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Little-Known Health Act Fact: Prison Inmates Are Signing Up

Sunday, March 09, 2014
New York Times
by ERICA GOODE

In a little-noticed outcome of President Obama’s Affordable Care Act, jails and prisons around the country are beginning to sign up inmates for health insurance under the law, taking advantage of the expansion of Medicaid that allows states to extend coverage to single and childless adults — a major part of the prison population. State and counties are enrolling inmates for two main reasons. Although Medicaid does not cover standard health care for inmates, it can pay for their hospital stays beyond 24 hours — meaning states can transfer millions of dollars of obligations to the federal government. But the most important benefit of the program, corrections officials say, is that inmates who are enrolled in Medicaid while in jail or prison can have coverage after they get out. People coming out of jail or prison have disproportionately high rates of chronic diseases, especially mental illness and addictive disorders. Few, however, have insurance, and many would qualify for Medicaid under the income test for the program — 138 percent of the poverty line — in the 25 states that have elected to expand their programs. Health care experts estimate that up to 35 percent of those newly eligible for Medicaid under Mr. Obama’s health care law are people with histories of criminal justice system involvement, including jail and prison inmates and those on parole or probation. “For those newly covered, it will open up treatment doors for them” and potentially save money in the long run by reducing recidivism, said Dr. Fred Osher, director of health systems and services policy for the Council of State Governments Justice Center. He added that a 2009 study in Washington State found that low-income adults who received treatment for addiction had significantly fewer arrests than those who were untreated. In Chicago, inmates at the Cook County Jail are being enrolled in Medicaid under the health care law as part of the intake process after they are arrested; the county has submitted more than 4,000 applications for inmates since Jan. 1. In Colorado, state prisoners are being signed up when they need extended hospitalization; 93 applications for inmates and 149 for parolees have been submitted so far. In the Portland area, more than 1,200 inmates have been enrolled through the state exchange, Cover Oregon, while Delaware and Illinois expect to start soon. Devon Campbell-Williams, an inmate serving time for assault in the Multnomah County Inverness Jail in Portland, Ore., applied for Medicaid in January with the help of an eligibility worker hired by the county to enroll inmates. When he gets out of jail in May, he said, he will have health insurance for the first time, coverage that will allow him to get treatment for his ankle, which he broke in 2007 and has been bothered by ever since. “It’s going to mean a lot,” Mr. Campbell-Williams said, adding that in the past, “I just went to the hospital, that was really about it.” Opponents of the Affordable Care Act say that expanding Medicaid has further burdened an already overburdened program, and that allowing enrollment of inmates only worsens the problem. They also contend that while shifting inmate health care costs to the federal government may help states’ budgets, it will deepen the federal deficit. And they assert that allowing newly released inmates to receive Medicaid could present new public relations problems for the Affordable Care Act. “There can be little doubt that it would be controversial if it was widely understood that a substantial proportion of the Medicaid expansion that taxpayers are funding would be directed toward convicted criminals,” said Avik Roy, a senior fellow at the Manhattan Institute, a conservative policy group. Language in the health care law also allows private insurance plans purchased through state exchanges to cover health care for people who are in jail awaiting trial, even in states that have not expanded Medicaid. But few prisoners have incomes high enough to afford the plans, even with federal subsidies, and most state and county correction systems are not yet set up to benefit from that coverage. In the past, states and counties have paid for almost all the health care services provided to jail and prison inmates, who are guaranteed such care under the Eighth Amendment. According to a report by the Pew Charitable Trusts, 44 states spent $6.5 billion on prison health care in 2008. In Ohio, health care for prisoners cost $225 million in 2010 and accounted for 20 percent of the state’s corrections budget. Extended hospital stays — treatment for cancer or heart attacks or lengthy psychiatric hospitalizations, for example — are particularly expensive. Stuart Hudson, managing director of health care for Ohio’s Department of Rehabilitation and Correction, said his department, which plans to start enrolling inmates in Medicaid when they have been in the hospital for 24 hours, expects to save $18 million a year through the practice, “although it’s hard to know for sure, because there’s other eligibility factors we have to keep in mind.” Nancy Griffith, Multnomah County’s director of corrections health, said the county expected to save an estimated $1 million annually in hospital expenses by enrolling eligible inmates and passing the costs to the federal government.More money could be saved over the long term, she added, if connecting newly released inmates to services helps to keep them out of jail and reduces visits to emergency rooms, the most expensive form of care. “The ability for us to be able to call up a treatment provider and say, ‘We have this person we want to refer to you and guess what, you can actually get payment now,’ changes the lives of these people,” Ms. Griffith said. Rick Raemisch, executive director of Colorado’s Department of Corrections, said that billing Medicaid for hospital care would save “several million dollars” each year. But as important, he said, was the chance to coordinate care for prisoners after their release. About 70 percent of prison inmates in the state have problems with addiction, he said, and 34 percent suffer from mental illness. Without health coverage, inmates leave prison with 30 days’ worth of medication and are then mostly left to their own devices. “If they go off their medication, oftentimes it can once again lead to more criminal activity,” Mr. Raemisch said. “So by keeping them medicated and keeping them mentally healthy, it really helps us in our re-entry efforts.” It costs far more to keep an inmate in prison than to provide treatment outside. Yet most health care experts agree that health coverage alone is not enough to keep chronic offenders on track. As essential as health insurance is for people trying to put together their lives after being incarcerated, the challenge of getting them into treatment, when they often did not have housing or jobs, was “a whole other kettle of fish,” said Bradley Brockmann, executive director of the Center for Prisoner Health and Human Rights in Providence, R.I. He is an author articles in a collection on the topic in the March issue of The Journal of Health Affairs. “The potential for this is so huge,” he said, “and it will take a lot more than just getting returning prisoners their Medicaid cards.”


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