Failure on Re-launch: The Consequences of the Gap in Healthcare Coverage for Reentering Youth

The United States is the leading country in the incarceration of juveniles. On any given day, around 27,587 juveniles are in residential correctional facilities.[1] Although there has been a significant decline in residential placement of juveniles, 75% from 2000 to 2022, the disproportionate representation of Black and brown youth is prevalent.[2] Once in these residential facilities, the responsibility for the health and well-being of youths falls onto the state or federal agency that has jurisdiction over them.[3] The crucial healthcare for juveniles in long-term correctional facilities provides both mental and physical services to treat a population that has “higher rates of substance abuse, acute illnesses, sexually transmitted diseases, unplanned pregnancies, and psychiatric disorders.”[4] Post-detention, the burden of the continuum of care, including obtaining medical records, securing prescriptions and medication, as well as re-enrolling in health care insurance, falls primarily on the justice-involved youth (JIY).[5] The majority of the JIY population rely on and are eligible for Medicaid as their primary form of health insurance.[6] Due to the inmate exception, Medicaid coverage is suspended or terminated upon detention, leading to a large barrier for JIY seeking health care coverage when reentering.[7] Barriers to accessing mental and physical health care services lead to a gap in health coverage for an already vulnerable population.[8] An overwhelming number of juveniles post-release have no health insurance, and 62% cite a lack of insurance as the reason they do not have a health provider.[9] The lack of a continuum of care results in juveniles using alternative routes for primary care, such as emergency rooms or no treatment at all.[10] These policy issues and barriers to care are exacerbated by inconsistent parental involvement, socioeconomic status, race, gender, and the cultural values of the family.[11] The barriers to accessing Medicaid for JIY not only create a gap in healthcare, disrupting the continuum of care, but lead to higher rates of recidivism, which endangers public safety and is more costly for the community as a whole. 

The factors preventing JIY from accessing healthcare coverage are both social and structural. Social barriers include unemployment, low educational attainment, and homelessness.[12] Each of these factors contributes to higher rates of recidivism. Structural barriers include understanding and meeting the requirements for re-enrollment, which can involve late penalties and delays.[13] Further, re-enrollment and navigation of Medicaid can lead to confusion and delay of care due to varying suspension enforcements across Medicaid agencies.[14] Socially, JIY can be returning to the factors that pushed or pulled them into the Criminal Justice System, such as adverse childhood experiences (ACEs), negative influences and social ties, and persistent isolation from social services.[15] The longer the health coverage gap and the higher the risk of the JIY’s health status, there is greater the percentage of negative impacts.[16]  Some success has been found by JIY who have been released with family support, schooling, and employment one year post-release.[17] However, only 23% of 16 to 18-year-old JIY report having Medicaid, which is a severe underrepresentation of the population eligible.[18]

The gap in coverage is detrimental to the process of reentry due to the higher needs of JIY who disproportionately represent chronic illness, mental illness, and addiction within the population.[19] According to a survey of reentering JIY, more than 60% report having a physical health condition, 28% report having an acute illness, 25% report having an injury, and 40-60% report having high substance abuse or mental challenges.[20] These survey results are alarming, given that 62% of JIY surveyed also lack a primary care provider and healthcare after incarceration, even though twice that amount had coverage before they were incarcerated.[21]. 

Black and brown JIY are disproportionately affected by the gap of coverage compared to their white counterparts as they are more likely to be involved in the Juvenile Justice System. Black youth are six times more likely to be incarcerated, while Latino and Indigenous youth are three and two times more likely, respectively, to be in correctional facilities compared to their white counterparts[22]. Further, Black and brown JIY have a disproportionately high rate of morbidity and mortality compared to their nonincarcerated peers.[23] Prior to entering incarceration, Black and brown JIY are overrepresented in the population that relies on Medicaid and, upon reentry, face larger barriers to healthcare access.[24]

The lack of a continuum of care upon re-entry leads to more costly healthcare, higher taxes, and a decrease in public safety for the general population, burdening the community and healthcare system. For one, the reliance of JIY at reentry on emergency visits for their primary form of health care increases the burden on the healthcare system and facilities. Further, it costs much more than the enrollment and coverage of the JIY in Medicaid. Emergency rooms are already oversaturated with patients in areas that are underserved due to a lack of social services. The public health of the community is harmed not only by higher costs and barriers to healthcare, but also through the re-involvement of the JIY in the Juvenile Justice System. Incarcerating a juvenile costs approximately 214,620 dollars a year, which is far higher than the enrollment of that same individual into Medicaid, at only 1600 dollars.[25] The prevention of a high-risk JIY recidivating can lead to “a savings of $1.7 to $2.3 million,” which can be spent on investing in public health services.[26]

In the past two years, policy solutions have responded to the lack of consistency across Medicaid agency standards and the high rates of recidivism. The SUPPORT for Patient and Communities Act, Subtitle D, proposed ending the termination of Medicaid by states when JIY entered incarceration. Since taking effect in 2019, the implementation of the act has been inconsistent state by state due to the lack of incentives for both the state and Medicaid agencies. Ending the termination of Medicaid for reentering JIY is only effective if there is institutional buy-in from both the correctional facilities and by the Medicaid agencies during the preparation for release and reentry[27]. Since 2008, California has prohibited termination of Medicaid for JIY, instead opting for suspension. In Massachusetts, Medicaid re-enrollment is a mandatory step in the pre-release process for JIY. In Connecticut, a 60-day waiting period before Medicaid suspension was implemented to combat the lack of a continuum of care for JIY.[28] Medicaid agencies and state governments have recognized the need for collaboration to ensure that youth are released with coverage as well as a supply of medication, prescriptions for the medication in hard copy, and their medical record to ensure continuity of care. 

In 2021, The Center for Medicare and Medicaid Services (CMS) published a set of guiding principles for states opting to allow Medicaid to cover certain services within the 90 days before release “to facilitate successful reentry transitions for Medicaid-eligible individuals leaving prisons and jails and returning to the community.”[29]  This would allow CMS, through the 1115 Demonstration Waivers, to bypass certain provisions of federal law prohibiting Medicaid coverage during incarceration for individual states. A state is eligible to submit waiver proposals if they provide case management services, medication-assisted treatment, and a 30-day supply of medication upon release. States are encouraged to go “above and beyond” in providing services to connect youth with a plan for a continuum of care upon release. CMS can consider temporary funding for each state. For California, Washington, and Montana, the waivers have already been approved since 2021, while this year, Illinois, Kentucky, Oregon, Utah, and Vermont will join them in a historical approval by CMS.[30]

In order to address the challenges of SUPPORT, the Omnibus Consolidated Appropriations Act and the Federal Opioid Crisis Response Act of 2023 targeted the inconsistency in each state’s correctional practices implementing healthcare covered by Medicaid agencies. The act requires states and Medicaid agencies to provide case management services for JIY 30 days prior to their release and 30 days after their release. During the window before release, the state also covers juveniles to receive necessary diagnostic screening services, including behavioral health screenings and referrals. These bills take effect in January 2025 and 2026, respectively, and all states will be required to provide these services to all JIY under 21 years of age.[31] While this Act provides an avenue of consistency for implementation and interagency collaboration and provides monetary incentivization for states, there are substantial challenges in implementation. Interagency cooperation between Medicaid and correctional facilities in enrolling JIY has had challenges. Submission of claims for Medicaid-covered services and documentation of care in electronic health record systems are persistent hurdles that juvenile facilities face. Medicaid agencies are struggling to navigate partnering and implementing health care services in the Juvenile Justice System, which lacks the infrastructure to provide health care.

Discontinuity of healthcare through the lack of Medicaid access is detrimental to JIY, as they represent a large, high-risk, and high-burden population. These healthcare challenges are exacerbated not only by their time incarcerated but also by the process of reentry. Further, Black and brown JIY are overrepresented in populations that rely on Medicaid and also face significant barriers to accessing care. While policy solutions are progressing to change the lack of uniformity across Medicaid agencies by ending termination, universalizing pre-release re-enrollment, and requiring relationships between Medicaid agencies, the historical implementation of solutions has left much to desire. Ensuring that Medicaid agencies and correctional facilities are forming a continuum of care for juveniles allows for funding to be reallocated from correctional facilities to community and social services, such as pre and post-release programs, to facilitate long-term health in a community-based context of care.

Sources:

1. National Center for Juvenile Justice, Number of facilities and youth held for an offense by facility operation (2022), https://www.ojjdp.gov/ojstatbb/jrfcdb/asp/display_profile.asp., Josh Rovner, Youth Justice By The Numbers The Sentencing Project (2024), https://www.sentencingproject.org/app/uploads/2024/08/Youth-Justice-By-The-Numbers.pdf. 
2. Id.
3. Elizabeth Barnert et al., Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review, 26 Journal of Correctional Health Care 113 (2020), https://www.liebertpub.com/doi/full/10.1177/1078345820915908 (last visited Sep 10, 2024).
4. Ravindra A. Gupta et al., Delinquent Youth in Corrections: Medicaid and Reentry Into the Community, 115 Pediatrics 1077 (2005), https://doi.org/10.1542/peds.2004-0776.
5. Elizabeth S. Barnert et al., Parent and Provider Perspectives on Recently Incarcerated Youths’ Access to Healthcare during Community Reentry, 110 Children and Youth Services Review 104804 (2020), https://www.sciencedirect.com/science/article/pii/S0190740919312125.
6. Elizabeth Barnert et al., Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review, 26 Journal of Correctional Health Care 113 (2020), https://www.liebertpub.com/doi/full/10.1177/1078345820915908.
7. The Social Security Act, Sec. 1905(a)(A),42 U.S.C. 1396d. 
8. Elizabeth Barnert et al., Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review, 26 Journal of Correctional Health Care 113 (2020), https://www.liebertpub.com/doi/full/10.1177/1078345820915908.
9. Id., Ravindra A. Gupta et al., Delinquent Youth in Corrections: Medicaid and Reentry Into the Community, 115 Pediatrics 1077 (2005), https://doi.org/10.1542/peds.2004-0776.
10. Ravindra A. Gupta et al., Delinquent Youth in Corrections: Medicaid and Reentry Into the Community, 115 Pediatrics 1077 (2005), https://doi.org/10.1542/peds.2004-0776.
11. Elizabeth S. Barnert, Nathalie Lopez & Paul J. Chung, Barriers to Health Care for Latino Youths During Community Reentry After Incarceration: Los Angeles County, California, 2016–2018, 110 Am J Public Health S63 (2020), https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2019.305374, Erin Partin, A Study of Factors That Affect the Likelihood of Juvenile Justice System Involvement.
12. Diane Fields & Laura S. Abrams, Gender Differences in the Perceived Needs and Barriers of Youth Offenders Preparing for Community Reentry, 39 Child & Youth Care Forum 253 (2010), https://www.proquest.com/docview/744248899/abstract/D023D26B5AA746EAPQ/1., Elizabeth S. Barnert et al., Parent and Provider Perspectives on Recently Incarcerated Youths’ Access to Healthcare during Community Reentry, 110 Children and Youth Services Review 104804 (2020), https://www.sciencedirect.com/science/article/pii/S0190740919312125.
13. Id.
14. Elizabeth Barnert et al., Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review, 26 Journal of Correctional Health Care 113 (2020), https://www.liebertpub.com/doi/full/10.1177/1078345820915908 (last visited Sep 10, 2024).
15. Diane Fields & Laura S. Abrams, Gender Differences in the Perceived Needs and Barriers of Youth Offenders Preparing for Community Reentry, 39 Child & Youth Care Forum 253 (2010), https://www.proquest.com/docview/744248899/abstract/D023D26B5AA746EAPQ/1.
16. Elaine Michelle Albertson, Geographic Access to Behavioral Health Services after Reentry from the Washington State Juvenile Justice System (2018), http://hdl.handle.net/1773/42397.
17. Diane Fields & Laura S. Abrams, Gender Differences in the Perceived Needs and Barriers of Youth Offenders Preparing for Community Reentry, 39 Child & Youth Care Forum 253 (2010), https://www.proquest.com/docview/744248899/abstract/D023D26B5AA746EAPQ/1.
18. Elizabeth Barnert et al., Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review, 26 Journal of Correctional Health Care 113 (2020), https://www.liebertpub.com/doi/full/10.1177/1078345820915908.
19. Ravindra A. Gupta et al., Delinquent Youth in Corrections: Medicaid and Reentry Into the Community, 115 Pediatrics 1077 (2005), https://doi.org/10.1542/peds.2004-0776 (last visited Sep 10, 2024).,Robert D. Jones, Providing Health Care and Mental Health Services to Juveniles, 74 Corrections Today 50 (2012), https://www.proquest.com/central/docview/1030141737/abstract/8755EFA733C64C5EPQ/9.
20. Elizabeth Barnert et al., Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review, 26 Journal of Correctional Health Care 113 (2020), https://www.liebertpub.com/doi/full/10.1177/1078345820915908.
21. Id., Carrie A. Pettus, Trauma and Prospects for Reentry, 6 Annual Review of Criminology 423 (2023), https://www.annualreviews.org/content/journals/10.1146/annurev-criminol-041122-111300.
22. Josh Rovner, Youth justice by the numbers The Sentencing Project (2024), https://www.sentencingproject.org/app/uploads/2024/08/Youth-Justice-By-The-Numbers.pdf. 
23. Mortality and Cause of Death Among Youths Previously Incarcerated in the Juvenile Legal System - PMC, https://pmc.ncbi.nlm.nih.gov/articles/PMC8703246/.
24. Disparities in Health Care Spending and Utilization Among Black and White Medicaid Enrollees - PMC, https://pmc.ncbi.nlm.nih.gov/articles/PMC9187949/.
25. Sticker Shock 2020: The Cost of Youth Incarceration, Justice Policy Institute (2020), https://justicepolicy.org/research/policy-brief-2020-sticker-shock-the-cost-of-youth-incarceration/.
26. Reducing Medicaid Coverage Gaps for Youth During Reentry, https://www.liebertpub.com/doi/epub/10.1089/jchc.20.03.0011, Ravindra A. Gupta et al., Delinquent Youth in Corrections: Medicaid and Reentry Into the Community, 115 Pediatrics 1077 (2005), https://doi.org/10.1542/peds.2004-0776.
27. H.R.6 - 115th congress (2017-2018): Support for patients and Communities Act | congress.gov | library of Congress, https://www.congress.gov/bill/115th-congress/house-bill/6. 
28.  Elizabeth Barnert et al., Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review, 26 Journal of Correctional Health Care 113 (2020), https://www.liebertpub.com/doi/full/10.1177/1078345820915908.
29.  Daniel Tsai, SMD 23-003 Medicaid (2023), https://www.medicaid.gov/federal-policy-guidance/downloads/smd23003.pdf. 
30. HHS authorizes five states to provide historic health care coverage for people transitioning out of incarceration, CMS.gov(2024), https://www.cms.gov/newsroom/press-releases/hhs-authorizes-five-states-provide-historic-health-care-coverage-people-transitioning-out. 
31. Consolidated Appropriations Act, 2023: Committee print of the Committee on Appropriations, U.S. House of Representatives, on H.R. 2617, (2023).