In the days and weeks following release from a carceral facility, meaningful access to health care can be the difference between life and death. People who have been recently released from a jail or prison are at drastically greater risk of death by suicide, overdose, and cardiovascular disease. More broadly, people who have been impacted by the criminal legal system are more likely to experience worse health outcomes as compared to the general public. In addition to the myriad negative health impacts of the carceral system, reincarceration contributes to meaningful gaps in health insurance coverage.
These stark health disparities make clear the need for policy changes that improve access to quality health care and lead to better health outcomes for people impacted by mass incarceration. Some of them are already taking root.
As of January 2025, all states will be required to implement certain screening, diagnostic, and targeted case management services for people in youth correctional settings. Additionally, before the presidential transition, the Health Resources and Services Administration, which oversees health services for people who are geographically isolated and economically or medically vulnerable, announced funding and new policy guidance encouraging health centers to provide prerelease services in prisons and jails. Initiatives such as these are designed to alleviate the multiple obstacles that can impact a person’s health during reentry; they remove administrative barriers to health-care services and coverage and encourage community-based services to engage with correctional settings in the days leading up to release.
All of this has laid the groundwork for reentry waivers, which, although varied by state, are a promising pathway for even broader and more sustainable transformation.
Section 1115 of the Social Security Act allows states to create experimental, pilot, or demonstration projects that are likely to assist in achieving the objectives of the Medicaid program. Commonly known as Section 1115 demonstration waivers, these programs have the ability to expand eligibility categories and increase the scope of coverage for Medicaid beneficiaries by allowing states to waive certain federal Medicaid requirements.
In 2018 Congress passed the bipartisan SUPPORT Act, which directed the Centers for Medicare and Medicaid Services (CMS) to issue guidance on how states may use Section 1115 waivers to provide limited Medicaid services for people nearing release from incarceration. Five years later, in 2023, CMS approved California to implement the first reentry waiver. Soon after, CMS released guidance on how states could structure their reentry waiver programs to meet a set of minimum requirements and obtain CMS approval.
The guidance—and more than a dozen subsequent state approvals—has clarified the framework for these waivers. At minimum, these programs are required to provide medication for addiction treatment alongside behavioral health supports, thirty days of prescription medication in-hand upon release, and—critically—case management to assist with discharge planning and meeting needs such as housing, nutrition, employment, and transportation (what are often referred to as health-related social needs, or HRSN).
Additionally, Medicaid programs must identify the scope of eligibility for the reentry waiver, the length of the prerelease eligibility window (between thirty and ninety days), any additional services provided beyond the minimum, and whether the program will operate in jails, prisons, and/or youth correctional facilities. Crucially, states are explicitly prohibited from allowing funds to support general carceral operations that are not tied to improving the health of people returning from incarceration, but otherwise state Medicaid programs and key stakeholders are free to craft a program that fits the needs of their state. This allows the Medicaid program to perform strategic outreach to partners, such as correctional associations or officials, managed care organizations, or community-based providers, and to develop responsive infrastructure to promote the goals of the waiver.
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A logical outgrowth of these new programs will be a strong partnership between Medicaid and corrections, but that partnership alone will likely be insufficient to achieve equitable health outcomes and disrupt cycles of criminalization and reincarceration. Yet developing statewide cross-sector collaboration, particularly for the first time, will require considerable resources and attention on the part of Medicaid and correctional authorities. Efforts to do this are well underway, particularly in states that have already received approvals.
Importantly, there is no indication so far that the Trump administration plans to terminate the waiver approvals and undo this work. However, if Republicans succeed in reducing federal funding for Medicaid, as they appear poised to do, significant drains on states could slow or interrupt efforts to roll out the reentry waivers. In addition, state changes to Medicaid eligibility or covered services could dampen the impact of the Medicaid waivers, even if implementation remains on track. In other words, support for the new Medicaid reentry waivers must go hand in hand with support for maintaining the current foundations of Medicaid itself—and advocacy toward that key goal will require all of us, not just decarceral and public health advocates.
CMS has recognized that case management is a “lynchpin” for successful transition back to the community. Ahead of implementation, case managers—typically people who work within community-based organizations or health centers and support people in navigating the health-care system—will be expected to perform a comprehensive needs assessment, create a tailored care plan, coordinate post-release appointments and referrals, and connect incarcerated people with post-release case management and services by establishing relationships prior to release. In addition to physical and behavioral health needs, case managers are explicitly responsible for connecting returning beneficiaries to services and providers who can help meet their identified HRSN (the health-related social needs discussed earlier). Identifying these needs is a complex process requiring much thought and care, and so case managers may need time beyond the prerelease window—and they will also likely need to rely on community resources for continued support post-release.
In addition to the demanding standards expected of case management, efforts to address the HRSN of newly released people bump into two known obstacles calling for additional support in the community. The first is discrimination: It is well documented that people with criminal legal system involvement face heightened levels of stigma, which impacts the ability to procure housing, employment, and other critical social needs. Moreover, there are laws and administrative policies that allow decision-makers to rely on criminal history as a justification to systematically deny applications for housing, housing assistance, and employment.
Second, people who have been incarcerated generally demonstrate mistrust toward health-care systems and carceral systems. Models and interventions that rely on the expertise of people with lived experience of incarceration have shown success in overcoming that mistrust and assisting with supporting sustained access to social needs and health care, but they are typically based outside carceral facilities. Employing and putting more formerly incarcerated people in these decision-making positions could help alleviate both concerns.
Reentry waivers are guided by the laudable goal of addressing health inequities and mitigating the overuse of incarceration. Prerelease enrollment in Medicaid and the expansion of robust discharge planning are inarguably valuable tools for addressing the harms that can occur during reentry. However, keeping people engaged and healthy when back in the community will require ongoing efforts. And if unaddressed, several factors threaten those aims. In certain public health circles, the practice of screening for and identifying social needs without sufficient follow up and intervention is known as building a bridge to nowhere—a concept that is instructive for policymakers and advocates involved in designing and implementing reentry waivers.
Community health centers and social service organizations have ample experience leveraging their resources to meet the needs of people with criminal legal system involvement. Yet many of these programs operate from a position of chronic underfunding, and they are often tasked with meeting the complex needs of communities that experience disproportionate levels of poverty and health inequities. Together, these factors often contribute to burnout for providers, high turnover, and difficulty scaling operations beyond short-term grant funding. Also, the waivers contemplate an increased number of beneficiaries engaging in health and social needs services, but they do not automatically account for how community supports will meet that need, which could potentially contribute to these trends.
Fortunately, reentry waivers benefit from several tools that policymakers and advocates can harness to address the tension between system innovation and public health threats to people readjusting to a life of freedom.
Community-based stakeholders, including people with lived experience, can be meaningfully engaged in reentry waivers through formal feedback mechanisms, proactive outreach, and technical assistance; they can also be sought out to serve as providers of pre- and post-release services. For example, community advisory boards offer an opportunity for Medicaid programs to solicit feedback, explain complex policy decisions, and to build trust in the community. Medicaid programs can also support the inclusion of community providers by encouraging correctional institutions to build upon and work alongside existing community resources. Finally, reentry waivers allow for the allocation of capacity-building funds to develop new data-sharing practices and other infrastructure. Used strategically, these funds can be leveraged to encourage community involvement, to support social service organizations in developing billing and reimbursement systems for their case management, or to encourage hub-and-spoke models and other creative solutions that partner social service organizations with community health centers to ease referral and service coordination.
Reentry waivers have potential well beyond increasing access to substance use treatment, smoothing post-release enrollment in Medicaid, and priming people for coordinated care upon leaving prison. To fulfill that potential, the waivers must be designed beyond the context of the carceral system, because that is only one side of the bridge. To truly build a bridge back to the community, we must center those who will travel it and those best suited to support them, while maintaining and bolstering the health-care and other community supports in the places they live, especially Medicaid.
Image: Marek Studzinski/Unsplash
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