With the expansion of Medicaid under the Affordable Care Act, an entire new population is eligible for government health care: low-income men.
And a new study by Johns Hopkins Bloomberg School of Public Health researchers suggests that in a single year, just a small number of programs has helped more than 112,000 people exiting prison or jail - the vast majority of whom are men - get health care coverage for which they hadn't qualified in the past.
The findings, published in the December issue of Health Affairs, suggest that if programs designed to ease the Medicaid enrollment process are expanded to more jurisdictions, many thousands more people who have served time may get access to health services that may not only improve their well-being but that research shows can reduce recidivism. Only 30 states and the District of Columbia have opted to expand Medicaid eligibility and most jurisdictions in those locations do not have programs designed to enroll people being released from jails and prisons.
"Typically, men who have serious health conditions ranging from schizophrenia to heart disease to diabetes who received medication while in prison or jail are released with as little as a week or two supply of medication and no access to a doctor," says the study's leader Colleen L. Barry, PhD, MPP, a professor of health policy and management at the Bloomberg School. "Now, depending on where they live, many are qualifying for health insurance through Medicaid as they leave jail or prison. We found that a handful of innovative programs have been created to enroll people in Medicaid and connect them with medical care upon release."
The first days and weeks back in the community can be lethal. A 2007 study in the New England Journal of Medicine found that in the two weeks after release the mortality rate among former prisoners was 13 times higher than in the general public, with the leading cause of death in this period being drug overdose.
Before the Affordable Care Act went into effect in 2014, Medicaid rules provided benefits to only certain limited groups of low-income people including pregnant women, children, and the disabled. With the expansion of Medicaid in 30 states and the District of Columbia, nearly all low-income people in participating states who earn less than 138 percent of the federal poverty level - or, in 2015, less than $16,000 in annual income for a single, childless adult or $33,000 for a family of four - are eligible. This opens the door to large numbers of people who may never have qualified for health insurance in the past. Based on income, nearly all of those being released from jail or prison in states that expanded Medicaid under the Affordable Care Act should now be eligible for insurance, Barry says.
For the study, Barry and her colleagues searched for programs that help enroll incarcerated individuals in Medicaid upon release. They found 64 such programs, half of them in California, that were in place as of January 2015. Only 42 of them have kept data on how many they have enrolled. But, those programs that have kept count had enrolled a total of 112,000 in Medicaid by January 2015, the overwhelming majority of whom are men.
Since many programs do not track enrollment, the researchers say, the number of new enrollees likely far exceeds 112,000.
Still, Barry says, many of those being released have mental illness or substance abuse problems. Many times, she says, when those with serious health conditions are released and the medication they may have been prescribed runs out, they end up having minor run-ins with the law, committing misdemeanors that land them back in jail. If they could be successfully connected with health care services and maintained on their medications, she says, research shows that they will be more likely to do well in their communities and avoid this cycle of re-arrests. She says much attention has been focused on the national problem of warehousing people with serious mental illness in jails and prisons instead of identifying better ways to connect them with effective health and mental health care services in the communities where they live.
Federal law prohibits those serving time from receiving Medicaid, so when someone enters prison or jail they lose their benefits but would receive treatment from the corrections system. But Barry says some states and counties have made it possible to simply suspend rather than terminate benefits while serving time. This means that upon release, Medicaid is automatically reinstated. Otherwise, it could take months before a new enrollment would go into effect.
In the Cook County Jail in Chicago, the roughly 300 inmates a day who come through the door are screened for Medicaid eligibility by social services staff as they are being booked. This gets the ball rolling so they can be enrolled upon release. Also, they are able to use their jail ID as a form of identification to enroll in Medicaid. Not having the right form of identification, Barry says, can be a barrier to enrolling.
But it may not be enough to just get Medicaid cards for the newly released. Barry says it is important for each community to help former inmates who need immediate care get medical appointments with doctors who take their insurance.
"If this change is going to make a difference, it's not enough to give people insurance," says study co-author Sachini N. Bandara, MS, a doctoral student at the Bloomberg School. "You need to facilitate access to health care providers. This is a population that has been largely ignored as they have fallen through the cracks in the system. These new Medicaid eligibility requirements are a huge opportunity to make a real difference in the lives of poor men."
"Leveraging the Affordable Care Act to Enroll Justice-Involved Populations in Medicaid: State and Local Efforts" was written by Sachini N. Bandara, MS; Haiden A. Huskamp, PhD; Lauren E. Riedel; Emma G. McGinty, PhD, MS; Daniel W. Webster, ScD, MPH; Robert E. Toone, JD; and Colleen L. Barry, PhD, MPP.
The study was funded by a grant from the Laura and John Arnold Foundation.