Racial disparities in use of non-emergency outpatient care by Medicaid-eligible adults after release from prison: Wisconsin, 2015-2017

Continuity of Prescription Medication Use Among Adults Leaving State Prison

Importance

Identifying prescription needs of adults returning from prison can inform intervention design to mitigate high morbidity and mortality during reentry to the community.

Objective

To characterize the prevalence and factors associated with continuity of medication use for treatment of chronic illness among adults returning to the community from prison.

Design, Setting, and Participants

This retrospective cohort study linked administrative records and prescription claims from the Wisconsin Department of Corrections and the Medicaid program. The study included all adults (aged 18-64 years) released from a Wisconsin state correctional facility between April 1, 2015, and June 30, 2017, after incarceration of at least 31 days who enrolled in Medicaid within the month of release. Analyses were conducted between May 2022 and May 2024.

Exposure

Receipt of a prescription medication commonly used for treatment of certain chronic conditions during the last 3 months of incarceration.

Main Outcomes and Measures

The primary outcome was medication continuity, which was defined as having a prescription medication claim in the first 6 months after release that was within the same chronic condition therapeutic class as the medication received during the last 3 months of incarceration.

Results

This cohort study included 13 792 individual releases representing 12 960 individuals from the Wisconsin state prison system who immediately enrolled in Medicaid upon release. These individuals had a mean (SD) age of 35.5 (10.5) years; 89.5% were male. In terms of race, 38.5% of individuals were Black and 57.2% were White. For one-third of individual Medicaid-enrolled releases (4302 [31.2%]), the individual received a prescription medication for a chronic condition. Prescription continuity was observed for 51.7%, with variability across drug class ranging from less than 20.0% to 71.6%. Classes with the highest continuity (eg, thyroid agents) were also those that treated serious chronic conditions, although gaps between realized and clinically recommended care remained. Continuity varied by race, sex, and age. Individuals with continuity were more likely to have had an outpatient visit in the 6 months following release than those without continuity (93.9% vs 55.6%; P < .001) despite similar Medicaid enrollment.

Conclusions and Relevance

In this study, prescription continuity between prison release and the community was limited, even for drugs with high clinical need and relevance for population health and especially among individuals who did not receive outpatient care in the 6 months post incarceration. These findings suggest that effective transitional care interventions may need to include increased emphasis on connecting with clinicians.

Racism in Drug Testing

Racial disparities in drug testing for substance-use disorders underscore systemic inequalities. Studies reveal that minority groups, particularly Black and Hispanic Americans, are disproportionately targeted for drug testing despite similar rates of drug use across racial lines. Such bias impacts employment opportunities, legal outcomes, and access to treatment. The overrepresentation of minorities in drug testing reflects broader societal prejudices, leading to a cycle of discrimination and marginalization. Addressing these disparities requires a multifaceted approach, including policy reform, increased awareness of implicit biases, and equitable health care practices to ensure fair treatment of all individuals struggling with substance-use disorders.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors

INTRODUCTION

As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage.

METHODS

In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release.

RESULTS

The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use.

CONCLUSIONS

Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

Medicaid Inmate Exclusion Policy and Infectious Diseases Care for Justice-Involved Populations

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs' Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

Health Care and Behavioral Service Use by Medicaid-Enrolled Adults After Release From Incarceration

OBJECTIVE

This study explored the characteristics and health care utilization of adults released from state prisons and enrolled in Medicaid in Indiana, which has policies to facilitate timely enrollment.

METHODS

Medicaid claims and Department of Corrections data were used to examine demographic and incarceration characteristics and health care utilization patterns of adults (N=15,929) released from state prisons and enrolled in Medicaid within 120 days of release, between 2015 and 2018.

RESULTS

More than 80% of participants had at least one health encounter within 120 days of initiating coverage, and nearly 50% used the emergency department. Those enrolled in Medicaid within 30 days of release were more likely to have behavioral health needs and to utilize subacute behavioral health care than those who enrolled later.

CONCLUSIONS

Understanding these patterns of health care utilization is essential to operationalizing procedures and interventions to support the health care needs of adults involved in the criminal legal system.

Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid

INTRODUCTION

Expanding access to medications for opioid use disorder is a cornerstone to addressing the opioid overdose epidemic. However, recent research suggests that the distribution of medications for opioid use disorder has been inequitable. This study analyzes the racial‒ethnic disparities in the receipt of medications for opioid use disorder among Medicaid patients diagnosed with opioid use disorder.

METHODS

Medicaid claims data from the Transformed Medicaid Statistical Information System for the years 2017-2019 were used for the analysis. Logistic regression models estimated the odds of receiving buprenorphine and Vivitrol within 180 days after initial opioid use disorder diagnosis on the basis of race‒ethnicity. Analysis was conducted in 2022.

RESULTS

Non-Hispanic Black people, non-Hispanic American Indian or Alaskan Native/Asian/Hawaiian/Pacific Islander people, and Hispanic people had 42%, 12%, and 22% lower odds of buprenorphine receipt and 47%, 12%, and 20% lower odds of Vivitrol receipt, respectively, than non-Hispanic White people, controlling for clinical and demographic patient variables.

CONCLUSIONS

This study suggests that there are racial‒ethnic disparities in the receipt of buprenorphine and Vivitrol among Medicaid patients diagnosed with opioid use disorder after adjusting for demographic, geographic, and clinical characteristics. The potential strategies to address these disparities include expanding the workforce of providers who can prescribe medications for opioid use disorder in low-income communities and communities of color and allocating resources to address the stigma in medications for opioid use disorder treatment.