Mainstream Health Care in Taiwan’s Prisons: A Model for Expanding Medicaid Coverage to Incarcerated Americans

The Patient Protection and Affordable Care Act authorizes the option and provides states with incentives to expand Medicaid eligibility to nonpregnant, nondisabled adults between the ages of 19 and 65 years earning at or below 138% of the federal poverty line.¹ This authorization, inadvertently perhaps, paved the way to expand Medicaid coverage for the formerly incarcerated people in the United States. States are split, and opinions are divided on this expansion. According to the US Government Accountability Office, as of 2014, 27 states (including Washington, D.C.) had moved to expand Medicaid coverage, whereas 24 states had not.² The proponents argued that expanding health coverage for former inmates can effectively and substantially reduce recidivism, and society will ultimately be better off despite inevitable extra costs.³ Opponents stressed the crowding effect of the expansion, which they argued would be unfair to the law-abiding populations traditionally covered under Medicaid.⁴ Amid the debates on Medicaid expansion in the United States, the reform in Taiwan that brought inmates under the coverage of its National Health Insurance (NHI) may serve as a reference to inform Americans on this issue.

In the United States, entering and leaving correctional facilities generally results in a hiatus of health insurance coverage.⁴ Although current federal law allows states to only suspend Medicaid eligibility for incarcerated individuals, 38 states and Washington, D.C., have gone beyond suspension to terminate eligibility.⁵ Former inmates are often left to their own devices; without well-coordinated assistance, they meet formidable obstacles to obtain any health coverage, which has been found to be a major factor for recidivism.⁶

TAIWAN’S 2010 REFORM

In Taiwan, while virtually all citizens are insured by the NHI, going to prison used to mean losing the entitlement to health coverage as inmates who were sentenced to serve time for more than two months were deprived of their insurance status. Those inmates were left to a system managed by the corrections authorities and exterritorial to the mainstream health system. As a result of a major reform that was concluded in 2011, however, NHI coverage was extended to the some 60 000 inmates in the 49 correctional institutions beginning January 1, 2013; in-prison health care has since been provided by the same medical system serving the general public. This made Taiwan one of the few countries that had mainstreamed health care in prison.

The premiums for inmates enrolled at the correctional institutions are paid by the Ministry of Justice from the government budget, which is assessed on the basis of the per capita national average cost.

The implementation of such a policy in Taiwan has produced the following positive instant effects: quality of in-prison care increased in terms of the structure and process, although it should take more time to evaluate the effect on the outcome; an overwhelming majority of the inmates felt better off with the NHI; and the families of the inmates are relieved from the medical bills and more receptive of their less fortunate family members in the prison. Health information integrated with the rest of the insured population made the health conditions in prisons transparent, which in turn will lead to further improvements in prison health through health promotion and health education programs. However, the cost sharing inadvertently created a new financial barrier for inmates to use medical services in prison; and coincidentally, Taiwan and the United States may well be the only two countries where copayments are extensively charged for in-prison health care.⁷

IMPLICATIONS FOR THE UNITED STATES

The health care systems in Taiwan and the United States are quite different, and the two nations may also possess distinct ethos for the administration of the correctional institutions. However, lessons for the United States can still be drawn.

As a country with 5% of the world’s population and 25% of the world’s inmates, it is of imperative importance for the United States to decrease the size of the incarcerated population, and strong evidence suggests that providing current and former inmates with health coverage is a key to reducing recidivism.⁸

A nation’s ethos can be converted by politicians’ acumen. When the policy was under consideration, Taiwan had debates similar to those in the United States. The debates then receded when people started to realize that this policy did not appear to negatively affect them. It is commendable that policymakers on both sides of the Pacific Ocean were smart enough to wrap this otherwise controversial policy into a far bigger framework of reform to neutralize the opposition. Political resistance is not insurmountable. A policy will eventually prevail if it is in line with the values of humanity.

Of course, the expansion of Medicaid for the formerly incarcerated is only a small step toward full coverage of all current and former inmates, but it is an affirmative step. Although covering the current inmates under a health program such as Medicaid may seem a bit far-reaching before the expansion for the formerly incarcerated proves to be desirable and feasible, it is noteworthy that taking away the exterritorial jurisdiction of prison health from the correctional system and mainstreaming it along with the general health care system has other benefits. First, it is a human rights issue to treat all citizens equally. Second, health coverage for inmates will lend a more positive prospect for the inmates after they return to the community, which would encourage them to maintain good health behavior. Third, as the information and statistics of inmates are made transparent, the problem of inmate health can be laid bare for further improvement. Fourth, to extend Medicaid coverage to more inmates and former inmates facilitates better community health, more continuity of care, and a more cost-effective health system. It is well recognized that good prison health is good public health.

Taiwan’s experience suggests that pushing this public health issue through may be emotionally challenging and politically sensitive but is morally commendable and technically possible.