Nearly 107,000 people died in 2021 from drug overdoses, more than five times the number of deaths by homicide in the same year.
And drug convictions only increase risk of death, while showing no evidence of deterring crime. An estimated 65 percent of incarcerated persons have a substance use disorder. And inmates in their first two weeks after release are 129 times more likely than the general population to die from drug overdose.
Ethnic minority populations, as well as indigenous, lesbian, gay, and transgender individuals, are disproportionately represented in jails and prisons. According to data from the federal National Institute of Justice, Black men are seven times as likely to be incarcerated as white men, and a study by the Pew Charitable Trust found that they stay in jail 12 days longer on average. These communities are already less likely to receive substance use disorder treatment.
Additionally, the incarcerated are more likely than the rest of the population to have chronic physical or behavioral health conditions. Jails have become a backstop for the mentally ill, and prisons a hospice for the sick and dying.
Ironically, we have had the equivalent of penicillin to treat this problem for nearly 60 years, but we have systematically denied it to this war’s casualties.
When Medicaid became available to low-income populations in 1965, it came with a caveat. After a long back-and-forth across party lines over who should be responsible for state and local jails’ healthcare, Congress decided that Medicaid should exclude people who were incarcerated. This exclusion is called the inmate exception. In 1965, there were roughly 210,000 people incarcerated across the U.S. As of 2020, that number has increased almost ninefold.
Federal incentives in the 1980s and ’90s to build jails, arrest for drug-related offenses, and impose mandatory minimum sentences fueled this situation. The local capacity to jail far exceeds the local provision of adequate healthcare. No standard of care exists for people who are incarcerated, and accreditation for jails and prisons varies widely. The reversal of Roe v. Wade may even threaten a related court precedent that gives states what little incentive they have for providing healthcare to prisoners.
This attack hasn’t gone without response. The Centers for Medicaid and Medicare Services recently offered guidance and support to states in applying for special permission to use federal funding for carceral healthcare spending. States can also use the funding to help connect people in jail to community services that support health-related social needs, improving health outcomes and reducing risk for recidivism.
Applying is a big lift for most states, even with guidance and support. Of the 15 states asking so far, only California has received special permission to use federal funding. States must make room in their budgets that they may not have and must account for the existing hodgepodge of carceral health spending sources.
Congress can take action to make the load a bit lighter.
The Reentry Act is co-sponsored by Republicans and Democrats alike. The bill allows for Medicaid coverage up to 30 days prior to release from incarceration. The bill would also lower the bar for states’ individual success in applying for a waiver specific to their populations’ needs.
Not only would the legislation save the states money, it would save the feds money too. A 2014 study found, and likely underestimated, that 7.2 percent of inpatient hospitalization expenditures and 8.5 percent of emergency room expenditures came from justice-involved individuals, despite only accounting for 4 percent of the general population. The survey doesn’t account for hospitalizations and emergency department visits driven by the overdose crisis today.
When a chronic condition goes undertreated, or its treatment is interrupted, and people aren’t connected to a community provider because they are in jail, their condition gets worse and they have to go to the hospital. The federal government spent $174 billion on hospital expenditures last year. Thus, the establishment of connections between inmates and community providers before release could save federal government more than $7 billion over 10 years due to hospital spending — nearly twice the projected cost of the bill.
The federal government has shot itself in the foot with the inmate exclusion, hemorrhaging missed savings and driving a national health crisis. Congress must pass the Reentry Act to stop the bleeding.
David Seaman is a Master of Science candidate in Addiction Policy and Practice (ADPP) at Georgetown University, and serves as president and founder of Hoyas for Recovery.