Health Beyond Lockup: Alabama Inmates, Re-entry, and Medicaid Expansion

Posted on by BUJPH
a drawing of a prisoner in a hospital bed

Illustration by Stella Tsogtjargal

Article by Caleb Ellis (caleb_ellis@brown.edu)

 

Introduction, Background, and Context:

Incarcerated individuals are more likely to experience chronic and physical conditions such as HIV/AIDS, serious mental illnesses, and substance use disorders compared to the general population.1 Tuberculosis is four times higher among inmates than the general population.1 Hepatitis is over eight times higher among inmates than in the general population.1 HIV/AIDS is two to seven times more prevalent among inmates than the general population.2 Mental illness is two to four times more prevalent in state prisons than in the community.3 Despite these conditions, many inmates do not have access to medical care upon release into the community because they do not have health insurance. Roughly 80% of the inmates who re-entered the community are uninsured.4 Prisoners and jail inmates with these conditions are more likely to be homeless, less likely to have been employed, and more likely to report a history of physical or substance abuse.5 These findings are more pressing when coupled with data detailing that 43% of Alabama’s jail population and 54% of Alabama’s prison population are Black individuals.6

The Affordable Care Act allows states to approve Medicaid expansion, which can make inmates eligible for Medicaid.8 However, under the Medicaid Inmate Exclusion Policy, Medicaid funds cannot be used to pay for inmate health services.1 This leads to Medicaid termination upon incarceration, which can create gaps in Medicare coverage and healthcare access upon release.9 Within the first two weeks of release, inmates are 12.7 times more likely to die compared to state residents without carceral system involvement.10 Additionally, inmates are 2.5 times more likely to be hospitalized within 7 days of release.11 The period of release and lack of health insurance has also been linked to disruptions to HIV treatment, decreased viral suppression, and decreased retention in care.12 Data has also shown that release is a period where inmates experience high risks of overdose and other substance use disorders.10

 

Current Alabama Policy on Medicaid and Inmate Eligibility

Alabama is one of 12 states that has not adopted Medicaid expansion.13 Citizens of Alabama only qualify for Medicaid if they are at or below 18% of the federal poverty level, which is low compared to the threshold of 138% experienced by states who approved Medicaid expansion.14 This policy leaves inmates and many other groups without Medicaid coverage.14 The state pays for all medical services provided to inmates.1 Under the Affordable Care Act, Alabama has an uninsured rate of 11.2%, which is estimated to drop to 6.2% if Medicaid is expanded.15 Additionally, Alabama is a state that currently has Medicaid suspension for inmates in jails but not prisons.16 With Medicaid expansion and suspension for prisoners, Alabama could decrease criminal justice spending and inmate recidivism while increasing community health and increasing Medicaid coverage by at least 25 percent.15

 

Policy Recommendations

Approval of Medicaid Expansion

The first major policy recommendation would be to expand Alabama’s Medicaid program. Medicaid expansion has been associated with positive benefits to criminal justice challenges like inmate Medicaid enrollment, criminal justice spending, inmate health care costs during and after release, and many others.17 Pre-Affordable Care Act research illustrates that Medicaid can reduce state spending by decreasing low-income adult interactions with the criminal justice system and increasing their access to substance abuse and mental health services.17 Medicaid expansion allows justice-involved populations to move beyond the label “criminal” and establish a new identity.

 

Significant State Savings:

Many states that have expanded Medicaid have also experienced large reductions in state expenditures. In Ohio, Medicaid expansion has been associated with a $10.3 million decrease in spending on inmate inpatient care.17 Medicaid expansion allowed Ohio to make inmates eligible for Medicaid and receive federal reimbursement for certain inpatient procedures.17 Kentucky, Michigan, Colorado, and Washington have also reported savings greater than or equal to $10 million.17 These large savings have the potential to be reinvested in establishing more efficient and available health care services in prisons and jails. Additionally, these funds could go towards increasing educational opportunities for industry, trade jobs, and professional careers.

 

The financial savings from Medicaid expansion also decreases the cost of housing justice-involved populations. Washington experienced a savings of $9,000 to $18,000 saved for each person given treatment through Medicaid: this adds up to a total of $100 million.17 Increasing Medicaid eligibility to inmates allows Alabama to divert carceral system funds to create inmate rehabilitation and improve inmate and community health. Moreover, this initiative opens funding that can be utilized to enhance the lives of justice-involved populations, their families, and their communities.

 

Effects on Inmate Recidivism and the Community:

Medicaid expansion has also been correlated to decreased inmate recidivism.18 After Medicaid expansion, then Ohio governor John Kasich reported a recidivism rate of 10 percent.18 Additionally, Washington found that arrests declined by 17 percent, 18 percent, and 33 percent across three groups of low-income adults who had alcohol and drug treatment.19 In interviews of inmates in Ohio’s Medicaid pre-release program, two-thirds of respondents attributed Medicaid as the reason behind their decreased recidivism.20 Inmates told reporters that Medicaid provided them with “balance and stability” by providing them relief from health costs and access to care that can manage their health.20 Majority of program respondents stated that having Medicaid made it easier to continue working or search for work.20 The data above demonstrates that when inmates are given access to health resources, they are more likely to remain stable within communities and experience longer periods without carceral system interaction. Through a

decrease in recidivism and improved access to healthcare, inmates become largely integrated with the community. Additionally, the community experiences longer periods of public safety.

 

Approval of Medicaid Suspension for Prisoners

For many justice-involved individuals, access to Medicaid is a major barrier to receiving medications and healthcare upon release. After individuals encounter the carceral system, their Medicaid benefits can either be terminated or suspended based on state legislation.21 Termination often leads to inmates being completely removed from Medicaid rolls, requiring inmates to submit new Medicaid applications upon release. Eligibility determinations can take up to 45 days, which is a long time for someone who has limited possessions, funding, and transportation.22 Within this waiting period, inmates are unable to access necessary health services like medications, preventive screenings, or appointments due to cost, barriers to housing, and jobs.25 Medicaid suspension offers faster reinstatement of Medicaid coverage upon release through its ability to maintain inmate eligibility while limiting access to inpatient service payments.26 Medicaid suspension provides releasees with a baseline of services required to continue some of the health routines they may have had while in prison.

 

Reimbursement for Inpatient Services and State Savings:

Medicaid suspension has also been linked to increased savings on inpatient services in penal facilities. States like New Mexico, Ohio, and Rhode Island suspend Medicaid coverage and allow full Medicaid coverage upon release.27 This suspension policy has allowed states to receive Medicaid payments for all inpatient care provided to incarcerated inmates.27 Implementation of Medicaid suspension saved Arizona a reported $30 million in 2015 by reducing capitation payments to managed care plans during inmate incarceration. In 2015, Massachusetts experienced savings of at least $4.2 million due to Medicaid coverage of inmate care.28 Through Medicaid suspension, these states have earned back some money and increased inmate access to healthcare upon release.

 

Increased Inmate Enrollment and Access to Care:

Inmate Medicaid enrollment has increased drastically due to Medicaid suspension. Connecticut reported that 60% of its inmate population is enrolled in Medicaid upon release.28 Massachusetts stated that over 70% of individuals released from prison in 2015 had a MassHealth application submitted and over 75% of applications were approved.29 Medicaid eligibility upon release has also had strong implications for inmate usage of health resources. Data from Connecticut shows that inmates who had Medicaid coverage before release connected to outpatient care more quickly than those who were not pre-enrolled.30 Inmates enrolled in Medicaid were also more likely to use outpatient care than inpatient care and more likely to use the emergency room than inmates who were not enrolled.28 Massachusetts data shows that among former prisoners with Medicaid coverage in the year after release, 84% of releasees used any covered service, including 50% of releasees who had behavioral health visits.31 Additionally, more than half of those with medical or behavioral health visits were seen within the first 60 days post-release.28 Medicaid coverage provides inmates with access to services that address their physical and behavioral health needs and support recovery for opioid use disorder, other substance use disorders, and preventative health services.27

 

Elimination of Gaps in Healthcare Upon Release:

Expanding Medicaid eligibility for inmates also can eliminate the gaps in healthcare coverage that justice-involved populations experience upon release. These gaps in healthcare manifest in chronic disease management, medication access, and clinic visits. Studies reveal that long-term care for HIV is very low after release. For instance, at 14 days post-release, only 21% of inmates accessed care, and only 34% by 30 days after release.12 Within the first 10-30 days of release, up to 80% of inmates released from prison do not access antiretroviral therapy, which is used for HIV and Hepatitis C treatment.32,33 Overall, these numbers demonstrate that the post-release period is a critical intervention time for justice-involved populations. The post-release period is when releasees are unable to continue to treat chronic diseases like HIV and Hepatitis C to the same extent they were treated during their time in the carceral facility. The lack of treatment for these diseases puts releasees, their families, and communities at risk through the possible exposure to unknown conditions and the worsening of known conditions.

 

The post-release period experience is more promising in states where inmates were linked to community care before release. Inmates who were able to link to care within 0-30 or 30-60 days experienced suppressed viremia (presence of virus in the blood) compared to the inmates who received care within 60-90 days.34 Additionally, studies in Rhode Island and North Carolina reveal that around 50% of releasees were having their first medical appointment at least 90 days post-release. 34 Those inmates also experienced a larger detectable viral load compared to inmates with earlier service dates.34 In other words, linkage to care and the length of time between release and clinic visits is strongly correlated with detectable viral load and inmate health. Though there is very little data on conditions like Hepatitis C, tuberculosis, and other chronic conditions, the data on HIV implies that inmate care could worsen upon release for those conditions. Justice-involved populations in Alabama are more than likely experiencing these effects during the 45-day Medicaid eligibility period post-release. This period is critical for sustaining the health of releases and enhancing their reintegration into the communities and lives they had before being sentenced. Additionally, this research implies that mental health, substance use, and similar disorders could also worsen during the Medicaid eligibility and post-release periods. Medicaid expansion ensures inmates can fully integrate into their communities and have a full chance at establishing a new life.

 

Final Conclusions

 

The current State of Alabama policy, which fails to make inmates and those over 18% of the federal poverty level eligible for Medicaid and terminates Medicaid for prisoners, is inadequate.13,14 To date, 39 states have approved Medicaid expansion, and 34 states have some form of Medicaid suspension in place.13 States like Ohio, Washington, Kentucky, and Michigan have benefited greatly from expanding Medicaid eligibility to inmates.17

 

  • Medicaid provides inmates with access to health services for conditions like HIV, AIDS, hepatitis C, severe mental illnesses, and other health conditions.23,24,27
  • Medicaid protects the families of inmates by providing releasing inmates with healthcare coverage that will avoid the spread of certain conditions and trouble in the immediate environment.
  • Medicaid decreases inmate recidivism and prevents inmates from dying in the immediate weeks following their release.11,18,19,
  • Medicaid reimburses Alabama legislatures for inpatient care provided to inmates. This saves millions of dollars that can be invested in community health centers and better care within prisons and jails.

 

By expanding Medicaid, the State of Alabama improves its coverage gap, increases inmate and low-income citizen Medicaid enrollment decreases inmate recidivism and regains millions of dollars.11,18,19 Medicaid suspension ensures prisoners have healthcare coverage upon release and supports their re-entry efforts.

 

References

  1. Winkelman, Tyler, Amy Young, and Meagan Zakerski. “Inmates Are Excluded from Medicaid – Here’s Why It Makes Sense to Change That.” Institute for Healthcare Policy & Innovation. The University of Michigan, February 27, 2017. https://ihpi.umich.edu/news/inmates-are-excluded-medicaid-%E2%80%93-here%E2%80%99s-why-it-makes-sense-change.
  2. David Cloud. On Life Support: Public Health in the Age of Mass Incarceration. New York, NY: Vera Institute of Justice, 2014.
  3. Prins, Seth J. “Prevalence of Mental Illnesses in U.S. State Prisons: A Systematic Review.” Psychiatric services (Washington, D.C.) 65, no. 7 (2014): 862–872.
  4. Rich, Josiah D, Redonna Chandler, Brie A Williams, Dora Dumont, Emily A Wang, Faye S Taxman, Scott A Allen, et al. “How Health Care Reform Can Transform The Health Of Criminal Justice–Involved Individuals.” Health Affairs Web exclusive 33, no. 3 (2014): 462–467.
  5. Gates, Alexandra, Samantha Artiga, Robin Rudowitz, “Health Coverage and Care for the Adult Criminal Justice-Involved Population.” The Henry J. Kaiser Family Foundation (2014).
  6. Vera Institute of Justice. “Incarceration Trends in Alabama.” Vera Institute of Justice. (2019). Vera Institute
  7. Vera Institute of Justice. “The Burden of Mental Illness Behind Bars.” Vera Institute of Justice. (2016). https://www.vera.org/the-human-toll-of-jail/inside-the-massive-jail-that-doubles-as-chicagos-largest-mental-health-facility/the-burden-of-mental-illness-behind-bars
  8. McKee, Catherine, Sarah Somers, “State Medicaid Eligibility Policies for Individuals Moving Into and Out of Incarceration.” The Henry J. Kaiser Family Foundation (2015).
  9. Albertson, Elaine Michelle, Christopher Scannell, Neda Ashtari, and Elizabeth Barnert. “Eliminating Gaps in Medicaid Coverage During Reentry After Incarceration.” American journal of public health (1971) 110, no. 3 (2020): 317–321.
  10. Binswanger, Ingrid A, Marc F Stern, Richard A Deyo, Patrick J Heagerty, Allen Cheadle, Joann G Elmore, and Thomas D Koepsell. “Release from Prison — A High Risk of Death for Former Inmates.” The New England journal of medicine 356, no. 2 (2007): 157–165.
  11. Wang, Emily A, Yongfei Wang, and Harlan M Krumholz. “A High Risk of Hospitalization Following Release From Correctional Facilities in Medicare Beneficiaries: A Retrospective Matched Cohort Study, 2002 to 2010.” JAMA internal medicine 173, no. 17 (2013): 1621–1628.
  12. Loeliger, Kelsey B, Jaimie P Meyer, Mayur M Desai, Maria M Ciarleglio, Colleen Gallagher, and Frederick L Altice. “Retention in HIV Care During the 3 Years Following Release from Incarceration: A Cohort Study.” PLoS medicine 15, no. 10 (2018): e1002667–e1002667.
  13. Kaiser Family Foundation. “Status of State Medicaid Expansion Decisions: Interactive Map.” (2022).
  14. Brooks, Tricia, Lauren Roygardner. “Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey.” (2019).
  15. Simpson, Michael. “The implications of Medicaid expansion in the remaining states: 2020 update.” Washington, DC: Urban Institute 500 (2020).
  16. Kaiser Family Foundation. “States Reporting Corrections Related Medicaid Enrollment Policies In Place for Prisons or Jails.” (2019).
  17. Guyer, Jocelyn, Deborah Bachrach, and Naomi Shine. “Medicaid Expansion and Criminal Justice Costs: Pre-Expansion Studies and Emerging Practices Point Toward Opportunities for States. State Health Reform Assistance Network. November 2015.”
  18. TIME, “Transcript: Read the Full Text of the Primetime Republican Debate,” (August 2015).
  19. Washington State Department of Social and Health Services Research and Data Analysis Division, Chemical Dependency Treatment, Public Safety: Implications for arrest rates, victims, and community protection, (February 2009).
  20. The Ohio Department of Medicaid. “2018 Ohio Medicaid Released Enrollees Study: A Report for the Ohio Department of Medicaid.” (2018).
  21. National Association of Counties. “Health Coverage and County Jails: Suspension vs. Termination.” (2014).
  22. Medicaid and CHIP Learning Collaboratives. “Ensuring Timely and Accurate Eligibility Determinations.” (2018).
  23. Binswanger I.A., Blatchford P.J, Mueller S.R., Stern M, F, “Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009.” Annals of Internal Medicine. (2013):159(9):592-600. doi: 10.7326/0003- 4819-159-9-201311050-00005
  24. HHS Opioid Abuse in the U.S. and HHS Actions to Address Opioid-Drug Related Overdoses and Deaths, March 26, 2015. Available at: https://aspe.hhs.gov/sites/default/files/pdf/107956/ib_OpioidInitiative.pdf.
  25. Guyer, Jocelyn, Kinda Serafi, Deborah Bachrach, and Alixandra Gould. “State Strategies for Establishing Connections to Health Care for Justice-Involved Populations: The Central Role of Medicaid.” Health Care for Justice-Involved Populations: Role of Medicaid | Commonwealth Fund. The Commonwealth Fund, January 11, 2019. https://www.commonwealthfund.org/publications/issue-briefs/2019/jan/state-strategies-health-care-justice-involved-role-medicaid#24.
  26. Congressional Research Service. “Medicaid and Incarcerated Individuals.” (2021). https://crsreports.congress.gov/product/pdf/IF/IF11830
  27. Wachino, Vikki, Samantha Artiga. “How Connecting Justice-Involved Individuals to Medicaid Can Help Address the Opioid Epidemic.” The Henry J. Kaiser Family Foundation (2019). https://www.kff.org/medicaid/issue-brief/how-connecting-justice-involved-individuals-to-medicaid-can-help-address-the-opioid-epidemic/
  28. Ryan, Jennifer, Lucy Pagel, Katy Smali, Samantha Artiga, Rubin Rudowitz, and Alexandra Gates. “Connecting the Justice-Involved Population to Medicaid Coverage and Care Findings from Three States.” The Henry J. Kaiser Family Foundation (2016).
  29. Massachusetts Department of Correction Performance and Outcome Measurements, Fiscal Year 2015.
  30. Hsiu-Ju Lin, Linda Frisman, and Coleen Gallagher, Expedited Medicaid Restoration in Connecticut, American Public Health Association Annual Meeting, Boston, MA, November 2013.
  31. Paul Kirby, Warren Ferguson, and Ann Lawthers, Post-Release MassHealth Utilization, Center for Health Policy and Research, University of Massachusetts Medical School.
  32. Baillargeon JG, Giordano TP, Harzke AJ, Baillargeon G, Rich JD, Paar DP. Enrollment in outpatient care among newly released prison inmates with HIV infection. Public Health Rep 2010; 125 (suppl 1): 64–71.
  33. 12 Baillargeon J, Giordano TP, Rich JD, et al. Accessing antiretroviral therapy following prison. JAMA 2009; 301: 848–57.
  34. Montague, Brian T, David L Rosen, Cara Sammartino, Michael Costa, Roee Gutman, Liza Solomon, and Josiah Rich. “Systematic Assessment of Linkage to Care for Persons with HIV Released from Corrections Facilities Using Existing Datasets.” AIDS patient care and STDs 30, no. 2 (2016): 84–91.
Caleb Ellis Stella Tsogtjargal