The Biden administration this week stepped up efforts to fund opioid addiction treatment in prisons and jails, a major part of its drug policy agenda, and called on states to adopt a new Medicaid program that will cover health care for incarcerated people.
Under new leadership from the Center for Medicare and Medicaid Services, states can ask the federal government to allow Medicaid to cover addiction treatment for up to 90 days before someone is discharged. Public health experts say providing treatment during this critical period could help people survive the often harsh conditions of jails and prisons and then more easily reintegrate back into the community.
Correctional facilities, where inmates disproportionately suffer from opioid use disorder and often cannot find treatment during and after their incarceration, have claimed a place at the forefront of a devastating overdose epidemic that now kills more than 100,000 Americans each year.
“That’s where most people are, and that’s where you’ll benefit the most,” said Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy, referring to the high concentration of incarcerated Americans with opioids. use disorder. The neglect of addiction treatment in prisons and jails, he added, comes at “the highest cost to society, to the taxpayer.”
The stakes of the issue are neatly represented by a series of white stripes towering over the common area of Curran-Fromhold Correctional Facility, a Philadelphia prison along the Delaware River that Dr. Gupta. The bars that line the second-floor walkway are, officials say, in part to prevent residents with opioid use disorder from jumping to attempt suicide when experiencing withdrawal symptoms.
Federal law bars incarcerated Americans from getting coverage through Medicaid, the federal-state health insurance program for low-income people, unless they are in an inpatient facility such as a hospital. The ban, known as the prisoner exclusion policy, means states, counties and cities typically foot the bill for programs that help opioid users manage or prevent the debilitating cravings and withdrawal symptoms that follow incarceration.
Curran-Fromhold’s treatment program offers methadone and buprenorphine, two of the most common and effective opioid addiction treatments that have been shown to reduce cravings. It is funded by the city of Philadelphia, making it an obvious target for Medicaid coverage, Dr. Gupta. Running treatment programs in prisons and jails can be expensive.
Bruce Herdman, chief of medical operations for the Philadelphia prison system, said if Pennsylvania secured Medicaid funding for the jail, the move would allow the system to save money on other key programs and medications.
“It will allow us to provide services that we currently cannot afford,” he said, referring to possible Medicaid funds.
Even before the new guidelines were issued, the Biden administration encouraged states to apply for the Medicaid program. In January in California became the first state for its approval, and more than a dozen other states are pending applications. Dr. Gupta said the new guidelines would most likely prompt more states to apply for Medicaid coverage for the kind of help Curran-Fromhold offers.
One state that could seek funding is Pennsylvania, which has struggled with a devastating increase in drug overdoses in recent years. A spokesman for the Pennsylvania Department of Human Services said state officials were still evaluating Medicaid enrollment plans and, in the meantime, were focused on restoring Medicaid benefits to inmates after their release.
Regina LaBelle, who served as acting director of the Office of National Drug Control Policy under President Biden, said she fears the state health department may not have the resources to apply for the program.
“It takes up a lot of time,” she said. “Do they have people in their office of Medicare and Medicaid services who can put time and energy into this document?”
Some conservative critics of opioid addiction treatment argue that because buprenorphine and methadone are opioids, their use should not be encouraged. But the Medicaid program has already shown bipartisan appeal, and some conservative-leaning states like Kentucky, Montana and Utah have applied for it.
For states that want to participate in the program, the federal government requires correctional facilities to offer methadone and buprenorphine. The guidelines also require states to suspend, rather than end, Medicaid coverage while people with insurance are incarcerated, allowing them to transition back into their health plans more quickly once they are released.
Dr. Gupta said such an approach could better allow those newly released to see the doctor they saw before their incarceration. Correctional facilities are also expected to provide inmates with 30 days of treatment after release, giving people a head start on re-entering society.
“These are all transitions where things fall apart, both from the outside-in transition and from the inside-out,” said Dr. Josiah D. Rich, an epidemiologist at Brown University.
People in prisons and jails are particularly vulnerable to fatal overdoses shortly after their release, when their tolerance to the drugs had weakened. Studies show that the risks of overdose in days and weeks after release is substantially reduced if the incarcerated person is taking buprenorphine or methadone.
About two million people are held in jails and prisons in the United States every day, and a substantial number of them suffer from an opioid use disorder, federal officials say. Withdrawal symptoms can be particularly acute during shorter stays in prisons, many of which do not have treatment programs. According to federal government estimates, about nine million people pass through prisons each year.
Buprenorphine and methadone usually require continuous, uninterrupted use to help drug users gradually dull their cravings. The average length of stay in a Philadelphia jail is about 120 days, meaning Medicaid with a 90-day coverage period could pay for treatment for most or all of the time a person spends there.
Researchers from the Jail and Prison Opioid Project, a group that Dr. Rich helps lead and which studies treatment among incarcerated people, they estimate that only about 630 of the approximately 5,000 correctional facilities in the country that offer drug treatment for opioid use disorder. Researchers estimate that 2 percent of incarcerated people in the United States are known to have received such treatment in jail or prison.
Dr. Gupta pointed to what he said is a glaring irony in much of America’s prison population: People are incarcerated for drug use, then denied treatment.
The Biden administration’s push for states to use Medicaid funds in jails and prisons overlaps with bipartisan efforts in the House and Senate to pass Medicaid Re-entry Actwhich would provide coverage for 30 days prior to the prisoner’s release.
The administration said that by summer, all 122 Federal Bureau of Prisons facilities will be equipped to offer drug treatment. But most incarcerated people they are in state and local jails and prisons, which feature a patchwork of treatment policies that can vary by location. Some correctional facilities allow only one treatment, while others allow medication only for those who received it prior to incarceration.
“There is a stigma around using medication for treatment, but also a stigma around opioid use disorder in general,” said Dr. Elizabeth Salisbury-Afshar, an addiction physician at the University of Wisconsin-Madison who has advised prisons on treatment programs. “There is a wider gap in education.”
Dr. Dorian Jacobs, a physician who helps run the addiction treatment program at Curran-Fromhold Prison, said she has met residents with opioid use disorder who did not realize it was an illness that should be treated like any other.
“It’s just part of who we are,” she said.