Date of Award

January 2026

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Lisa Puglisi

Abstract

Background: Although incarcerated people in the United States (U.S.) have a higher healthcare burden compared to the general population, they have been historically excluded from community health systems, health research, and efforts to improve health outcomes. The transition from incarceration back to the community is associated with a high mortality rate, in part because carceral and community healthcare systems are largely siloed from each other. Given the high recidivism rate in the U.S., it is important to understand how multiple transitions of care between incarceration and the community affect health outcomes, especially for diseases such as cancer, which often require long-term and multidisciplinary treatment. However, the relationship between multiple transitions of care and health outcomes has not yet been studied in the carceral context.

To address transitions of care from incarceration to the community, the Reentry Section 1115 Demonstration Opportunity allows states to apply to extend Medicaid coverage to incarcerated individuals up to ninety days prior to release. As part of this waiver, states are required to provide a plan by which to evaluate health outcomes. However, there is no unified guidance on the quality metrics or evaluation measures that states should use in evaluating the efficacy of expanded Medicaid coverage.

Research Aims: This project has two aims. First, to understand how transitions of care between incarceration and the community are associated with cancer outcomes. Second, to identify recommendations for Medicaid 1115 Reentry waiver implementation evaluation.

Questions: (1) Is there an association between transitions of care between incarceration and the community and cancer outcomes? (2) How should states evaluate Medicaid 1115 Reentry waivers?

Methods: To evaluate the association of transitions of care with cancer outcomes, we used a database linking data from the Connecticut Tumor Registry, a statewide cancer registry, with data from the Connecticut Department of Correction to identify people with a history of incarceration who were diagnosed with cancer between 2005 and 2016. We used descriptive statistics to analyze the patient cohort, including demographic information, incarceration history, and cancer characteristics. For each patient, we computed the number of post-diagnosis movements into and out of incarceration using data from the Department of Correction. We then calculated the movement density for each case, which we defined as the total number of movements divided by years spent in the study, with patients being censored at time of death. We used Cox proportional hazards regression models, adjusting for covariates, to investigate the association between movement density and cancer-specific and all-cause mortality.

To identify priorities and quality measures for Medicaid 1115 Reentry waivers, we solicited input from diverse stakeholders through structured group discussions and focused interviews. After collating feedback and priority areas, we identified existing Centers for Medicare and Medicaid Services measures that aligned with these priorities. We then conducted four structured interviews with people with experience in Medicaid administration, correctional health care, and private healthcare insurance to assess for feasibility and other feedback. We then presented the proposed program evaluation components, measure domains, and quality measures to community health workers, healthcare providers, and researchers, to ensure that the product aligned with their priorities.

Results: Aim 1. Our sample contained 2,323 people, of which 10.3% were diagnosed while incarcerated, 20.6% were diagnosed within one year of release, and 69.1% were diagnosed with cancer more than one year after release. For people diagnosed while incarcerated, higher movement density was associated with worse all-cause mortality (adjusted hazard ratio=1.31, 95% confidence interval=1.21-1.41, p<0.001) and worse cancer-related mortality (adjusted hazard ratio=1.33, 95% confidence interval=1.21-1.47, p<0.001). For patients diagnosed within one year of release, movement density was not associated with all-cause or cancer-related mortality. For patients diagnosed more than one year after release, there was no association between movement density and cancer-related mortality, but higher movement density was associated with improved all-cause mortality (adjusted hazard ratio=0.62, 95% confidence interval=0.44-0.86, p<0.001).

Aim 2. Recommended program evaluation components included medications for behavioral health and other chronic conditions, infrastructure, equity, and utilization. Priority domains included behavioral health, disparities-sensitive wellness and prevention, and chronic illness. Proposed quality measures included screening for depression and follow-up, initiation and engagement of substance use disorder treatment, colorectal cancer screening, cervical cancer screening, adult immunization status, and hypertension management.

Statement of impact: Through this work, we establish a better understanding of how incarceration is related to the health outcomes of incarcerated people, identifying how a carceral system characterized by high rates of incarceration and recidivism, in conjunction with carceral and community health systems that are highly siloed, can lead to worse cancer outcomes for those diagnosed with cancer while incarcerated. Moreover, we investigate how Medicaid 1115 Reentry waivers can represent an unprecedented step to expanding healthcare access to incarcerated people, identifying how these waivers can be best leveraged to improve health.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 07/14/2027

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