Study: Opioid use disorders are undertreated among formerly incarcerated Virginians on Medicaid

This article was reprinted with permission from Virginia Mercury

A new Virginia Commonwealth University study shows that opioid use disorders are underdiagnosed and undertreated among formerly incarcerated Virginians enrolled in Medicaid.

Among the 4,652 adults released from state prisons in 2022, the study shows 85% were enrolled in Medicaid within one month of their release. While 13%, or 514 of these adults had a diagnosis of opioid use disorder, only a quarter received medication treatment through Medicaid.

By comparison, 78% of all Medicaid members with an opioid use disorder in state fiscal year 2021 received treatment.

“Based on national statistics, we expected more people to receive a diagnosis and treatment for opioid addiction,” said Dr. Peter Cunningham, the lead study researcher and interim chair of the Department of Health Policy at VCU’s School of Population Health. “This is concerning because having an undiagnosed, untreated opioid use disorder greatly increases the risk of overdose.”

The study is part of an ongoing evaluation with the Department of Medical Assistance Services to review the addiction recovery and treatment services program, a comprehensive benefit designed to provide substance use disorder treatment services to Medicaid members.

Since Virginia expanded Medicaid in 2019, Cunningham said most adults being released from jails or prisons in the commonwealth qualify for coverage. However, delays in setting up a treatment plan and complications transitioning back to community living pose several barriers to accessing healthcare needs.

Barriers to care

While incarcerated individuals are able to apply for Medicaid, their benefits — including substance use disorder treatment services — are unavailable to them until after their release.

That system, said Libby Jones, program director at the Overdose Prevention Initiative, is by design through the federal Medicaid inmate exclusion policy in the Social Security Act of 1965. As a result, the burden of inmate healthcare expenses falls to the local jurisdiction where jails and prisons are located.

“That is a problem in the sense that oftentimes folks are only getting the bare minimum of their healthcare addressed,” Jones said. “What’s not being addressed are the underlying issues.”

Cunningham emphasized that there needs to be a focus on identifying and getting people into treatment before they’re released, as opioid addictions can still be fueled while incarcerated. However, he said facilities may express hesitancy offering medication assisted treatment because some are classified as controlled substances.

Utilizing Medicaid benefits upon release can also be challenging, Cunningham said. When a person enrolls in Medicaid, he said they start out in the “fee-for-service” system where they don’t have a particular network of providers, meaning “you’re kind of on your own to figure out …  where you’re going to go.”

Some individuals have to wait up to a month after their release to be assigned a specific health plan to help navigate their benefits and find providers, a time frame Jones said is crucial for accessing treatment. According to a 2018 North Carolina study, formerly incarcerated individuals are 40 times more likely to overdose within the first two weeks after their release.

“It’s not only a concern in terms of the increased risk of overdose and death, but it’s also if their addiction isn’t managed, that’s going to affect their transition into the community,” Cunningham said. “It’s going to affect their ability to find work and stable housing and it’s potentially going to lead to reincarceration.”

Many formerly incarcerated individuals face additional barriers to treatment upon their release, said Cunningham, like lacking a stable home or transportation, as well as being unaware of their options to get help. That transition period, he said, can be very unstable and uncertain and getting treatment may not be a priority for some.

“A lot of them are kind of just falling through the cracks,” Cunningham said.

Solutions moving forward

Jones said treatment programs within jails and prisons have been shown to have a great impact on reducing overdoses, recidivism rates and lowering costs for the facilities.

For example, Chesterfield County Jail has a program, funded primarily by grants and the county itself, that provides access to both medication for opioid disorder treatment and therapy. The re-arrest rate for people in the program, Jones said, was almost half for people who were released from jail who hadn’t been in the program.

Despite the Chesterfield jail program’s success, the Fairfax County Adult Detention Center is the only other jail in the commonwealth to utilize it. Members of Congress, including U.S. Rep. Abigail Spanberger, D-Prince William, visited the facility this January to hear from inmates participating in the program.

Inmates “feel hope for their life post-release because they are finally stable, they’re able to learn skills that will help them gain employment,” Jones said. “None of this would have been possible had they not received treatment.”

Investing in similar programs has been shown to also save money for prisons and jails. A 2022 Kentucky criminal justice treatment outcome study showed that for every $1 spent on the state’s correction-based substance use disorder treatment, there is a $4.54 cost offset.

Jones said having Medicaid services provided during incarceration would “dramatically” help address treatment accessibility by covering some of the costs typically paid for by localities and could bring about similar programs in other jails and prisons.

“Not only would it pay for the medications, it would also establish … standards of care. … If you are a Medicaid beneficiary, there are certain standards of care that you are entitled to,” Jones said. “So having those standards of care all put into place in the carceral system would also improve healthcare.”

This is why Jones is advocating for Congress to pass two bills, the Due Process of Continuity of Care Act and Reentry Act, both of which are bipartisan and backed by U.S. Rep. Jennifer McClellan, D-Richmond. The former would allow inmates to retain their Medicaid benefits while incarcerated and the latter, also backed by U.S. Reps. Gerald Connolly, D-Fairfax, and Spanberger, would restart the inmate’s benefits 30 days prior to their release to prevent gaps in coverage.

While some might disagree with the concept of investing in inmates or formerly incarcerated individuals, Cunningham emphasized that most people in prisons and jails are going to be released at some point and should be given the opportunity to succeed in life.

“Whatever your view on people with criminal records or people in prisons is, I think it’s in everybody’s best interest to make sure that when they are released, we give them the best chance to reintegrate into the community,” Cunningham said.

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