Expanding Access to Basic Reentry Services Will Improve Health, Well-Being, and Public Safety

The current U.S. criminal legal system’s approach to holding people accountable obstructs those returning home from a period of incarceration from accessing basic resources—including health care, employment, education, housing, and food assistance—and is antithetical to breaking the cycle of offending.¹ Partly because of systemic failures to connect reentering individuals to necessary resources, nearly three-quarters of people returning from prison are rearrested within five years of release.² Of these failures, restrictions that limit access to adequate health care services are one of the most influential factors underlying recidivism. And while everyone deserves to be safe in their communities, policymakers have neglected to sufficiently prioritize reentry health care services over more punitive measures, thus failing to create meaningful and lasting safety for individuals and their communities.³

Although those returning to their communities after incarceration can have complex and overlapping needs, access to adequate health care is critical given that this population experiences threats to their physical and mental well-being at a rate disproportionate to that of the general population.⁴ According to a 2008 Urban Institute report, one-half of men and two-thirds of women who were rearrested after a period of incarceration had a chronic physical ailment such as asthma, diabetes, hepatitis, HIV/AIDS, or cardiovascular disease.⁵Research has also revealed that mental health disabilities and substance use disorders are staggeringly prevalent in the U.S. prison population: Around half of incarcerated individuals experience co-occurring mental health disabilities and substance use disorders.⁶

These ailments are often untreated before incarceration. Many people’s first opportunity to access health care resources is when they are incarcerated.⁷ Once released, individuals are often cut off from the care they received while incarcerated, further destabilizing their lives and increasing their likelihood of reoffending or even death.⁸ A study examining 14 years of New York State parole data found that each additional year spent in prison resulted in a two-year decrease in lifespan, with death rates peaking two weeks after release, which can be a result of people losing access to medications and treatment they received while incarcerated.⁹

Connecting formerly incarcerated individuals to services to address health-related social needs immediately upon release is essential to equip them to successfully reintegrate into their communities and prevent recidivism.¹⁰ Policymakers can support these efforts by:

• Expanding Medicaid coverage, including increased funding for community-based services, for returning and incarcerated individuals to make physical and behavioral health services more accessible
• Supporting the creation of culturally competent community health infrastructure, such as mental health and substance use treatment programs
• Expanding the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) benefits to support formerly incarcerated individuals
• Passing automatic record expungement measures at the state and federal levels

Addressing the health care and health-related social needs of people returning to their communities should be a part of a comprehensive approach to reentry. When taken together, these measures provide a more restorative way of addressing underlying health issues and reducing recidivism, improving public safety by interrupting cycles of crime.¹¹

The transition from incarceration to reentry poses significant challenges, with access to insurance and affordable health care being key determinants of recidivism rates and subsequent successful reintegration.¹² Half of those incarcerated in state prisons are uninsured at the time of their arrest, and one 2008 study found that 78 percent of men and 66 percent of women were still uninsured two to three months after release.¹³ This is the case despite formerly incarcerated individuals having more significant health care needs than the general population.¹⁴ Without insurance, formerly incarcerated individuals forgo needed care or are often forced to seek health care at facilities that are costly and not designed to support long-term or preventive care, such as hospitals or urgent care centers.¹⁵ Consequently, treatable medical conditions can worsen into acute crises, such as heart attacks or sepsis resulting from infectious disease, which can lead people to rely on emergency services.¹⁶ These stopgap measures are inadequate to support individuals who require sustained care for their ailments over time, and they put substantial strain on health care services.¹⁷

Given that many returning individuals have low incomes, a large portion of this population is likely eligible for Medicaid coverage.¹⁸ Yet, until recently, federal policy barred incarcerated individuals from eligibility for coverage, even though studies have shown that increasing access to Medicaid—either by maintaining coverage for the duration of incarceration or reinstating coverage just prior to release—decreases the likelihood of repeat offending.¹⁹

Both the federal administration and states have started the crucial work of expanding Medicaid access for reentering individuals.²⁰ In 2023, the Biden-Harris administration issued guidance for states interested in using waiver demonstrations under Section 1115 of the Social Security Act to extend Medicaid coverage to eligible incarcerated individuals who are soon to be released.²¹ The waiver allows states to provide eligible individuals Medicaid coverage for specific services 90 days prior to their release and connects individuals to health care services in the community. These services can include case management, medication-assisted treatment for substance use disorders, and a 30-day supply of prescription medication.

As of October 2024, 11 states have been approved by the Centers for Medicare and Medicaid Services for Section 1115 reentry Medicaid demonstration waivers, with applications from an additional 14 states and Washington, D.C., pending approval.²² While it is still too early to assess the full impact of the federal Medicaid program, results from similar demonstration waivers at the state level show promising results. For example, Massachusetts, while not a reentry demonstration, has used its Section 1115 waiver to create its Flexible Services Program.²³ Since the program’s inception in 2018, 93 percent of individuals referred have been connected to community organizations’ support services. Early reports also indicate that program members rely on emergency rooms for care less frequently, intake more nutritional food, and have better housing stability scores than nonmembers. Similar programs specifically for reentering individuals could be set up using the Section 1115 waivers.

In addition to this vital step, Congress should repeal the Medicaid Inmate Exclusion Policy, which would remove the federal prohibition on using Medicaid funds to provide services to incarcerated individuals.²⁴ This would allow incarcerated and formerly incarcerated people to maintain continuity of care before, during, and after incarceration. Removing this exclusion at the federal level is the best way to ensure that all incarcerated and formerly incarcerated people have access to the health care they need.

Community mental health infrastructure

People with mental health disabilities are overpoliced and overincarcerated.²⁵ An estimated 37 percent of those in prisons and jails have a mental illness, compared with 18 percent of the general population.²⁶ Yet carceral settings rarely provide adequate mental health care: An estimated 3 in 5 people with a history of mental health disabilities do not receive quality treatment while incarcerated in prison.²⁷Communities often lack longer-term options to care for these individuals post-release.

Solutions for supporting those with mental health disabilities must be comprehensive, from swiftly and effectively assessing an individual’s needs for mental health support at admission, to providing care while they are incarcerated, to connecting them with community-based services immediately upon release and following up regularly thereafter.²⁸ Mental health services must also be culturally competent, affordable, and easy to enroll in without significant administrative burdens.²⁹

Specifically, post-incarceration care should consist of evidence-based practices such as assertive community treatment, through which patients receive around-the-clock, community-based, wraparound services tailored to each individual.³⁰ These services can include medication and case management, treatment, and job placement assistance. Connecting with formerly incarcerated people who are trained as peer mental health specialists has also been shown to be helpful to those reentering.³¹ One study conducted in Massachusetts found that compared with the state’s average recidivism rate, reentering individuals who participated in a peer support program were two-and-a-half times less likely to be reincarcerated.³²

Congress should support legislation that enables the development, implementation, and expansion of accessible pre- and post-release mental health services, ultimately making communities safer. The Second Chance Reauthorization Act of 2024 would reauthorize the Second Chance Act of 2008, which provides funding for programs geared toward improving reentry for returning individuals, including support for post-incarceration behavioral health programs.³³ One important program is the Second Chance Act Crisis Stabilization and Community Reentry Program, which provides funding to state and local governments to support the implementation of clinical and recovery support services for people recently released from correctional facilities and in need of mental health or substance use services.³⁴

Community-based substance use programs

An estimated 58 percent of those in prison have a substance use disorder, compared with 17.3 percent of the general population, and a leading cause of death in the first two weeks post-release for those reentering is drug overdose.³⁵ The death rate for returning individuals are more than 12 times higher than the death rate of the general population, with overdose accounting for nearly one-quarter of all deaths.³⁶

Community-based substance use treatment programs have several advantages over hospital settings, including the ability to:³⁷

• Adapt treatment to address the root causes of individual substance use
• Ensure people remain close to their support systems
• Increase the likelihood that individuals will spend more time in treatment, a key indicator of successful recovery
• Be cost-effective

Strategies for supporting reentering individuals struggling with substance use disorders include connecting them with medication-assisted treatment programs while incarcerated and in the community after release and removing requirements that they abstain from substance use before being admitted to treatment programs.³⁸ Treatment must also be voluntary. Compulsory treatment programs are not only “less effective in terms of long-term substance use outcomes,” but they are also more harmful; involuntary treatment has been associated with an increase in the risk of nonfatal overdose.³⁹

Additional funding resources could also be used to create and maintain evidence-based, accessible community health programs and rehabilitation centers that would be contiguous with prerelease care. Many local programs that support reentering individuals experiencing an array of mental health, substance use, and behavioral health challenges have seen success.⁴¹ For example, in Webb County, Texas, the Border Reentry and Community Integration Program provides substance use treatment for released individuals and has seen fewer arrests, fewer symptoms of depression and anxiety, and increased housing stability among program participants.⁴²

Moreover, creating substance use treatment programs within corrections centers is essential⁴³ to reduce recidivism and save lives. Individuals who participated in substance use treatment programs while in prison and received continued care afterward “were 7 times more likely to be drug free and 3 times less likely to be arrested for criminal behavior” than those who did not.⁴⁴ Treatment program participants were also more likely to successfully recover from substance use and break cycles of crime and incarceration, thereby improving individual quality of life and reducing the likelihood of rearrest.⁴⁵

Good nutrition is an essential aspect of health and wellness. Yet the challenges of reentry can affect a returning individual’s ability to meet the most basic nutritional needs for themselves and their families. Research shows that returning individuals are more likely to fall below the poverty line and “are twice as likely to experience food insecurity than the general public.”⁴⁶ SNAP and TANF are valuable social safety net programs that help provide food and financial assistance to individuals in need.⁴⁷ However, current federal law lets states ban individuals convicted of a drug-related felony from these programs.⁴⁸

Ending social safety net program restrictions for individuals with a conviction is critical to ensure people returning to their communities are fully supported in meeting their basic nutritional needs. Congress should pass legislation such as the RESTORE Act, which would repeal the SNAP drug felony ban and allow individuals to apply for the program up to 30 days before their release.⁴⁹

For far too many individuals, the collateral consequences of an arrest or conviction record can limit their ability to obtain quality employment opportunities and ultimately limit access to employer-sponsored health insurance. Nearly 60 percent of people under age 65 in the United States receive health insurance coverage through an employer.⁵⁰ But as many as 90 percent of individuals leaving incarceration do not have health insurance access, in part due to unemployment.⁵¹ For these individuals, having a job is not only essential for financial security; it is also a crucial resource to help them access health care and ultimately improve life outcomes that will help break the cycle of reoffending.

Currently, there are no mechanisms available to expunge records at the federal level. And while most states do provide an opportunity to have certain records expunged, the process usually involves an arduous and time-consuming court petition process. Policymakers nationwide—at both the federal and state levels—are working to enact policy measures known as clean slate measures, which automate the expungement process for eligible records and levels the playing field for directly affected job seekers.⁵²

Twelve states have already passed clean slate legislation, including Pennsylvania, which has sealed more than 45 million records through its automated process since the measure was first enacted in 2018.⁵³ The success of clean slate measures has encouraged federal lawmakers to introduce the Clean Slate Act, which would establish the first expungement system for eligible federal drug-related offenses.⁵⁴ Federal lawmakers are also working to support clean slate measures at the state level through the Fresh Start Act.⁵⁵ This measure would create a federal grant program to support states working to implement their own automatic record clearance measures.

Addressing the basic health needs of individuals reentering their communities would improve public safety. Reentering people are often denied access to health care, mental health support, and substance use treatment—all services that would support them in successfully rebuilding their lives and break cycles of offending. Public safety solutions for people coming home from incarceration should be designed to address underlying health issues during the reentry process, focusing on rehabilitation and providing second chances, all of which promote safer communities.