Missouri faces a historic opportunity to provide Medicaid coverage to currently incarcerated individuals through the new Medicaid Reentry Section 1115 Demonstration Opportunity. This opportunity, also known as a Section 1115 waiver, allows states to cover a package of pre-release services for up to 90 days prior to the individual’s expected release date. In order to provide the greatest benefit, Missouri should include county and city jails in the planning, drafting, and implementation of its Section 1115 waiver.
1. Jails House the Largest Number of Incarcerated Missourians.
Jails house more than five times as many individuals than prisons annually. Although Missouri state prisons house more individuals than jails do on any given day, more Missourians cycle through jails than prisons. On a single day in Missouri in 2015, prisons housed 30,337 individuals while county jails held a total of 11,372 individuals. From an annual perspective, however, four county jails had annual counts for 2015 that were greater than the ten busiest state prisons combined.[1] Most of these individuals are eligible for Medicaid.
2. Jails House the Sickest Incarcerated Missourians.
The American criminal justice system is the largest provider of mental health care on the planet. Incarcerated individuals experience much higher rates of chronic, acute, and mental health issues than the general public; those in jails are sicker than those in prisons. People incarcerated in jails have higher incidences of mental illness and substance use than those in prisons: serious psychological distress (26% v. 14%, almost twice as many, compared to 5% among the general population) and major depressive disorder (31% v. 24%).[2] 63% of jail residents report having a substance use disorder, compared to 58% of prison residents.[3]
3. Most State Waivers Consider Jails Necessary Participants.
As of August 2024, CMS has accepted waivers from eleven states and thirteen more states have waiver applications pending. Arkansas, California, Illinois, Massachusetts, New Hampshire, New Mexico, Oregon, Utah, Vermont, Washington, and West Virginia include state prisons, county and city jails, and juvenile facilities in their definition of “correctional facilities.”
4. The Missouri Sheriffs’ and Jail Administrators’ Associations Want to Provide These Services.
The Missouri Sheriffs’ Association has identified Medicaid coverage pre-release as a critical tool for improving reentry success and is eager to work with the state on the waiver. Medicaid coverage for these services will make it financially feasible for jails to coordinate critical reentry services.
Expanding Medicaid access for incarcerated individuals in Missouri needs to include those in jails in order to reach the greatest number of people and provide the greatest benefit to the state.
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[1] The top ten busiest state prisons had a total annual count of 8,141 compared to the top ten busiest county jails, with a total head count of 78,211. St. Louis City, Greene, St. Louis, and Jackson counties each had annual counts over 9,000. Vera Institute of Justice, Incarceration Trends in Missouri: Incarceration in Local Jails and State Prisons (2019), https://www.vera.org/downloads/pdfdownloads/state-incarceration-trends-missouri.pdf.
[2] Jennifer Bronson & Marcus Berzofksy, Bureau of Justice Statistics, Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-2012, NJC No. 250612 (Jun. 2017), https://bjs.ojp.gov/library/publications/indicators-mental-health-problems-reported-prisoners-and-jail-inmates-2011.
[3] Natasha Camhi, Dan Mistak, and Vikki Wachino, Commonwealth Fund, Medicaid’s Evolving Role in Advancing the Health of People Involved in the Justice System (Nov. 2020), https://doi.org/10.26099/903e-r786.