Day 49 — Medicaid at 50: Keeping people out of jail and prison

Over the coming weeks this blog will highlight a key feature of Medicaid and the individual states that administer Medicaid and CHIP leading up the the program’s 50th anniversary (July 30th). Hopefully, you’ll learn some interesting facts about Medicaid and each of the 51 state programs.

The great thing about health care is that basically everything is related to it. This is especially true for Medicaid, which is such an essential part of the social safety net. For instance, we don’t always thing of our correctional system as a public health issue, but it is: the largest mental health facility in the country is the Cook County Jail. About one in five people in the prison system have a serious mental illness (SMI), and 30-60% of inmates have a substance use disorder. Nearly a quarter of inmates with a serious mental illness have served three or more prior incarcerations. This is a tragedy.

The good news is that people with serious mental illness really benefit from access to health care. A program that linked ex-offenders with mental illness to Medicaid right when they were released decreased recidivism by 16%. Before the Affordable Care Act (ACA), many at-risk inmates weren’t eligible for Medicaid because most of them are single adults. Now, much of this population is eligible for Medicaid based on income guidelines, and some states are putting together transitional programs that can connect people to Medicaid and community-based care once they are released. This matters because ex-offenders have a 12x higher risk of mortality and the risk of death is highest in the two weeks after release.

This is a great example of how good health policy can have benefits beyond the individual patient and the health system. Imprisoning people is really expensive – a year in federal prison costs $28,893.40. In addition to reducing recidivism, ensuring that vulnerable populations have access to care though Medicaid can hopefully reduce the chance that people will be locked up in the first place.

P.S. For the dedicated Medicaid nerd: The Personal Responsibility and Work Opportunity Reconciliation Act (Clinton welfare reform of 1996) allowed states to exclude people with drug-related felony convictions from welfare benefits, which for administrative reasons could then ban them from receiving Medicaid. (Drug offenders account for 48% of federal prisoners, and similarly high proportions of state prison populations.) The ACA enables categorical eligibility for Medicaid based on income, which opens the doors for a lot of people who were previously excluded because of the “welfare ban”.

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