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commentary

(The RAND Blog)

October 3, 2013

Medicaid Access for the Formerly Incarcerated Under the ACA: Helping the Oft-Forgotten

by Lois M. Davis

America's prison population tends to be sicker than the general population, with chronic health conditions, infectious diseases, and especially high mental health and drug treatment needs. Unfortunately, this population also has high uninsured rates. Add to that the fact that such individuals tend to be released from state prisons and jails in an uncoordinated fashion and you have a huge access barrier — very few mechanisms exist to effectively link the formerly incarcerated to the health care they need.

Fortunately, the expansion of Medicaid eligibility under the Affordable Care Act (ACA) opens up the possibility for many formerly incarcerated individuals to gain access to health insurance for the first time. Only recently have policymakers, public safety officials, and public health officials begun to focus attention on enrolling this difficult-to-reach population.

To better understand the opportunities that the ACA presents for improving access to care for the formerly incarcerated population, we examined the health care needs of newly released prisoners in California. This included examining:

  • the need for mental health and substance abuse treatment
  • which communities are most affected by prisoner reentry
  • the capacity of the health care system in those communities
  • and the experiences of released prisoners, service providers, and families of incarcerated individuals.

We also developed innovative measures to assess the capacity of the health care safety net in four communities: Alameda, Los Angeles, San Diego, and Kern Counties.

We found that inmates self-report a high burden of chronic diseases (e.g., asthma, hypertension) and infectious diseases (e.g., hepatitis, tuberculosis). These conditions require regular health care for effective management. We showed that self-reported mental health and drug treatment needs in this population also are particularly high. Yet the capacity of county safety nets to meet these needs varied by the type of health care service, geographic area (across and within counties), and race/ethnicity.

As policymakers consider how to ensure access to services for the formerly incarcerated population, they will need to take into account this variation in the capacity of county safety nets.

While Medicaid eligibility under the ACA offers an historic opportunity, enrolling the formerly incarcerated into the health exchanges or Medicaid will be neither simple nor straightforward. Many formerly incarcerated individuals have little experience navigating the county and community health care systems, and the different “silos” in the health care and social services systems can complicate the referral process for those with a complex set of needs.

Our recommendations included developing Medicaid enrollment strategies especially for those with mental illness or chronic health conditions, including processes to reinstate Medicaid benefits as part of prerelease planning, and developing enrollment specialists trained to work with this population. These recommendations will help states and counties put into place the mechanisms to better serve this oft-forgotten population and leverage the resources and provisions of the ACA to do so.


Lois Davis is a senior policy researcher at the nonprofit, nonpartisan RAND Corporation.

This commentary appeared on The RAND Blog on October 3, 2013