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.