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.
This new issue brief from SHADAC researchers, funded by the California Health Care Foundation (CHCF), identifies the unique opportunities states should consider when designing evaluation plans specific to their justice-involved populations, provides an overview of justice-involved 1115 demonstration initiatives, and summarizes what is known from existing evaluations of these activities. The brief also identifies a set of opportunities to design robust and equity-focused 1115 demonstration evaluation plans specific to justice-involved populations. Given the complex dynamics, unique obstacles, and varied experiences justice-involved individuals face, a new, more equity-focused evaluation approach is needed.
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.
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: