‘We’re worried this will have an impact on overdose death rates around the country’

Since the Affordable Care Act passed 15 years ago, more than 21 million low-income and disabled people have gained health insurance and the ability to access mental health care and addiction services. Indeed, Medicaid is the largest funder of these services in the country.

One group that has long been excluded from Medicaid – and, for the most part, any effective health coverage – is people who are reentering society after being incarcerated in prisons or jails. When they are freed, they have a very difficult time accessing health care – including services that can help them cope with substance use and mental health challenges. And that can be deadly: A 2018 study in the American Journal of Public Health found that in the first two weeks after release, former inmates were 40 times more likely than members of the general population to suffer a fatal overdose; over the course of a year, they were 11 times more likely.

In recent years, advocates and policy makers have attempted to address this by pursuing policy changes that allow incarcerated people to be enrolled onto Medicaid shortly before their release. That way, they’ll be able to get care as soon as they are free – including treatment for addiction. California was the first to get federal permission to do this and other states have been trying to follow.

Advocates fear these kinds of efforts could be on the chopping block as the Trump Administration and Congressional Republicans eye massive spending cuts. The push by House Republicans to cut federal spending by $880 billion over ten years, for example, could only come through massive cuts in Medicaid. . 

“Having access to health coverage including as people come out of prisons and jails has an impact on people’s ability to be successful as they’re reentering the community from incarceration,” said Gabrielle de la Guéronnière, vice president of health and justice policy at Legal Action Center. 

De la Guéronnière and other advocates fear that these kinds of efforts could be on the chopping block as the Trump Administration and Congressional Republicans eye massive spending cuts. The push by House Republicans to cut federal spending by $880 billion over ten years, for example, could only come through massive cuts in Medicaid. Various Republican-backed bills in Congress seek to impose work requirements on people as a condition of being enrolled in Medicaid.

MindSite News spoke with de la Guéronnière, who has worked for decades to expand health coverage for substance use disorders and to end discrimination against people with histories of drug and alcohol usage. 

This conversation has been edited for brevity and clarity.

Josh McGhee: What parts of Medicaid do we think will be under attack in the coming weeks, and how would these cuts affect people?

Gabrielle de la Guéronnière: Cutting Medicaid – funding or programming – is going to have an impact on the people served by the program across the board. We’re very worried about proposals to cut funding, to reduce the federal match for these services, or proposals like work requirements. Anything that cuts Medicaid funding or restricts coverage is going to hurt people – including people who are leaving incarceration.

We’re talking about really devastating cuts that are being discussed. The House has told the House Energy and Commerce Committee to make $880 billion worth of cuts over 10 years. Due to what the committee has in its jurisdiction, the majority of that would have to be Medicaid. We know that Medicaid is a critical source for substance use disorder services, medications for opioid use disorder.

We’re very worried that this will have an impact on overdose death rates around the country knowing that’s an extremely vulnerable time as people are coming home from incarceration. We are concerned about both substance use disorders being a huge risk for people and mental health conditions. For people coming home, suicide is also a great risk since its such a stressful time for people. 

We’re concerned about all of these different proposals. I mentioned work requirements. We know that people who have arrest and conviction records have barriers to employment. We’re extremely worried about the impact of conditioning health insurance on an ability to demonstrate work.

How much progress has been made in the effort to get Medicaid coverage for people preparing to leave prison?

There has been a push from policy makers and stakeholders all across the country to try to better leverage Medicaid as people are coming out of incarceration. It led to legislation at the federal level that instructed the Centers for Medicare and Medicaid Services to issue guidance about how states could accomplish this using a demonstration waiver.  

This came out in 2023, and we now have 19 very diverse states that have sought or gained approval from the federal government to allow for federal Medicaid to pay for certain services before people come home. For states that were part of the Mediciad expansion, it is 90% federal dollars. 

We only have a few states who are able to implement this now. California was the first state to receive federal approval for its Medicaid reentry waiver, and they actually started billing. Some states received approval as recently as January at the end of the Biden-Harris Administration. It’s not quite up and running everywhere, but there is a huge interest and that includes very diverse states and a number of states with Republican governors. 

We’ve also seen a lot of support from the law enforcement and corrections community. They understand that people having better access to health care when leaving incarceration will be better across the board for people’s health outcomes and preventing recidivism.

In states that expanded Medicaid under the Affordable Care Act, the federal government pays 90% of the cost of care and the states pick up the other 10%. What do we know about proposals to cut the federal match? 

A lot of this is still under discussion, but we have heard recently that Republican leadership is focusing on that 90% and wanting it to be less, so more state funds would go into it.

 A number of states have trigger laws, so if a change is made at the federal level to decrease the amount of federal dollars for Medicaid services,  expanded eligibility in the state would end or be reduced. We could see people lose their coverage completely. We could see states try to restrict costs and try to limit access to certain kinds of services or interventions. Or make changes in how they determine who is eligible. It could become more expensive for people, which is a huge concern for so many.

Once you make a change to the Medicaid program, it’s really going to have an impact on all kinds of people – children, people with disabilities, people with chronic health conditions.

Are there other concerns we should have?

Yes. SNAP [the Supplemental Nutrition Assistance Program], is critically important for people coming home from incarceration. We’re very concerned about cuts that would make it more difficult for people and their families to access nutritional support and get the food that they need. 

We can see work requirements connected to SNAP – people having to demonstrate that they’re working. That could have an impact on their ability to access those benefits. We could see changes to eligibility criteria so people are less able to access SNAP benefits.

These Medicaid reentry waivers have strong bipartisan support around the country. There’s a lot of agreement that this makes people more successful when they come home. Any kind of threat to Medicaid is going to impact these popular waivers. We can’t look at it in isolation from each other. It’s all connected.