Years before he took over the Merrimack County Department of Corrections, Superintendent Ross Cunningham took a chance on another county’s correctional facility.

Facing overcrowding, Sullivan County was contemplating building a new jail. Instead, Cunningham advocated for something else: funding for mental health and substance use treatment within the jail.

The goal: Treat more people for substance use disorders inside to help them break a dangerous cycle when they get out. The results: A dramatic drop in re-incarceration rates, Cunningham said.

Last year, Cunningham brought a similar program Merrimack County, making it one of the earliest counties to include Medication Assisted Treatment behind the jail walls.

Now, Cunningham is pushing for a bigger change with a higher bar to clear – getting the federal government to pay for those services.

Since 1965, the federal Medicaid program has existed to provide health care primarily to low-income people, but it’s always excluded the incarcerated. Even as the program grew over the years – recently in 2010, when it expanded to cover dramatically more people – that limit, the Medicaid Inmate Exclusion, has stayed intact.

Two members of Congress are pressing to get that limit removed; one is running for president. On Monday, New Hampshire Congresswoman Annie Kuster joined with New Jersey Sen. Cory Booker for a roundtable to promote the Humane Correctional Health Care Act.

Fifty years ago, the creators of Medicaid took a “shortcut” when it came to prisons and jails, Kuster said.

“If you were to design a system to fail Americans including taxpayers, families, communities and those with substance use and mental health issues, this is the system you would design,” Kuster said.

Booker characterized the effort as a way to break an often deadly cycle of incarceration, treatment, release and overdose within the opioid epidemic.

“It seems like we’re more comfortable spending millions and millions of dollars on re-arresting, re-arresting, re-arresting as their lives and their families and often their communities suffer as a result,” he said. “As opposed to doing the smart, intelligent interventions that are necessary to stop the spiral of addiction and mental health crises in individuals’ lives.”

The idea is one that has caught the attention of Commissioner Helen Hanks of the Department of Corrections as well.

New Hampshire currently houses 2,500 people in state prison facilities, which provide inmates everything from primary health care to ongoing mental health treatment. But due to Medicaid restrictions, the only procedures that prisons can reimburse for are episodes that involve in-patient hospital care.

As a result, more than $11 million a year is paid from state funds to deliver health care to inmates, according to Hanks – health care that for most prisoners would be covered by New Hampshire’s Medicaid expansion program on the outside.

The Department of Corrections already works with the state’s Department of Health and Human Services to try to make the interruption in coverage as minimal to inmates as possible. As early as 30 days before an inmate’s release, the Department of Corrections makes an effort to enroll that person in the state’s Medicaid expansion program, which covers up to 138% of the poverty level.

For many under the system, similar care to what they were receiving inside can continue on the outside. But allowing Medicaid into jails and prisons in the first place would ease the process, Hanks argued.

“It helps create one less piece to worry about in the process,” Hanks said. “It creates an efficiency and continuity.”

Meanwhile, the bill could also help to even out standards of care across New Hampshire correctional facilities, Hanks said. That standard dictates which services and procedures are covered by those incarcerated and which are not.

Right now, while state-run prisons have uniform standards, county corrections can vary widely.

The state prison system, for instance, uses the existing Medicaid formulary as a guide for which pharmaceuticals to offer, even if officials can’t bill the Medicaid program directly. But county jails and facilities, whose budgets are dictated by county delegations and a county-specific property tax, may deviate greatly, Hanks said.

Often, the quality of one New Hampshire county jail’s health care over another comes down to the size of its budget and how often it’s been sued.

It ebbs and flows based on litigation in each county, she said. “That starts telling them how to do care.”

Kuster’s bill, Hanks said, would address those disparities.

“It would mean that … all of those standards of care would become, essentially, unilaterally similar,” she said. “So it wouldn’t depend on where you are incarcerated because Medicaid has now become the standard of care in corrections.”

Monday’s roundtable brought a few dozen onlookers into the offices of New Futures, a Concord-based health advocacy group. But convincing Republicans in Congress to approve a major expansion of one of the countries biggest federal health programs is more than a simple list.

Still, Kuster claimed that the savings by creating a healthier population and reducing the inflow into jails and prisons would outweigh the costs.

“Consider the fact that we, the taxpayers, pay for our prisons to grow and grow and grow with completely inadequate resources and very poor outcomes,” she said. “And what it leads to is very, very high recidivism rates.”

Booker nodded along. 

“If you were a fiscal conservative, you would not do this to yourself,” he said of the present system. “It is the most irrational waste of taxpayer dollars.