHIP coverage during the pre-release period, build partnerships with community-based organizations, and ensure smooth handoffs to behavioral health providers. States also now have the option to use federal funds to provide Medicaid and CHIP services for eligible youth pending disposition of charges.
3. Involve People with Lived Experience in Policy and Practice Changes
No one understands the impact of involvement with the criminal legal system better than those with direct, lived experience. State Medicaid agencies can center people with direct personal experience of incarceration in policymaking efforts through mechanisms like their states’ Beneficiary Advisory Councils. In Massachusetts, formerly incarcerated people are advising state agencies on pre-release services as part of the state’s 1115 waiver demonstration.
States can support workforce expansion that engages people with lived experience of incarceration in meaningful work serving others as peer counselors and community health workers. The Transitions Clinic Network uses a care delivery model at sites in 14 states that includes training formerly incarcerated people to work as community health workers. The model has been shown to reduce criminal legal system involvement, emergency department utilization, and parole violations.
4. Strengthen Health Care Services in the Community
People with criminal legal involvement face significant barriers to care and have higher rates of health-related social needs, behavioral health needs, chronic conditions, and infectious diseases. While care transitions during reentry are critical, access to culturally appropriate care once back in the community is also essential to addressing longstanding health care inequities.
State Medicaid agencies can require that health plans engage people who are incarcerated prior to release and provide suitable care coordination, as has been done in Ohio and New Mexico. Medicaid agencies and health plans can encourage providers to adopt care delivery models such as open access scheduling, which can help individuals facing access barriers to more readily secure appointments. Medicaid agencies can work with correctional agencies to ensure that their traditional reentry provider and community partners are able to bill Medicaid for services.
5. Apply for 1115 Waivers to Cover Services for Reentering Population
Perhaps the highest impact action states can take now is to join the 25 states with active or pending waivers and apply for the Medicaid Reentry Section 1115 Demonstration Opportunity. The waivers offer Medicaid-covered pre-release services, including evidence-based addiction treatment (MAT) for alcohol and opioid use disorders, which are prevalent in incarcerated populations and increase the risk of recidivism and overdose.
Under the waiver, Medicaid agencies have the opportunity to collaborate with people with lived experience in incarceration to develop a reinvestment plan, which can mobilize federal funds to support broader prevention, diversion, and decarceration goals and services in communities.
Improving Care and Criminal Justice Outcomes
Today, Medicaid agencies have historic new opportunities to address the health care needs of individuals at risk or involved in the criminal legal system. By investing in behavioral health models that help prevent and divert people from entering the system and connecting people to evidence-based care (like MAT and peer supports) upon release, Medicaid can play a crucial role both in preventing future arrests and reducing recidivism. Improving access to health care at these critical points not only meets the physical and behavioral health needs of these individuals, it also reduces unnecessary involvement in the criminal legal system, ultimately enhancing public safety alongside health and well-being.
