Contributor: Breaking the Cycle—RSAT Program Improving Reentry in Arizona

The health of justice-involved populations has become a priority for the federal government and over a dozen states. These populations have disproportionately worse health outcomes and higher health care costs relative to the general population.¹ Additionally, the majority of people involved with the criminal justice system are Medicaid eligible.² California was the first state to receive approval of a reentry 1115 waiver to allow for the use of federally matched Medicaid dollars to pay for re-entry services for individuals who are incarcerated. 1115 demonstrations give states additional flexibility to design and improve their programs by piloting new, innovative approaches to their Medicaid programs. Fourteen other states, including Arizona (AZ, KY, MA, MT, NH, NJ, NM, NY, OR, RI, UT, VT, WA, and WV), have pending requests to CMS for similar incarceration reentry waiver authority approval.³

Arizona is particularly well suited to benefit from the 1115 reentry waiver because it already has a robust justice-involved reentry initiative called the Residential Substance Abuse Treatment (RSAT) Program. RSAT is emerging as an archetype of successful reentry programs that can serve as a template for other states to emulate. Initial data show that the RSAT reoffend rate of 13% (n=235) is statistically significantly lower than the statewide Arizona recidivism rate of 36.3%⁴ (n = 7536) by 64% (P < .001; z-test). (The reoffend rate was generated using data from 235 RSAT program graduates dating back to November 2021; the numerator for the reoffend rate was defined as those who have reoffended, absconded, or violated their parole.) By breaking the cycle of incarceration, the RSAT program is demonstrating a meaningful financial return on investment (ROI) with an estimated 3-year ROI of $4.7 million per 235 RSAT graduates.⁵ The Figure shows how RSAT can simultaneously generate positive social and economic outcomes in the long run. This article explores the key elements contributing to the program's success and implications for reentry strategies nationwide.

Figure: Cost-Effectiveness of RSAT Program

The RSAT Program Approach

Holistic Skills Development
The RSAT Program's success can be attributed to its comprehensive approach to providing cognitive, behavioral, social, and vocational skills. The goal is to empower graduates with the ability to manage and overcome substance use disorders and related challenges. By addressing multiple dimensions of an individual's life, the RSAT Program equips participants with a robust skill set for successful reintegration into society.

Release Planning
Traditionally, released inmates are only offered minimal support with a cursory confirmation of where they will be living and a nominal amount of money that generally fails to cover the intended combination of transportation (bus pass), food, and clothing. RSAT graduates, conversely, are better set up for a successful transition into the community by having support with obtaining government identification and a Social Security number; enrollment in the Arizona Medicaid program, also known as the Arizona Health Care Cost Containment System, or AHCCCS; connection to clinical care and medication; and alerting various community partners about their release, a critically important step to ensure continuity of care for released inmates who are actively receiving medical care. This proactive approach is a key driver of reducing recidivism to prison.

Incorporation of Peer Recovery Support Specialist
Another unique differentiator of the RSAT Program is the involvement of a Community Peer Recovery Support Specialist (PRSS). The PRSS not only serves as a role model for successful reentry but also facilitates the community connection process, which begins as soon as 6 months prior to release. By screening across 14 social needs domains, the PRSS helps ensure that RSAT members receive support in crucial areas such as housing, health care, and employment skills, among others. On average, RSAT members indicate a need in 8 out of 14 social needs domains.

Community Partner Collaboration
RSAT graduates often have the opportunity to transition to community housing partners who offer vocational training/employment, medication-assisted treatment, and behavioral therapy in one location. This integrated approach significantly enhances the chances of successful reintegration into society and reduces the risk of reoffending. The RSAT program is able to offer this level of integration with community services through partners like Success Care. Success Care is a substance use disorder care program and supporter of RSAT. An important predictor of success for RSAT graduates is engagement with community resources. The patients seen by Success Care have a 34-day engagement in alcohol or other drug (AOD) treatment rate of 68, 139% higher than the 2021 Medicaid health management organization Engagement of AOD treatment rate, which is 28%.⁶ (Calculation logic consistent with Healthcare Effectiveness Data and Information Set measure definition; generated using 2023 data on 218 MAT program participants.) Success Care credits the use of PRSS professionals as a crucial factor bridging the gap between clinical and social care needs. This additionally underscores the effectiveness and importance of incorporating peer support into re-entry programs.

Call to Action

Arizona's success with the RSAT Program should inspire nationwide efforts to reform reentry strategies. The following key actions can be taken:

1. Building Support Among Corrections Officers

For other states to succeed in implementing an RSAT-like model, they should cultivate support among corrections officers on the ground for such a program to ensure a seamless transition from incarceration to reentry programs.

2. Curriculum and Community Partnerships

State policy innovators should develop necessary curriculum and community partnerships (such as in-reach engagements by PRSS professionals) for 6 to 12 months of prerelease programming. RSAT’s curriculum can serve as a template and policy leaders in other states can adapt that template to the local culture and processes.

3. Immediate Connection to Health Care System

Administrators of RSAT-like programs should ensure an immediate connection to the healthcare system, coupled with PRSS services, at the time of inmate’s release.

4. Broadly Offer Medications for Opioid Use Disorder Services Behind the Walls
Given the high prevalence of opioid use disorder (OUD) among inmates, it is important to offer medications for OUD to all inmates in need, recognizing its effectiveness in supporting recovery from OUD.

5. 1115 Waivers
Per the Figure, the RSAT program saved Arizona $6667 per RSAT graduate per year. With the average Medicaid spending in Arizona per adult per year at $3831 and with the federal government paying over 64% of that (the federal government pays at least 50% of Medicaid cost for all states), the ROI on state taxpayer dollars is profound if an RSAT-like program is paid for by Medicaid dollars.⁷ Reentry 1115 waivers that are based on the RSAT model could be a boon for vulnerable Medicaid beneficiaries and a huge saver of state and federal taxpayer dollars.

Conclusions

Arizona's RSAT Program stands as a testament to the transformative power of a holistic and community-driven reentry approach. By learning from its success, sharing best practices, and advocating for policy changes, we can pave the way for a more effective and compassionate reentry system nationwide. At a macro level, providing expanded coverage and addressing the complex needs of this unique population will yield better health outcomes, reduced recidivism, and drive down health care costs over the long-term. Managed care organizations play a crucial role in this process, as they are at the forefront of managing health care services to individuals transitioning from incarceration to the community. With the robust ROI data, investing in programs like RSAT not only benefits criminal justice–involved individuals, but also society at large.

References

1. Kinner SA, Wang EA. The case for improving the health of ex-prisoners. Am J Public Health. 2014;104(8):1352-1355. doi:10.2105/AJPH.2014.301883
2. Howard J, Solan M, Neptune J, Mellgren L, Dubenitz J, Avery K. The importance of Medicaid coverage for criminal justice involved individuals reentering their communities. Office of the Assistant Secretary for Planning and Evaluation. April 2016. Accessed February 20, 2024. https://aspe.hhs.gov/sites/default/files/migrated_legacy_files/146076/MedicaidJustice.pdf
3. State waivers list. Medicaid.gov. Accessed February 20, 2024. https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html
4. Recidivism rate by state. Wisevoter. Accessed February 12, 2024. https://wisevoter.com/state-rankings/recidivism-rates-by-state/#arizona
5. FY 2020 operating per capita cost report. Arizona Department of Corrections, Rehabilitation, and Reentry. June 28, 2021. Accessed February 5, 2024. https://corrections.az.gov/sites/default/files/documents/reports/adcrr-percapcostreport_fy2020-final.pdf
6. HEDIS measures: initiation and engagement of substance use disorder treatment (IET). National Committee for Quality Assurance. Accessed February 5, 2024. https://www.ncqa.org/hedis/measures/initiation-and-engagement-of-alcohol-and-other-drug-abuse-or-dependence-treatment/
7. Federal medical assistance percentage (FMAP) for Medicaid and Multiplier. KFF. Accessed March 14, 2024. https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier