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A few years ago, on a reporting trip to Indiana, I met a man who shot and killed his two-year-old daughter in the throes of a nervous breakdown. Reenacting the biblical story of Abraham sacrificing Isaac, he thought God would intervene to save her.
He was convicted of child murder and sent to state prison, where he remained on psychiatric medication for 25 years. Then he went out and spent weeks scrambling to enroll in Medicaid, the government health insurance program, until he ran out of medication. “I have a severe mental disorder, and that's the reason I committed the crime in the first place,” he told me at the time.
Over the past decade, an increasing number of states have recognized the importance of providing health insurance to ex-prisoners. Recently, states and the federal government have gone a step further and proposed Put people on Medicaid before they go out into the free world again.
People in prisons and detention centers often sicker Compared with the general population, after release, More likely to rely on expensive stopgap care in emergency rooms. Within two weeks of release, formerly incarcerated people Almost 13 times more likely to die The most common causes are drug overdose, heart disease, homicide and suicide.
But for years, they were unable to get Medicaid — first because the original 1965 Medicaid law excluded anyone from prisons and jails (as well as large inpatient psychiatric hospitals and drug treatment centers). Second, because Medicaid primarily covers children, pregnant women, and people with disabilities. People in mass incarceration are mostly young, able-bodied men who do not qualify.
That changed in 2010, when Congress passed the Affordable Care Act. The new rules apply to 40 pointed out took advantage of New coverage of the lawmeaning anyone with zero or very low income (almost all incarcerated people) is eligible for free or highly subsidized government health insurance.
States and counties have worked to streamline the Medicaid process so that incarcerated people can enroll as soon as they become eligible, which is the moment they are released. Some states and counties have set up workshops to help people fill out paperwork while incarcerated. Others attempted to link corrections and health department data to merge release dates and names of eligible participants. But government bureaucracies are slow and inefficient, and waiting until someone is released to activate Medicaid often causes delays and mishaps.
For the guy I met in Indiana, that meant he had to apply for Medicaid from scratch when he got home. As his antipsychotic medication tapered off, he called the program increasingly frantically and scrambled to find his birth certificate and other documents. “People with mental illness who have committed violent felonies are about to be released from prison and we're not prepared for anything?” he told me at the time.
During the COVID-19 pandemic, officials have released many people, often without doctors to follow up and without adequate health care plans, exposing the vast disparity between America's detention and health care systems. This has serious consequences for both prisoners and the society to which they return.
Therefore policymakers hope a provision in the medicaid law This allows for pilot projects that would otherwise violate the rules. The Centers for Medicare and Medicaid Services has now approved “reentry waivers” in four states, allowing people in jails and prisons to have Medicaid coverage for up to 90 days before release. At least 18 more states Exemption requestedGabrielle de la Guéronnière of the Legal Action Center, a nonprofit that advocates for changes in criminal justice policy, said there are other apps in the works.
The idea is not only to get people health insurance before they get out of prison, but also to get case managers and health care providers into prisons to develop health care plans that can be implemented after people get out. Grant-funded nonprofits have been doing this on a small scale in several states. The ability to bill Medicaid would make these services more widely available.
Transitions Clinic Network is one of them. Their executive director, Shira Shavit, a physician at the University of California, San Francisco, recalled a patient her team met before discharge. He had severe kidney disease, so they arranged for him to receive dialysis in San Diego and prepare for discharge there. A case manager helped arrange accommodation and transportation to his medical appointments.
But Shavit said that days before his release, his parole officer placed him in San Francisco. “Because we were tracking his case, we found this out and we were able to make adjustments — make an appointment in San Francisco, have him come to my clinic, and get him on dialysis without missing a day,” she said. Without the connection they made before his release, “he would have missed his appointment in San Diego. No one would have known where he went.”
Last year, California became first state Obtain a waiver that allows incarcerated individuals to enroll in Medicaid 90 days before release. Soon, federal Medicaid authorities Suggest other states do the same. The agency quickly approved the waiver request washington, Montana Most recently, Massachusetts. Applications from 18 additional countries state yes To-do.
bipartisanship Congressional proposal Medicaid coverage will be available 30 days prior to release national policyno state application is required.
Federal officials are experimenting with broader waivers that would allow Medicaid to meet “health-related social needs,” such as housing and food. These have become “part of a larger discussion (recognizing that poverty does make people unhealthy),” said Dan Mystak, an attorney with Community Oriented Correctional Health Services, which has been a policy agency. Promote exemption for re-entry for many years.
These efforts have been met with some criticism. States would have to design their own exemption programs so they don't spend more money than they would otherwise, but fiscal conservatives argue that's not happening. The Manhattan Institute is a conservative think tank, Called them recently “A One-Way Ratchet for Increasing Medicaid Costs.”
But many in the criminal justice system passionately Accept proposed changes, including the sheriffs who oversee more than 3,000 county jails across the country. Because the average jail time is less than a month, nearly all health care in jails will be covered by Medicaid rather than the county. “This is a huge win!” Massachusetts Sheriff's Department Posted on Facebook.
Prison administrators also hope that placing most people on Medicaid will help them maintain the same care after they leave prison as they did before entering prison. Peter J. Koutoujian, the sheriff of Middlesex County near Boston, said it “really will reduce crime and save lives.” Koutoujian is a member of the major county sheriffs in the United States, Advocate for allowing people in prisons to receive Medicaid.
The new effort may also help lower the number of people returning to prison. Data collected by Shavit and her colleagues from clinics show that people who meet with case managers before release, especially incarcerated case managers, have lower chances of success Eventually he was imprisoned again for parole violation.. They also found Fewer people rely on emergency rooms care and systems Save money.
But Medicaid funding has yet to make its way to prisons or jails. Getting the health care system, the sheriff, and the corrections department to work together is a huge bureaucratic lift. All four states that received waivers are still working to clear those administrative hurdles before the money can start flowing. California plans to have its system operational this fall.