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:
- Overdose mortality rates between those who have Medicaid and those who do not
- Post-release drug-related opioid reoffending
- 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.
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.
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.
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.
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.
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.
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.
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:
- Develop a rubric for evaluating partnerships’ efficiency and alignment with national transit decarbonization goals.
- 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.
- 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:
- Currently, only 36 out of the 50 states have policies that allow the use of P3s. The remaining 14 states should pass legislation authorizing the use of P3s for public transportation projects so that they too can benefit from this financing model and access federal P3 funding opportunities.
- In 2016, the DOT launched the Build America Bureau to assist with financing transportation projects. The Bureau administers the Transportation Infrastructure Finance and Innovation Act (TIFIA) program, which provides financial assistance through low-interest loans for infrastructure projects and leverages public-private partnerships to access additional private-sector funding. Currently, only about 30% of all loans through the TIFIA are used for public transit projects while 66% are used on tolls and highways. Local and regional agencies should use the TIFIA loan more to fund public and active transit projects.
- EPA should specify in its Greenhouse Gas Reduction Fund guidelines that public and active transit projects are eligible for investment from the fund and can leverage public and private partnerships. EPA is set to distribute $27 billion through the Fund for carbon pollution reduction: $20 billion will go towards nonprofit entities, such as green banks, that will leverage public and private investment to fund emissions reduction projects, with $8 billion allocated to projects in low-income and disadvantaged communities; $7 billion will go to state and local agencies and nonprofits in the form of grants or technical assistance to low-income and disadvantaged communities. EPA should encourage applicants to include public and active transportation projects, which can play a significant role in reducing carbon emissions and air pollution, in their portfolios.
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.
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.
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.
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.”