In recent years, a growing number of states have recognized a troubling pattern: individuals leaving prison are at significantly higher risk of opioid overdose, relapse, and untreated mental illness in the days and weeks after release. In response, a policy shift is gaining momentum across the nation—expanding Medicaid coverage for incarcerated individuals prior to their release from correctional facilities.
This movement, catalyzed by California’s landmark waiver approval in January 2023, represents a shift in how states view the intersection of public health and criminal justice reform. By offering access to critical health services before reentry, states aim to reduce overdose deaths, improve long-term recovery outcomes, and ease the societal and economic burden of recidivism.
California Leads the Way
California was the first state to receive federal approval under an 1115 waiver to begin providing limited Medicaid coverage for incarcerated individuals 90 days before their release. This groundbreaking move—part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative—sought to build a “bridge” between incarceration and the community, offering access to essential medical and behavioral health services.
The urgency of this change is hard to overstate. According to the New England Journal of Medicine, formerly incarcerated individuals are 129 times more likely to die from an overdose in the first two weeks after release than the general public. With around 63% of people in jail and 58% in prison struggling with substance use disorders (SUDs), the current system—where Medicaid benefits are largely suspended during incarceration—has proven dangerously inadequate.
A Groundswell of State Action
Since California’s waiver approval, other states have rapidly followed suit. Washington became the second state to secure approval, and as of early 2024, at least 16 additional states have pending proposals. States like New Hampshire, West Virginia, Montana, and Kentucky have submitted waivers that focus specifically on SUD and mental health treatment for incarcerated populations.
“There’s really a groundswell of state interest,” said Vikki Wachino, founder of the Health and Reentry Project (HARP). “We see very poor health outcomes after people leave prison and jail… but the real standout is with respect to opioid overdoses.”
By building connections to care while individuals are still in custody, Medicaid coverage for incarcerated individuals can serve as a lifeline—and in many cases, a second chance.
The Barriers to Treatment—and a Path Forward
One of the largest barriers to reentry treatment is cost. Most behavioral health providers are unable or unwilling to offer services inside correctional settings without reimbursement. That’s where 1115 waivers come in, unlocking federal funding to allow for a limited set of Medicaid services—such as medication-assisted treatment (MAT), care coordination, and peer support—to be offered before release.
“The waivers basically build a bridge to help people access services right after release,” Wachino noted. “It’s about health care, but it’s also about giving people second chances and the difference that health care can make between life and death.”
By approving Medicaid coverage for incarcerated individuals, states are addressing not only a public health crisis but also an economic one. Reducing recidivism and avoiding costly emergency services saves taxpayer money while improving individual and community outcomes.
Political Will on Both Sides of the Aisle
What makes this issue particularly unique in today’s divided political climate is the level of bipartisan support. Both conservative and progressive states have recognized the long-term cost savings and moral imperative behind expanding Medicaid coverage for incarcerated individuals. Whether the focus is on criminal justice reform, public health, or fiscal responsibility, there is agreement that the current system is broken.
New Hampshire’s waiver, for example, is explicitly designed to provide care coordination to individuals with substance use disorder (SUD), serious mental illness (SMI), and serious emotional disturbance (SED) while still in prison. Other states, like West Virginia, have followed a similar blueprint, showing how adaptable the waiver approach can be across different political landscapes.
Real Impact, Real Lives
Organizations like Groups Recover Together—a Massachusetts-based provider offering Suboxone treatment and peer-led therapy—have seen firsthand how access to care immediately post-release can be transformative.
“If you can get an individual plugged into treatment within the first 24 to 48 hours after release,” said Cooper Zelnick, the company’s chief revenue officer, “you can massively reduce fatal overdose, relapse, and recidivism.”
Yet without Medicaid coverage for incarcerated individuals, that crucial treatment window is often missed, with devastating consequences. That’s why implementation matters. States must convene stakeholders across healthcare, law enforcement, corrections, and lived experience communities to ensure a seamless transition of care.
A Nationwide Movement in the Making
While California and Washington have set the precedent, other states are not far behind. Maine, for example, has used grants since 2018 to serve the uninsured during the post-incarceration period, and is now expected to pursue formal waiver approval. Experts predict that it’s only a matter of time before Medicaid coverage for incarcerated individuals becomes a standard component of reentry nationwide.
“It is a real opportunity to connect people to services and strengthen their health and the health of the communities that they live in,” Wachino said. “This is a very substantial step forward, both by state and federal leaders.”
Conclusion: A Bridge Toward Recovery
The post-release period is a uniquely vulnerable time, particularly for individuals with untreated mental illness or substance use disorders. By providing Medicaid coverage for incarcerated individuals, states can begin to close a deadly treatment gap—one that has persisted for far too long.
As more states move to implement 1115 waivers, this policy shift has the potential to not only save lives, but also to redefine how we support some of our most marginalized and underserved populations. The bridge from incarceration to recovery is finally being built—and its foundation is access to healthcare.
