Criminal justice reform is a major public policy issue for this generation. The United States has the highest per capita incarceration rate in the world, with nearly 2.3 million people currently incarcerated.

Criminal justice reform is also an urgent health equity issue. Incarcerated individuals have worse health outcomes than the general population before, during, and after incarceration. They are more likely than the general population to have chronic diseases (including high blood pressure and diabetes) and infectious diseases (including hepatitis, HIV/AIDS, and tuberculosis). Substance abuse and mental illness are especially prevalent, due both to the War on Drugs—a more aggressive approach to drug enforcement policy—and deinstitutionalization, a movement in the mid-twentieth century that was meant to move people with severe mental illness from state psychiatric hospitals to community care, but too often led to incarceration due to a lack of community-based alternatives. One study found that in the first two weeks after release, the death rate of former inmates in Washington State was more than 12 times greater than that of the general population, primarily due to drug overdose, cardiovascular disease, homicide, and suicide. Despite these disparities, incarcerated people have historically been left without health coverage upon release, often ineligible for Medicaid, without employer-based insurance, and unable to afford market-based insurance. As noted in a recent Health Affairs Blog post, access to health care is an essential yet often ignored aspect of successful re-entry. Medicaid expansion under the Affordable Care Act (ACA) thus offered an unprecedented opportunity for formerly incarcerated people to gain access to health care.

Health Care Access While Incarcerated

The criminal justice system is the only place in the US where health care is guaranteed, per the US Supreme Court case Estelle v. Gamble, which ruled that denial of health care constituted as cruel and unusual punishment and in violation of the Eighth Amendment. Although quality varies, and in many states incarcerated individuals are still required to pay copayments for prescription medication, incarceration may be the first time some populations have reliable access to health care. For these populations, this has measurable impacts: Several studies have found lower mortality rates among incarcerated black men than non-incarcerated black men in the same age group. Although the causal reasons are debated, public health scholars Christopher Wildeman and Emily Wang note that “protective effects of current imprisonment for this group might be driven by a decreased risk of death by violence or accidents, reduced access to illicit drugs and alcohol, and improved health care access.”

Yet upon release from prison, health care often disappears. About 80 percent of formerly incarcerated people are uninsured and are often unable to continue medical treatments they received while incarcerated. This can be dangerous in a population that has such high rates of chronic disease and infectious disease that requires regular care, such as HIV. In the years since the passage of the ACA, dozens of programs have popped up across the US to increase inmate participation in Medicaid post-release.

State Strategies To Expand Coverage

While formerly incarcerated people have never been legally excluded from Medicaid, the demographics of the group mean the majority are simply unqualified. Even for those who do qualify in Medicaid expansion states, there are many barriers formerly incarcerated people face that make it difficult to enroll upon release. For one, they are dealing with other urgent issues such as housing or employment and may not have time or bandwidth to seek health insurance post-release. They also might not have the required identification such as a birth certificate or driver’s license to enroll in Medicaid, which can be confiscated upon booking and takes time and money to obtain post-release. The expansion of Medicaid was an opportunity for states to increase health care coverage for this population with federal funding. A spring 2018 review by the Henry J. Kaiser Family Foundation using data from the annual Medicaid budget found 38 states are working with prisons and 32 are working with jails to help facilitate Medicaid enrollment prior to an inmate’s release date. Additionally, in 37 states Medicaid benefits are suspended, rather than terminated, upon being incarcerated in prison. Half of states also reported that they are working to enroll parolees in Medicaid.

There are four main strategies that these programs employ:

Suspension, rather than termination, of Medicaid benefits upon incarceration;

Allowing inmates to apply for Medicaid prior to release, to ease their transition and prevent any gaps in health care coverage;

Allowing formerly incarcerated people to use alternative identification to enroll in programs; and

Presumptive eligibility to ensure that people can receive Medicaid even as their application is being reviewed.

Unfortunately, administrative issues and lack of capacity of corrections staff remain an issue. For example, a report by Kaiser Health News and the Marshall Project found that in 2016, Indiana enrolled 90 percent of all released individuals in Medicaid, but only half of them activated their coverage—at the time, they were required to activate via phone call. The state has since eliminated this requirement. Additionally, some states that suspend, rather than terminate, Medicaid benefits upon incarceration do not automatically re-enroll people upon release, leading to temporary gaps in coverage at a time when they need it most.

Insight From Massachusetts

In many states, it is still unclear if these enrollment options will impact health outcomes of formerly incarcerated people. Upon release, formerly incarcerated individuals are less likely to have a primary care physician, more likely to be admitted to the hospital for preventable reasons, and more likely to use the emergency department for medical services than the general population. Will increased enrollment in Medicaid change these behaviors? Or will discrimination that is often faced by formerly incarcerated people continue to dissuade them from seeking care?

Massachusetts may offer some insight. In 2006, under a Section 1115 waiver, the state expanded its Medicaid eligibility rules to include more nondisabled, childless adults. This meant increased coverage for formerly incarcerated people, and the state now facilitates Medicaid enrollment six months prior to release. Re-entry counselors also make appointments with local primary care physicians prior to an inmate’s release and arrange placements in substance abuse or other care facilities as needed. This effort seems to have a positive impact: A 2011 study found that 84 percent of inmates released between July 1, 2008 and December 31, 2008, used at least one MassHealth service in their first year post-release, which includes medical care, behavioral health treatment, and prescription drug coverage.

Savings For States

Overall, Medicaid expansion is expected to produce net savings for states; the Center for Budget and Policy Priorities notes that “as more people gained coverage, hospitals’ uncompensated care costs—and thus, for some states, payments to hospitals to help cover those costs—fell.” Virginia, for example, which passed expansion in June 2018, is projected to save $421 million in its first two years, while Michigan is projected to save $1 billion by 2021 due to savings on mental health services and increased tax revenue.

Enrolling currently incarcerated people in Medicaid—or suspending, rather than terminating, their enrollment upon incarceration—also has financial benefits to states. For the most part, states cannot seek reimbursement for medical care of people in prison, unless they are in a community-based (not prison) hospital for more than 24 hours. In this case, if the individual is enrolled in Medicaid, the state may be reimbursed up to 50 percent for this care.

Through these Medicaid reimbursements, Arkansas saved $2.7 million, Colorado saved $10 million, Kentucky saved $16.4 million, and Michigan saved $19 million inpatient costs for prisoners in combined fiscal years 2014 and 2015. Although Massachusetts did not take advantage of this opportunity, a state auditor estimated the state would have saved $11.6 million in fiscal years 2011 and 2012. Of course, states with Medicaid expansion will benefit most greatly from these reimbursements, as more of their incarcerated population will be eligible for Medicaid.

Communitywide Impacts

Access to insurance will not solve health outcomes of formerly incarcerated individuals. During re-entry, they are impacted by many social determinants of health—heightened stress, searching for employment and stable housing, and rebuilding family ties (more than half of currently incarcerated people are parents of minor children). But Medicaid is one important space of intervention to ensure people are able to continue the care they need. Beyond individual health outcomes, studies in Florida and Washington have shown that Medicaid enrollment upon release was associated with a 16 percent recidivism reduction among former inmates with severe mental illness.

Incarceration does not just impact the millions who are incarcerated but has wide reaching community impacts. Families are impacted: More than one million children have a parent in prison and are at greater risk for mental illness, substance abuse, antisocial behavior, and school suspension or expulsion. Community engagement is impacted: More than six million people can’t vote in the US because of past felony convictions. And, of course, it is an issue of racial injustice: Black men are six times more likely to be incarcerated than white men, and Latino men are twice as likely to be incarcerated.

Given the initial findings on usage of Medicaid services, reduced recidivism, and state savings—as well as the potential to improve the lives of millions—it seems advantageous for all states to expand Medicaid to our formerly incarcerated community members.