Eliminating Gaps in Medicaid Coverage During Reentry After Incarceration

Providing Equitable Surgical Care to Patients in Law Enforcement Custody: A Review

Importance

Approximately 2 million individuals are incarcerated in the US. Surgical needs increase with age, and an aging prison population means an increasing need for surgical care for incarcerated individuals. Challenges in logistics, privacy, communication, and comorbidities put people in law enforcement custody at risk for suboptimal care and outcomes. Little guidance exists for surgeons seeking to provide equitable care for these patients.

Observations

No national statistics are available on the need for surgery among incarcerated people. Autopsy data suggest that nearly a quarter of deaths among incarcerated individuals were attributable to causes that could have been treated with surgery, yet few received surgical care before death. Across the spectrum of custody, including police detention, jail, prison, probation, and parole, access to consistent preoperative and postoperative care are major challenges, as is sustaining appropriate levels of privacy and communication. Incarcerated people are often accompanied by guards, preventing privacy. Patients are shackled to hospital beds, restricting mobility. For incarcerated individuals, access to postoperative medication may be curtailed when they return to jail or prison. To be effective advocates for patient-centered care and to achieve the best outcomes, surgeons must remain vigilant to specific barriers to care.

Conclusions and Relevance

Individuals in law enforcement custody have particular needs regarding communication, surgical planning, and perioperative and postoperative care. Clinicians must remain alert to these challenges and serve as advocates for these marginalized patients, even adjusting their care practices. Professional societies and health systems can bolster care for this marginalized population by developing and disseminating guidelines and pathways for patient-centered surgical care for individuals in law enforcement custody.

Structural and healthcare predictors of substance use-related death following release from incarceration: A retrospective cohort study in Rhode Island, 2018-2020

BACKGROUND

Incarcerated individuals are at a high risk of substance use-related death after release. While prior research has demonstrated that this is partially due to loss of tolerance during incarceration and return to use after release, structural and healthcare use factors that may also impact overdose risk have been underexplored. We assessed the relationship between structural factors (e.g., housing services received) and health care use (e.g., emergency department use) and overdose risk at 12-months post-incarceration in Rhode Island in the United States.

METHODS

We used a retrospective cohort study design. Rhode Island Department of Corrections (RIDOC) data were linked with individual-level data across state agencies. Cumulative incidence of substance use-related death was estimated as a function of structural and healthcare factors using hazard ratios from cause-specific cox landmark models for dynamic predictions.

RESULTS

There were 9696 individuals in the analytic sample. Most deaths that occurred within 12 months post-release involved substance use (N = 96). People who had more previous incarcerations had a higher risk of substance use-related death. Reporting taxable wages (aHR: 0.52; 95 % CI: 0.25, 1.09) was weakly associated with in a lower risk of substance use-related death while being admitted to the hospital (aHR: 1.79; 95 % CI: 0.91, 3.53) was weakly associated with a slightly higher risk of substance use-related death 12-months post-release.

CONCLUSION

Structural factors were weakly associated with reduced risk of substance use-related death post-release from incarceration. Conducting needs assessments (e.g., identifying employment needs) and interventions (e.g., employment training programs) prior to or at release that address these structural factors are critical for reducing this risk. Further, these findings contribute to the evidence that decarceration should be used a public health tool given the high risk of substance use-related death post-release.

Special Considerations Related to Race, Sex, Gender, and Socioeconomic Status in the Preoperative Evaluation: Part 1: Race, History of Incarceration, and Health Literacy

Patients anticipating surgery and anesthesia benefit from preoperative care to lower risks and facilitate services on the day of surgery. Preparing patients often requires extensive evaluation and coordination of care. Vulnerable, marginalized, and disenfranchised populations have special concerns, limitations, and needs. These patients may have unidentified or poorly managed comorbidities. Underrepresented minorities and transgender patients may either avoid or have limited access to health care. Homelessness, limited health literacy, and incarceration hinder perioperative optimization initiatives. Identifying patients who will benefit from additional resource allocation and knowledge of their special challenges is vital to reducing disparities in health and health care.

The State of Medical Education on Criminal Justice Health: A Systematic Review

BACKGROUND

The justice-involved population faces significant health disparities yet is often overlooked in medical education, resulting in medical providers having limited preparation to serve this community. The objective of this study is to understand the scope and context of medical education in correctional healthcare.

METHODS

Literature was systematically reviewed for curriculum on correctional healthcare aimed at undergraduate or graduate medical learners in U.S. educational institutions. The search strategy was developed with the guidance of a medical research librarian and included five literature databases, which were analyzed by two data analysts. The risk of bias was assessed using the appropriate Critical Appraisal Skills Programme checklists.

RESULTS

Our search identified 49 studies highlighting 95 unique curricula. Curricula were evenly split between the undergraduate (n = 44) and graduate (n = 50) level. The two most represented specialties were psychiatry (n = 43) and general medicine (n = 30). Educational modalities included clinical rotation (n = 48), didactics (n = 14), or a combination (n = 28). Curricula increased knowledge in correctional and specialty-specific medicine and improved attitudes towards justice-involved patients; however, there was no significant effect on plans to work with the justice-involved population. Common themes of curricula included treating justice-involved patients with respect (n = 23), structure and function of the legal system (n = 20), and career recruitment (n = 16).

DISCUSSION

There is limited education on the care of the justice-involved population and most learners are unlikely to experience education on this population during their training despite the extensive and unique health and psycho-social needs of this population. Quality of education remains variable and challenging to assess due to limited outcome data and the low quality of literature; however, our thorough search strategy and standardized approach allow for a complete and accurate representation of the literature.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Registration number CRD42023427470.

Characterizing Aging-Related Health in Older Women with a History of Incarceration: Multimorbidity, Polypharmacy, Mortality, Frailty, and Depression

OBJECTIVE

To characterize aging-related health in women with past CLSI and compare with women with no-CLSI.

METHOD

Health and Retirement Study Wave 11 and 12 data from women age >50 with CLSI were compared with data from women age >50 with no-CLSI. Generalized linear models were estimated for aging-related health outcomes.

RESULTS

The group with CLSI (n = 230) was significantly younger than the no-CLSI group (n = 8035) yet had more physical, functional, and mental health challenges and fewer resources. Incarceration significantly predicted aging-related outcomes of multimorbidity, polypharmacy, mortality, frailty, and depression.

DISCUSSION

Earlier onset of physical and functional health conditions in women with past CLSI has implications for health education and promotion, clinical practice, and intervention design.

Medication for opioid use disorder service delivery in carceral facilities: update and summary report

The opioid overdose crisis intersects critically with the criminal legal system where individuals with opioid use disorder (are significantly overrepresented. Subsequently, incarceration increases the risk of opioid overdose due to reduced tolerance, interrupted social supports, and limited access to treatment. Medications for opioid use disorder (MOUD), such as methadone, buprenorphine, and naltrexone, have been shown to reduce opioid-related mortality and improve outcomes for those in carceral settings. Despite this, access to MOUD in jails and prisons remains limited due to stigma, concerns about medication diversion, and logistical challenges. This paper reviews the current state of knowledge on MOUD in carceral settings, summarizing the prevalence of treatment programs, the role of novel formulations like injectable buprenorphine, and barriers to implementation. It also explores the continuum of care, emphasizing the importance of initiating MOUD during incarceration and ensuring continuation upon release to prevent treatment gaps. Recent policy changes, such as Sect. 1115 Medicaid waivers, offer promising avenues for expanding access, but retention in treatment and post-release outcomes remain significant challenges. The paper provides a comprehensive overview of existing literature and updates on MOUD service delivery, including the impact of recent policy shifts and research on outcomes such as recidivism and health improvement. It concludes by identifying key areas for future research, including strategies to improve treatment retention, address systemic barriers through criminal justice reform, and enhance care coordination during the transition from incarceration to the community.

Prevalent Adverse Childhood Experiences Among Young Adults Returning Home From Jail: The Need for Trauma-Informed Reentry Services

Prevalence of adverse childhood experiences (ACEs) and the extent to which they relate to health among young adults (ages 18-25) returning home from jail is underexamined. To build on the growing literature examining associations between ACE exposure among young people involved with carceral systems and health, we (1) measured ACE prevalence and (2) explored associations between ACEs and health/well-being indicators among young adults experiencing reentry. Using a telephone survey on reentry experiences, participants completed an ACE screening, single-item responses on health and social indicators, and five-item responses on substance misuse. Fisher's exact tests and t tests compared sociodemographic and health-related factors by the levels of ACEs. Among the 85 participants, 66 (78%) reported four or more ACEs and 48 (56%) reported six or more ACEs, including divorced parents (n = 69, 81%), witnessing violence (n = 63, 74%), and household member incarceration (n = 60, 71%). Higher exposure to ACEs was associated with mental health diagnoses, psychiatric medication prescriptions, psychiatric hospitalizations, drug dependence, binge drinking, and cannabis misuse. High ACE exposure among young adults experiencing reentry portends worse mental health and high rates of substance use. Findings signify an opportunity to apply a trauma-focused developmental framework to support emerging adults during the crucial reentry period.

Peer navigation intervention for individuals with serious mental illness reentering the community after jail incarceration: a qualitative case study

BACKGROUND

Criminal legal system-involved individuals with serious mental illness (SMI) experience more challenges accessing mental health and other community services than those without a history of criminal legal system involvement. A formative qualitative study was conducted to explore feasibility and acceptability and inform the adaptation of a mental health peer navigation intervention for individuals with SMI reentering the community after jail incarceration.

METHODS

In-depth qualitative interviews and focus-group discussions were conducted with mental health peer navigators (i.e., certified mental health peer support specialists, peer recovery coaches) and individuals with lived experience of SMI and criminal legal system involvement (N = 20 total). Data were analyzed using applied thematic analysis.

RESULTS

Four major themes emerged: (1) Feasibility and acceptability of peer-provided services: all participants reported that peer navigation services would be feasible and acceptable for individuals with SMI reentering the community after jail incarceration; (2) roles of peer navigators in addressing barriers to care: peers can address barriers to care experienced during community reentry and contribute towards service linkage/engagement; (3) shared identity and combating stigma: having a shared identity with peer navigators may minimize the impact of stigma and make it easier for clients with multiple marginalized identities to seek support; and (4) peer navigator skills and recommendations for the planned program: essential peer navigation skills include authenticity, reliability, active listening, advocacy, trauma-informed care, motivational interviewing, and empathy. Recommendations for the planned program include initiating services while clients are in custody, emphasizing the voluntary nature of peer support, knowing the limits of a peer navigation intervention, and offering support for peer navigators while on the job.

CONCLUSION

Participants saw peer navigation services for individuals with SMI with criminal legal system involvement as potentially feasible and acceptable. Such programs may enhance their impact by offering supportive supervision, emphasizing the voluntary nature of the service, and acknowledging recovery as a self-directed endeavor.

Primary care need and engagement by people with criminal legal involvement: Descriptive and associational analysis using retrospective data on the entire population ever detained in one southeastern U.S. county jail 2014-2020

More than 7 million people are released each year from U.S. jails or prisons, many with chronic diseases that would benefit from primary care in their returning communities. The objective of this study was to provide an in-depth, payer-agnostic description and associational analysis of primary care need and utilization by all individuals ever detained in one county detention facility over a 7-year period. Detention records 2014-2020 were merged with data from an electronic health record with excellent coverage of local primary care, emergency, and hospital services. We found low primary care participation for the group as a whole, with under three quarters of those with serious chronic diseases ever seeing a primary care provider over a 7-year period and less than half ever having a year with more than one visit. Multivariable regression models estimated associations between individual characteristics (demographic, detention-related, and clinical) and ever having access to primary care (logistic) and the number of primary care visits (zero-inflated negative binomial). We found that having more jail bookings was associated with fewer primary care visits, but not one-time access, even controlling for time out of community, age, insurance, and other demographic characteristics. This finding was driven by subgroups with chronic disease such as hypertension, obstructive lung disease, and diabetes, who most need regular primary care. Being Black retained an independent effect, even controlling for bookings and other variables, and was also associated with fewer primary care visits, though not one-time access. To promote primary care utilization among individuals who have the combined challenges of repeated jail involvement and chronic disease, it is crucial to focus on engagement, as much as formal access. Access to health insurance alone will not resolve the problem; Medicaid expansion should be coupled with specialized, tailored support to promote engagement in primary care.

Perinatal Health Outcomes Among Women on Community Supervision: A Scoping Review

The purpose of this scoping review is to review the extant literature regarding perinatal health outcomes for women on community supervision in the United States. PubMed, CINAHL, Scopus, PsycINFO, and Public Health were searched for peer-reviewed articles published in the United States from January 1, 1970, to March 7, 2023. After removal of duplicates and review of 1,412 article titles and abstracts, 19 articles were retrieved for full-text review; this yielded 4 studies for inclusion. Studies range in size from 10 to 292 participants (N = 405) and only two reported geographic locations. Three studies comprised probation or parole and two studies included court-mandated treatment for substance use. All studies examined outcomes during the postpartum period, such as mood disorder or substance use severity. No studies evaluated the health of women during pregnancy and/or childbirth. To enhance health equity and reduce maternal morbidity and mortality among women on community supervision, more inclusive research that examines health outcomes during the perinatal period is needed. Furthermore, there must be interventions that address the social determinants of health, racial and systemic discrimination, socioeconomic barriers, and violence that are often experienced among women with criminal justice system involvement.

Childhood Behind Bars: Children and the US Juvenile Legal System

This article examines the epidemiology of the US juvenile legal system, which disproportionately impacts youth with multiple marginalized identities and exacerbates health inequities. Policy changes that can improve the treatment of children who display disruptive behavior are highlighted, so as to lay out a path forward for supporting children and enhancing health equity while bolstering public safety. Finally, this article concludes that the systemic racism pervasive in the juvenile legal system signals an important role for pediatrics to advance racial equity and transform our approach to childhood.

When Medication Treatment for Opioid Use Disorder Gets Disrupted by Extra-Clinical Variables, How Should Clinicians Respond?

Structural and systemic discrimination against people with substance use disorder is pervasive. Clinicians caring for patients receiving medications for opioid use disorders (MOUDs) should plan for possible disruptions of treatment caused by arrests and pretrial confinement in jails. This case commentary suggests that harms caused by such treatment disruption can be mitigated by clinicians who take some of the practical approaches outlined in this commentary to better preserve continuity of care for people receiving MOUD.

Advancing Youth Justice: The Child and Adolescent Psychiatrist's Role

Child and adolescent psychiatrists (CAPs) play a crucial role beyond the provision of clinical care. CAPs are uniquely placed to understand and help patients navigate the fine line among psychiatric care, health and well-being, and the laws and policies supporting or impairing these processes. Focusing on vulnerable populations, such as legal system impacted youth and families, CAPs can contribute to the ongoing development of a more just and equitable world for the children of today and of tomorrow.

State Medicaid Initiatives Targeting Substance Use Disorder in Criminal Legal Settings, 2021

Objectives. To document state Medicaid pre- and postrelease initiatives for individuals in the criminal legal system with substance use disorder (SUD). Methods. An Internet-based survey was sent in 2021 to Medicaid directors in all 50 US states and the District of Columbia to determine whether they were pursuing initiatives for persons with SUD across 3 criminal legal settings: jails, prisons, and community corrections. A 90% response rate was obtained. Results. In 2021, the majority of states did not report any targeted Medicaid initiatives for persons with SUD residing in criminal legal settings. Eighteen states and the District of Columbia adopted at least 1 Medicaid initiative for persons with SUD across the 3 criminal legal settings. The most commonly adopted initiatives were in the areas of medication for opioid use disorder treatment and Medicaid enrollment. Out of 24 possible initiatives for each state (8 initiatives across 3 criminal legal settings), the 2 most commonly adopted were (1) provision of medication treatment of opioid use disorder before release from criminal legal settings (16 states) and (2) facilitation of Medicaid enrollment through suspension rather than termination of Medicaid enrollment upon entry to a criminal legal setting (14 states). Initiatives pertaining to Medicaid SUD care coordination were adopted by the fewest (9) states. Conclusions. In 2021, states' involvement in Medicaid SUD initiatives for criminal legal populations remained low. Increased adoption of Medicaid SUD initiatives across criminal legal settings is needed, especially knowing the high rate of overdose mortality among this group. (Am J Public Health. 2024;114(5):527-530. https://doi.org/10.2105/AJPH.2024.307604).

Disparities in access to appointments for contraceptive services among Black, Hispanic, White, and recently incarcerated women in Alabama, Louisiana, and Mississippi

OBJECTIVE

To measure differences in access to contraceptive services based on history of incarceration and its intersections with race/ethnicity and insurance status.

DATA SOURCES AND STUDY SETTING

Primary data were collected from telephone calls to physician offices in Alabama, Louisiana, and Mississippi in 2021.

STUDY DESIGN

We deployed a field experiment. The outcome variables were appointment offers, wait days, and questions asked of the caller. The independent variables were callers' incarceration history, race/ethnicity, and insurance.

DATA COLLECTION METHODS

Using standardized scripts, Black, Hispanic, and White female research assistants called actively licensed primary care physicians and Obstetrician/Gynecologists asking for the next available appointment for a contraception prescription. Physicians were randomly selected and randomly assigned to callers. In half of calls, callers mentioned recent incarceration. We also varied insurance status.

PRINCIPAL FINDINGS

Appointment offer rates were five percentage points lower (95% CI: -0.10 to 0.01) for patients with a history of incarceration and 11 percentage points lower (95% CI: -0.15 to -0.06) for those with Medicaid. We did not find significant differences in appointment offer rates or wait days when incarceration status was interacted with race or insurance. Schedulers asked questions about insurance significantly more often to recently incarcerated Black patients and recently incarcerated patients who had Medicaid.

CONCLUSIONS

Women with a history of incarceration have less access to medical appointments; this access did not vary by race or insurance status among women with a history of incarceration.

Policy solutions to eliminate racial and ethnic child health disparities in the USA

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Challenging Health Inequities in Incarceration: a Call for Equitable Care for Kidney Disease and Hypertension

PURPOSE OF REVIEW

To review the current literature on care of hypertension and chronic kidney disease for people who are currently and formerly incarcerated, and to make recommendations for improving outcomes.

RECENT FINDINGS

There is a growing body of literature describing care for kidney disease and hypertension for incarcerated and formerly incarcerated individuals that documents the provision of care itself, notably that many jails contract with private companies; the system is not designed to provide sustained, chronic disease care; and the transition from incarceration to community is fraught with gaps in care. However, deficiencies in data collection and regulation still limit our understanding of the quality of care provided in jails and prisons. Furthermore, more data is needed to understand the impact of structural racism in the criminal legal system on overall disparities in care for hypertension and kidney disease. Insurance coverage rates for people who were formerly incarcerated continue to be lower than the general population despite Medicaid expansion in many states. There is little recent data regarding kidney replacement therapy for this population despite known variation in dialysis modalities and transplant programs by state. Transitions clinics, which connect people who were formerly incarcerated with care in the community upon release, are growing and are important avenues by which to deliver care. People who are incarcerated are disproportionately affected by hypertension and kidney disease, yet data regarding the extent of these inequities and availability of quality care is lacking. More work is needed to understand the care of individuals with kidney disease and hypertension in prisons and to improve outcomes for these common chronic conditions. Both providing effective treatment of kidney disease and hypertension in prisons and jails and providing coordinated, quality transition to community care upon release represents an important opportunity for reform in care for a marginalized population.

Previous Incarceration, Health Insurance, and the Affordable Care Act in the U.S

INTRODUCTION

This study examines the association between prior incarceration and health insurance status and whether living in a state adopting the Affordable Care Act (ACA) Medicaid expansion moderates this relationship.

METHODS

Data are from the National Longitudinal Study of Adolescent to Adult Health (Wave I [1993-1994], Wave IV [2008], and Wave V [2016-2018]; N=8,965). Multiple logistic regression with multiplicative interaction terms were performed to assess the relationship between previous incarceration and ACA Medicaid expansion on (1) being insured and (2) being on public health insurance. Analyses were performed in 2023.

RESULTS

Findings demonstrate a positive and statistically significant interaction in the association between previous incarceration and living in a state with ACA Medicaid expansion on having public health insurance (OR=2.402; 95% CI=1.257, 4.588).

CONCLUSIONS

The ACA Medicaid expansion was associated with a greater likelihood of public health insurance coverage for formerly incarcerated persons in the U.S. These findings suggest that Medicaid expansion could be critical in improving health insurance coverage among formerly incarcerated individuals who are a population that is more likely to be uninsured.

Cancer equity for those impacted by mass incarceration

The cancer disparities between people with incarceration histories compared with those who do not have those histories are vast. Opportunities for bolstering cancer equity among those impacted by mass incarceration exist in criminal legal system policy; carceral, community, and public health linkages; better cancer prevention, screening, and treatment services in carceral settings; expansion of health insurance; education of professionals; and use of carceral sites for health promotion and transition to community care. Clinicians, researchers, persons with a history of incarceration, carceral administrators, policy makers, and community advocates could play a cancer equity role in each of these areas. Raising awareness and setting a cancer equity plan of action are critical to reducing cancer disparities among those affected by mass incarceration.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans

BACKGROUND

Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes.

OBJECTIVES

To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older.

RESEARCH DESIGN

Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions.

SUBJECTS

Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447).

METHODS

Mental illness, SUD, medical multimorbidity.

RESULTS

An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49).

CONCLUSIONS

Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

The Reentry Health Care Hub: Creating a California-Based Referral System to Link Chronically Ill People Leaving Prison to Primary Care

People released from prison experience high health needs and face barriers to health care in the community. During the COVID-19 pandemic, people released early from California state prisons to under-resourced communities. Historically, there has been minimal care coordination between prisons and community primary care. The Transitions Clinic Network (TCN), a community-based non-profit organization, supports a network of California primary care clinics in adopting an evidence-based model of care for returning community members. In 2020, TCN linked the California Department of Corrections and Rehabilitation (CDCR) and 21 TCN-affiliated clinics to create the Reentry Health Care Hub, supporting patient linkages to care post-release. From April 2020-August 2022, the Hub received 8420 referrals from CDCR to facilitate linkages to clinics offering medical, behavioral health, and substance use disorder services, as well as community health workers with histories of incarceration. This program description identifies care continuity components critical for reentry, including data sharing between carceral and community health systems, time and patient access for pre-release care planning, and investments in primary care resources. This collaboration is a model for other states, especially after the Medicaid Reentry Act and amid initiatives to improve care continuity for returning community members, like California's Medicaid waiver (CalAIM).

"We're the CHATS old-heads": Engaging with evidence-based practice in a reentry agency

Philadelphia has one of the country's largest populations re-entering society after incarceration. Reentry services have been critiqued for their ineffectiveness. Scholars note the lack of evidence-based practices (EBPs) in the field, and the challenges of translating them. Through a case study of one reentry agency implementing an EBP, we examine engagement with the intervention by clients and service providers. Qualitative interviews were conducted with clients and staff (n = 35). A grounded theory using sensitizing concepts approach was used to analyze the data. Productive engagement with the intervention was facilitated by: (1) translatability of the core EBP elements so that they addressed client and staff needs, (2) accessibility to the intervention by enhancing subjective ownership and successfully navigating logistical barriers, and (3) collectivity among participants and staff that helped them address societal and structural barriers. Productive engagement with an EBP can resist carceral processes in reentry service-provision.

The case for transitional services and programs for older adults reentering society: a narrative review of US departments of correction and recommendations

PURPOSE

Older adults who are or have been incarcerated constitute a growing population in the USA. The complex health needs of this group are often inadequately addressed during incarceration and equally so when transitioning back to the community. The purpose of this paper is to discuss the literature on challenges older adults (age 50 and over) face in maintaining health and accessing social services to support health after an incarceration and to outline recommendations to address the most urgent of these needs.

DESIGN/METHODOLOGY/APPROACH

This study conducted a narrative literature review to identify the complex health conditions and health services needs of incarcerated older adults in the USA and outline three primary barriers they face in accessing health care and social services during reentry.

FINDINGS

Challenges to healthy reentry of older adults include continuity of health care; housing availability; and access to health insurance, disability and other support. The authors recommend policy changes to improve uniformity of care, development of support networks and increased funding to ensure that older adults reentering communities have access to resources necessary to safeguard their health and safety.

ORIGINALITY/VALUE

This review presents a broad perspective of the current literature on barriers to healthy reentry for older adults in the USA and offers valuable system, program and policy recommendations to address those barriers.

Incarceration History and Health Insurance and Coverage Changes in the U.S

INTRODUCTION

This study examines the association of incarceration history and health insurance coverage and coverage changes in the U.S.

METHODS

Individuals with and without incarceration history were identified from the National Longitudinal Survey of Youth 1997 with follow-up through 2017-2018 (n=7,417). Generalized estimating equations were used to examine the associations between incarceration history and health insurance and coverage changes in the past 12 months. This study also assessed variation in associations by incarceration duration, frequency, and recency and reoffence history. Analysis was conducted in 2022.

RESULTS

Individuals with incarceration history were more likely to be uninsured (AOR=1.69; 95% CI=1.55, 1.85) and to experience year-long uninsurance (AOR=1.34; 95% CI=1.12, 1.59) and were less likely to have stable health insurance coverage (AOR=1.30; 95% CI=1.08, 1.56) than individuals without incarceration history. Longer duration and more frequent incarcerations were associated with a higher likelihood of lack of and unstable insurance coverage and year-long uninsurance.

CONCLUSIONS

People with an incarceration history had worse access to health insurance coverage. Targeted programs to improve health insurance coverage may reduce disparities associated with incarceration.

A Widening Divide: Cigarette Smoking Trends Among People With Substance Use Disorder And Criminal Legal Involvement

People with substance use disorder (SUD) smoke cigarettes at a rate more than twice that of the general population. Policies and programs have focused on promoting smoking cessation among people with SUD, yet it is unclear whether interventions have adequately reached the subgroup involved in the criminal legal system, who have among the highest smoking rates. Drawing on repeated cross-sections of the National Survey on Drug Use and Health, we found that smoking rates declined by 9.4 percentage points overall among people with SUD from 2010 to 2019, but rates remained virtually unchanged among the subgroup with criminal legal involvement. In regression analyses focused on people with SUD, three-quarters of the excess smoking burden for those with criminal legal involvement at baseline (2010-13) was accounted for by controlling for sociodemographics, substance use type, health insurance, and recent SUD treatment. However, even after we controlled for these same factors, the disparity in smoking prevalence among people with SUD between those with and without criminal legal involvement remained constant over time. These findings underscore the need for smoking cessation interventions focused on the criminal legal system, including correctional facilities and SUD treatment programs that serve people in this population.

Incarceration status at buprenorphine initiation and OUD treatment outcomes during pregnancy

Introduction

Opioid use disorder (OUD) is a leading cause of pregnancy-associated deaths. OUD treatment with buprenorphine (BUP) reduces overdose risk and improves perinatal outcomes. Incarceration can be a barrier to receipt of OUD treatment during pregnancy and postpartum. The objective of this study was to examine differences in BUP continuation at delivery by patients' incarceration status at the time of BUP initiation.

Methods

This is a secondary analysis of a retrospective cohort study of pregnant patients with OUD who delivered at an academic medical center and initiated BUP between January 1, 2018, and March 30, 2020. The primary outcome was BUP continuation at delivery, abstracted from the state prescription monitoring program and electronic medical record, along with incarceration status. Bivariate analysis was used to assess the relationship between BUP continuation and incarceration status.

Results

Our sample included 76 patients, with 62% of patients incarcerated at BUP initiation (n = 47). Among the entire sample, 90.7% (n = 68) received BUP at delivery. Among patients who were incarcerated at BUP initiation, 97% remained on BUP at delivery; among patients who were not incarcerated at BUP initiation, 79% remained on BUP at delivery (p = 0.02).

Conclusion

In our sample from a health system housing a care model for pregnant and parenting people with OUD with local jail outreach, BUP continuation rates at delivery were high, both for patients who were and were not incarcerated at BUP initiation. Findings are intended to inform future work to develop and evaluate evidence-based, patient-centered interventions to expand OUD treatment access for incarcerated communities.

The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity

IMPORTANCE

Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending.

OBJECTIVE

To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity.

EVIDENCE REVIEW

Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included.

FINDINGS

Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity.

CONCLUSIONS AND RELEVANCE

Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.

Policy Solutions to End Gaps in Medicaid Coverage during Reentry after Incarceration in the United States: Experts' Recommendations

Aims

We sought to gather experts' perspectives on Medicaid coverage gaps during reentry to identify high-yield policy solutions to improve the health of justice-involved individuals in the United States.

Subject and Methods

We interviewed 28 experts at the intersection of Medicaid and criminal justice via telephone between November 2018 and April 2019. Interviewees included Medicaid administrators, health and justice officials, policy makers, and health policy researchers. We performed thematic analysis of semi-structured interview transcripts to identify emergent themes and distill policy recommendations.

Results

Three themes emerged: 1) Medicaid coverage gaps during reentry contribute to poor health outcomes and recidivism, 2) Excessive burden on justice-involved people to re-activate Medicaid leads to coverage gaps, and 3) Scalable policy solutions exist to eliminate Medicaid coverage gaps during reentry. Policy recommendations centered on ending the federal "inmate exclusion," delaying Medicaid de-activation at intake, and promoting re-activation by reentry. Experts viewed coverage gaps as problematic, viewed current approaches as inefficient and burdensome to families and systems, and recommended several policy solutions.

Conclusion

By pursuing strategies to eliminate Medicaid gaps during reentry, policymakers can improve health outcomes and efficiency of government spending on healthcare, and may reduce cycles of incarceration.

Aging with Incarceration Histories: An Intersectional Examination of Incarceration and Health Outcomes among Older Adults

OBJECTIVES

Experiences with incarceration are linked to poor mental and physical health across the life course. The purpose of this research is to examine whether incarceration histories are associated with worse physical and mental health among older adults. We apply an intersectionality framework and consider how the intersection of sexism and racism leads to unequal health outcomes following incarceration among women and people of color.

METHODS

We employ two measures of health (i.e., number of depressive symptoms and physical limitations) to broadly capture mental and physical health. Using data from Waves 11 and 12 of the Health and Retirement Study (HRS), we estimated a series of general linear models (GLM) to analyze differences in health by incarceration history, gender/sex, and race/ethnicity.

RESULTS

Findings suggest that experiences with incarceration are associated with a greater number of physical limitations and more depressive symptoms among older men and women, net of sociodemographic characteristics, early-life conditions, and lifetime stressful events. Formerly incarcerated women, particularly women of color, had more physical limitations and depressive symptoms, relative to other groups.

DISCUSSION

These findings suggest that incarceration histories have far-reaching health implications. Older women of color with incarceration histories experience markedly high levels of physical limitations and depressive symptoms in later life.

Trends In The Use Of Treatment For Substance Use Disorders, 2010-19

Rapidly rising drug overdose rates in the United States during the past decade underscore the need to increase access to treatment among people with substance use disorders (SUDs). We analyzed trends in the use of treatment services among people with SUDs during the period 2010-19, using data from the National Survey on Drug Use and Health. Compared with 2013, outpatient visits for general health in the prior year increased 3.6 percentage points by the 2017-19 period. Use of any SUD treatment in the prior year remained unchanged, but treatment use among people involved in the criminal legal system increased by about 6.2 percentage points by the end of the study period. Among those receiving SUD treatment, there was a 14.9-percentage-point increase in having treatment paid for by Medicaid between 2010-13 and 2017-19. Although access to general medical care and insurance coverage have improved for people with SUD, our study findings underscore the importance of renewed efforts to increase the use of SUD treatment.

Evaluation of Changes in US Health Insurance Coverage for Individuals With Criminal Legal Involvement in Medicaid Expansion and Nonexpansion States, 2010 to 2017

This cross-sectional study compares changes in health insurance coverage from 2010 to 2017 for low-income US adults with criminal legal involvement in states that did and did not adopt the Medicaid expansion provision of the Affordable Care Act.

"A Catch-22": A Firsthand Account of Barriers and Facilitators to Accessing Health Care During Reentry

Although a history of incarceration is associated with poor long-term health status, the experience of seeking health care access during reentry is complex. Semistructured open-ended interviews were conducted among individuals with a recent history of incarceration (N = 20). The majority of participants were male (90%) and African American (80%). The majority (55%) had one or more chronic medical conditions, 40% reported active substance addiction, and 75% reported having a chronic psychiatric condition. In qualitative analysis, participants described the three biggest facilitators to accessing health care as eligibility for Medicaid, support through reentry organizations, and online resources. Participants said the major barriers to accessing health care were multiple and competing priorities, limitations of Medicaid, and lack of access to health records. Ensuring individuals with a history of incarceration are connected to the public assistance programs for which they are eligible is an important public health initiative and may facilitate successful reintegration.

Reducing Medicaid Coverage Gaps for Youth During Reentry

Although many justice-involved youth (JIY) rely on Medicaid, due to the federal "inmate exclusion" Medicaid is often suspended or terminated upon youth's intake to detention, which can lead to coverage gaps at release. We interviewed 28 experts on Medicaid and the justice system and conducted thematic analysis to identify solutions for reducing Medicaid coverage gaps during reentry. Participants viewed coverage gaps during reentry as a significant public health problem to which JIY are especially vulnerable. Recommended solutions for reducing coverage gaps for JIY included (a) leave Medicaid activated, (b) reactivate Medicaid before or during reentry, (c) enhance interagency collaboration, and (d) address societal context to ensure health care access for Medicaid-eligible JIY. Doing so may improve health outcomes and reduce cycles of youth incarceration.

Cancer Care in the Incarcerated Population: Barriers to Quality Care and Opportunities for Improvement

Importance

Cancer is the leading cause of mortality in incarcerated individuals older than 45 years and the fourth leading cause of mortality overall. Health care professionals face increasing challenges to provide high-quality care under the confines of prison regulations and procedures.

Observations

Adjusted for age, race, sex, and year of diagnosis, the standardized incidence ratio for all cancers is more than 2-fold higher in incarcerated vs general populations. Among deaths occurring in state and federal prison systems, cancer is the overall leading cause of mortality with lung cancer being the leading cause of cancer-related mortality followed by liver, colon, and pancreatic cancers, respectively. Access to high-quality oncological services remains variable; however, cost of care represents about a fifth of overall annual prison expenditures. Given the enormous patient burden, coupled with the rushed discretionary screenings performed by jail and prison nursing staff, early cancer symptoms are often missed altogether or misdiagnosed as a chronic illness or as acute infections. As such, many incarcerated individuals present with more advanced cancer stage. Incarcerated individuals have limited, if any, access to the internet, social media, and other sources of information, which severely limits their ability to research treatment options. Within the prison setting, access to professionals with special skills in assisting with social and spiritual concerns is also generally limited, and less than 4% of prisons have hospice programs. There are no uniform quality-of-care monitoring standards for correctional systems and facilities, nor are there mechanisms for reporting comparable performance data to enforce quality control within correctional health care systems.

Conclusions and Relevance

There is a growing trend in cancer incidence among incarcerated patients, which is multifactorial including barriers in access to care, increased burden of chronic medical conditions, and decreased screening tests. Efforts are needed to ensure quality health care outcomes for incarcerated patients with cancer.

Disparities in cancer prevalence, incidence, and mortality for incarcerated and formerly incarcerated patients: A scoping review

BACKGROUND

Racial and ethnic minority status, structural racism, low educational attainment, and poverty are consistently associated with cancer disparities and with higher rates of incarceration. The objective of this scoping review is to conduct a qualitative synthesis of the literature on cancer prevalence, incidence, mortality, and disparities in these outcomes for incarcerated and formerly incarcerated patients, as this literature is fragmented and heterogenous.

METHODS

This scoping review included Bureau of Justice Statistics reports and searched PubMed in May 2021 for all English language studies published between 1990 and 30 April 2021, that reported on cancer prevalence, incidence, or mortality for incarcerated or formerly incarcerated individuals in the United States.

RESULTS

Twenty studies were selected. Data on cancer prevalence and incidence were scarce but suggested that incarcerated and formerly incarcerated patients have a similar overall risk of cancer diagnosis as the general population, but elevated risk of certain cancers such as cervical, lung, colorectal, and hepatocellular carcinoma for which effective prevention and screening interventions exist. Cancer mortality data in state and local jails as well as prisons were robust and suggests that both incarcerated and formerly incarcerated patients have higher cancer mortality than the general population.

CONCLUSIONS

Incarcerated and formerly incarcerated patients likely have a higher risk of dying from cancer than the general population, but important gaps in our knowledge about the extent and drivers of disparities for this population remain. Additional research is needed to guide interventions to reduce cancer disparities for patients experiencing incarceration.

Predict Health Care Accessibility for Texas Medicaid Gap

Medicaid is a unique approach in ensuring the below poverty population obtains free insurance coverage under federal and state provisions in the United States. Twelve states without expanded Medicaid caused two million people who were under the poverty line into health insecurity. Principal Component-based logistical regression (PCA-LA) is used to consider health status (HS) as a dependent variable and fourteen social-economic indexes as independent variables. Four composite components incorporated health conditions (i.e., “no regular source of care” (NRC), “last check-up more than a year ago” (LCT)), demographic impacts (i.e., four categorized adults (AS)), education (ED), and marital status (MS). Compared to the unadjusted LA, direct adjusted LA, and PCA-unadjusted LA three methods, the PCA-LA approach exhibited objective and reasonable outcomes in presenting an odd ratio (OR). They included that health condition is positively significant to HS due to beyond one OR, and negatively significant to ED, AS, and MS. This paper provided quantitative evidence for the Medicaid gap in Texas to extend Medicaid, exposed healthcare geographical inequity, offered a sight for the Centers for Disease Control and Prevention (CDC) to improve the Medicaid program and make political justice for the Medicaid gap.

"I'm not gonna be able to do anything about it, then what's the point?": A broad group of stakeholders identify barriers and facilitators to HCV testing in a Massachusetts jail

BACKGROUND

Despite national guidelines promoting hepatitis C virus (HCV) testing in prisons, there is substantial heterogeneity on the implementation of HCV testing in jails. We sought to better understand barriers and opportunities for HCV testing by interviewing a broad group of stakeholders involved in HCV testing and treatment policies and procedures in Massachusetts jails.

METHODS

We conducted semi-structured interviews with people incarcerated in Middlesex County Jail (North Billerica, MA), clinicians working in jail and community settings, corrections administrators, and representatives from public health, government, and industry between November 2018-April 2019.

RESULTS

51/120 (42%) of people agreed to be interviewed including 21 incarcerated men (mean age 32 [IQR 25, 39], 60% non-White). Themes that emerged from these interviews included gaps in knowledge about HCV testing and treatment opportunities in jail, the impact of captivity and transience, and interest in improving linkage to HCV care after release. Many stakeholders discussed stigma around HCV infection as a factor in reluctance to provide HCV testing or treatment in the jail setting. Some stakeholders expressed that stigma often led decisionmakers to estimate a lower "worth" of incarcerated individuals living with HCV and therefore to decide against paying for HCV testing.".

CONCLUSION

All stakeholders agreed that HCV in the jail setting is a public health issue that needs to be addressed. Exploring stakeholders' many ideas about how HCV testing and treatment can be approached is the first step in developing feasible and acceptable strategies.

Transitioning into the Community: Perceptions of Barriers and Facilitators Experienced By Formerly Incarcerated, Homeless Women During Reentry-A Qualitative Study

Formerly incarcerated, homeless women on parole or probation experience individual-and structural-level barriers and facilitators as they prepare to transition into the community during reentry. A qualitative study was undertaken using focus group methods with formerly incarcerated, currently homeless women (N = 18, M_age = 37.67, SD 10.68, 23-53 years of age) exiting jail or prison. Major themes which emerged included the following: (1) access to resources-barriers and facilitators during community transition, (2) familial reconciliation and parenting during community transition, and (3) trauma and self-care support during community transition. These findings suggest a need to develop multi-level interventions at the individual, program and institutional/societal level with a gender-sensitive lens for women who are transitioning to community reentry. It is hoped that providing such resources will reduce the likelihood of homelessness and reincarceration.

Pregnancy Prevalence and Outcomes in U.S. Jails

OBJECTIVE

To describe the number of admissions of pregnant people to U.S. jails and the outcomes of pregnancies that end in custody.

METHODS

We prospectively collected pregnancy data from six U.S. jails, including the five largest jails, on a monthly basis for 12 months. Jails reported de-identified, aggregate numbers of pregnant people admitted, births, preterm births, cesarean deliveries, miscarriages, induced abortions, ectopic pregnancies, and maternal and newborn deaths.

RESULTS

There were 1,622 admissions of pregnant people in 12 months in the selected jails. The highest 1-day count of pregnant people at a single jail was 65. The majority of these admissions involved the release of a pregnant person. Of the 224 pregnancies that ended in jail, 144 (64%) were live births, 41 (18%) were miscarriages, 33 (15%) were induced abortions, and four were ectopic (1.8%). One third of the births were cesarean deliveries and 8% were preterm. There were two stillbirths, one newborn death, and no maternal deaths.

CONCLUSION

About 3% of admissions of females to U.S. jails are of pregnant people; extrapolating study results to national female jail admission rates suggests nearly 55,000 pregnancy admissions in 1 year. It is feasible to track pregnancy statistics about this overlooked group.