The primary purpose of Obamacare's Medicaid expansion is to enroll millions more Americans into health coverage. But it could also have an unintended secondary effect: reducing crime in the United States.
The Medicaid expansion opens the public insurance program to a low-income group that, for decades, it has typically excluded: adults without children. Many prisoners leaving jail fall into this category — and could stand to benefit from the insurance expansion. That new coverage, experts say, could expand access to needed services in a way that could reduce future criminal behavior.
People with behavioral health issues often end up incarcerated instead of in treatment
People who interact with the correctional system have typically been left out of the Medicaid program.
About 88 percent of people with jail stays are male and nearly half are under age 25, according to a policy brief by the Center on Budget and Policy Priorities. Medicaid, meanwhile, has usually covered, pregnant women, the elderly, the disabled and low-income adults with children.
Prisoners don't have Medicaid while they're incarcerated, but expanding the public program means health coverage for more of this population after release. And it's a population that can benefit from that coverage: people in jail have higher rates of chronic diseases like diabetes, hepatitis, and HIV/AIDS.
A 2005 report from the Department of Justice also highlights the prevalence of mental illness among the incarcerated population. That year, over half of prison and jail inmates reportedly had a mental health problem. Inmates with mental health problems were also substantially more likely to use illegal drugs; three-quarters of the incarcerated population with mental illness met criteria for substance dependence or abuse.
Prisoners with these types of medical issues are more likely to re-enter the correctional system after release or parole when compared to ex-inmates without mental health or substance abuse issues, according to the report.
And only 11 percent of inmates with these disorders received treatment during their stays in jail.
Before Obamacare, many ex-inmates would have had limited, if any, access to services to treat these issues after release. But under health reform, the Medicaid expansion includes coverage for mental health and substance abuse services, and they have to cover them at parity — they can't be treated differently from "physical" health benefits.
Evidence to date is promising, though not conclusive
A small body of research suggests that better access to health care upon leaving prison can reduce the number of ex-convicts who end up incarcerated a second time.
In 2007, Michigan enacted the Prisoner Reentry Initiative, which, among other things, connected individuals recently released from prison with health care services. The ex-inmates were paired with "medical homes" and given assistance in accessing primary care, specialty care, and medicine.
Since the program began, overall recidivism has fallen among that population from 46 percent to 21.8 percent. It's impossible to say how much of this is attributable to the health care initiative, but staff members believe that it made a substantial contribution.
It was a resource-intensive effort, though. Medical navigators visited inmates before release to help initiate a transition back into the community. That involved organizing a transfer of medical records to the individual's new doctor, setting up a primary care visit within two weeks of release or parole, and arranging prescription drug coverage.
The Department of Justice found similar trends in Florida and Washington state after ex-inmates were connected with Medicaid services.
"I don't think we should be over-selling this, but I think that there is genuine benefit here," says Harold Pollack, a professor of public policy and co-director of the University of Chicago Crime Lab. "One of the key unknowns is whether these programs will be implemented effectively, in a way that actually engages people."
There are still wrinkles in providing access to these services
While any access to mental health and substance abuse services is an improvement over no access at all, there are some issues that still need to be worked out.
Many ex-inmates who suffer from such disorders might benefit from residential treatment — therapy that's delivered at a facility where they also live. But under Medicaid expansion, many of these patients will only have access to outpatient services.
Medicaid has to abide by a rule forbidding the use of federal Medicaid dollars to pay for mental health services in residential facilities larger than 16 beds, if those residential facilities are primarily used to treat mental health or substance abuse disorders. This regulation dates back decades, to a time when such institutions for too often held the mentally ill in barbarous conditions.
And sorting out the nitty-gritty of mental health and substance abuse benefits will fall to individual states.
"The scope is always in question — what does that mean is covered, how much is covered? That's going to depend a lot of the states," said Judy Solomon, vice president for health policy at the CBPP. "Are the states really going to be creative and do this in a way that's consistent with best evidence? That would be inclusive of a range of social and community-support services."
And there's another "scope" issue to consider: 24 states still haven't expanded the public program at all.