May 18, 2009 It is time for states to suspend, rather than terminate, the Medicaid benefits of inmates while they are incarcerated, say correctional health care experts from The Miriam Hospital in a commentary published online by the Journal of General Internal Medicine.
Although federal law does not mandate Medicaid termination for prisoners, 90 percent of states have implemented policies that withdraw inmates' enrollment upon incarceration, which the authors say leaves a vulnerable population uninsured following release.
In the article, Josiah D. Rich, MD, MPH, notes that each year, the United States releases more than 10 million people from the nation's correctional facilities. Re-entry into the community for former inmates is a vulnerable time – especially for those with mental illness – and is marked by difficulties adjusting and increased drug use. In addition, the risk for dying is sharply increased in the first two weeks after release, with drug overdose, cardiovascular disease, homicide and suicide among the leading causes of death.
"We know that having Medicaid at the time of release leads to increased access to and utilization of services, as well as decreased drug use and re-incarceration. However, without coverage, former inmates face tremendous, and potentially fatal, health risks and are forced to rely on emergency rooms for medical care, placing the burden of cost on hospitals and state agencies," says Rich, co-director of the Center for Prisoner Health and Human Rights at The Miriam Hospital and The Warren Alpert Medical School of Brown University.
He also points out that releasing inmates without medical coverage can contribute to an increased spread of infectious diseases, since many prisoners with hepatitis C, HIV and tuberculosis pass through the correctional system. Other communicable diseases, such as influenza, are commonly spread in prisons.
Although Medicaid has prohibited the use of federal funds to cover medical, mental health or substance use treatment costs incurred by inmates in jails and prisons, Rich says that Medicaid law does not require that states terminate recipients' enrollment while incarcerated. Unfortunately, federal rules establish only the minimum requirements and states have the freedom to enact tougher regulations.
"This leaves many inmates potentially facing months of reenrollment paperwork and bureaucracy upon release before they can get any medical coverage," he says, noting that the process – which also involves meeting with Social Security Income and Medicaid representatives to determine eligibility – can often take up to three months.
Former inmates with mental health issues, who are often struggling with addiction, lack of transportation and homelessness, have the most difficulty with the complicated Medicaid re-enrollment process. Coincidentally, Medicaid is the single largest payer for mental health services and is a crucial resource for the 16 percent of inmates reporting current mental illness, as well as for the additional 14 percent reporting past psychiatric treatment.
Rich suggests that states follow the lead of New York, which passed Medicaid Suspension Legislation in 2007, requiring the state to suspend Medicaid for those who are enrolled at the time of incarceration and permitting immediate reinstatement upon release.
"With the United States now leading the world in the number of incarcerated individuals and length of sentences, the issue of Medicaid termination is critical, not just to the nearly 10 million people in our correctional system but to the communities and health care systems to which they return," Rich says.
Rich is an infectious disease specialist at The Miriam Hospital and associate professor of medicine and community health at Alpert Medical School. Commentary co-authors include Sarah E. Wakeman, a medical student at Alpert Medical School, and Margaret E. McKinney, MD, from Stanford University School of Medicine. The work was supported in part by grants from the National Institute on Drug Abuse and the Center for AIDS Research, both affiliated with the National Institutes of Health.
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