The expansion of Medicaid eligibility under the Affordable Care Act (ACA) is allowing a significant number of individuals who previously had no means to obtain health insurance gain access to healthcare for the first time. This is one step towards narrowing the gap of healthcare disparities that exist in this country. However, it simultaneously challenges the healthcare community to prepare for an influx of new patients not previously engaged in care. One such example of those who may newly qualify for insurance are those who have recently been incarcerated.
In the past, 90% of inmates being released from prison or jail lacked health insurance and, thus, access to healthcare. However, under the ACA, many former inmates will now be eligible for Medicaid upon release. Former inmates comprise a unique patient population as they carry a greater burden of certain medical problems, primarily infectious diseases, addiction, and mental health conditions, which not only affect the individuals themselves but the communities to which they return.
To better understand the opportunities (and challenges) that the ACA presents for improving access to care for the formerly incarcerated population, RAND Corporation examined the healthcare needs of recently released prisoners in California, a state where the number of individuals released from prison has increased threefold in the past twenty years and is expected to continue to grow. The report focused on two key questions: (1) what health care needs do newly released inmates have and (2) what role health care play in affecting successful integration back into communities?
With regard to the first question, previous research reveals that due to the higher rates of incarceration among low-income people, who are more likely to be medically underserved, prisoners have far more health problems than does the general population. Some of the health problems of inmates reflect the high-risk behaviors and circumstances (e.g., prostitution or substance use) that led to incarceration.For example, despite the fact that rates of HIV and hepatitis C infection have decreased in all US populations since the 1990s, HIV prevalence remains 5 times higher in state/federal corrections than in the general public, with hepatitis C prevalence being 9-10
times higher in incarcerated than non-incarcerated individuals. But the higher rates of health problems of inmates cannot be blamed simply on prior high risk behaviors. Approximately 40% of inmates are diagnosed with diabetes, hypertension, asthma, or other chronic conditions, rates consistently higher than among the general population.[i] Unfortunately, as the prison population ages, we can only expect the number of inmates with chronic disease to grow.
If the disproportionate rate of physical health problems among inmates seems concerning, the increased rates of mental health and substance abuse disorders among prisoners are downright terrifying. In the RAND Corporation’s evaluation, over 65% of California inmates reported issues with substance dependence or abuse with only 22% actually receiving treatment or other interventions for their addictions. This is consistent with national surveys of the prison population reporting greater than 50% of inmates with a substance abuse disorder yet as little as 15% receiving treatment for it while incarcerated or upon release. Mental health disorders are frequently found coinciding with substance use, and the rate of inmates who qualify as having a DSM-IV mental health disorder is well over 50%.
Prisons and jails are now the largest institutions in the United States housing the mentally ill, yet the majority lack any mental health services to address these needs.
Despite the sub-optimal addiction and mental health services, one of the great ironies of mass incarceration in the United States is that the mandatory provision of healthcare to all inmates, in addition to the fact that inmates are provided with stable food and shelter, results in a shrinking of the mortality gap between blacks and whites. Black inmate mortality rates are lower than the general US black population whereas white inmate mortality rates remain the same or even increase slightly when compared to the general white male population. Unfortunately, such gains are completely offset by the significant increase in mortality among all prisoners immediately upon release.
The risk of death for previously incarcerated individuals is 3.5 times that of the general population in the same geographic area. However, within the first two weeks after release from prison, the risk of death among former inmates is 12.7 times that of other residents in the same community and rates of death from a drug overdose are 129 times higher than the general population, followed by homicide, suicide, and cardiovascular disease.
This brings us back to the fact that for the 600,000 inmates who are released from prison and 7 million who leave jail each year, many will now qualify for health insurance for the first time in their lives under the ACA. Based on the data above, we know that these individuals will be sicker, at higher risk for death, and more likely to have comorbid addiction and substance use disorders then the general population. We also know that they are at the highest risk of dying from these issues within 2 weeks of their release. This makes having health insurance essential, but inadequate if not linked with access to timely care.
In their report, RAND Corporation came up with some recommendations to address these challenges. Perhaps one of the most important measures healthcare communities can do is work with local Department of Corrections to expand pre-release planning efforts such as scheduling medical appointments with providers prior to an inmate’s release and ensuring an inmate has an adequate supply of essential medications before he/she leaves prison.
Many inmates would also benefit from release directly to a substance abuse program; this too would be safer and more effective if arranged prior to release, to the extent that there is availability in such programs. In some states, such as Rhode Island, community physicians also see patients in prison so a doctor-patient relationship has already been established and promotes continuity of care immediately upon release.
Engaging important stakeholders can also provide great assistance in coordinating post-release healthcare. Partnering with community and faith-based organizations that have experience working with post-release populations is one way to do this. Unfortunately, competing interests of finding housing, food, and employment often take precedence over healthcare during the post-release time period. Uniting medical and mental health services with programs that have experience addressing these other issues might be beneficial in keeping a recently released prisoner engaged in his or her healthcare.
Another process, identified by many ex-prisoners as being extremely effective, is for healthcare organizations to utilize patient navigators or community health workers. These are individuals from the same community as the newly released patient, often from the same socioeconomic background and with prior history of incarceration themselves, who have successfully reintegrated into the community and learned to navigate the healthcare system. They can, in turn, provide peer support and advice regarding the challenges of accessing medical and mental health care as well as accompany ex-prisoners to their appointments.
Finally, recognizing the incredible need for addiction and mental health services is crucial. At a minimum, communities and local public health departments need to effectively identify and quantify the numbers of inmates they serve so they can ensure adequate resources to care for their needs. Ideally, linking such services with routine medical care would be most effective since substance use and mental health are often comorbidities and are disproportionately associated with infectious diseases and other medical complications.
Furthermore, since the majority of the US correctional population is in prison or jail for drug-related charges, expanding these services could help reduce recidivism and the ongoing negative impact substantial rates of incarceration has on neighborhoods of low socioeconomic status and minority populations.
[i] Dumont et al. Public health and the epidemic of incarceration. Annu Rev of Public Health 2012; 33: 325-339.
 Binswanger IA et al. Release from prison—a high risk of death for former inmates. New Engl J Med 2007; 356: 157-65.
Christin Price is a physician completing her training as a clinical and research fellow in Infectious Diseases at Brigham and Women’s Hospital and Massachusetts General Hospital. Prior to this, Christin went to Weill Cornell Medical College for medical school followed by an internship and residency in Internal Medicine at Brigham and Women’s Hospital where she will return next year as a Chief Resident. Her clinical interests include caring for patients with HIV and hepatitis C. Her main research interests include prevention/intervention among patients who have HIV and/or hepatitis C in the setting of substance use/addiction.