Medicaid, the health care insurance program that is jointly funded by federal and state governments, has been enlarged under the Affordable Care Act, alternately referred to as ACA and Obamacare, and now covers more low-income earning adults including those included within the prison population. A new nationwide survey of state prison administrators found that with the expansion of Medicaid eligibility prison systems have begun to support prisoners' enrollment in Medicaid as a way to help lower prison system costs while also improving prisoners' access to health care after release. "Enrollment improves access to basic health services, including substance use and mental health services and can in turn benefit the health of the communities and families to which prisoners return,” Dr. Josiah D. Rick, director of the Center for Prisoner Health and Human Rights at the Miriam Hospital, said in a press release. “There is a possibility that there will be decreased recidivism as people get treatment for their mental illness and addiction." The study appears in the American Journal of Public Health.

Medicaid Before and After the ACA

Prior to the Affordable Care Act, Medicaid routinely provided coverage for adults if they were disabled, 65 or older, or, in cases of non-elderly adults, if they were low-income parents, other caretaker relatives, or pregnant women. Some people who did not fit those requirements also received Medicaid in about half of the states, which were able to provide coverage, often in some but not all cases, through state-funded programs. Under the previous laws, then, a health care insurance coverage gap existed for low-income adults.

To fill in gaps in coverage for the poorest Americans, provisions under the Affordable Care Act created a minimum Medicaid income eligibility level across the country. Beginning in 2014, individuals under age 65 with incomes below 133 percent of the federal poverty level (calculated as $11,490 for an individual in 2013) became eligible for Medicaid in every state, with eligibility extended to non-disabled adults under the age of 65 without dependent children. Those eligible for Medicaid will receive a benchmark benefit or benchmark­ equivalent package that includes the minimum essential benefits provided by the insurance exchanges. Along with a benchmark plan, benefits also include prescription drugs, preventive and obesity-related services, tobacco cessation programs, and health homes for those enrollees suffering from chronic conditions. Medicaid under ACA also promotes prevention, wellness, and public health and helps people receive long-term care services and support in their home or the community.

Medicaid, then, has expanded not only eligibility but also services and the impact on various populations remains to be seen, and for this reason one particular team of researchers chose to explore potential effects and benefits for the prison population.

Study Results

Under the constitution, prisoners have a right to adequate medical attention, which comprises a significant expense of prison financing; in 2008, a Pew Charitable Trust survey based on Bureau of Justice statistics revealed that out of $36.8 billion in overall institutional correctional expenditures, nearly $6.5 billion went to prison health care in 2008. Although a small percentage of prisons provide some health care services for select prisoners under Medicaid, most do not and in 2000 — prior to enactment of the ACA — nearly all states had policies terminating Medicaid enrollment upon incarceration.

To better understand policies and practices employed in state prison systems (SPS), Rich and his co-researchers surveyed prison administrators from December 2011 through August of 2012. Survey questions included Medicaid termination or suspension upon incarceration, assistance reenrolling in Medicaid, challenges reenrolling in Medicaid, and screening previously nonenrolled prisoners for potential Medicaid eligibility. Of the 42 state prison systems that responded to the survey, the policies of two-thirds dictated termination of Medicaid coverage and 21 percent suspension of coverage when a prisoner was first incarcerated. Of these systems requiring termination or suspension, more than two-thirds provided assistance to help prisoners reenroll in Medicaid once they were released. Generally, the researchers found, suspension promoted timely reactivation of Medicaid benefits upon release.

"The difficult reality is that terminating Medicaid during incarceration, which is what is occurring in the majority of prison systems today, can be harmful to this population, as well as costly to the general public," Rich said. "Instead, we should be moving toward using this period of incarceration as an opportunity to reduce expensive post incarceration emergency room and inpatient hospital care."

The survey also showed that most state prison systems had policies in place that identified prisoners who were potentially eligible for Medicaid and provided assistance with the Medicaid applications. In 15 state prison systems, Medicaid applications were submitted so that benefits could be used during incarceration to pay for inpatient care received in the community. With several states planning to expand Medicaid eligibility in 2014, the number of released prisoners with access to routine care could increase dramatically, the researchers noted. They suggest as well future investigation of successful prison systems and the financial implications of enrollment for prisons and the Medicaid program. Certainly one inference drawn from this study would be that individual states might investigate where and when Medicaid and prison health care systems — both paid for by taxpayers — overlap. Might one or the other be scaled back in order to save state dollars?

Source: Rosen DL, Dumont DM, Cislo AM, Rich JD, Brockmann BW, Traver A. Medicaid Policies and Practices in US State Prison Systems. American Journal of Public Health. 2014.