Recently, in JAMA Health Forum, we analyzed whether health insurance expansions under the Affordable Care Act (ACA) — including state Medicaid expansions — improved health and social outcomes for formerly incarcerated people. Our findings are relevant for a rapidly evolving area of health policy: Nearly half of U.S. states have applied for or secured waivers to expand Medicaid’s role in covering health care services for individuals preparing to reenter the community after incarceration.
Our analysis reveals that health insurance expansions like those enacted through reentry waivers can deliver benefits, including increasing insurance coverage and decreasing reincarceration risk. Our review also highlights gaps in evidence about how expansions have impacted other key outcomes like access to and cost of care. To improve the design and increase adoption of Medicaid expansions for the reentry population, we must invest in rigorous research to address these gaps. Collaboration among state policymakers — including Medicaid administrators and departments of corrections — can facilitate evidence generation and effective implementation of Medicaid coverage for people transitioning from incarceration.
Background on Reentry Waivers
The Centers for Medicare and Medicaid Services (CMS) recently issued guidance inviting states to apply for Section 1115 waivers allowing Medicaid to cover certain health services for incarcerated people that are otherwise prohibited by law. The goal is to improve outcomes among people who transition back into the community after incarceration, a population that suffers from disproportionately high morbidity and mortality rates. The types of services covered by the waivers include case management, medication-assisted treatment for substance use disorders, a postrelease supply of needed prescription drugs, and more (e.g., family planning care, infectious disease treatment).
As of this writing, CMS has approved these waivers for 11 states; applications from 13 other states are pending. The approved waivers vary in scope, covering different benefits, eligible settings, and Medicaid coverage periods. California was the first state to implement its waiver in October 2024.
ACA Expansions Are Associated with Higher Insurance Coverage and Lower Criminal Involvement
Our review found that ACA health insurance expansions were strongly associated with two outcomes: increased insurance coverage and decreased reincarceration risk. Several studies found that implementation of the ACA was associated with lower uninsurance rates among people with histories of incarceration. Moreover, five investigations studied changes in reincarceration rates and crime rates post-ACA and suggest Medicaid expansion is associated with decreased crime rates and reincarceration. For example, one study suggested that Medicaid expansion was associated with decreased rates of burglary and robbery, motor vehicle theft, and violent crime. Another found the rates of individual returns to prison within one and two years of release were significantly lower in expansion states versus nonexpansion states.
Research on other outcomes (e.g., access to care, health gains) was either scant or conflicting. Several studies focused on substance use and mental illness treatment, but they diverged in whether ACA coverage expansions were associated with improved access to these forms of care.
A Much Stronger Evidence Base Is Needed for Reentry Health Policy
A wealth of data supports the ACA’s impact on health among the noninstitutionalized population. But the literature on people with histories of incarceration is comparatively sparse. More than half of available studies draw from only two data sources: the National Survey on Drug Use and Health (NSDUH) and Treatment Episode Data Set: Admissions datasets. The linkage of health and criminal/legal data is rare; NSDUH is one of the only surveys to collect both types of data.
Our review suggests that reentry waivers are well positioned to benefit people with histories of incarceration. But without rich data sources measuring health outcomes and incarceration history, determining whether these interventions are working will be difficult. Creating novel datasets will require meaningful collaboration between policymakers and researchers.
Massachusetts has created the Public Health Data Warehouse, which links data across state government agencies. In a 2023 study, we used this dataset to study rates of opioid overdose among racial and ethnic minority individuals released from prison. If other states were to create similar resources, we could more effectively understand health and social welfare outcomes among people with incarceration histories and evaluate how existing policy interventions are affecting those outcomes.