The 2010 Patient Protection and Affordable Care Act (ACA), health care reform, comes at a particularly unique time in the criminal justice system – a time when mass incarceration policies are being scaled back and more prisoners are being released to the community. The ACA attempts to tackle weaknesses in the existing health insurance system and in the treatment delivery system through a variety of mechanisms. These changes could dramatically improve the health and justice outcomes of over five million US adults in the justice system.

The relative poor health of jail and prison inmates is well documented. Inmates have high rates of many chronic medical conditions, mental health disorders, and substance abuse disorders (Wilper et al. 2009). In addition, their rates of hypertension, asthma, and arthritis are higher than the general population even after controlling for race, education, and other socioeconomic differences (Binswanger et al. 2007, 2009), and rates of infectious diseases including current or chronic hepatitis C and HIV/AIDS are also high (National Commission on Correctional Health Care 2002; Maruschak 2010). Finally, sexual victimization rates in jail are higher than reported in community (Beck and Harrison 2008).

Justice-involved individuals are less likely than others to have insurance coverage. Working-age men in general have high rates of uninsurance. And, offenders’ health status and constrained employment prospects after conviction and incarceration make obtaining health insurance less likely for them than for other adults.

Because they have relatively high rates of substance abuse disorder and low rates of insurance, offenders must rely on a part of the health care delivery system that is reliant on scarce and shrinking public financial support (Buck 2011). Offender surveys have found that addiction treatment services are underutilized; few community justice agencies integrated their services with substance abuse providers; and the quality of community treatment is frequently quality (Taxman et al. 2007).

This research paper provides an overview of health insurance and challenges in securing coverage for offenders today. It then addresses the Affordable Care Act, including how prisoners and jail inmates are likely to be affected by the new federal health care reform law, as well as potential future impacts, challenges, and opportunities.
Fundamentals
Having health insurance means treatment will be less costly to individuals when they seek health care. Thus, insurance removes a financial barrier to care. Numerous studies have found that having health insurance is associated with obtaining more health services and having better health outcomes (Manning et al. 1987; Card et al. 2008). However, health insurance coverage can present a challenge for the justice population. For working-age adults in the United States, the primary source of health insurance is through employer-provided insurance offered to fulltime employees (DeNavas-Walt et al. 2012). Very few nonelderly adults purchase coverage on their own. The justice population, particularly those reentering the community, may be disconnected from the workforce and need time to find housing, retool, and secure jobs. If their work is part-time, temporary, or low pay, then employer-based health coverage may not be available or affordable.

Medicaid is another important source of health insurance coverage for adults, primarily for adults who have disabilities and who have low incomes. In 40 states, poor, disabled individuals who receive Supplemental Security Income (SSI) also receive Medicaid. Medicaid has not traditionally covered childless adults who do not have disabilities. Only in 12 states does Medicaid coverage include poor adults, regardless of SSI. However, individuals who enter prison or jail may have their SSI benefits suspended, meaning they lose their Medicaid coverage as well. Both income and health benefits must be reinstated upon reentry into the community. Lacking health insurance criminal justice populations have traditionally relied on a web of safety net providers to meet their complex health care needs.

Health Benefits Covered by Insurance Today. Private insurance typically covers a range of medical services, but often with a share of the cost borne by the patient through deductibles, meaning the amount paid by the member before insurance begins, or through cost-sharing, meaning the amount paid by the patient when treatment is sought. Newer, so-called high deductible heath plans with a deductible of at least $1,000 ($2,000 for a family) have become more common in the United States and included 13 % of the privately insured in 2011 (Fronstin 2011).

Coverage for behavioral health care is often less generous for behavioral health than for general medical care, a consequence of longstanding concerns about the overuse of mental health services (Glied and Cuellar 2006). Consequently, behavioral health coverage traditionally has required greater financial contribution on the part of the patient and has placed limits on how much treatment would be covered. Efforts over many years to place mental and medical benefits on more equal footing ultimately lead to the federal Mental Health Parity and Addiction Equity Act of 2008. This Act required that mental health and substance abuse care be covered like other medical care, at least in large group health insurance plans. Under parity mental health and substance use, disorder coverage – if such benefits are offered – must be equivalent along co-payments and deductibles, maximum visits, annual and lifetime dollar limits, and out-of-network coverage. However, the law does not require that health insurance include any behavioral health benefits, only that they be equivalent if offered. The law also does not affect Medicaid unless Medicaid is offered to beneficiaries through privately managed care plans.

Research has found parity legislation to increase use of mental health and substance abuse services by removing significant financial barriers (Frank et al. 2001; Goldman et al. 2006; Dave and Mukerjee 2008). In light of high rates of mental health and substance abuse disorder, this is a potentially very important development for offenders.

Medicaid play s a unique role in coverage for low-income individuals with complex chronic conditions, as it covers many services that private insurance does not. Medicaid covers services such as targeted case management, personal care, and wrap-around services that are important for people with complex chronic conditions, such as HIV/AIDS or severe mental illness (Kaiser Family Foundation 2011). The same is not true for substance abuse coverage where coverage under Medicaid is frequently limited in amount and by type of provider (Kaiser Family Foundation 2011).

One particular challenge for Medicaid beneficiaries is the cumbersome application and renewal process. For inmates in particular, this process imposes onerous documentation, ongoing renewal, and identification requirements. Inmates who receive Medicaid by virtue of their SSI benefits have their SSI benefits are suspended while they are incarcerated or even in halfway houses that are under the auspices of the department of corrections. Additional restrictions apply to individuals with outstanding felony warrants or violators of parole or probation (Cuellar and Cheema 2012). Individuals who are incarcerated for longer than a year have a greater task, as they must reestablish the existence of their disability and wait for SSI determinations before accessing Medicaid.

Health Care Delivery Today. The justice system has the largest concentration of people with substance abuse disorders, and 50 % of those with substance abuse disorders have co-occurring mental health conditions (Taxman et al. 2007). Yet, the general substance abuse treatment system is arguably less robust than other parts of the delivery system, including mental health, in part because funding from insurance and Medicaid has been lacking. Of the 20 million individuals with alcohol and drug abuse disorders, only 10 % received treatment in the past year (Center for Behavioral Health Statistics and Quality, 2012). Among those not treated, 44 percent cited lack of insurance and cost as impediments to care and one quarter of the insured reported lack of coverage or affordability.

The general substance abuse delivery system is characterized by many small providers who are frequently understaffed. One third of addiction treatment settings do not contract with a physician or have one on staff and fewer than a half employ masters-level counselors or above (Buck 2011). Furthermore, substance abuse treatment is not well integrated with other medical care, such as HIV (Altice et al. 2011; Berg et al. 2011). Only 30 % of community substance abuse treatment programs offer HIV treatment and counseling. Lack of insurance coverage, staff training, and patient acceptance have been cited as barriers to the integration of HIV care into substance abuse treatment programs (Bini et al. 2011).

In contrast, mental health delivery has benefitted from expanded insurance coverage through Medicaid coverage of people with disabilities, insurance parity, and technology changes. Unlike substance abuse disorders, mental health disorders of sufficient severity are qualifying impairments under the SSI program which conveys eligibility for Medicaid in many states. This coverage, combined with state decisions to cover evidence-based mental health treatments, has led to greater insurance-based financing for mental health care.

Access to care by specialists remains a challenge in many communities (Cunningham 2009). The 2008 Community Tracking Survey of primary care physicians, e.g., family practice or internal medicine doctors, found that 42 % had trouble accessing high-quality specialty care for their patients and 59 % were unable to obtain specialty mental health services they thought were medically necessary for their patients. The relatively lack of mental health specialists, paired with innovations in pharmaceuticals and screening tools for common mental disorders, has led to more mental health care being provided in primary care settings than ever (Frank and Glied 2006).

Changes Under Health Care Reform. Health care reform, specifically, the Patient Protection and Affordable Care Act (ACA), has the potential to improve care for offenders, particularly those who live in the community, in several ways: (1) Most individuals must obtain health insurance. (2) Medicaid will be expanded significantly, particularly for childless adults who have income below 138 % of the federal poverty level. (3) Insurance exchanges will be created through which individuals can receive federal subsidies to purchase private coverage. (4) Numerous initiatives are created to address fragmented care for individuals with chronic conditions.

The ACA requires nearly every resident of the United States to obtain health insurance by January 1, 2014. Before the Supreme Court decision on the constitutionality of the ACA, the Congressional Budget Office estimated there would be 30–33 million newly insured individuals, with 17 million newly covered through Medicaid and 23 million covered through new health insurance exchanges, and a small reduction in employer-provided coverage (Congressional Budget Office, March 2012). These initial estimates assumed all states would expand Medicaid. However, the Supreme Court decision in National Federation of Independent Business v. Sebelius, 132S. Ct. 2566 (2012) held that states could choose whether or not to expand eligibility for coverage under their Medicaid program pursuant to the ACA and, despite strong financial incentives, not all states likely will elect to expand (Congressional Budget Office, July 2012). Further, some states may delay expansion until after 2014 and some may seek federal approval for partial expansions. As a result, the Congressional Budget Office scaled back its estimates concluding that seven million fewer individuals will be in states that expand Medicaid coverage by 2016 and four million more will be uninsured relative to prior estimates.

The Medicaid expansion is particularly important to criminal justice populations. Medicaid will become the primary source of health insurance for most low-income individuals, including childless adults. Medicaid is a shared federal-state financial responsibility, and states that expand coverage will pay proportionately less for the newly eligible Medicaid beneficiaries. The fact that states may not expand Medicaid will particularly affect criminal justice populations as they overwhelmingly represent low-income men. And, in those states where Medicaid is not expanded, there will be less financial support to bolster a treatment system that is fragmented and where low-income individuals frequently cannot find care when it is needed.

Cuellar and Cheema (2012) estimated that 21–34 % of prisoners released each year would be enrolled in Medicaid. Applying a similar methodology for jail inmates implies that a total of 2.4–3.6 million prison and jail inmates who are released would be eligible for Medicaid. The estimates are based on the average incomes of individuals with demographics similar to those of released prison and jail inmates and take into account a possible wage penalty from having a criminal record and the fact that some inmates will not have lived in the United States sufficiently long to qualify for benefits. In light of the more recent Supreme Court decision, these estimates should be scaled back by as much as 60 %.

Historically, states have found that fewer people actually enroll in Medicaid than are eligible, as few as 50–75 % of eligibles. This makes health care reform an opportunity only. It must be matched with substantial efforts to reach out and enroll individuals who are newly eligible for Medicaid and involved in the criminal justice system. To date, such outreach has not been particularly salient because so few nondisabled individuals met eligibility requirements. Going forward, outreach will require a new type of collaboration between criminal justice and Medicaid.

The criminal justice population that will be eligible for Medicaid is only a fraction of the estimated ten million newly covered Medicaid beneficiaries. However, their high health care needs and complex social conditions could pose new challenges for Medicaid health plans. Outreach, enrollment and education of providers, and health plans are key steps to improving health for the criminal justice population under reform.

Individuals not eligible for Medicaid can receive assistance obtaining health insurance through new health insurance exchanges under the ACA. The new health insurance exchanges will offer subsidies, on a sliding scale, to those with income up to 400 % of the federal poverty level who buy private coverage. The amount of the subsidy will depend on the enrollee’s income relative to the federal poverty level and the cost of local plans. Cuellar and Cheema (2012) estimate that 50–54 % of released offenders would be eligible for a subsidy, based on their income if plan premiums are sufficiently high. In light of the Supreme Court decision, these estimates should be increased slightly.

Systematic outreach and simplified enrollment are emphasized under health reform, both in Medicaid and in exchanges. Federal assistance is available for states toward the design and implementation of the necessary enrollment technology. All states must engage in consumer information and outreach and related activities must be reported to the federal government. From the perspective of the criminal justice population, a strong enrollment system is one that can incorporate relevant corrections information when determining eligibility. Eligibility is determined based on vital, employment and income information and, therefore, correctional data can fill important data gaps for inmates. Inmates might also be handed key documents, including incarceration dates, to ease income verification and identification. Correctional facilities could also communicate release dates to eligibility offices. To smooth the transition from prison to post-release health care, community providers could be identified in advance. However, in some instances these steps may not be feasible as the average jail has a weekly turnover rate of over 60 %. Nonetheless, states can involve corrections, probation, and parole representatives in system design and include them in subsequent training programs.

Whereas health insurance today can vary considerably in terms of covered services and coverage limits, under health care reform the newly insured population will have insurance that covers “essential health benefits.” The essential benefits must include mental health and substance abuse disorder treatment, as well as preventive and wellness services and chronic disease management, and behavioral health parity provisions will apply.

An increase in funding for behavioral health services is expected under health care reform, stemming from private insurance and Medicaid coverage. Providers of behavioral health services, including those who deliver care to individuals at risk of incarceration, must adapt to an environment where funds are tied to insurance, rather than grants from states or the federal government. This means greater adoption of financial information systems, professional credentialing to meet insurers’ network requirements, and the ability to track the amount and quality of care delivered.

Over and above expanding health insurance, the health care reform law provides incentives to change how treatment providers coordinate care. Several provisions in the ACA promote new care delivery models for individuals with chronic conditions, including medical or health homes models. These models have enormous potential. Medical homes receive financial support specifically to manage chronic conditions and coordinate care across a range of specialists. For criminal justice populations, these medical homes will need strong ties to mental health and substance abuse treatment providers. Ideally, these medical homes will coordinate with corrections and probation departments around benefit enrollment, continuity of treatment from prison to community treatment, and have a basic understanding of probation terms and court orders.

Significant changes are likely for addiction treatment providers. Some anticipate that in the wake of the ACA, care delivery for substance abuse will shift away from traditional substance abuse providers (Buck 2011). Because the ACA emphasizes and rewards primary care–based models, more care may shift to primary care. This offers the promise that both the medical and behavioral health needs of offenders could be more comprehensively addressed and coordinated. Whether care improves will depend in part on how rapidly evidence-based care can be delivered in the traditional medical sector for this population. Another delivery model is to have the traditional behavioral health system integrate medical and chronic disease care. The success of either approach has yet to be determined on a wide scale, but considerable investment is being made, financial incentives are in place, and the intuitive appeal is strong.

Much of the burden of enrolling newly insured individuals through Medicaid and through health exchanges will fall on states. States face the practical challenges of orchestrating health insurance coverage for 30 million individuals, a fraction of whom are in criminal justice and have not only complex eligibility circumstances, but also complex health needs. Actively assisting inmates to enroll in health plans will remove financial barriers to treatment. Developing medical and health home models that can address offenders’ complex health and behavioral health could be beneficial to both public health and public safety.

Bibliography:

 	
Altice FL, Bruce RD, Lucas GM et al (2011) HIV treatment outcomes among HIV-infected, opioid – dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multi-site study. J Acq Immun Def Synd 56(Suppl 1):S22–S32
 	
Beck AJ, Harrison PM (2008) Sexual victimization in jails reported by inmates, 2007. NCJ-221946. U.S. Department of Justice, Office of Justice Programs, Washington, DC
 	
Berg KM, Litwin A, Li Z et al (2011) Directly observed anti-retroviral therapy improves adherence and viral load in drug users attending methadone maintenance clinics: a randomized controlled trial. Drug Alcohol Depend 113(2–3):192–199
 	
Bini EJ, Kritz S, Brown LS et al (2011) Barriers to providing health services for HIV/AIDS, hepatitis C virus infection, and sexually transmitted infections in substance abuse treatment programs in the United States. J Addict Disorder 30(2):98–109