The Affordable Care Act and Corrections
The Association of State Correctional Administrators
Summer Meetings, August 9, 2013
The COCHS Approach:
Public Safety and Community Health
• Public safety and public health systems are intertwined.
• Similarly, the health of the justice-involved population is
intertwined with the health of the general population.
• Connecting health care in the criminal justice system to
health care in the greater community preserves the
investments jurisdictions make in their justice-involved
populations.
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Presentation Overview
1. Health Care, Recidivism, and Costs
2. Eligibility, Coverage, and Enrollment
3. The Role of Health Information Technology
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1. Health Care, Recidivism, and Costs
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Washington State: “The Mancuso Effect”
Reduced Crime / Improved Health & Safety
When SUD treatment was offered to very low income adults—a
population that included many individuals with histories of
justice-involvement—research found:
• Reduced crime and recidivism, and correlated savings to
crime victims and the criminal justice system.
• Improved physical and mental health, and significant cost
savings in health care.
–
–
Mancuso, D, Felver, B. Bending the Health Care Cost Curve by Expanding Alcohol/Drug Treatment, Washington
State DSHS Research and Data Analysis Division, RDA Report 4.81 (Sept 2010).
Mancuso, D, Felver, B. Providing chemical dependency treatment to low-income adults results in significant public
safety benefits, Washington State DSHS Research and Data Analysis Division, Report 11.130 (Feb 2009).
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Washington State: Criminal Justice System Benefits
Decline in arrests relative to
untreated comparison group
33%
Cost savings to criminal
justice system per dollar of
cost
$1.16
Cost savings to crime
victims and criminal justice
system per dollar of cost
$2.83
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Washington State: Medical Costs Decrease with Treatment
Growth in medical costs
relative to coverage
group:
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Justice-Involvement and Insurance
• Most justice-involved individuals currently lack insurance
coverage, limiting access to treatment.
• Few justice-involved individuals today are enrolled in
Medicaid because they have not been eligible as single,
childless adults.
• One study found that 90% of individuals have no health
insurance upon release from jail.
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Justice-Involvement and Insurance
• According to a recent NASADAD study, less than 3% of
Massachusetts residents are uninsured, but the uninsured
residents “are likely to have elevated rates of chronic SUDs.”
• In fact, approximately 22% of the admissions for publicly
funded SAT in MA in 2009 were uninsured. The uninsured
population was disproportionately low-income and young
adult, Black, and Hispanic, characteristics that mirror the
demographics of the justice-involved population.
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Limited Access to Treatment
Limited coverage contributes to limited access to treatment in
the community. One study found that 80% of individuals in jail
with chronic medical conditions had not received treatment in
the community prior to arrest.
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Release from Prison –
A High Risk of Death for Former Inmates
• A 2007 study reported overall increased mortality rates for
former inmates in Washington State: 3.5x greater than the
general population.
• Mortality was the highest during the first two weeks after
release: 12.5x greater than the general population.
• The study found a high incidence of death due to: overdose,
HIV, homicide, motor vehicle accidents, cancer, liver disease.
Binswanger, Ingrid A., Stern, Marc. Deyo, Riahard A. Heagerty, Patrick J. Cheadle, Allen. Elmore, Joann G. and Thomas Koepsell. New England
Journal of Medicine, 356:157-165. January 2007.
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Health Care, Recidivism, and Costs
• Improving access to treatment can reduce recidivism, reduce
health care costs, and reduce correctional system costs.
• The first step toward achieving these outcomes is maximizing
coverage by enrolling eligible justice-involved individuals in
Medicaid and QHPs.
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2. Eligibility, Coverage, and the
Enrollment Process
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Expanded Coverage
A. The ACA allows qualified individuals to enroll in federally
subsidized qualified health plans (QHPs) offered through the
states’ new health insurance exchanges.
B. The ACA allows the expansion of Medicaid at state option to
cover millions of society’s most vulnerable individuals.
 QHP and Medicaid expansion coverage begins January 2014
with applications available October 2013.
 Up to 32 million Americans will be newly covered.
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Medicaid Eligibility
• In Medicaid expansion states, Medicaid will be newly
available to non-elderly adults with income up to 138% FPL,
regardless of health status, gender, or parental status.
• COCHS estimates that about 2/3 of the justice-involved
population will be eligible for Medicaid under the expansion,
creating access to health care for many individuals for the
first time.
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Medicaid Coverage for Justice-Involved
• Justice-involved individuals residing in the community (e.g.,
re-entering the community from prison, on probation/parole,
etc.) can be eligible for Medicaid and can receive coverage
(i.e., services provided can be paid for by Medicaid).
• Medicaid coverage is not available for individuals in prison or
jail (i.e., services provided cannot be paid for by Medicaid),
but individuals who are otherwise eligible retain their
eligibility while in prison or jail and can enroll.
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42 U.S.C.§1396d(a)(27)(A); 42 CFR§435.1010
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Medicaid Coverage: Inpatient Hospitalization
However, there is a significant exception to the preclusion of
Medicaid coverage for prison and jail inmates:
• Medicaid coverage is available for prison and jail inmates
who are eligible for Medicaid and who are inpatients in noncorrectional medical facilities for at least 24 hours.
Correctional agencies could achieve major cost-savings by
developing processes to enroll eligible individuals.
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42 U.S.C.§1396d(a)(27)(A); 42 CFR§435.1009(b)
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Medicaid Coverage: Suspension vs. Termination
In many states, an individual’s Medicaid enrollment is
terminated upon incarceration. A previously enrolled
beneficiary would be required to re-apply for Medicaid in the
event of a potentially billable hospital stay and upon re-entry
into the community.
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Medicaid Coverage: Suspension vs. Termination
However, federal guidelines urge states to suspend rather than
terminate Medicaid upon incarceration. Suspension would make
it easier to reinstate coverage in the event of a hospital stay and
upon re-entry into the community.
–
Letter from Centers for Medicare and Medicaid Services to State Medicaid Directors, May 25, 2004,
Subject: Ending Chronic Homelessness,
http://jfs.ohio.gov/ohp/bcps/OHMedAdvComm/documents/ENDING_CHRONIC_HOMELESSNESS.PDF
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QHP Eligibility
• Qualified individuals with income from 138% - 405% FPL will
be able to purchase QHPs with federal premium subsidies
through the health insurance exchanges.
• COCHS estimates that about 1/3 of the justice-involved
population will be eligible for premium subsidies to buy QHPs
through the exchanges.
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QHP Coverage for Justice-Involved
• Regarding QHPs available through health insurance
exchanges, the ACA specifies that: “[a]n individual shall not
be treated as a qualified individual if, at the time of
enrollment, the individual is incarcerated, other than
incarceration pending the disposition of charges.”
• This means that, subject to the requirements of health plans,
individuals may be able to newly enroll or maintain existing
coverage through a QHP while incarcerated while pending
disposition of charges.
• Services provided while the individual is pending disposition
can potentially be paid for by the QHP.
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QHP Coverage for Justice-Involved
• As is the case with Medicaid, justice-involved individuals
residing in the community, (e.g., re-entering the community
from prison, on probation/parole, etc.) can be eligible for
federally subsidized QHPs and can receive coverage.
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Enrollment: Single Application
• Individuals will be able to apply for Medicaid and QHPs
through a single application.
• Application will be available online, in-person, over phone,
i.e., a “no wrong door” approach.
• Application for Medicaid and QHPs opens in October 2013.
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Enrollment: Federal Data Hub
• The federal government will establish an electronic service,
the “data hub,” that states can use to obtain or verify
eligibility information.
• Information will be available from the Social Security
Administration, the Department of Treasury, and other third
party sources.
• Information available through the data hub could include
income, citizenship status, identity, etc.
• States must use the data hub if the necessary information is
available rather than requesting the information from
applicants.
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Enrollment: Authorized Representatives
• An individual can designate an authorized representative, or
“A-Rep,” to manage the enrollment process on his or her
behalf.
• Designating an A-Rep generally requires the beneficiary’s
signature.
• Correctional officials could act as A-Reps for individuals under
various forms of criminal justice supervision.
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Enrollment: Various Models for Justice-Involved
Populations
• Population of data fields through existing databases, as in
Connecticut.
• Authority for state or county essentially to act as authorized
representative, as in California.
• Eligibility workers stationed in correctional settings, as in
Maryland.
• Community-based organization assists with application at
facility intake, as in Cook County, IL.
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Enrollment: Connecticut Model
• The Department of Social Services has collaborated
with the Department of Corrections.
• The Medicaid application populates with data from
the Department of Corrections database.
• Enrollment is targeted to begin upon discharge.
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Enrollment: California Model
• California SB 92 (2011) allows the California
Department of Corrections and Rehabilitation to act
on behalf of a state prison inmate for purposes of
applying for Medicaid or determining Medicaid
eligibility, without requiring the participation of the
inmate.
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Enrollment: Maryland Model
• Medicaid eligibility workers are stationed at
correctional facilities.
• Eligibility workers assist inmates with applications
prior to release.
• Enrollment is targeted to begin upon discharge.
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Enrollment: Cook County Model
• A community-based organization has a contract with
the Cook County Health and Hospital System to
assist justice-involved individuals with enrollment.
• Application assistance begins at jail intake.
• Enrollment is targeted to begin upon discharge.
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3. The Role of Health Information
Technology
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Bridges to Connectivity
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Health Information Technology
• HITECH Act
• Meaningful use
• Corrections and EHRs
• More reason for Medicaid suspension rather than
termination
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Questions?
www.cochs.org
510-595-7360
Steve Rosenberg srosenberg@cochs.org
Ben Butler bbutler@cochs.org
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