Eliminating Gaps in Medicaid Coverage During Reentry After Incarceration

Abstract

This commentary explores the health and social challenges associated with gaps in Medicaid health insurance coverage for adults and youths exiting the US criminal justice system, and highlights some potential solutions.

Because a high proportion of recently incarcerated people come from low-income backgrounds and experience a high burden of disease, the Medicaid program plays an important role in ensuring access to care for this population. However, the Medicaid Inmate Exclusion Policy, or “inmate exclusion,” leads to Medicaid being terminated or suspended upon incarceration, often resulting in gaps in Medicaid coverage at release. These coverage gaps interact with individual-level and population-level factors to influence key health and social outcomes associated with recidivism.

Ensuring Medicaid coverage upon release is an important, feasible component of structural change to alleviate health inequities and reduce recidivism. High-yield opportunities to ensure continuous coverage exist at the time of Medicaid suspension or termination and during incarceration prior to release.

On any given day in the United States, approximately 2.2 million adults and 45 000 youths are incarcerated in prisons or jails, or in residential placement in juvenile facilities.^1,2 Incarceration has long-term health,^3,4 social,⁵ and economic⁶ consequences in the lives of adults and youths. One important pathway to these negative consequences is often overlooked: the disruption in Medicaid coverage at intake.

A high proportion of people in the criminal justice system are eligible for Medicaid. This is especially true in states that expanded Medicaid under the Patient Protection and Affordable Care Act (ACA), where it is estimated that 80% to 90% of incarcerated people are now eligible.⁷ Given that 650 000 people are released from prison⁸ and more than 10 million are admitted to local jails annually,⁹ Medicaid is an important form of health insurance coverage for at least several hundred thousand justice-involved individuals each year.

However, because of federal legislation that established the Medicaid Inmate Exclusion Policy, or “inmate exclusion,” nearly all incarcerated people on Medicaid lose coverage upon entering the criminal justice system.¹⁰ The inmate exclusion prohibits payment of federal Medicaid funds for services provided to an “inmate of a public institution,” except when the person is a “patient in a medical institution,”¹¹ typically only for inpatient care. As a result, Medicaid is commonly suspended or terminated at intake. The exclusion applies both to adults in correctional facilities and to youths who have been involuntarily detained.¹² Too often, this disruption means that people who arrived with Medicaid leave the correctional system without insurance coverage.

Prior literature has emphasized the negative impact of the inmate exclusion on health care quality during incarceration.¹³ We extend this discussion by highlighting the law’s impact during an incarcerated person’s reentry to the community. It is likely that the disruption in Medicaid coverage caused by the inmate exclusion contributes to persistent low rates of insurance coverage among formerly incarcerated people. Even after implementation of the ACA, in 2014, over 30% of nonelderly adults with recent justice system involvement remained uninsured, compared with 15% of those with no involvement.¹⁴ Thus, despite the landmark case Estelle v. Gamble, which established a right to health care during imprisonment,¹⁵ current law may actively create barriers to care following imprisonment by causing Medicaid disenrollment or suspension. Beyond legal rights, the inmate exclusion may also threaten the human right to health by limiting access to services.¹⁶ In this commentary, we examine the issue of gaps in Medicaid coverage for people reentering the community after incarceration, and propose solutions to disrupt current trends.

IMPORTANCE OF MEDICAID AFTER INCARCERATION

Under the ACA, adults in Medicaid expansion states can qualify for coverage if their household income is below 138% of the federal poverty level.¹⁷ A large proportion of formerly incarcerated people meet this criterion. One study found that in the year after incarceration only 55% of working-age men reported earnings, with median annual earnings of $10 090, signifying that most would qualify for Medicaid after release.¹⁸

Medicaid is also important because of the disproportionate disease burden in the incarcerated population. One analysis found that compared with the general population aged 18 to 65 years, adults in prison had 1.2 times the odds of having hypertension, 1.3 times the odds of asthma, 4.2 times the odds of hepatitis, and 4.8 times the odds of cervical cancer.¹⁹ Over half of incarcerated adults meet criteria for drug dependence or abuse, and between 15% and 25% meet criteria for serious psychological distress, compared with 5% of the general population.^20,21 Similar trends of disproportionate morbidity exist for youths. Approximately 50% to 75% of justice-involved youths meet criteria for a mental health disorder.²² This population also experiences high rates of substance use disorder, sexually transmitted infections, and reproductive health needs compared with the general youth population.²³ Table A (available as a supplement to the online version of this article at http://www.ajph.org) compares the health status, utilization, and insurance coverage of justice-involved individuals and the general population.

These health conditions can be exacerbated by reentry, when formerly incarcerated people often face difficulties related to unemployment, housing, reconnecting with services, and reestablishing social connections.^3,24,25 For example, one analysis found that self-reported health status worsened for those with physical health conditions during the year following release. During incarceration, one quarter of men and one third of women rated their health as fair or poor, whereas after release one third of men and half of women reported fair or poor health.²⁶ A national study using Medicare data found that formerly incarcerated people had 2.5 times the odds of matched controls of being hospitalized within 7 days of release.²⁷ A similar study found that compared with adults with no criminal justice involvement, adults on parole had 1.2 times the odds of having been hospitalized in the past year and 1.4 times the odds of an emergency department visit.²⁸ Formerly incarcerated people also experience markedly high mortality during reentry. One analysis found that justice-involved individuals had 12.7 times the risk of death within two weeks after release compared with state residents of the same age, gender, and race, and 3.5 times the risk of death during the average follow-up period of 1.9 years.²⁹

Ensuring access to preventive health services during reentry may be especially critical for incarcerated people with mental illness or substance use disorder. One study of people on parole in California found that 53% of those with mental illness were reincarcerated within one year, compared with 30% of those without mental illness. Importantly, reincarceration for those with mental illness was often due to technical violations such as failing to attend mental health appointments.³⁰ Similarly, a systematic review of behavioral health interventions concluded that providing interventions after release is important for preventing recidivism.³¹ Medicaid coverage could thus reduce risk of reoffending by increasing access to behavioral health care. Indeed, Medicaid has been associated with increased utilization of mental health and substance use treatment among formerly incarcerated people,¹⁴ suggesting that coverage may be key to successful reentry.

Additional subpopulations may be highly affected by gaps in Medicaid coverage. For example, continuity of coverage may be important for youths, given the biological and psychological vulnerability associated with their age.³² At the same time, older incarcerated people are likely to have higher rates and earlier onset of geriatric conditions compared with nonincarcerated older adults,³³ and may rely on Medicaid until eligible for Medicare. Furthermore, because structural inequities lead to a disproportionate rate of both poor health and incarceration for people of color,^34–36 Medicaid coverage during reentry may be particularly important for incarcerated people from diverse racial and ethnic backgrounds.

HEALTH AND SOCIAL EFFECTS OF GAPS IN COVERAGE

Because Medicaid plays a crucial role in the lives of justice-involved people, it is imperative to understand how the inmate exclusion influences gaps in coverage, and thereby affects health and social outcomes. We developed a conceptual diagram of how the inmate exclusion may affect these factors (Figure A, available as a supplement to this article at http://www.ajph.org).

It is important to recognize that the inmate exclusion operates in the context of population-level inequities that influence how individuals experience health care and the criminal justice system. For example, in 2017, sentenced Black males were imprisoned in state and federal facilities at nearly six times the rate of White males.³⁷ As has been extensively documented, structural racism leads to high rates of both incarceration and morbidity for people of color,³⁴ and researchers have documented links between incarceration and health disparities between racial groups.^35,36 Related to these systemic inequities, individual-level factors such as health, socioeconomic status, and prior interactions with the legal system also influence risk of incarceration,³⁸ leading to disproportionate rates of Medicaid suspension and termination for certain populations.

Upon incarceration, disruption of Medicaid places a burden of reenrollment on agencies and justice-involved people.³⁹ Additional research is needed to confirm the causes of discontinuous Medicaid coverage at release, but it is likely that resource and process barriers within correctional and Medicaid organizations contribute to coverage gaps. In addition, release dates can be unpredictable, making it difficult to coordinate the timing of Medicaid applications. One study of people with severe mental illness in jail found that 49% were released through unpredictable mechanisms and only 19% had adequate time for reentry planning.⁴⁰ As a result, eligible people may frequently not be enrolled in Medicaid upon release.

Unfortunately, current literature provides limited information on the prevalence of Medicaid coverage gaps during reentry for the justice-involved population. However, it is clear that gaps occur.^14,41 One pre-ACA study of formerly incarcerated people found that 78% of men and 66% of women were uninsured two to three months after release, and 68% of men and 58% of women were still uninsured eight to 10 months later.²⁶ Studies of the general population have documented associations between gaps in Medicaid coverage and increased emergency room use,^42,43 increased rates of hospitalization for chronic conditions,⁴⁴ and decreased rates of filling prescriptions.⁴² Given the high burden of disease and challenges of reentry, it is likely that these adverse utilization patterns in the general population could be even more harmful for formerly incarcerated people who experience discontinuous Medicaid coverage.

In addition to potential negative health effects, gaps in Medicaid coverage during reentry may be linked to recidivism. One study of people with HIV undergoing reentry found that those with health insurance during the 30 days following release had approximately 60% lower odds of recidivism compared with those without insurance, and that being uninsured was associated with shorter time to reincarceration.⁴⁵ Thus, gaps in Medicaid coverage can perpetuate social inequities by contributing to cycles of reincarceration, rather than treatment and rehabilitation.

POINTS OF INTERVENTION AND MODEL STRATEGIES

Literature on Medicaid enrollment during reentry indicates two main opportunities for intervention to eliminate gaps in coverage: (1) at the point of Medicaid suspension or termination and (2) prior to release, either during reentry or earlier in incarceration.

Suspension or Termination

The most far-reaching strategy to eliminate gaps in Medicaid during reentry would be ending the inmate exclusion, allowing federal Medicaid funds to pay for preventive and other nonemergency medical care during incarceration. Removing the payment restriction could improve quality of care during incarceration by increasing treatment options, especially for substance use disorder.¹³ It would also greatly reduce or eliminate gaps in Medicaid coverage during reentry, thereby addressing an important factor that contributes to adverse outcomes. Although ending the inmate exclusion would require federal legislation or a successful judicial challenge, doing so would relieve the administrative burden associated with suspending or terminating Medicaid,³⁹ and mitigate the negative outcomes that occur when recently incarcerated people face coverage gaps.

Although less impactful than ending the inmate exclusion, the effect of Medicaid disruption could be lessened by adopting suspension-only policies that temporarily inactivate, rather than terminate, coverage. Currently, about one in four states terminate, rather than suspend, Medicaid.⁴⁶ Suspension has been associated with timely Medicaid reactivation,⁴⁷ and advocates note that it requires little administrative burden and can often be implemented without legislation.⁴⁸

Notably, and relevant to youths, in 2018 the federal government passed the Substance Use-disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT for Patients and Communities Act), H.R.6,⁴⁹ which instructed that states “shall not terminate eligibility for medical assistance” and “may suspend coverage” for youths in the juvenile justice system. This statute will likely mitigate issues associated with Medicaid coverage gaps for youths, as changing state policy from termination to suspension has been associated with improved continuity of insurance.⁵⁰ One high-impact strategy may be for stakeholders to ensure effective implementation of the SUPPORT for Patients and Communities Act so that Medicaid is no longer terminated for justice-involved youths.

Opportunities Prior to Release

Another approach encouraged by the SUPPORT for Patients and Communities Act, for both youths and adults, is pursuing “innovative strategies” to ensure that eligible people are enrolled in Medicaid upon release.⁴⁹ Model strategies for enrollment already exist in many jurisdictions. Under a Section 1115 Medicaid waiver, the Cook County Jail in Illinois implemented a program to enroll incarcerated people in Medicaid at intake; intake was selected rather than reentry because release can occur at unpredictable times, leading to incomplete screening.⁵¹ A similar program in Connecticut enrolled detained people in health insurance prior to trial.⁵² In North Carolina, a state that did not expand Medicaid, a program to enroll hospitalized incarcerated people in Medicaid led to approximately $10 million in savings for the state’s prison system, and demonstrated the importance of projected cost savings in generating legislation.⁵³ Programs that enroll people during incarceration can also reach those who are eligible for Medicaid but not enrolled at intake, thereby widening access to health care services when formerly incarcerated people return to their home communities.

Reducing the amount of time required to process Medicaid applications may also help eliminate gaps in coverage. In Washington State, a program to expedite coverage for incarcerated and institutionalized people with mental illness increased Medicaid enrollment and use of outpatient mental health services within 90 days of release.⁵⁴ Additionally, once people are enrolled in Medicaid, there may be value in helping them navigate the health system. An evaluation of a health insurance literacy curriculum for incarcerated people in Montana found that participants improved their knowledge of the ACA and health insurance plans.⁵⁵

Reducing administrative silos between Medicaid and criminal justice agencies could also facilitate Medicaid enrollment during reentry by enabling information transfer and establishing interorganizational processes. For example, government agencies in Arizona and Washington State strengthened data systems to improve information sharing between health care and correctional institutions, with a goal of enrolling justice-involved people in insurance.⁵⁶ Public agencies in Maryland and in Los Angeles County, California also established organizational infrastructure that engaged staff across agencies to link incarcerated people to health insurance and services upon release.⁵⁷

Finally, states that have not yet expanded Medicaid under the ACA should consider the impact of Medicaid restrictions for the criminal justice system. One commentary underscored Medicaid expansion in Southern states as an important opportunity to improve health outcomes for justice-involved people.⁵⁸ Another analysis argued that Medicaid expansion will be most effective for incarcerated people if it involves cross-sector coordination between health care organizations and correctional institutions, and is accompanied by a suspension-only policy.⁵⁹

CONCLUSIONS

There is a need for action to eliminate gaps in Medicaid coverage at release from incarceration. Given the success of current initiatives that prevent coverage gaps, policymakers and practitioners should consider scaling up existing models. It may also be beneficial to expand policies developed in the juvenile justice context to the adult context. For example, the prohibition on Medicaid termination stipulated in the SUPPORT for Patients and Communities Act could be extended to the adult correctional system. Additionally, as public discourse continues around health reform in the United States, it may be strategic to include provisions in future legislation that eliminate or mitigate the negative impacts of the inmate exclusion. To inform policy development, research should identify the prevalence and impact of gaps in Medicaid coverage during reentry, and evaluate prospective solutions. Implementing these or other strategies to ensure Medicaid continuity during reentry represents a feasible, high-yield opportunity to transform current systems to reduce recidivism and alleviate health inequity.