Health-Related Social Needs and Risk-Need-Responsivity: Mapping Where Medicaid and Criminal Justice Meet

When states began pursuing the federal opportunity to waive the Medicaid “inmate exclusion” through 1115 Reentry Demonstrations, a critical question emerged: What does the health care system have in common with the justice system, and how can those areas of overlap be turned into shared strategy?

Anyone who’s worked across justice and health care knows that these two systems often address many of the same people, issues, and goals, but they use different models to frame the discussion. Bridging that gap requires a shared language to align health and safety.

The first step is decoding some profession-specific language to reveal strategies that help people at the intersection of both systems. Social determinants of health describe the broader community conditions that influence health and well-being. The health care system uses the health-related social needs (HRSN) framework to identify non-medical factors within those conditions that affect a person’s health and stability. The HRSN domains map directly to people and areas where Medicaid can be leveraged to address those needs.

Meanwhile, the justice system uses the evidence-based Risk-Need-Responsivity (RNR) model to assess criminogenic risk, needs for support, and responsivity to an individual’s circumstances and match people to appropriate interventions to reduce future justice involvement.

When you compare these two models, the overlap is apparent, and the conclusion is profound: Addressing factors known to improve health can also reduce the risk of recidivism.

The same factors that drive poor health outcomes—unstable housing, social isolation, unemployment, food insecurity—are also among the strongest predictors of justice involvement. At the root of both is the larger issue of people and communities struggling to have their basic needs met, often because of inequitable access to health and social services. The overlap between these models creates a powerful opening for health and behavioral health leaders, including Medicaid agencies, and justice system leaders to work together around shared priorities.

To help these two systems align, CSG Justice Center staff members Sarah Wurzburg and Bridget Rivera Degnan created two charts. The first shows where the two frameworks overlap, and the second shows how Medicaid can address each shared HRSN.

The HRSN and RNR Overlap

How Health-Related Social Needs Relate to Risk-Need Responsivity—and How Criminal Justice and Health Systems Can Respond

How to Use Chart 1

As part of the Medicaid and Corrections Policy Academy, the CSG Justice Center and Center for Health Care Strategies, funded by the Bureau of Justice Assistance, worked with 6 states to improve reentry outcomes for people with complex needs in the justice system. CSG Justice Center staff developed Chart 1 to help state Medicaid, behavioral health, and corrections leaders identify shared priorities and build a common framework for serving people in the justice system with complex health and behavioral health needs.

Here are 3 ways to use Chart 1:

• For state and county policy leaders: Identify where your existing programs and funding streams are already addressing shared risk factors and where the gaps are. The overlap between HRSN and RNR domains creates a natural agenda for cross-agency planning conversations.
• For practitioners doing case planning: Develop integrated case plans (collaborative comprehensive case plans) that address the full picture of an individual’s needs instead of only the slice visible from one system’s vantage point.
• For health and behavioral health leaders: The HRSN domains identify where health and social services coverage, including Medicaid (in some states), can be leveraged, if this has been prioritized in the state. Chart 2 below outlines specific Medicaid mechanisms available to address each domain.

How Medicaid Can Help

The Medicaid 1115 demonstrations have created a significant new opportunity for states to use Medicaid to address the needs of people who are or have been incarcerated, but Medicaid’s potential reach extends beyond reentry. The chart below outlines how existing Medicaid funding can be leveraged across each HRSN domain to reduce unnecessary incarceration and help people remain stable in their communities.

Medicaid Can Keep People Out of Prison

Examples of How States Can Use 1115 Demonstration Funds

How to Use Chart 2

This chart is most useful as a planning and gap-analysis tool. Here are a few ways to apply it:

• For health, Medicaid, and behavioral health leaders: Review which of these Medicaid mechanisms your state already uses, which remain untapped, and potential levers for expanding coverage and services.
• For state and county justice leaders: Identify where Medicaid could be picking up costs your system is currently absorbing and build the case for cross-agency conversations with your Medicaid counterparts.
• For diversion and reentry programs: Think through whether Medicaid or other health and social service benefits could be leveraged to provide additional funding and support to people. This might be through a partnership with a health care provider or becoming a Medicaid biller or a third-party administrator supporting the state Medicaid agency.
• For practitioners doing case planning: Identify which services may be billable to Medicaid for the individuals you serve, and where you may need to connect clients to other funding streams when Medicaid coverage falls short.

When Medicaid Isn’t Enough

Not every state will have all these Medicaid benefits in place. When gaps exist, states have options:

• Leverage other health, behavioral health, or justice funding streams to fill the gap.
• Conduct a Medicaid and justice data match to identify the gaps in the system.
• Open new billing codes within the existing state plan.
• Amend the state plan to add new benefits.
• Apply for a 1115 Demonstration to address systemic gaps at scale.

The goal is a whole-of-government approach where Medicaid is a powerful tool among many, and where state, local, and nonprofit leaders are mapping their existing resources against the full picture of what justice-involved individuals need to succeed in order to support equitable access to health care across communities.

How the CSG Justice Center Can Help

Our policy experts and data researchers help states, local governments, and community-based providers identify and implement cross-system solutions across Medicaid, behavioral health, and justice partners.

Through our new Counties Aligning Health and Safety initiative, for instance, we’re currently accepting applications from local leaders who want to maximize their return on recent investments in behavioral health and diversion. Without an evidence-informed, cross-systems plan, counties risk spending millions only to maintain or worsen the status quo.

Learn how your county can pilot our new cross-systems framework to align justice and health systems.

Additionally, through our Reentry 2030 initiative, we’re helping states expand Medicaid coverage. For example, North Carolina aims to ensure Medicaid enrollment upon release for all eligible people and connect everyone with serious mental illness, substance use disorders, or significant cognitive impairments to treatment. Washington is working to enroll all eligible people in Medicaid 90 days before release.

Learn how your state can get involved in Reentry 2030.