The Patient Protection and Affordable Care Act, upheld in June by the Supreme Court, grants the incarcerated and those being released from prison a first-ever chance to get comprehensive, continuous health care.
But how and when that promise becomes a reality remains uncertain, according to experts on prison and jail health care interviewed by The Crime Report.
The key question is how many states will either resist or be unable to meet the Jan. 1, 2014 deadline for expanding Medicaid to the uninsured, including inmates and those being paroled or placed on probation after that deadline.
Medicaid expansion is the new health care law's main vehicle for covering the uninsured. But under the Court's ruling, states can opt in or out of that expansion without fear of losing federal Medicaid funds.
Thus far, 16 states have firmly committed to the expansion; while Republican governors in at least 22 states—26 states comprised the Supreme Court litigants—have balked, according to David Chandra, senior policy analyst at the Center for Budget and Policy Priorities.
Two-thirds of the uninsured reside in states whose governors oppose the Act's new Medicaid provisions.
With that as a backdrop, an estimated 90 percent of the nation's jail inmates and 85 percent of state and federal prisoners currently lack health insurance. Where the Medicaid expansion does take effect, it will grant a full, if basic, menu of primary, dental and mental health care to those whose incomes are 133 percent or less of the federal poverty level.
Waiting For Details
Those who work in correctional health applaud the move—even as they wait to see whether, how and where it will be applied to inmates.
"We're hoping there will be a positive reception to these populations receiving services," said Michael DuBose, chief executive officer for Oakland, Calif.-based Community Oriented Correctional Health Service, which builds partnerships between jails and community-based health care programs.
"But we know that, especially in local communities where there is already a shortage of capacity, there will be a tremendous drain on that current capacity."
Medicaid, which is paid for with state and federal funds, is currently mandated only for inmates who are under 21, over 65, disabled, or pregnant. Prison health care experts contacted for this story worried that at least in the short run, the costs of extending Medicaid to a larger number of inmates in states that are willing to accept the expanded program will strain a correctional system already having difficulty attracting physicians and other health professionals.
Many medical professionals simply do not find prisons and jails appealing places to work. That is one reason why the level of current care available in jails and prisons differs widely among states and localities and, some critics contend, is often of abysmal quality.
The experts contacted by TCR identified other unresolved issues involving the future of what has long been a nationally fragmented system of health care in jails and prisons. A shortlist of the questions that still need to be addressed includes:
- Will there be sufficient correctional staff to administer the expanded Medicaid services and those offered by the coming health care exchanges, which the government also will support with income-based subsidies and extend to the currently and those preparing to be released from prison?
- Will inmates be allowed the ease of online applications for the full menu of services, including mental health care, mandated by the new law?
- For prisoners aged 26 and younger who now can remain on their parents' insurance—presuming they are still in contact with their parents—how will prisons link with those private insurers?
- How will post-prison health care be arranged prior to release from prison?
- Once they've re-entered society, will their Medicaid coverage be accepted, or will they be shunned by physicians who dismiss Medicaid reimbursements as too insufficient to cover the cost of care they provide?
Seeing the Doctor
"Just because you have coverage doesn't mean you have an appointment with a doctor," said consultant Donna Strugar-Fritsch of Health Management Associates, a Lansing, Michigan-based firm whose clients include correctional systems across the country.
Health reform "creates a whole new demand for discharge planning," she added. "Who will …help them learn the system they now have access to—but don't know what to do with? There are lots of positives but also lots of challenges."
Her firm is already conferring with some prison officials who are trying to figure out how to proceed down this new path.
Others, however, have suggested that they've neither the inclination nor the resources to, for example, link the 26-and-under population with their parents' private insurers, Strugar-Fritsch said.
Revamping the nation's patchwork of correctional health care services so that they're more streamlined and efficient will be key to any correctional health overhaul, she added.
For example, scheduling every prisoner who requests to sleep in the bottom bunk a doctor's appointment to determine whether a physical disability necessitates such an arrangement cuts into time better spent addressing critical health concerns.
"They shouldn't be using their doctors that way but no one has had a major reason to shake that up," Strugar-Fritsch said. "Now they do."
Outside of prison, treating the formerly incarcerated in emergency rooms—the uninsured among them often land there—also is imprudent and expensive.
Those costs will remain if newly insured—but medically un-savvy— ex-prisoners aren't schooled in, say, how to see their primary care physician for a common cold or other non-emergency needs.
Sick, formerly incarcerated people with health care access are less likely to recommit crimes that land them in prison, studies have shown.
"I don't think the public recognizes…how much addiction issues [for example] drive a great deal of morbidity and mortality, the physical effects, and also drive street crimes, shoplifting, thefts, robbery, a lot of the gang-related violence, shooting deaths," said Dr. Keith Barton, medical director for Correctional Health."
The prospect of less recidivism is one reason that even cash-strapped states should forge ahead with on the reforms, observers said.
Indeed, some state officials are concurring with U.S. Department of Health and Human Services projections that, overall, increases in Medicaid spending to cover the new law's expansion will be offset by decreases in, for example, money spent caring for the uninsured in emergency rooms and existing government allocations to hospitals serving the indigent.
Which states opt out—and which are bluffing right now—will not be known until after the November elections. And, perhaps, later still, until the crucial 2013 budget-crunching and cutting is on the table, experts said.
For the 10 to 16 states that already are moving ahead with Medicaid expansion and establishing the exchanges, none have cemented, as yet, a clear system for signing people up—to say nothing of health care planning for discharged inmates who will get health care.
"It's far too early to understand all of this fully yet," said Strugar-Fritsch of Health Management Associates, observing that many prison and jail officials are "very undecided" about how much of the program they want to undertake.
"Much of this," she added, "is probably going to be decided one [system] at a time."
Freelance journalist Katti Gray covers health, criminal justice, higher education and other topics for a range of national and regional magazines, newspapers and online news sites. She is a contributing editor at The Crime Report.