Medicaid expansion improves health care services for prison population

As Medicaid eligibility expands under the Affordable Care Act, prison systems are increasingly supporting prisoners' enrollment in Medicaid as a way to help lower prison system costs and improve prisoners' access to health care upon release. These are the findings of a nationwide survey of state prison administrators that was led by Josiah D. Rich, M.D., M.P.H., director of the Center for Prisoner Health and Human Rights, based at The Miriam Hospital. The study is published online in advance of print in the American Journal of Public Health.

"This study is unique because of the timing with the expansion of Medicaid. We know that an increasing number of prison systems, although far from all, are helping prisoners enroll in Medicaid in preparation for their return to the community," explained Rich. "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. There is a possibility that there will be decreased recidivism as people get treatment for their mental illness and addiction."

As the basis for their study, researchers surveyed state prison system administrators from December 2011 through August of 2012. Administrators were asked about Medicaid enrollment practices within their prison system with a focus on four areas—was Medicaid terminated or suspended when an individual was first incarcerated; was assistance provided to help those prisoners being released reenroll in Medicaid; the challenges related to reenrolling; and screening previously non-enrolled prisoners for potential Medicaid eligibility.

Of the 42 state prison systems that responded to the survey, two thirds employed policies of terminating Medicaid coverage when a prisoner was first incarcerated, while 21 percent suspended coverage. And of those systems that either terminated or suspended coverage, more than two thirds of them provided assistance to help prisoners reenroll in Medicaid once they were released. More than one third assessed whether prisoners requiring community inpatient care during their incarceration might be eligible for Medicaid coverage.

In 2000, nearly all states had policies terminating Medicaid enrollment upon incarceration. Researchers found that reinstating Medicaid benefits in suspension states was not automatic and was challenging, similar to the challenges faced in states where benefits were terminated. Researchers did find that in suspension states resumption of benefits generally occurred within a month of 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, but not enrolled previously, 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.

Researchers noted that with several states planning to expand Medicaid eligibility in 2014, the number of released prisoners with access to routine care could increase dramatically. Medicaid expansion could also increase financial incentives for state prison systems to provide Medicaid enrollment assistance to prisoners requiring hospital inpatient care during their incarceration.

They also noted that future research should look at the state prison systems that successfully help enroll in Medicaid to determine the characteristics of those programs and the financial implications of enrollment for prisons and the Medicaid program.

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