Stripped of Medicaid: Ex-Inmates' Struggle for Coverage

Almost everyone who is incarcerated loses their health insurance. The loss of coverage leads to an extended, sometimes years-long period after their release where many cannot access health care.

Although some inmates lose their insurance because they lose their jobs upon incarceration, the phenomenon can be largely attributed to the Federal Medicaid Inmate Exclusion Policy (MIEP), which prohibits Medicaid from covering incarcerated people, even if they were previously enrolled or eligible. Due to this policy, almost all prisoners will lose their health insurance during the prison intake process. The MIEP was created to save the federal government money, ensuring that the cost of inmate medical care was shifted to state and county prisons.

Although incarceration automatically strips them of their Medicaid coverage, there is no equivalent system to reconnect released prisoners with health insurance. The tedious process of navigating the insurance landscape is consequently thrust into the laps of individuals when they return to the community.

Because of the complexities of Medicaid enrollment and any number of other priorities one has after being released from prison, formerly incarcerated people have a higher likelihood of prolonged uninsurance compared to those without a history of imprisonment. This situation is especially harmful because health often worsens during and after imprisonment, including the risk of overdose for persons who used drugs prior to incarceration.

An increasing number of people with complex medical needs enter the system, and without Medicaid coverage, the financial responsibility falls on the justice system.

Alexander Testa and colleagues hypothesized that reconnecting with public health insurance might be easier in states that expanded Medicaid coverage under the Affordable Care Act (ACA). These expansions broadened eligibility criteria, offering a better chance for previously incarcerated individuals to enroll upon release. The researchers used data from the National Longitudinal Study of Adolescent to Adult Health to track participants’ history of incarceration, health insurance status, and whether they lived in a Medicaid expansion state.

People with a history of incarceration living in Medicaid expansion states were more likely to be insured than those living in non-expansion states. Specifically, 92% of formerly incarcerated people were insured in states with expanded Medicaid, compared to only 77% in non-expansion states.

Expanded Medicaid increases the number of enrollees by widening eligibility criteria, simplifying applications, and raising the income cut-off for exclusion. This higher income cut-off is a key factor in connecting more Americans with affordable health insurance. Some Medicaid expansion states also implemented simplified documentation requirements and unified applications for various assistance programs to reduce paperwork and ease the burden on applicants.

For the formerly incarcerated population, the efforts to boost Medicaid accessibility are leading in the right direction. In 2021, the Congressional Research Service found that, in Medicaid expansion states, many individuals transitioning out of prison were eligible for Medicaid for the first time.

Some states recognize the need for change and are exploring pre-release Medicaid enrollment for inmates. In Massachusetts, for example, correctional facilities are responsible for submitting Medicaid applications on behalf of inmates before release.

Despite the encouraging steps being made in Medicaid expansion states to cover formerly incarcerated people, the Medicaid Inmate Exclusion Policy (MIEP) continues to strip otherwise eligible incarcerated people of Medicaid coverage, passing the financial burden onto counties and states. Senator Cory Booker (D-N.J.) and others reintroduced the Humane Correctional Health Care Act which aims to end the MIEP.

Doug Iosue, Superintendent of Cheshire County Department of Corrections, New Hampshire, asserts that abolishing the Medicaid Inmate Exclusion Policy is crucial for the justice system’s efficiency and ensuring continuity of care. An increasing number of people with complex medical needs enter the system, and without Medicaid coverage, the financial responsibility falls on the justice system. According to Iosue, the MIEP “is not a sustainable model and creates an incredible burden.”

The Humane Correctional Health Care Act would allow inmates to continue to be covered by Medicaid during their incarceration and, with insurance in place, would decrease the likelihood of recidivism caused by untreated mental illnesses and substance use disorders.

Photo via Getty Images