Abstract
Objectives. To estimate health insurance and health care utilization patterns among previously incarcerated men following implementation of the Affordable Care Act’s (ACA’s) Medicaid expansion and Marketplace plans in 2014.
Methods. We performed serial cross-sectional analyses using data from the National Survey of Family Growth between 2008 and 2015. Our sample included men aged 18 to 44 years with (n = 3476) and without (n = 8702) a history of incarceration.
Results. Uninsurance declined significantly among previously incarcerated men after ACA implementation (–5.9 percentage points; 95% confidence interval [CI] = −11.5, –0.4), primarily because of an increase in private insurance (6.8 percentage points; 95% CI = 0.1, 13.3). Previously incarcerated men accounted for a large proportion of the remaining uninsured (38.6%) in 2014 to 2015. Following ACA implementation, previously incarcerated men continued to be significantly less likely to report a regular source of primary care and more likely to report emergency department use than were never-incarcerated peers.
Conclusions. Health insurance coverage improved among previously incarcerated men following ACA implementation. However, these men account for a substantial proportion of the remaining uninsured. Previously incarcerated men continue to lack primary care and frequently utilize acute care services.
Before implementation of the Affordable Care Act (ACA), uninsured rates ranged from 40% to 90% among individuals recently released from prison or jail.1–3 Uninsurance among this population is problematic because substance use disorders,4 mental illness,5,6 and chronic physical health conditions7 are highly prevalent and contribute to elevated mortality rates upon release.8,9 In addition, formerly incarcerated individuals are hospitalized and use emergency department (ED) services at higher rates than do individuals without an incarceration history.10,11
According to analyses from the National Survey on Drug Use and Health, uninsured rates declined among some justice-involved populations (those recently arrested, on parole, or on probation) after implementation of the ACA’s key provisions: Medicaid expansion and Marketplace plans.12,13 However, insurance trends among those specifically with a history of incarceration have not been reported, and additional data sets have not been used to corroborate earlier findings of significant insurance changes among justice-involved individuals. There are also no national estimates of the proportion of remaining uninsured with a history of incarceration. Finally, whether patterns of health care utilization among previously incarcerated individuals changed after implementation of the ACA is unknown. Evaluation of the ACA’s impact among previously incarcerated individuals is critical because it can guide policymakers who wish to optimize policies and programs for this high-risk population.
To address these gaps in knowledge, we analyzed multiple years of a national, cross-sectional survey of young men, including those with a history of incarceration, to examine (1) health insurance changes following implementation of the ACA’s key provisions on January 1, 2014; (2) the proportion of remaining uninsured men with a history of incarceration; and (3) whether access to primary care or ED use improved for previously incarcerated men.
METHODS
We pooled the 3 most recent 2-year waves of the National Survey of Family Growth (July 2008–June 2010, September 2011–September 2013, and September 2013–September 2015) to create our analytic data set.14 The National Survey of Family Growth is a multistage probability-based, nationally representative household survey of individuals aged 15 to 44 years. Interviews were conducted in-person using computer-assisted personal interviewing techniques in a respondent’s household. Response rates were between 67% and 75% during our study period.15 The survey was designed and administered by the National Center for Health Statistics within the Centers for Disease Control and Prevention.
The fourth quarter of 2013 was considered a washout period because of active policy implementation related to the ACA’s coverage expansion, and we excluded all data from this period (September 2013–December 2013). We limited our sample to men aged 18 to 44 years because incarceration histories were not collected from women. Men in this age group account for the majority of individuals in jail or prison.16,17 The sample did not include currently incarcerated individuals.
Independent Variable and Outcome Measures
We determined incarceration history by responses to the following questions: “In the last 12 months, have you spent any time in a jail, prison, or a juvenile detention facility?” and “Have you ever spent time in a jail, prison, or a juvenile detention center?” We labeled men incarcerated at any point as “previously incarcerated,” and we labeled men who responded “no” to both questions as “never incarcerated.”
Individuals were asked whether they had ever been without health insurance in the past 12 months, whether they currently had health insurance, and their current type of coverage. We labeled those with current coverage who reported Medicaid, the Children’s Health Insurance Program, state-sponsored health plan, Medicare, military health care, or other government health care and did not report private insurance as “publicly insured.” We considered individuals with and without current insurance coverage who indicated a period of time without health insurance in the past 12 months to have had gaps in coverage.
We determined whether respondents had a regular source of care by responses to the question “Is there a place that you usually go to when you are sick or need advice about health?” and, if yes, the question, “What kind of place is it?” We categorized respondents whose usual source of care was an ED, an urgent care center, or a hospital room as not having a usual source of primary care. We identified respondents with an ED visit on the basis of whether they selected “hospital emergency room” in response to the question “What place or places did you go for service(s) [in the last 12 months]?”
Statistical Analysis
We estimated univariate frequencies as proportions for sociodemographic characteristics of respondents, stratified by incarceration history. We conducted significance testing for comparisons using the Pearson χ2 test. We then tabulated uninsurance rates among men with and without a history of incarceration over 3 periods (July 2008–June 2010, September 2011–August 2013, January 2014–September 2015), spanning implementation of the ACA’s key provisions: Medicaid expansion and Marketplace plans. We compared uninsurance rates among men with and without a history of incarceration using logistic regression. Among previously incarcerated men, we used logistic regression and predictive margins to compare the prevalence of uninsurance, public insurance, private insurance coverage, and gaps in health insurance before (September 2011–August 2013) and after (January 2014–September 2015) implementation of the ACA’s key provisions.
Next, we calculated the proportion of young men who were uninsured, with public insurance, or with private insurance and reported a history of incarceration.
Finally, we used multivariable logistic regression and predictive margins to examine changes in health care utilization. We compared differences in having a regular source of care, using the ED as a regular source of care, or reporting an ED visit in the past 12 months between individuals with and without a history of incarceration both before and after implementation of the ACA. We also compared outcomes among previously incarcerated men before and after ACA implementation. Our models controlled for age, race/ethnicity, income, education, marital status, employment, self-reported health, and drug use.
We conducted all analyses using complex survey design commands and the 2-year National Survey of Family Growth weighting variables provided by the National Center for Health Statistics. We have presented weighted data to permit national inferences, unless otherwise noted. We analyzed data using Stata SE version 14.2 (StataCorp, College Station, TX), and we considered a P < .05 to be statistically significant.
RESULTS
Our unweighted sample consisted of 12 178 men aged 18 to 44 years at the time of interview. Approximately one quarter (25.8%) of the weighted sample had a history of incarceration. Among men with a history of incarceration, 25.3% had been incarcerated within the past 12 months, half (49.9%) had been incarcerated more than once, and 23.7% reported that their last period of incarceration was 1 month or longer. Table A (available as a supplement to the online version of this article at http://www.ajph.org) provides additional study population sociodemographic characteristics.
Health Insurance
Uninsurance declined significantly following implementation of the ACA for men with and without a history of incarceration (Figure 1). Uninsurance decreased 5.9 percentage points ([pp]; 95% confidence interval [CI] = −11.5, −0.4) among previously incarcerated men (Figure 2) and 6.6 pp (95% CI = −10.4, −2.7) among men without a history of incarceration between 2011 to 2013 and 2014 to 2015. Uninsurance declined to a greater degree among men with a recent history of incarceration (within past 12 months) than among men with a distant history of incarceration (more than 12 months before interview), although this difference was not statistically significant (recent incarceration: −10.2 pp; 95% CI = −22.2, 1.7; distant incarceration: −4.7 pp; 95% CI = −11.8, 2.4; difference: −5.5 pp; 95% CI = −20.5, 9.5). Uninsurance remained substantially higher among previously incarcerated men than among never-incarcerated peers (previously incarcerated men: 32.5%; 95% CI = 28.5, 36.5; never incarcerated men: 16.7%; 95% CI = 14.4, 18.9; difference: 15.9 pp; 95% CI = 11.6, 20.1).
FIGURE 1—
Uninsurance Rates Among Young Men With and Without a History of Incarceration: National Survey of Family Growth, United States, 2008–2015
FIGURE 2—
Insurance Status Among Previously Incarcerated Young Men Before (2011–2013) and After (2014–2015) Implementation of the Affordable Care Act: National Survey of Family Growth, United States
*P < .05.
Between 2011 to 2013 and 2014 to 2015, the proportion of previously incarcerated men with private insurance increased significantly (6.8 pp; 95% CI = 0.1, 13.3; Figure 2). We found no significant change in the proportion with public insurance (–0.8 pp; 95% CI = −6.3, 4.6). The proportion of previously incarcerated men with gaps in health insurance coverage also did not change significantly following implementation of the ACA (pre-ACA, 45.5% vs post-ACA, 45.6%; P = .97).
Previously incarcerated men were overrepresented among uninsured (38.6%) and publicly insured (29.9%) men aged 18 to 44 years and underrepresented among those privately insured (18.6%) during the post-ACA period (Table 1).
TABLE 1—
Proportion of Uninsured, Publicly Insured, and Privately Insured Men, Aged 18–44 Years, With a History of Incarceration: National Survey of Family Growth, United States, 2014–2015
| Insurance Status | Previously Incarcerated, Weighted % (95% CI) | Never Incarcerated, Weighted % (95% CI) |
| Uninsured | 38.6 (33.6, 43.9) | 61.4 (56.1, 66.5) |
| Public | 29.9 (25.1, 35.1) | 70.1 (64.9, 74.9) |
| Private | 18.6 (15.8, 21.7) | 81.5 (78.4, 84.2) |
Note. CI = confidence interval. The sample size was n = 3315.
Health Care Utilization
In adjusted analyses, previously incarcerated men remained significantly less likely to report a regular source of primary care after ACA implementation than did men without a history of incarceration (difference = −13.0 pp; 95% CI = −18.3, −7.6; Table 2). Similarly, in the post-ACA period, previously incarcerated men were significantly more likely to report using the ED as a regular source of care or for any reason than were men who had never been incarcerated (difference = 2.7 pp; 95% CI = 0.7, 4.7; difference = 6.0 pp; 95% CI = 3.0, 9.0, respectively).
TABLE 2—
Adjusted Differences in Health Care Utilization Among Men, Aged 18–44 Years, With and Without a History of Incarceration: National Survey of Family Growth, United States, 2011–2015
| Utilization Outcome | Previously Incarcerated, Weighted % (95% CI) | Never Incarcerated, Weighted % (95% CI) | Difference,a Weighted % (95% CI) |
| Regular source of primary careb | |||
| Pre-ACAc | 52.5 (49.2, 55.8) | 62.8 (60.4, 65.2) | –10.3 (–14.3, –6.2) |
| Post-ACAd | 48.4 (43.2, 53.6) | 61.4 (58.0, 64.7) | –13.0 (–18.3, –7.6) |
| ED as regular source of care | |||
| Pre-ACAc | 4.5 (3.2, 5.8) | 3.0 (2.1, 4.0) | 1.5 (–0.1, 3.0) |
| Post-ACAd | 5.4 (3.3, 7.4) | 2.7 (1.8, 3.7) | 2.7 (0.7, 4.7) |
| ED visit past 12 mo | |||
| Pre-ACAc | 12.4 (8.4, 16.3) | 6.0 (4.7, 7.2) | 6.4 (2.2, 10.6) |
| Post-ACAd | 11.8 (8.9, 14.7) | 5.8 (4.1, 7.4) | 6.0 (3.0, 9.0) |
Note. ACA= Affordable Care Act; CI = confidence interval; ED = emergency department. The sample size was n = 7434.
Adjusted for age, race/ethnicity, income, education, marital status, employment, self-reported health, and drug use.
We categorized respondents whose usual source of care was an ED, urgent care center, or hospital room as not having a usual source of primary care.
September 2011–August 2013.
January 2014–September 2015.
Previously incarcerated men were equally likely to report a regular source of primary care (P = .18), the ED as a regular source of primary care (P = .47), and an ED visit for any reason (P = .80) during the pre-ACA and post-ACA periods.
DISCUSSION
In this national sample of previously incarcerated US men aged 18 to 44 years, we found that uninsurance declined following implementation of the ACA’s Medicaid expansion and Marketplace plans but remained significantly higher than uninsurance rates among men without a history of incarceration. Previously incarcerated men constitute nearly 40% of the remaining uninsured men in young and middle adult years. Because this age group accounts for more than 70% of uninsured adult men,18 previously incarcerated men constitute a substantial proportion of the general uninsured male population. Our findings also suggest that gains in health insurance coverage have not translated into positive changes in health care utilization patterns. Taken together, these data suggest that important gains in health insurance have been made among previously incarcerated men since implementation of the ACA but that many continue to lack a regular source of primary care and generally rely on high-acuity services for care.
Our findings build on recent studies that suggest there are improvements in health insurance coverage among justice-involved individuals following ACA implementation.12,13 We show that men specifically with a history of incarceration experienced significant improvements in health coverage. However, unlike previous work, our analysis includes a substantial number of men with more distant histories of incarceration (more than 12 months before interview). Because uninsurance remains elevated among previously incarcerated men compared with men without a history of incarceration, it may be helpful to assist men leaving jail or prison with health insurance enrollment and sustain this outreach beyond the first year after release to ensure that justice-involved individuals are aware of and engaged in health-related programs for which they remain eligible.
An important distinction between our findings and previous work with other samples relates to the type of insurance coverage responsible for declines in uninsurance. One recent study that included men and women with past year arrest, parole, or probation found that uninsurance rates dropped primarily because of gains in Medicaid.12 Our findings suggest that insurance gains stemmed from increases in private insurance coverage, which contrasts with pre-ACA models that predicted Medicaid would cover more previously incarcerated individuals than would the Marketplaces.2,3
Several considerations may shed light on this discrepancy. First, our study population was somewhat more educated and had higher rates of employment than did other justice-involved samples, which included older adults. Younger individuals, such as the young men in our sample, have seen more robust job growth since the Great Recession.19 Therefore, a larger proportion may have qualified for subsidies via their state Marketplace rather than Medicaid. Second, nonexpansion states have disproportionately high rates of incarceration, whereas expansion states may have larger populations in community corrections (the population surveyed in earlier studies)20; the comparatively higher proportions of our sample in states without Medicaid expansion would not have had the opportunity to enroll in Medicaid. Finally, because of the young age of our population, we may be detecting an effect of the dependent coverage mandate that expanded parental health insurance to individuals up to age 26 years.21
Despite insurance gains among previously incarcerated men, we found persistently low reporting of a regular source of primary care. In addition, previously incarcerated men continued to utilize the ED at significantly higher rates than do their peers without a history of incarceration. Although health insurance coverage is a necessary first step to improving access to health care among this population, it is insufficient. The previously incarcerated men in our sample would likely benefit from additional discharge services that aim to reduce ED and hospital visits by coordinating primary care visits and specialty follow-up.22,23
Limitations
Our study has important limitations. Justice-involved individuals are likely underrepresented because those currently incarcerated are not surveyed. We were also unable to assess the exact timing of incarceration and health insurance enrollment because of the cross-sectional design of the survey.
Public Health Implications
The ACA has garnered considerable interest as a unique opportunity to improve access to health care for justice-involved individuals.24 Our findings suggest that the ACA has improved health insurance coverage for many previously incarcerated men, but these coverage gains have not translated into positive changes in health care utilization. Future work should evaluate the impact of health insurance coverage through the ACA on health outcomes and costs among justice-involved individuals.
ACKNOWLEDGMENTS
Support for this research was provided by the Robert Wood Johnson Foundation (RWJF) and the US Department of Veterans Affairs (VA).
Note. The views expressed here do not necessarily reflect the views of the RWJF or the VA.
HUMAN PARTICIPANT PROTECTION
Our analysis was exempt from human participant review because it fell under the University of Michigan Medical School’s policy for research using publicly available data sets with de-identified responses.
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