Fixing the Coverage Gap After Incarceration

Healthcare insurance in the U.S. can be spotty, even with expansion of coverage under the Affordable Care Act. One of the remaining problem areas is coverage for people who are leaving prison or jail. In nonfederal cases, state and county governments pay for healthcare during the period people are incarcerated. But once they are released, there is often a gap before they get signed up for coverage by Medicaid or another payer. For people with chronic health conditions, that gap can lead to medical conditions getting out of control and acute episodes that lead to hospitalization or premature death.

The federal Medicaid Reentry Act of 2021 is designed to remedy the situation. Currently, Medicaid programs are explicitly prohibited from covering incarcerated individuals. The proposed law would permit Medicaid to cover people starting 30 days before they are to be released. Advocates and public health officials say that would mean a smoother transition and increase the chances that recently incarcerated people will receive the medical services they need.

But the Reentry Act could have some unintended consequences. Utsha Khatri, M.D., of the Institute for Heath Equity Research at the Icahn School of Medicine at Mount Sinai in New York and Tyler N.A. Winkelman, M.D., M.Sc., of the Health, Homelessness, and Criminal Justice Lab at the Hennepin Healthcare Research Institute in Minneapolis outlined a few of the consequences in an opinion piece published in April in the New England Journal of Medicine.

Would prisons and jails put off medical care until the 30-day period before release so the cost would fall on a Medicaid program? Would care be substandard? New quality improvements might need to be developed and supported. And the Reentry Act may have little, if any, effect on coverage in the 12 states that haven’t expanded Medicaid, they noted. There are also practical problems of implementing coverage and working with prison and jail officials.

Many people in jail are awaiting trial, incarcerated because they couldn’t afford bail or were denied it. Khatri and Winkelman said they agree with the National Association of Counties and the National Sheriffs’ Association that the Reentry Act should be amended so the ban on Medicaid coverage for incarcerated people would not extend to people in jail who are awaiting trial. They also noted the Reentry Act wouldn’t deal with the larger issue of the harms done by mass incarceration.

In their view, the Reentry Act should be “coupled with broader policies redirecting people away from the harmful carceral system.” In 2021, the Reentry Act was attached to the sweeping Build Back Better legislation that passed in the House but stalled in the Senate. Khatri and Winkelman said Congress may consider the Reentry Act as a separate piece of legislation this year.