Connecting Utility-Scale Renewable Energy Resources with Rural-Urban Transmission

There is a vast amount of wind and solar power ready to be harvested and moved to market across the United States, but it must be connected through long-distance transmission to protect against intermittency instability. Strategically placed long-distance transmission also ensures that rural and urban populations benefit economically from the transition to clean energy.

The Biden-Harris Administration should facilitate the transition to a clean grid by aggressively supporting utility-scale renewable energy resources in rural areas that are connected to urban centers through modernized high-voltage direct current (HVDC) transmission. To move toward total electrification and a decarbonized grid, the Department of the Interior (DOI) and the Bureau of Land Management (BLM) must encourage renewable energy production on federal land through the BLM’s multiple-use mandate. BLM must work in tandem with the Department of Energy (DOE), Department of Transportation (DOT), and the Federal Energy Regulatory Commission (FERC) to transport increased clean power generation through newly constructed HVDC lines that can handle this capacity.

This two-pronged approach will move loads from high-generation, low-demand rural areas to low-generation, high-demand (often coastal) urban hubs. As residents in the East arrive home from work and turn on their TVs, the sun is still up in the West and can provide for their energy needs. As residents in the Northwest wake up, grind coffee, and tune into the news, they can rely on power from the Midwest, where the wind is blowing.

Challenge and Opportunity

Utility-Scale Renewable Energy Development on Federal Land 

After taking office, the Biden-Harris Administration rejoined the Paris Climate Agreement and committed the United States to reduce greenhouse gas (GHG) emissions by 50–52% below 2005 levels by 2030. The Inflation Reduction Act (IRA) is a positive step toward meeting these GHG emissions goals. The IRA allocated $369 billion to climate and energy security investments, which should be used to bolster development of renewables on federal lands. Together with the Infrastructure Investment and Jobs Act, this funding affords an enormous opportunity.

Building utility-scale renewable energy infrastructure such as wind or solar requires a vast amount of space. A utility-scale solar power plant could require between 5 and 10 acres of land in order to generate enough energy to power approximately 173 homes

The federal government owns a vast amount of land, some of which is viable for wind and solar. To be exact, the federal government owns 640 million acres of land (nearly one-third of all U.S. land), which is managed through the Bureau of Land Management (BLM), the Fish and Wildlife Services (FWS), the National Park Service (NPS), the Forest Service (USFS), and the Department of Defense (DOD). 

Land owned by the BLM (245 million acres) and the USFS (193 million acres) falls under similar multiple-use, sustained-yield mandates. The majority of those combined 438 million acres under BLM jurisdiction are the concern of this memo. According to the Federal Land Policy and Management Act of 1976 (FLPMA), resources and uses on those federal lands must be used in a balanced combination that “best meets present and future needs of the American people.” This multiple-use mandate presents an enormous opportunity for deployment of utility-scale renewable energy resources. The BLM manages over 19 million acres of public lands with excellent solar potential across six states and 20.6 million acres of public lands with excellent wind potential. This land is ripe for utility-scale renewable energy generation and will be critical to achieving the nation’s decarbonization goals. Green energy generation on these lands should be privileged. 

Together, the 15 central U.S. states account for the majority of national wind and solar technical potential. However, these states are projected to comprise only a third of the nation’s electrical demand in 2050. Population-dense and predominantly coastal cities have higher energy demand, while the Midwest and Southwest are dominated by rural communities and public land. Transmission lines are needed to transport renewable energy from these central states to the urban centers with large energy markets.

Transmission Development on a Rural-Urban Grid

The U.S. grid is split into three regions: the Western Interconnection, the Eastern Interconnection, and ERCOT Interconnection (Texas). These three regions are only minimally connected nationally, regionally, or even through interstate connections due to intense localism on the part of utilities that are not financially incentivized to engage in regional transmission. There are three key utility ownership models in the United States: private investor-owned utilities (IOUs), public power utilities owned by states or municipalities, and nonprofit rural electric cooperatives (co-ops). 

The Federal Energy Regulatory Commission is an independent agency that regulates the interstate transmission of electricity. In this capacity, it ensures that regional goals are established and met. Two types of entities established by FERC, regional transmission organizations (RTOs) and independent system operators (ISOs), help to coordinate regional transmission across utilities. RTOs are voluntary bodies of utilities that streamline and coordinate regional transmission initiatives and objectives. ISOs are independent and federally regulated entities that coordinate regional transmission to ensure nondiscriminatory access and streamline regional goals. ISOs and RTOs are similar, but RTOs generally have jurisdiction over a larger geographic area. Two-thirds of the nation’s electricity load is served in ISO/RTO regions. The remainder of the energy market is dominated by vertically integrated utilities that manage both transmission and distribution.

Establishing more connections among the three regional grids will support renewable energy development, reduce GHG emissions, save consumers money, increase resilience, and create jobs. Connecting the power grid across states and time zones is also vital to peak load control. Greater connection mitigates the inherent instability of renewables: if clouds cover the sun in the East, winds will still blow in the Midwest. If those winds die, water will still flow in the Northwest’s rivers.

The best way to make connections between regional and local grids is through high-voltage direct current electrical transmission systems. HVDC transmission allows for the direct current (DC) transfer of power over long distances, which is more energetically efficient than alternating current (AC).

There is precedent and forward momentum on developing interstate transmission, including projects like SunZia in the Southwest, TransWest Express in the Mountain West, Grain Belt Express in the Midwest, and Champlain Hudson Power Express in the Northeast. The Midcontinent Independent System Operator (MISO) recently approved $10.3 billion in regional HVDC lines, a move that is projected to generate up to $52.2 billion in net benefits through mitigated blackouts and increased fuel savings. 

Though co-ops account for the smallest percentage of utilities (there are 812 total), they are found in the primarily rural Midwest, where there is high generation potential for solar and wind energy. Here, utility participation in RTOs is low. FERC has expressed disinterest in mandating RTO participation and in taking punitive action. However, it can incentivize regional planning through RTO membership or, where unappealing to local utilities, incentivize regional transmission investment through joint ownership structures. 

The Biden-Harris Administration has taken the first steps to address these issues, such as releasing an Action Plan in 2022 to encourage federal agencies to expedite the permitting process of renewable energy. The president should expand on the existing Action Plan to build a larger coalition of contributors and also encourage the following recommendations to facilitate maximum clean-energy transition efficiency. Achieving the Biden-Harris Administration decarbonization targets requires the tandem development of rural utility-scale renewable energy and regional HVDC transmission to carry this energy to urban centers, benefiting people and economies across the United States. 

Plan of Action

Recommendation 1. BLM should prioritize renewable energy permit awards near planned HVDC transmission lines and existing rights-of-way. 

Compared to FY20, BLM reported that it has increased renewable energy permitting activities by 35%, supporting the development of 2,898 MW of onshore solar, wind, and geothermal energy generation capacity. BLM received 130 proposals for renewable energy generation projects on public lands and six applications for interconnected transmission lines in 2021. The transmission line proposals would support 17 GW of energy, which would also support the transmission of renewable energy on non-federal land across the Southwest.

DOI can directly support renewable energy generation by instructing BLM to ensure that contracts are awarded through the multiple-use, sustained-yield mandate in a specific way. Though Section 50265 of the IRA mandates that oil and gas leases must continue, DOI can plan with an eye to the future. Renewables built on public lands should be constructed in areas closest to planned HVDC transmission, including but not limited to Kansas, Wyoming, and New Mexico. Renewables should always take precedence over coal, oil, and natural gas in areas where existing or future HVDC transmission lines are planned to begin construction or upgrades. Renewables should also always take precedence near railways and federal highways, where HVDC transmission is more easily implemented. Contracts for renewables near planned HVDC interstate transmission lines and existing rights-of-way like railways and highways should be given precedence in the awards process. This will prime the grid for the Biden-Harris Administration’s decarbonization goals and ensure that oil and gas generation is situated closer to legacy lines that are more likely to be retired sooner. DOI has unique considerations due to Section 50265 of the IRA, but it can still coordinate with other federal agencies to manage its constraints and judiciously prioritize transmission-adjacent renewable energy generation sites. 

Recommendation 2. FERC should incentivize regional transmission planning by encouraging federal-local partnerships, introducing joint-ownership structures, and amending Order 1000.

FERC should encourage RTOs to prioritize regional transmission planning in order to meet decarbonization goals and comply with an influx of cheaper, cleaner energy into its portfolio. The FERC-NARUC Task Force is a good starting point for this cooperation and should be expanded upon. This federal-state task force on electric transmission is a good blueprint for how federal objectives for regional planning can work hand-in-hand with local considerations. FERC can highlight positive cases like SB448 in Nevada, which incentivizes long-distance transmission and mandates the state’s participation in an RTO by 2030. FERC should encourage utility participation in RTOs but emphasize that long-distance transmission planning and implementation is the ultimate objective. Where RTO participation is not feasible, FERC can incentivize utility participation in regional transmission planning in other ways. 

FERC should incentivize utility participation in regional transmission by encouraging joint-ownership structures, as explored in a 2019 incentives docket. In March 2019, FERC released a Notice of Inquiry seeking comments on “the scope and implementation of its electric transmission incentives regulations and policy.” Commenters supported non-public utility joint-ownership promotion, including equity in transmission lines that can offset customer rates, depending on the financing structure. In February 2023, FERC approved incentives for two of Great River Energy’s interstate transmission projects, in which it will own a 52.3% stake of the Minnesota Iron Range project and 5% of the Big Stone project. In the Iron Range project, Great River can use a 50% equity and 50% debt capital structure, placing the construction expenses on its rate base. The cash flow generated by this capital structure is necessary for the completion of this interstate transmission line, and FERC should encourage similar projects and incentives.

FERC should amend Order 1000—Transmission Planning and Cost Allocation. As former Commissioner Glick has noted, Order 1000 in its current iteration unintentionally encourages the construction of smaller lines over larger-scale regional transmission lines because utilities prefer not to engage in potentially lengthy, expensive competition processes. In April 2022, FERC published a Notice of Proposed Rulemaking (NOPR), which, among other things, attempts to address this perverse incentive by amending the order “to permit the exercise of a federal rights of first refusal for transmission facilities selected in a regional transmission plan for purposes of cost allocation, conditioned on the incumbent transmission provider establishing joint ownership of those facilities.” Amending this rule and allowing federal ROFR for joint ownership structures will encourage partnerships, spread risks across more parties, and allow greater access to large investments that traditionally require an insurmountable capital investment for most investors new to this sector. The NOPR also encouraged long-term regional transmission planning and improved coordination between local and regional entities and implementation goals. The amendment was supported by both utilities and environmental groups. Public comments were closed for submission in summer 2022. Now, over a year later, FERC should act quickly to issue a final rule on amending Order 1000.

In addition to incentivizing more regionally focused transmission planning at the utility level, federal agencies should work together to ensure that HVDC lines are strategically placed to facilitate the delivery of renewable energy to large markets. 

Recommendation 3. The Biden-Harris Administration should encourage the Department of Transportation to work with the Grid Deployment Office (GDO) and approve state DOT plans for HVDC lines along existing highways and railroads. 

In 2021, the Federal Highway Administration (FHWA) released a memorandum providing guidance that state departments of transportation may leverage “alternative uses” of existing highway rights of way (ROW), including for renewable energy, charging stations, transmission lines, and broadband projects, and that the FHWA may approve alternative uses for ROWs so long as they benefit the public and do not impair traffic. The GDO, created by the Biden-Harris Administration, should work directly with state DOTs to plan for future interstate lines. As these departments coordinate, they should use a future highway framework characterized by increased electric vehicle (EV) usage, increased EV charging station needs, and improved mass transit. This will allow DOT to reinterpret impeding the “free and safe flow of traffic.” The FHWA should encourage state DOTs to use the SOO Green HVDC Link as a blueprint. The idea of reconciling siting issues by building transmission lines along existing rights-of-way such as highways or railroads is known to this administration, as evidenced by President Biden’s reference in a 2022 White House Statement and by FERC’s June 2020 report on barriers and opportunities for HVDC transmission. 

Recommendation 4. DOI, the Department of Agriculture (USDA), DOD, DOE, and the Environmental Protection Agency (EPA) should sign a new Memorandum of Understanding (MOU) that builds on their 2022 MOU but includes DOT.

In 2022, DOI, USDA, DOD, DOE, and the EPA signed an MOU that would expedite the review process of renewable energy projects on federal lands. DOT, specifically its FHWA and Federal Railroad Administration (FRA), should be included in this memorandum. The president should direct these agencies to sign a second MOU to work together to create a regional and national outline for future transmission lines and prioritize permit requests that align with that outline. This new MOU should add the DOT and illustrate the specific ways that FHWA and FRA can support its goals by repurposing existing transportation rights-of-ways. 

Recommendation 5. All future covered transmission planning should align with the MOU proposed in Recommendation 4. 

Under Section 50152 of the IRA, the DOE received $760 million to distribute federal grants for the development of covered transmission projects. Section 50153 appropriates an additional $100 million to DOE, which is specifically tailored to wind electricity planning and development, both offshore and interregional. The DOE should require that all transmission planning using this federal funding align with the long-term outline created under the MOU recommended above. Additionally, preference should be given to transmission lines (receiving federal funding) that link utility-scale renewable energy projects with large urban centers.

Recommendation 6. The EPA should fund technical and educational training to rural and disadvantaged communities that might benefit from an influx of high-demand green energy jobs. 

The federal government should leverage existing funding to ensure that rural and disadvantaged communities directly benefit from economic development opportunities facilitated by the clean energy transition. The EPA should use funds from Section 60107 of the IRA to provide technical and educational assistance to low-income and disadvantaged communities in the form of job training and planning. EPA funding can be used to ensure that local communities have the technical knowledge to take advantage of the jobs and opportunities created by projects like the SOO Green HVDC Link. Because this section of the IRA only funds up to $17 million in job training, this should be allocated to supplement community colleges and other technical training programs that have established curricula and expertise. 

To ensure that efforts are successful in the long term, federal agencies, utilities, and other stakeholders must have access to accurate and current information about transmission needs nationwide. 

Recommendation 7. Congress should fund regular updates to existing future transmission needs studies. 

Congress must continue to approve future research into both halves of the electrification equation: generation and transmission. Congress already approved funding for the NREL Electrification Futures Study and the NREL Interconnections SEAM Study, both published in 2021. These studies allow NREL to determine best-case scenario models and then communicate its research to the RTOs that are best positioned to help IOUs plan for future regional transmission. These studies also guide FERC and the GDO as they determine best-case scenarios for linking rural clean energy resources to urban energy markets. 

In addition, Congress must continue to fund the GDO National Transmission Needs Study, which was funded by the Bipartisan Infrastructure Law (BIL). This study researches capacity constraints and congestion on the transmission grid and will help FERC and RTOs determine where future transmission should be planned in order to relieve pressure and meet needs. The final Needs Study was issued in summer 2023, but it must be updated on a regular basis if the country is to actively move toward grid coordination. 

The Summer 2023 Needs Study included, for the first time, modeling and discussion of anticipated future capacity constraints and transmission congestion. As the grid continues to evolve and different types of renewable energy are integrated into the grid, future needs studies should continue to include forward-looking models under a variety of renewable energy scenarios.

Conclusion

The Biden-Harris Administration has rejoined the Paris Climate Agreement, affirming their commitment to significant decarbonization goals. To achieve this end, the administration must follow a two-pronged approach that facilitates the installation of utility-scale renewable energy on public lands in the Midwest and Southwest and expedites the implementation of HVDC transmission lines that will link these resources to urban energy markets. 

It is impossible to meet the Biden-Harris Administration climate goals without drastic action to encourage further electrification, renewable energy development, and transmission planning. Fortunately, these actions are ripe for bipartisan coordination and are already supported through existing laws like the IRA and BIL. These recommendations will help meet these goals and secure a brighter future for Americans across the rural-urban divide.

Frequently Asked Questions
What recent efforts has FERC taken to modernize transmission?

FERC has made recent strides toward encouraging transmission modernization through Order No. 2023. While this rule primarily addresses the “largest interconnection queue size in history” and takes steps to accelerate the interconnection process, it does not address the lack of transmission capacity and infrastructure nationally. Order No. 2023 is a vital step forward in interconnection process modernization, and it should be the first of many toward large-scale transmission planning.

How many utility-scale solar and onshore wind plants are currently in use on public lands?

As of November 2021, BLM-managed lands produced 12 GW of power from renewable energy sources, through 36 wind, 37 solar, and 48 geothermal permitted projects. To put this number into perspective, 1 GW is enough to power approximately 750,000 homes. Helpfully, BLM maintains a list of planned and approved renewable energy projects on its lands. Additionally, the Wilderness Society maintains an interactive map of energy projects on public lands.


In contrast, BLM manages over 37,000 oil and gas leases, including over 96,000 wells.

How will states benefit from renewable energy development on public lands?

Due to their high renewable-energy development potential, Midwest and Southwest states stand to disproportionately gain from a clean energy jobs boom in the fields of construction, management, and the technical trades. Given the West’s and Northeast’s desire for a decarbonized grid and their comparatively greater energy use, these states will benefit by receiving greater amounts of renewable energy to meet their energy needs and decarbonization goals.

How many regional HVDC transmission lines are currently planned or approved?

The United States lags in the number of HVDC transmission lines, particularly compared to China and Europe. In 2022, only 552 miles of high voltage transmission were added to the United States. Currently, there are four regional transmission lines proposed, two of which expect to begin construction this year. Of these planned lines, three are in the Midwest and Southwest, and one is in the Northeast. While this is progress, China has recently invested $26 billion in a national network of ultra-high-voltage lines.

Why does this memo focus on BLM multiple-use, sustained-yield mandates and not the other five purveyors of U.S. public lands?

Five agencies manage federal land, including BLM, USFS, FWS, NPS, USDA, and DOD. However, only BLM and USFS operate under the FLPMA’s multiple-use, sustained-yield mandates, and their land-use mandates are similar. The other agencies’ mandates require them to protect and conserve animals and plants, promote tourism and engagement with public lands, and manage military installations and bases. This said, BLM and USFS are the best candidates for developing utility-scale renewable energy resources through their specific mandates. This memo focuses on the larger of those entities, which has greater potential for substantial renewable energy development and an established permitting system. As discussed in this USFS and NREL study, the study of renewable-energy resource construction on national forest system lands is still in early stages, whereas BLM’s policies and systems are developed.

Why is tribal land not included in this proposal? How can stakeholders on tribal lands take advantage of federal funding to build similar resources and connect their populations through HVDC transmission lines?

It is not within the scope of this memo to address issues specific to Tribal lands. However, various federal agencies offer clean energy funding specifically for Tribes, such as the Tribal Energy Loan Guarantee Program. If desired by Tribal communities, the U.S. government should prioritize funding for HVDC transmission lines that link Tribal power generation to Tribal urban centers and utility grids. For tribes seeking guidance on implementing utility-scale projects, Navajo Nation can serve as one model. Navajo Nation has the highest solar potential of any tribal land in the country. They have successfully constructed the Kayenta Solar Project (55 MW of energy), and have finalized leases for the Cameron Solar Plant (200 MW) and the Red Mesa Tapaha Solar Generation Plant (70 MW). The Cameron project alone will generate $109 million over the next 30 years for tribal coffers through tax revenue, lease payments, and energy transmission payments. Another example is the solar energy portfolio of Moapa Band of Paiute Indians. The Tribe manages a growing portfolio of utility-scale solar projects, including Moapa Southern Paiute Solar Project (250 MW), and the first utility-scale installation on tribal land. Currently under development are the Arrow Canyon Solar Project, the Southern Bighorn Solar Project, and the Chuckwalla Solar Projects, all of which feature joint ownership between tribal, federal, and private stakeholders.

Health Care Coverage for the Incarcerated Population to Reduce Opioid-Related Relapse, Overdose, and Recidivism Rates

Summary

Untreated substance use disorders (SUDs) are common among those who pass through the criminal justice system. At both the state and federal levels, re-entry into communities is a critical time period for these individuals. Preventing opioid relapse and potential overdose post-release can prevent recidivism, and improve an individual’s life after time in jail. Medication-assisted treatment (MAT) for opioid use disorders (OUDs) can help some sustain recovery. However, there are many barriers that interfere with the distribution of medication: cost, accessibility, and distribution are difficult to overcome, along with a lack of professionals trained to prescribe medication for OUDs.

To address this facet of the growing opioid crisis, the United States Department of Justice (DOJ) and the Centers for Medicare & Medicaid Services (CMS) should facilitate the accessibility for medications for OUDs (MOUDs) and train professionals to prescribe MOUDs. Additionally, incarcerated individuals with an OUD should have intensive case management that continues through reintegration into society. Finally, Medicare coverage should be available in order to continue treatment and support successful reentry into their community. Together, these will help reduce risks of recidivism, opioid-related relapse, and overdoses during reintegration back into their community.

Challenge and Opportunity

Approximately 65% of the United States prison population has a substance use disorder. An estimated 17% of those detained in state and federal prisons who meet the criteria for substance use disorder have an opioid use disorder specifically. Repeated drug usage causes a person to grow physiologically reliant on the drug, requiring more to have the desired effect, known as increasing tolerance. Individuals with an OUD lose their tolerance to the drug while incarcerated, which sets them at a greater risk of overdose mortality upon release. The risk of mortality from a lethal overdose is more than 12 times greater than that of another person within two weeks of being released from jail or prison. A meta-analysis determined that MOUDs during incarceration increased post-release treatment involvement and reduced opioid use post-release. Similarly, a randomized control trial at a Baltimore pre-release prison setting, showed that those who began methadone therapy and counseling while in prison were more likely to continue treatment post-release. They also had reduced rates of opioid use re-offending over the course of six months compared to those who received counseling only.

Methadone, buprenorphine, and naltrexone are MOUDs that have been authorized by the Food and Drug Administration for the treatment of OUDs. Research on the utilization of MOUD has demonstrated to be an effective treatment, specifically with methadone and buprenorphine. However, the distribution amount of MOUDs in the criminal justice system settings is low: only 3.6% of incarcerated individuals with OUD across the United States were prescribed and administered buprenorphine. According to the Pew Charitable Trusts and Substance Abuse and Mental Health Services Administration (SAMHSA), just 14 states administered at least one MOUD, 39 states provided naltrexone in jail or prison settings, and only one state (Rhode Island) provided all three MOUDs. Increasing the percentage of MOUD administration in carceral settings and after release across the United States is critical in order to reduce opioid overdose deaths. 

Rhode Island’s Approach to Opioid Use Disorder Treatment

The Rhode Island Department of Corrections (RIDC) is the first correctional system to launch an extensive program to screen individuals for an OUD upon entry, offer all three MOUDs to eligible incarcerated individuals, and continue with treatment post-release. The RIDC MAT program provides incarcerated individuals with access to MOUDs, and counseling during incarceration. RIDC MAT also provides linkage to care after release through a partnered non-profit organization, Community Organization for Drug Abuse Control (CODAC) Behavioral Healthcare. Together, RIDC and CODAC have established a successful pipeline for the continuation of MAT post-incarceration. Prior to an individual’s release date, CODAC develops a re-entry strategy with the assistance of case management and care providers. As a result, Rhode Island’s statewide overdose fatalities decreased by 12% in the first year of this program’s adoption, while post-incarceration overdose deaths decreased by 61%. A decrease in mortality rates related to opioid overdose post incarceration allows approximately $7,300 more in personal income per individual’s extended years of life. Other states have turned to Rhode Island’s MAT program to learn from and advocate for incarcerated individuals in order to treat OUDs during and after incarceration, and help reduce recidivism. 

Challenges for Implementation

Despite these strong results, challenges remain. 

Opioid use treatment and services are covered by health insurances under the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. However, incarcerated individual healthcare coverage is entirely operated by the state, which contributes to the above mentioned disparities in drug therapeutic access and counseling–but only while incarcerated. As individuals transition back into society, if they do not have health insurance to pay for their MOUDs or other rehabilitation treatments, they lose treatment, and experience an increased likelihood of relapse. 

The Medicaid Inmate Exclusion Policy under the Social Security Act prevents and prohibits Medicaid coverage while incarcerated, making it difficult for formerly incarcerated individuals to acquire healthcare upon release, and thus access MOUDs. The majority of these individuals qualify for Medicaid upon release since they are low-income and fall below the federal poverty line. In 2018, Congress provided waiver opportunities for CMS to connect individuals who were recently released from jail/prison to healthcare across the states, but not federally. 

Medicaid Section 1115 Waivers

To combat this gap, states are waiving the Medicaid Inmate Exclusion Policy to provide Medicaid coverage for incarcerated individuals upon release by filing Section 1115 waivers. A section 1115 waiver is a provision within the Social Security Act that grants the Secretary of Health and Human Services the authority to waive specific requirements within the Medicaid program. Section 1115 waivers offer states the flexibility to design and implement innovative approaches to enhance access to healthcare. To obtain approval, states must submit proposals outlining their proposed changes and demonstrate that the waiver will not increase federal government expenditures over the waiver period. Once approved, the waiver permits the states to operate the Medicaid program with modified, exempted, or alternative requirements. For instance, Section 1115 waivers from New Hampshire and Utah were approved, enabling the expansion of healthcare coverage to incarcerated individuals. Under the waiver, incarcerated individuals are granted full Medicaid coverage for care coordination and provider services, which commences approximately one month prior to their release. 

Plan of Action

The Biden Administration has urged states to submit Section 1115 waivers to propose options for expanding coverage in order to reduce health disparities, remove barriers to MOUDs treatment access, and find long-term solutions to OUDs issues. It is imperative that the federal government prioritize reducing relapse, and opioid overdose mortality rates during incarceration and post-release in order to reduce recidivism. The DOJ, CMS, and SAMHSA should collaborate to develop a pipeline that expands training across professionals, have MOUDs more accessible to correctional facilities, and have healthcare coverage post-release.

Recommendation 1. Compare and contrast the Section 1115 waivers submitted by states to encourage and detail advantages to the remaining states. 

A root of the issue is the failure to provide pre-release healthcare coverage to incarcerated individuals in order for them to continue having coverage post-release. Hence, increasing the access to healthcare post-release by states applying for Section 1115 waivers to propose measures and assist incarcerated individuals in obtaining healthcare coverage is important. Currently 35 states have filed approved Section 1115 waivers. Collecting data on these states would provide insight into how these waivers reduce recidivism and overdose rates. The Agency for Healthcare Research and Quality (AHRQ) should issue an open call for evidence synthesis to delve into the impacts of Section 1115 waivers. By doing so, AHRQ would aim to conduct a comprehensive analysis of the impacts and outcomes from the implementation of Section 1115 waivers. This initiative would contribute to evidence-based decision-making and further enhance the understanding of the implication of Section 1115 waivers on healthcare. Examples of data collection that could be obtained to assess the success of Medicaid resources are: 

  1. Overdose mortality rates between those who have Medicaid and those who do not 
  2. Post-release drug-related opioid reoffending
  3. Economic impact such as quality-adjusted life years gained. 

Once the data has been gathered, it is essential that the dataset is made publicly accessible to researchers. The dataset can be published on the CMS data website, enabling widespread access and utilization for researchers. This accessibility will allow researchers to examine the significance of reducing overdose-related fatalities after incarceration and assess how the expansion of Section 1115 waivers could contribute to achieve this reduction. 

Recommendation 2. Increase opioid treatment program accessibility during and after incarceration.

Rhode Island’s MAT program has shown to be effective in reducing opioid overdose deaths. A replica of the Rhode Island program has improved OUD treatment to reduce opioid related relapses and death in a correctional facility in Massachusetts. In order to provide intensive case management when individuals come into contact with the criminal justice system and adequately rehabilitate them, correctional facilities should use a method similar to that used by Rhode Island’s Department of Corrections MAT program. Since correctional facilities and licensed professionals must be accredited by the DEA and SAMHSA to provide MOUDs, individuals will have the opportunity to have access to MOUDs at Opioid treatment programs (OTPs) during and after incarceration who are certified. Thus, the DOJ and SAMHSA should collaborate with CODAC and similar organizations to increase OTP accessibility across correctional facilities during and after incarceration. These organizations can assist with creating a re-entry treatment plan during incarceration and continue after release. Incarcerated individuals will have access to MOUDs at OTPs as well as counseling. This aims to increase accessibility to MOUDs, licensed therapists, and medical doctors.

Recommendation 3. Intensive case management during incarceration should continue when reintegrating back into the community. 

The DOJ, CMS and OTPs should further collaborate to establish a pipeline that aids individuals to combat OUDs. Currently, upon release, formerly incarcerated individuals’ MOUD treatment is terminated and they do not have access to treatment unless they are referred to a rehabilitation center or seen by a licensed professional. The first two weeks after release are crucial because there is a higher risk of relapsing. Thus, it is essential for correctional facilities to assist incarcerated individuals to apply for Medicaid within a few months of release to access  MOUDs and therapy. Medicaid would cover MOUD costs and counseling services at OTPs or similar organizations. MOUD treatment should be administered during prison in order to commence proper rehabilitation, whether that is at a correctional facility or an OTP. Subsequently, continuing their pharmacological treatment in parallel with counseling post-release reduces relapse, withdrawal symptoms, and overdose deaths. This aims to expand access while in a correctional facility and continue treatment post-release to reduce opioid mortality rates.

Conclusion

Opioid relapses and overdoses following imprisonment have escalated significantly, accelerating the chance of overdose mortality. Incarcerated individuals with an OUD should get comprehensive case management while incarcerated that continues as they reintegrate into their communities. However, the Social Security Act prevents incarcerated individuals from receiving Medicaid coverage while incarcerated. Implementing these measures will decrease overdose mortality rates, risk of relapse, and reduce recidivism.

Frequently Asked Questions
What is the economic benefit of this proposal?

In Massachusetts, researchers were able to assess an estimated cost and benefits of administering MOUDs during incarceration, using the Researching Effective Strategies to Prevent Opioid Death (RESPOND) simulation model. The availability of all three MOUDs during incarceration showed that it was cost effective at approximately $7252 per quality-adjusted life year gained and reduced 1.8% of opioid related overdose deaths.

How will this proposal be funded?

The U.S Department of Health and Human Services (HHS) has provided science and community-based approaches to combat the opioid epidemic crisis. In the past years, the HHS has allocated $2 billion in grants to help reduce opioid mortality and relapse rates across the United States. Researchers and community-based organizations can apply for grant money from HHS for data collection on how Section 1115 waivers have improved reducing recidivism and overdose rates.


The DOJ has approximately allocated $340 million in grant award funding money to battle the opioid crisis. $7.2 million dollars have been used to treat individuals with a substance use disorder and assist with support during incarceration and reentry services.

Why should this be a federal concern rather than state level?

The United States is in the middle of an emerging life-threatening opioid epidemic crisis that is affecting over 33,000 deaths per year from prescription and synthetic opioids. The opioid epidemic crisis is highly prevalent among the criminal justice population. This impacts individuals across the country, not just in specific states. The federal government should encourage individual states to apply for federal funding that is available in order to combat the opioid epidemic crisis.

How do correctional facilities and partnered organizations become an accredited and certified OTP?

The use of MOUDs in OTPs in the United States is regulated by the 42 Code of Federal Regulations (CRF) 8. This regulation established a system for accrediting and certifying OTPs in order to grant the ability to dispense and administer FDA approved MOUDs. More information on the process of accrediting and certifying OTPs can be found in SAMHSA website.

What are the limitations for this proposal?

Given the rigorous nature of the accreditation process, obtaining accreditation for OTPs can be an intricate process, which involves several steps and requirements, including: thorough assessments of program infrastructure, staff qualification and training, and compliance with regulatory standards. These factors collectively contribute to the length of the accreditation process, potentially deterring some facilities from pursuing OTP status. Another aspect to consider is the decision-making process of states regarding the application for Section 1115 waivers. One significant consideration revolves around funding and financial considerations. States often conduct an extensive evaluation to assess the potential financial implications and cost-sharing arrangements associated with the Section 1115 waiver before finalizing their decision to apply. Despite these challenges, it is crucial to acknowledge that implementing OTP accreditation and Section 1115 waiver approvals play a crucial role in reducing relapse rates post-incarceration, while also creating a more comprehensive and effective healthcare system that saves lives by addressing the opioid crisis and minimizing recidivism.

Collaboration for the Future of Public and Active Transportation

Summary

Public and active transportation are not equally accessible to all Americans. Due to a lack of sufficient infrastructure and reliable service for public transportation and active modes like biking, walking, and rolling, Americans must often depend on personal vehicles for travel to work, school, and other activities. During the past two years, Congress has allocated billions of dollars to equitable infrastructure, public transportation upgrades, and decreasing greenhouse gas pollution from transportation across the United States. The Department of Transportation (DOT) and its agencies should embrace innovation and partnerships to continue to increase active and public transportation across the country. The DOT should require grant applications for funding to discuss cross-agency collaborations, partner with the Department of Housing and Urban Development (HUD) to organize prize competitions, encourage public-private partnerships (P3s), and work with the Environmental Protection Agency (EPA) to grant money for transit programs through the Greenhouse Gas Reduction Fund. 

Challenge and Opportunity

Historically, U.S. investment in transportation has focused on expanding and developing highways for personal vehicle travel. As a result, 45% of Americans do not have access to reliable and safe public transportation, perpetuating the need for single-use vehicles for almost half of the country. The EPA reports that transportation accounts for 29% of total U.S. greenhouse gas emissions, with 58% of those emissions coming from light-duty cars. This large share of nationwide emissions from personal vehicles has short- and long-term climate impacts. 

Investments in green public and active transit should be a priority for the DOT in transitioning away from a personal-vehicle-dominated society and meeting the Biden Administration’s “goals of a 100% clean electrical grid by 2035 and net-zero carbon emissions by 2050.” Public and active transportation infrastructure includes bus systems, light rail, bus rapid transit, bike lanes, and safe sidewalks. Investments in public and active transportation should go towards a combination of electrifying existing public transportation, such as buses; improving and expanding public transit to be more reliable and accessible for more users; constructing bike lanes; developing community-owned bike share programs; and creating safe walking corridors. 

In addition to reducing carbon emissions, improved public transportation that disincentivizes personal vehicle use has a variety of co-benefits. Prioritizing public and active transportation could limit congestion on roads and lower pollution. Fewer vehicles on the road result in less tailpipe emissions, which “can trigger health problems such as aggravated asthma, reduced lung capacity, and increased susceptibility to respiratory illnesses, including pneumonia and bronchitis.” This is especially important for the millions of people who live near freeways and heavily congested roads. 

Congestion can also be financially costly for American households; the INRIZ Global Traffic Scorecard reports that traffic congestion cost the United States $81 billion in 2022. Those costs include vehicle maintenance, fuel cost, and “lost time,” all of which can be reduced with reliable and accessible public and active transportation. Additionally, the American Public Transportation Association reports that every $1 invested in public transportation generates $5 in economic returns, measured by savings in time traveled, reduction in traffic congestion, and business productivity. Thus, by investing in public transportation, communities can see improvements in air quality, economy, and health.

Public transportation is primarily managed at the local and state level; currently, over  6000 local and state transportation agencies provide and oversee public transportation in their regions. Public transportation is funded through federal, state, and local sources, and transit agencies receive funding from “passenger fares and other operating receipts.” The Federal Transit Administration (FTA) distributes funding for transit through grants and loans and accounts for 15% of total income for transit agencies, including 31% of capital investments in transit infrastructure. Local and state entities often lack sufficient resources to improve public transportation systems because of the uncertainty of ridership and funding streams.

Public-private partnerships can help alleviate some of these resource constraints because contracts can allow the private partner to operate public transportation systems. Regional and national collaboration across multiple agencies from the federal to the municipal level can also help alleviate resource barriers to public transit development. Local and state agencies do not have to work alone to improve public and active transportation systems. 

The following recommendations provide a pathway for transportation agencies at all levels of government to increase public and active transportation, resulting in social, economic, and environmental benefits for the communities they serve. 

Plan of Action

Recommendation 1. The FTA should require grant applicants for programs such as the Rebuilding American Infrastructure with Sustainability and Equity (RAISE) to define how they will work collaboratively with multiple federal agencies and conduct community engagement. 

Per the National Blueprint for Transportation Decarbonization, FTA staff should prioritize funding for grant applicants who successfully demonstrate partnerships and collaboration. This can be demonstrated, for example, with letters of support from community members and organizations for transit infrastructure projects. Collaboration can also be demonstrated by having applicants report clear goals, roles, and responsibilities for each agency involved in proposed projects. The FTA should: 

  1. Develop a rubric for evaluating partnerships’ efficiency and alignment with national transit decarbonization goals. 
  2. Create a tiered metrics system within the rubric that prioritizes grants for projects based on collaboration and reduction of greenhouse gas emissions in the transit sector.
  3. Add a category to their Guidance Center on federal-state-local partnerships to provide insight on how they view successful collaboration. 

Recommendation 2. The DOT and HUD should collaborate on a prize competition to design active and/or public transportation projects to reduce traffic congestion. 

Housing and transportation costs are related and influence one another, which is why HUD is a natural partner. Funding can be sourced from the Highway Trust Fund, which the DOT has the authority to allocate up to “1% of the funds for research and development to carry out . . . prize competition program[s].”

This challenge should call on local agency partners to provide a design challenge or opportunity that impedes their ability to adopt transit-oriented infrastructure that could reduce traffic congestion. Three design challenges should be selected and publicly posted on the Challenge.gov website so that any individual or organization can participate. 

The goal of the prize competition is to identify challenges, collaborate, and share resources across agencies and communities to design transportation solutions. The competition would connect the DOT with local and regional planning and transportation agencies to solicit solutions from the public, whether from individuals, teams of individuals, or organizations. The DOT and HUD should work collaboratively to design the selection criteria for the challenge and select the winners. Each challenge winner would be provided with a financial prize of $250,000, and their idea would be housed on the DOT website as a case study that can be used for future planning decisions. The local agencies that provide the three design challenges would be welcome to implement the winning solutions.

Recommendation 3. Federal, state, and local government should increase opportunities for public-private partnerships (P3s). 

The financial investment required to develop active and public transportation infrastructure is a hurdle for many agencies. To address this issue, we make the following recommendations: 

Conclusion

The road to decarbonizing the transportation sector requires public and active transportation. Federal agencies can allocate funding for public and active transit more effectively through the recommendations above. It’s time for the government to recognize public and active transportation as the key to equitable decarbonization of the transportation sector throughout the United States.

Frequently Asked Questions
What are examples of transit public-private partnerships (P3s)?

Most P3s in the United States are for highways, bridges, and roads, but there have been a few successful public transit P3s. In 2018 the City of Los Angeles joined LAX and LAX Integrated Express Solutions in a $4.9 billion P3 to develop a train system within the airport. This project aims to launch in 2024 to “enhance the traveler experience” and will “result in 117,000 fewer vehicle miles traveled per day” to the airport. This project is a prime example of how P3s can help reduce traffic congestion and enable and encourage the use of public transportation.

How can P3s be further supported through federal policy beyond the recommendations in this memo?

In 2021, the Congressional Research Service released a report about public-private partnerships (3Ps) that highlights the role the federal government can play by making it easier for agencies to participate in P3s.

What are examples of existing green banks and infrastructure banks?

The state of Michigan has a long history with its Michigan Saves program, the nation’s first nonprofit green bank, which provides funding for projects like rooftop solar or energy efficiency programs.


In California the California Alternative Energy and Advanced Transportation Financing Authority works “collaboratively with public and private partners to provide innovative and effective financing solutions” for renewable energy sources, energy efficiency, and advanced transportation and manufacturing technologies.


The Rhode Island Infrastructure Bank provides funding to municipalities, businesses, and homeowners for projects “including water and wastewater, roads and bridges, energy efficiency and renewable energy, and brownfield remediation.”