Medicaid’s New Prisoner Population

By Kate Rogers

Under the Affordable Care Act’s expansion of Medicaid, 25 states and the District of Columbia have broaden their health coverage for low-income individuals and the uninsured—the population the law was originally intended to help. The New York Times reported Sunday this expansion is helping another, perhaps unintended group to get care, by allowing prison inmates to sign up and have full coverage on their first days of freedom.

Medicaid’s expansion includes those making up to 138% of the federal poverty level to enroll in the program, according to the newspaper which cited experts estimating 35% of this expanded population in this group include inmates or those with a history of criminal incarceration, parole or probation.

President Obama recently touted that seven million Americans were able to enroll in Medicaid due to the program’s expansion under his signature legislation, but critics put the number somewhere between one and three million first-time enrollees.

The Centers for Medicare and Medicaid Services stated that the law does not provide care for people in prison. “According to longstanding policy, Medicaid does not pay for the care of incarcerated individuals while they are in prison. The ACA did not change this policy,” CMS spokesperson Joanne Peters told in an email message.

Paul Howard, director of the Center for Medical Progress at the Manhattan Institute, says Medicaid expansion naturally winds up encompassing the prisoner population because so many of its members are childless adults and low-income men.

“By definition, people coming out of prison have low incomes and are often divorced or single, and they will be eligible with that 35% of the expanded eligibility,” Howard says.

While inmates are incarcerated, they are covered by the prisons’ health-care system, according to Howard who adds that inmates that have an extended hospital stay are shifted onto Medicaid to cover those costs.

Upon being released for prison, individuals are Medicaid eligible. The prisons the New York Times article refers to are located in states that expanded Medicaid eligibility.

“Prisons can prep inmates to sign them up and have them ready to go [with coverage] once they are released,” he says. “It’s a way of connecting the population within the health-care system. A very high percentages of [former inmates] have mental health problems and chronic illnesses, but giving them an insurance card with Medicaid doesn’t mean they will see their providers regularly.”

Howard says this move is hardly the solution to such a prevalent problem, and is a small part in the myriad of challenges facing recently-released inmates. If they don’t get coverage via Medicaid, they would likely be subsidy-eligible on state and federal exchanges, he says. Subsidies are available for those making up to 400% of the federal poverty level, at about $45,000 for an individual.

Under the ACA, every individual in the country has to have insurance by the end of open enrollment period on April 1, or they will face a fine of up to $95 a year or 1% of their annual income for failing to comply.

Prison advocates say the move is beneficial for all parties, as states have long grappled with how to continue treatment for people once they leave the prison population. Having them transitioned onto Medicaid will avoid that gap.

"Around the country, states have long wrestled with the question of how to ensure that people returning from prison and jail are able to maintain psychological and mental treatment after they finish their sentences. From a public safety perspective, it is best to ensure that people aren't having medication and treatment pulled out from under them at the same moment that they're returning to the community. As a result, many states are working to take advantage of the new options available for ensuring continuity of treatment for people in this critical transition,” Robert Coombs, director of communications at the Council of State Governments Justice Center said in an email statement.

But Howard is skeptical.

“This needs an entire wraparound approach,” Howard says of bettering the community of recently-released inmates. “It’s housing, it’s jobs, it’s mental health—this is a small piece of the puzzle but not a cure-all.”

The cost shift benefits states that expanded eligibility, in which the federal government pays for 100% of the expansion through 2020, when they drop coverage to 90% of costs.

“States and hospitals like it,” he says. “Hospitals get better reimbursement from this population and the states like it because the federal government pays.”