How states can help formerly incarcerated individuals stay sober

With few signs of the nationwide opioid crisis slowing down, it’s critical that individuals who have started addiction treatment stay on the path to recovery. One of the best ways is with medications for opioid use disorders, or MOUD, that help lessen the user’s cravings and withdrawal symptoms.

These drugs, primarily methadone, buprenorphine and naltrexone, support an individual’s sustained recovery and reduce the risk of relapse, along with the resulting overdose deaths, infections and criminal behavior. Despite the cost of the medication, MOUDs have been found to be more cost-effective than no treatment or treatment with no medication.

Among those who most benefit from MOUD are incarcerated individuals nearing their release date. Jails and prisons are slowly but surely expanding incarcerated individuals’ access to MOUDs, but the number of facilities doing so remains small. According to a survey last year, 30% of jails provide buprenorphine and a little over 20% offer methadone or naltrexone. But the individuals who got those medications tended to be those who were already on them prior to being incarcerated rather than people preparing for reentry. 

That’s primarily because a federal law bars incarcerated individuals from using Medicaid to pay for treatment services, except for inpatient hospital care. That means individuals’ Medicaid coverage is suspended when they enter the corrections system, and they get medical services from the state during the time they serve. Reinstating Medicaid coverage postrelease can be a lengthy, complicated process, said Shelly Weizman, associate director of the Addiction and Public Policy Initiative at Georgetown University’s O’Neill Institute for National and Global Health Law.

“They might have a gap in insurance coverage until their Medicaid gets turned back on; sometimes it can be 45 days or longer,” she said. “That’s exactly the window where research shows people overdose and die—in the first few weeks after release. So having unbroken coverage through Medicaid has huge implications for preventing overdoses.” 

Generally jails lack a streamlined way of transferring treatment of opioid use disorders back to Medicaid prior to the individual’s release so they have coverage when they leave, Weizman said. Interruptions like that to someone’s continuity of care can be detrimental to a successful, long-term recovery from an opioid addiction.

“[W]ithout access to affordable health care services post-release, individuals who were formerly incarcerated often do not seek outpatient medical care, including needed [substance use disorder] or mental health treatment and are at significantly increase risk for emergency department use and hospitalization,” the Centers for Medicare and Medicaid Services officials said in a letter last year to state Medicaid directors. 

This is where Medicaid 1115 waivers can make a difference. The waivers allow jails and prisons to provide inmates with Medicaid-funded care and transition services for between 30 and 90 days prior to their release. They can help to fill the short-term services gap during the reentry period. With continued Medicaid coverage, the transition of care is more seamless for formerly incarcerated individuals, reducing the burden of finding a new health provider they can access and afford, Weizman said. 

Correctional officials often cite staffing shortages and the cost of MOUD as barriers to expanding access and availability of treatment resources, according to a recent publication from the O’Neill Institute for National and Global Health Law. The waivers can help with that too.  

Plus, states can use the waivers not just to help with the cost of the MOUD but also to request enhanced federal funding for capacity building, such as the hiring and training of staff to help implement reentry initiatives. Waivers can also cover improving facilities’ IT systems to better track program data and enable seamless communication among correctional staff, Medicaid providers, managed care plans and other stakeholders. 

The waivers can also support the implementation of reentry services like community-based or peer-recovery programs, which Weizman said are significantly effective in keeping individuals on track with their recovery journey. 

California became the first state last year to have its 1115 reentry waiver approved by the Centers for Medicare and Medicaid Services, and it serves as a model for other states looking to develop reentry programs, CMS officials said. Montana and Washington state have also had their reentry waivers approved, and about a dozen states are awaiting federal approval. 

The Golden State, for instance, plans to provide MOUD to incarcerated individuals for up to 90 days before their release, going beyond the 30-day minimum.  Plus, California’s reeentry program provides physical and behavioral health consultations, lab and radiology services and access to community health worker services. Individuals will also receive necessary medications or medical equipment upon release and be referred to community-based providers to help implement their reentry care plan. To evaluate its program, the state will evaluate the relationship between postrelease outcomes and the provision and timing of substance use disorder services.

“We really have to rethink how we’re funding health care in order to … not just to save lives, but prevent people from coming back through the doors of carceral settings,” Weizman said.