Termination of Medicaid Policies and Implications for the Affordable Care Act

We appreciate Rosen et al. surveying state prison systems on policies impacting Medicaid enrollment for current and recently released prisoners.¹ We would like to expand upon their findings to discuss the implications of these policies in light of Medicaid expansion under the Affordable Care Act (ACA).²

At this time, 26 states and the District of Columbia have expanded Medicaid to cover individuals with incomes below 138% of the Federal Poverty Level, with the potential of reaching more than 7.5 million uninsured adults.³ About 80% of individuals released from prison are uninsured, and nearly all of them will be Medicaid-eligible under the ACA. Conservative estimates are that up to half of the 700 000 prisoners released annually may obtain coverage through the expansion. Some estimate that roughly 22% of all newly eligible persons will be justice involved.^4,5 However, these estimates do not account for the effect of state policies which terminate Medicaid benefits for imprisoned individuals.

We surveyed state Medicaid or Social Service departments between July 2012 and March 2014 on their Medicaid eligibility criteria for individuals residing in correctional facilities. Twenty-one of the 26 states expanding Medicaid under the ACA responded, and 18 states (69%) terminate Medicaid upon prison incarceration. Using these responses, we estimated that termination policies might put continuity of care at risk for more than 134 000 prisoners annually (Table 1) or 2% to 39% of enrollable adults under ACA criteria returning home from prison.⁶ This, moreover, is a conservative estimate because it only includes one year of release data and does not account for the rare but wrongful termination of Medicaid benefits when individuals cycle through jails.

TABLE 1—

Medicaid-Expansion States and Prison Releasees as a Percentage of Potential Enrollment

	Uninsured Adults Eligible for Medicaida	2012 Release From Prisonb	Releasees as a Total Percentage of Uninsured, %
Termination states
Arizona	339 000	13 000	4
Arkansas	236 000	6298	3
Connecticut	79 000	6014	8
Delaware	26 000	4012	15
Hawaii	47 000	1631	3
Illinois	632 000	30 108	5
Kentucky	291 000	16 215	6
Massachusetts	61 000	2871	5
Minnesota	188 000	7730	4
Nevada	207 000	5399	3
New Hampshire	4000	1555	39
New Jersey	337 000	10 817	3
New Mexico	153 000	3371	2
North Dakota	23 000	1069	5
Rhode Island	44 000	967	2
Vermont	13 000	1963	15
Washington	355 000	18 181	5
West Virginia	112 000	3293	3
Total	3 147 000	134 494	4
Suspension states
California	2 206 000	47 454	2
Colorado	247 000	10 919	4
Iowa	113 000	5221	5
Maryland	199 000	10 347	5
Michigan	426 000	13 199	3
New York	705 000	24 224	3
Ohio	590 000	21 628	4
Oregon	215 000	5023	2
Total	4 701 000	138 015	3

Note. District of Columbia was not included in the analysis because data were not available from Bureau of Justice Statistics.

^aData from Kaiser Family Foundation, 2014.³

^bData from US Bureau of Justice Statistics, 2012.⁶

The period immediately following release is especially high-risk for former inmates, with death rates substantially higher than that of the general population.⁷ Terminating Medicaid eligibility relegates a prisoner to reapplying upon release.⁸ Without coverage, former prisoners have difficulties seeing a primary care doctor, refilling medications, or accessing mental health and substance abuse treatments. Even as some states have begun to integrate enrollment in prerelease procedures,⁹ these actions are not universal and will not offset the human costs of disenrolling large numbers of individuals from Medicaid each time they are imprisoned. This issue will only be magnified as millions of individuals across the Unites States enroll in Medicaid under the ACA.