For most Americans, technology has become ubiquitous with basic daily function. While the COVID-19 pandemic exposed the severity of the digital divide, it also revealed a great potential for technology to bridge those inequalities. Rising concerns around restricted technology access during incarceration were especially notable (15, 16). From mediating access to educational resources, connecting with distant family, accessing healthcare, and developing digital literacy skills, the benefits of technology access in prisons and jails are manifold (17, 18).

The intense social isolation at the peak of the pandemic was assuaged by virtual family visits, providing essential connections to loved ones (19). Telehealth was also utilized for medical care without sending the person outside of the facility. Telehealth has increased access to care, including behavioral health services and specialized treatment typically unavailable within carceral facilities (20–22). Future expansion of telehealth could allow justice impacted individuals to further engage in behavioral health services with their families (22, 23). This use of digital technology during the pandemic provides clear evidence of how technology might be used moving forward to provide needed services and increase the chances of successful reentry (18, 24, 25). Figure 1 illustrates the benefits of telehealth access within carceral systems and for reentry.

Despite the existing evidence, technology access continues to be heavily contested. Restricted Wi-Fi access on designated devices is available in some facilities, but many simply deny internet access (26). Some states have policies related to use of computers, internet access, and social media, but there are few standardized regulations regarding digitization in carceral environments (27). In cases of the former, the use of tablets designed by for-profit companies is stifled by paywalls (16). Some facilities have continued to use virtual visits in addition to in-person visits (28).

Amidst all this complexity, there must also be concern that even after release, technology use may be stifled under the surveillance of community carceral providers—halfway houses, probation, and parole officers—and by lack of internet access, smart devices, and digital literacy (26, 29, 30). Without access to digital technology during incarceration, people leave carceral facilities unprepared for life in a world where most interactions, from finding a job or a home to connecting with service providers and family, require access to digital devices and the internet (18).

The COVID-19 pandemic had a profound impact on the health of justice impacted populations. Justice impacted populations experienced a disproportionate burden of COVID-19 in comparison to the general U.S. population. By June 2020, the COVID-19 infection case rate was 5.5 times higher for justice impacted individuals in prisons than the U.S. general population case rate of 587 per 100,000 (31). The disproportionate impact has been attributed to close habitation, the inability to effectively physically distance, overcrowding, poor ventilation, limited access to hygiene products, frequent transfers of incarcerated individuals between facilities, and the migration patterns of correctional staff (32). In efforts to reduce the rapid transmission of COVID-19 among justice impacted populations, correctional facilities limited transport for non-life threatening healthcare related visits and activities (33).

In response to these challenges, the rapid proliferation of telehealth in correctional facilities, due to physical distancing policies, Medicare expansion for telehealth services, and some funding specifically for this effort, emerged as a promising innovation to improve access to care for justice impacted populations to meet medical and behavioral health needs (34). Telehealth interventions utilized during the COVID-19 pandemic included the use of information and communication technologies, such as video conferencing technology, telephone calls, and tablets, to conduct consultations, medication management, evaluations, and therapy (35–38). Several facilities utilized telehealth to deliver mental healthcare services, to facilitate the treatment of substance use disorders, and to improve access to routine healthcare for individuals incarcerated in rural areas (20, 22, 23, 37, 39, 40). Since the progression of the COVID-19 pandemic, key legislation in several states, such as Michigan, Minnesota, and North Carolina, has been introduced to expand access to telehealth in correctional facilities and to improve healthcare outcomes for justice impacted individuals (41, 42).

Few, if any, studies have examined the effect of Medicaid policy on the availability and accessibility of telehealth in carceral systems. However, these policies may have an outsized impact on patient care quality and health outcomes. While Medicaid is not a significant funding source for healthcare in jails and prisons, its imprimatur as a large insurer could improve access to care for many underinsured and underresourced patient populations (43).

In some cases, Medicaid prohibits the use of funds for justice impacted individuals in a public institution except when the individual is a “patient in a medical institution” organized to provide medical care (27). States have the latitude to submit customized Medicaid program modifications adopted and operationalized once approved by the Centers for Medicare and Medicaid Services.

These modifications are waivers under Section 1115 of the Social Security Act (44). Commonly known as 1,115 waivers, these demonstration projects may facilitate or restrict Medicaid benefits necessary to access needed care, depending on the state (45, 46). For example, Indiana’s 2015 1,115 Medicaid waiver expedited coverage for justice impacted adults by initiating Medicaid applications while in custody and temporarily suspending coverage where it was previously just discontinued (47). Researchers (48) found that this waiver was associated with increased coverage for justice impacted adults. Notably, Indiana’s Medicaid program levies penalties on beneficiaries who lapse on their coverage (48).

Research evaluating the impact of 1,115 waiver programs and subsequent demonstration projects on healthcare outcomes is still developing, and much of it excludes telehealth in jails or prisons. Thus, there are few incentives given 51 different approaches to Medicaid, i.e., reimbursement opportunities for telehealth providers who serve justice impacted populations.

Telehealth has been used to support justice impacted individuals while in prison and after their release by facilitating patient-provider communication and shared decision making (e.g., during telemedicine visit) (49). More recently, greater attention has been focused on the use of digital health technology to support management of health conditions (e.g., smartphone app to manage cardiovascular disease) (50), and facilitate connections to community resources and peer support (e.g., smartphone app to support individuals during their reentry period and transition back to the community) (51, 52). Digital health tools and services can benefit individuals with a history of incarceration, however, people with this lived experience must be included in the design process to enhance usefulness, implementation success, and sustainability.

Studies have demonstrated needed design enhancements to improve use of digital health technologies for justice impacted individuals (53, 54). User-centered design (UCD) methods can be used to create telehealth tools that are context-specific, culturally sensitive, effective and engaging. UCD is an iterative design process, and the users’ and their needs are the focus in each step of the process, which includes understanding the context of use, specifying the user requirements, creating design solutions, and evaluating the telehealth tool (55). Failure to include intended users in the design process may result in the development of a tool that not only fails to meet the intended users’ needs but may not be context or culturally-relevant or trauma-informed, and may maintain the status quo and/or contribute to intervention-generated inequalities (56). A current study codesigning a mobile app with individuals with a history of incarceration to provide support as they rejoin their communities found there was need for content and features that allow users to easily access resources for employment, housing, healthcare, and medical needs (including mental health and substance use), community health workers, formal and informal support, and easy navigation of Department of Corrections Rights (57).

There are many considerations for implementation of telehealth tools to support justice impacted individuals. Access to internet enabled devices (e.g., smartphone), broadband internet access, preferred modes of communication, privacy and confidentiality concerns, and the digital and health literacy of the intended users must be considered (53). One caveat is that justice impacted individuals may have infrequent access to devices to use telehealth services and resources. This may be due to monitoring by individuals in restrictive community settings (e.g., halfway house) that limit access to personal devices, such as smartphones. Therefore, options to save data (e.g., patient reported outcomes) to cloud storage, and additional security (e.g., require personal identification number to unlock app after a specific time of inactivity has passed) should be considered when developing telehealth tools to support justice impacted individuals.

Introducing telehealth communication in correctional facilities offers significant benefits for enhancing healthcare outcomes for justice impacted individuals (13). However, this endeavor also raises ethical, legal, and social concerns that necessitate thorough consideration to ensure a lasting and sustainable impact. Limited research articulates the extent of the risk these implications pose for justice impacted individuals. However, there are some researchers who have voiced opinions on the advantages and disadvantages of technology in carceral environments (58). Health researchers, policymakers, and correctional administration must also consider the ethical, environmental, technological, and operational concerns when introducing and implementing digital health technologies, like telehealth services, for justice impacted individuals to maintain equitable and fair practices and standards.