Obamacare Will Make Ex-Cons Healthier

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National Journal
Sophie Novack
Dec. 5, 2013, 3:24 p.m.

Obama­care will ex­pand health in­sur­ance cov­er­age to mil­lions of pre­vi­ously in­car­cer­ated in­di­vidu­als, and it’s set to have big im­pacts on both pub­lic safety and pub­lic budgets.

“Jail and pris­on are ex­tremely ex­pens­ive re­sponses to pub­lic health prob­lems,” said Kara Dansky, seni­or coun­sel at the Amer­ic­an Civil Liber­ties Uni­on. Un­der the Af­ford­able Care Act, Dansky said, “states and counties are able to save money and im­prove pub­lic safety. When in­di­vidu­als have ac­cess to the ser­vices they need, they are much less likely to en­gage in crim­in­al activ­ity.”

As many as 4 mil­lion former in­mates stand to be­ne­fit from new­found eli­gib­ilty for Medi­caid, ac­cord­ing to one es­tim­ate. And since men­tal health and sub­stance-ab­use is­sues will be covered un­der Obama­care, com­munity health stands to be­ne­fit.

States have the op­tion to ex­pand Medi­caid un­der the health care law, and those that opt in will ex­pand cov­er­age to all res­id­ents at or be­low 133 per­cent of the fed­er­al poverty level. Pre­vi­ously Medi­caid did not cov­er child­less adults, ex­cept in cases of dis­ab­il­ity.

Those who have been pro­cessed through the crim­in­al justice sys­tem — a pop­u­la­tion that is primar­ily lower-in­come, of­ten has more health prob­lems, and is usu­ally lack­ing cov­er­age — have a huge amount to gain from ex­pan­ded cov­er­age.

Cur­rently around 70 to 90 per­cent of the ap­prox­im­ately 10 mil­lion in­di­vidu­als re­leased from pris­on or jail each year are un­in­sured, ac­cord­ing to a Decem­ber 2013 re­port from the Coun­cil of State Gov­ern­ments Justice Cen­ter.

As a res­ult of the ACA, 6 mil­lion to 7 mil­lion of those com­ing out of jails are likely to qual­i­fy for Medi­caid, the Cen­ter for Health Care Strategies said in a present­a­tion in Septem­ber. About half of them could en­roll, fol­low­ing state de­cisions to par­ti­cip­ate, the group es­tim­ated.

The Justice De­part­ment es­tim­ates these in­di­vidu­als will com­prise about 35 per­cent of those who will qual­i­fy for cov­er­age in states ex­pand­ing Medi­caid.

The change does not im­pact those who are cur­rently in­car­cer­ated, as their care is provided by the in­sti­tu­tion and paid for by the state or county. Those in jail or pris­on are not eli­gible to en­roll in plans through the ex­changes, or to be covered by Medi­caid dur­ing their time, even if they were pre­vi­ously en­rolled. The ex­cep­tion is if they are trans­ferred out for lengthy hos­pit­al stays.

Re­pub­lic­an law­makers have ex­pressed con­cern about tax­pay­ers pay­ing for this cov­er­age, par­tic­u­larly giv­en the stigma as­so­ci­ated with in­car­cer­a­tion. House En­ergy and Com­merce Chair­man Fred Up­ton, R-Mich., and Rep. Joe Pitts, R-Pa., sent a let­ter Oct. 9 to Gene Dodaro, head of the Gov­ern­ment Ac­count­ab­il­ity Of­fice, rais­ing these con­cerns.

“The Medi­caid pro­gram is already strug­gling to meet the health care needs of our poorest and sick­est Amer­ic­ans. We must bet­ter un­der­stand the true costs of ex­pand­ing the pro­gram to any new pop­u­la­tion and weigh such costs with the com­pet­ing in­terests of our na­tion’s most vul­ner­able law-abid­ing cit­izens,” they wrote. A com­mit­tee spokes­per­son said Thursday that they await in­form­a­tion as GAO has ac­cep­ted the re­quest.

Yet the in­creased cov­er­age will ac­tu­ally save states and counties that are ex­pand­ing Medi­caid a great deal of money, and a health­i­er pop­u­la­tion would save more in the long run.

“This is really sig­ni­fic­ant for com­munit­ies be­cause if in­di­vidu­als are in­car­cer­ated in jail or pris­on, either the state or county is re­quired to pay for their health needs,” Dansky said. “Now there is the op­por­tun­ity to use fed­er­al dol­lars to cov­er health care needs of those re­leased in­to com­munit­ies.”

In­di­vidu­als in­volved in the crim­in­al justice sys­tem have high rates of chron­ic and com­mu­nic­able dis­eases, in­clud­ing tuber­cu­los­is, hep­at­it­is, and HIV, as well as men­tal health and sub­stance-use dis­orders. The Es­sen­tial Health Be­ne­fits un­der the ACA in­clude the re­quire­ments that men­tal health and sub­stance-use dis­orders be covered at par­ity with oth­er med­ic­al be­ne­fits.

Ac­cess to treat­ment for men­tal health and sub­stance-use is­sues re­duces re­cidiv­ism rates, im­prov­ing pub­lic safety and sav­ing state and loc­al com­munit­ies ad­di­tion­al fund­ing for pris­ons and jails.

Dansky says the ex­pan­sion also has the po­ten­tial for even more far-reach­ing im­pacts.

“We think [the law] presents the op­por­tun­ity to make needed changes to sen­ten­cing laws and policies,” she said. “It would en­cour­age states’ ex­pand­ing to in­crease pre­tri­al di­ver­sion and avoid in­car­cer­a­tion in the first place.”

For crimes like low-level drug of­fenses, it’s pos­sible ex­pan­ded in­sur­ance cov­er­age could lead states to em­ploy treat­ment ser­vices and avoid the costs and neg­at­ive im­pacts of in­car­cer­a­tion, though it’s still too early to eval­u­ate these pro­grams.

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