The Patient Protection and Affordable Care Act (ACA) will expand access to affordable health insurance for millions of Americans. In states that choose to implement the Medicaid expansion for low-income adults, Medicaid will provide an important new pathway to coverage. Yet, even in states that choose to expand Medicaid a significant proportion of the low-income nonelderly adult population will be excluded from the Medicaid expansion due to their immigration status. Legal permanent residents, in most circumstances, are ineligible for Medicaid benefits for the first five years during which they reside legally in the U.S. and unauthorized immigrants are excluded from Medicaid coverage. SHADAC Issue Brief #35 provides the first state-specific estimates of the number of uninsured low-income adults that will potentially be excluded from the Medicaid expansion because of their immigration status.

Download a PDF of the brief.

Medicaid is a vital source of coverage for the almost four million justice-involved individuals living in the community – individuals who are disproportionately poor and people of color. Upon release from prison or jail, many of these individuals face significant obstacles navigating and accessing medical and behavioral health care services. Therefore, many state Medicaid programs, as well as the federal government, are looking at ways to improve continuity of coverage, provide seamless transitions back to the community, and reduce disparities in health care access. A major obstacle states face in trying to improve access to care for justice-involved individuals is the Medicaid inmate exclusion policy – a provision in the Social Security Act Amendments of 1965 that prohibits use of federal Medicaid funds for most health care services during incarceration. One way a growing number of states are trying to support reentry for justice-involved individuals is by providing Medicaid services prior to release from prison or jail through a Section 1115 demonstration waiver. Under Section 1115 of the Social Security Act, states can apply for a waiver to test new policies in their Medicaid program that federal rules typically do not allow.

In April 2023, the Centers for Medicare & Medicaid Services (CMS) issued new guidance outlining opportunities for states to design 1115 demonstration projects to improve care transitions for incarcerated individuals. Before the CMS guidance was released in January 2023, California became the first state to receive 1115 demonstration authority approval to waive the inmate exclusion and provide some Medicaid services in the 90 days pre-release. As of February 2023, an additional fourteen states have pending reentry demonstration proposals before CMS.

Key recommendations for designing a robust and accountable evaluation of justice-involved initiatives. 

1. Center the voices of people with lived experience in the evaluation approach

2. Collect robust monitoring data in order to build evidence for a topic where existing knowledge is limited

3. Consider additional meaningful outcome measures outside typical health outcomes

4. Seek to understand the unique experiences of different populations in the data analysis plan in order to address equity

5. Prioritize cross-sector data linkage activities and start planning early

To complete this work, SHADAC researchers reviewed states’ 1115 waiver applications, related CMS guidance and public waiver documentation, relevant grey and peer-reviewed literature, and conducted interviews with 11 key informants with expertise in state Medicaid, federal policy, justice-involved health care, evaluation, and lived experience.

Related Reading: 
Targeting Justice-Involved Populations through 1115 Medicaid Waiver Initiatives: State Implementation Experiences (SHADAC)
From Corrections to Community: Reentry Health Care (CHCF Project)

This work is supported by:

SHADAC hosted a one-hour webinar on Wednesday, April 5th to discuss the rising Medicaid undercount. With many states and stakeholders eager to understand the topic further, this webinar provided an overview of issues related to the Medicaid undercount along with relevant policy implications. View a recording of this webinar below!

• The extent to which, how, and why 2021 coverage data underestimated Medicaid coverage and/or overestimated uninsurance

• The data and methodology used to calculate the undercount

• How policy and advocacy may be impacted by the growing Medicaid undercount

The panel also answered questions from the audience following their presentation. Due to time constraints, the panelists were unable to answer all audience-submitted questions live. Please click here to view those additional Q&A. 

Speakers

Lynn Blewett

Director @SHADAC

Dr. Lynn Blewett is the Founding Director of SHADAC, as well as a Professor in the Division of Health Policy and Management at the University of Minnesota, School of Public Health, where she teaches graduate courses on the U.S. health care system and international health systems. Her health policy experience includes legislative work for the U.S. Senate and state policy work as Director of the Health Economics Program for the Minnesota Department of Health.

Benjamin Sommers

Senior Counselor @Assistant Secretary for Planning and Evaluation (ASPE)

Dr. Benjamin Sommers is a health economist, primary care physician, and professor. Dr. Sommers currently serves as a Senior Counselor to the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services, where he was previously the Deputy Assistant Secretary for Health Policy. He is also the Huntley Quelch Professor of Health Care Economics at the Harvard School of Public Health. His research interests include health insurance markets, Medicaid, health disparities, and the health care safety net.

Robert Hest

Senior Research Fellow @SHADAC

Robert Hest is a Senior Research Fellow at SHADAC. Mr. Hest provides expertise in survey data, quantitative data analysis, data visualization, and health coverage policy. Mr. Hest also manages SHADAC’s State Health Compare website, coordinating data processing, quality assurance, dissemination, and documentation of data. In addition, Mr. Hest provides technical assistance to states and other organizations on topics related to health coverage, cost, and access.

Genevieve Kenney

Co-Director and Senior Fellow @Urban Institute

Genevieve M. Kenney is co-Director and a Senior Fellow in the Health Policy Center at the Urban Institute. Dr. Kenney is an expert on Medicaid, CHIP, and health outcomes for low-income adults, children, and families. She has also played a lead role in a number of Medicaid and CHIP evaluations, including multiple congressionally mandated evaluations of CHIP, and has conducted state-level evaluations of the implementation of managed care and other service delivery reform initiatives and policy changes in Medicaid and CHIP.

Joan Alker

Executive Director @Georgetown University Center for Children and Families

Joan Alker is the Executive Director and Co-Founder of the Georgetown University Center for Children and Families and a Research Professor at the McCourt School of Public Policy at Georgetown University. She is a nationally recognized expert on Medicaid and the Children’s Health Insurance Program (CHIP) and is the lead author of CCF’s annual report on children’s health coverage trends.