In 1965, the Social Security Act created Medicaid as an insurance program to support access to healthcare for persons with limited income. The Social Security Act established the Inmate and the Institutions for Mental Disease exclusion policies to prohibit Medicaid reimbursement for services delivered in institutions, but it also allowed states to test new ways of delivering care through application for an 1115 MIEP waiver. In 1965, healthcare services available to persons living in the community were not routinely offered to incarcerated populations (16). In 1976, the United States Supreme Court ruled in Estelle v Gamble that correctional settings that failed to provide incarcerated persons with adequate medical care commensurate with the community-standard was a violation of the Eighth Amendment of the US Constitution. Although access to healthcare in correctional settings has vastly improved since then, wide variability remains (17,18).

Before the Affordable Care Act Medicaid expansion in 2014 (19), many persons released from incarceration did not meet their states’ Medicaid eligibility requirements, which often did not cover low-income adults without children. In states that expanded Medicaid under the Affordable Care Act, most persons became eligible for Medicaid at the time of release from incarceration; however, MIEP continued to prevent activation of Medicaid coverage during incarceration. In 1997, the Centers for Medicare & Medicaid Services (CMS) modified the scope of the MIEP by reinstating Medicaid coverage for incarcerated persons who are hospitalized >24 hours but continued to prohibit Medicaid coverage for outpatient services during incarceration (20).

As of January 2024, at least one quarter of states, including Massachusetts, had applied for an 1115 MIEP waiver. In 2023, CMS granted 1115 MIEP waiver requests to California and Washington to cover transitional care services provided to persons in the 90 days before their release from incarceration (39), and CMS issued guidance to help states understand what provisions might be waived (40). In December 2021, Massachusetts submitted an 1115 MIEP waiver request with input from many collaborators, including but not limited to the Massachusetts Sheriffs’ Association and Department of Correction. As outlined in the waiver application, the major goals for Massachusetts are to improve prerelease and postrelease care management and connection to healthcare services, to improve healthcare outcomes, and to decrease outcome disparities (41,42). Incarcerated persons who meet Massachusetts Medicaid income eligibility criteria would be able to receive Medicaid covered services during a prerelease period. To ensure that all persons incarcerated within a facility have equal access to healthcare services, correctional budgets would need to support provision of Medicaid-covered services for persons who do not meet Medicaid eligibility requirements. Massachusetts originally requested coverage during a prerelease period of 30 days (43); the recent CMS guidance allowed a prerelease period of up to 90 days (40), and Massachusetts resubmitted its waiver request on October 16, 2023, proposing coverage 90 days before release for all incarcerated persons (43).

An 1115 MIEP waiver would provide several opportunities for improving infectious disease care. High-cost, evidence-based medications (e.g., for treatment for hepatitis C and preexposure prophylaxis for HIV) could be initiated before release and supported by robust linkage to care programs after release. Medications and treatment for substance use disorder could be augmented, reimbursed, and continued seamlessly in the community, enhancing opportunities for successful re-entry. Intensified support for care coordination and for linkage to care at the time of re-entry has also been proposed in the newest application—a strategy that has been shown to increase continuation of care and improve infectious disease outcomes (44–46). Care coordination staff embedded within the jail or prison would assist with completion of health insurance paperwork, scheduling of clinician appointments, and other tasks at re-entry. Data sharing between the correctional health system and the community health system would be improved. An 1115 MIEP waiver could change the experience of a person with an infectious disease or substance use disorder transitioning from correctional to community healthcare (Table).

The 1115 MIEP waiver requested by Massachusetts would support a warm handoff, either through in-person or telehealth meetings, in which the clinician who will be treating the person in the community can meet with the jail or prison clinician. Medicaid enrollment during incarceration would enable providers to schedule appointments for persons soon after their expected release date; in some cases, the community provider might meet with the patient in person or via telehealth visit before release (47). The process of such handoffs is intended to reduce apprehension about stigmatizing experiences in the community and to improve engagement in postrelease care. The approach used by the Transitions Clinic Network, with 48 clinics across the country, serves as a model for hiring, training, and supporting a workforce dedicated to health at the time of re-entry (48,49).

As states implement MIEP-related policy changes, they should develop monitoring systems to help identify potential delays in healthcare access that may occur during incarceration or at the time of re-entry into the community. Moreover, states should establish accountability processes to ensure that correctional settings do not delay healthcare delivery until 90 days before release, when Medicaid could reimburse services rendered. For example, persons with liver disease from hepatitis C should be prioritized for treatment as soon as possible. Collaborative systems of care and open communication between clinicians, correctional administrators, and public health agencies should ensure that appropriate healthcare is delivered throughout incarceration and at re-entry into the community.

Building on 1115 MIEP waiver–associated successes and lessons in California, Washington, and, eventually, Massachusetts, state Medicaid agencies can request to waive the federal MIEP to positively affect eligible justice-involved persons and the broader public. Repealing MIEP at the federal level would eliminate the need for states to apply for MIEP waivers. The growing number of 1115 MIEP waiver applications signals the strength of cross-sector partnerships among public health, policy, healthcare, and correctional leaders that can be leveraged for more robust legislative change to improve continuity of healthcare for incarcerated persons.