How Medicaid Expansion Helps Incarcerated Persons Amid COVID-19

States can use Medicaid expansion and additional Medicaid policies—such as beginning Medicaid eligibility determinations pre-release and suspending Medicaid coverage during incarceration—to handle the coronavirus pandemic’s effects on incarcerated populations, a study published in Health Affairs found.

“The first months of transition back into the community are a particularly vulnerable period for justice-involved people, especially after long periods of incarceration,” the study stated.

“Expediting coverage for justice-involved populations leaving prisons or jails is currently recommended by many policy researchers and experts to facilitate better access to care, which in turn can reduce the use of high-acuity health services for nonurgent conditions, increasing successful transitions.”

Indiana expanded its Medicaid program, known as the Healthy Indiana Plan, in February 2015 along with two other policies that expedited the eligibility and enrollment processes for formerly incarcerated—or justice-involved—populations.

The policies allowed Indiana Department of Correction (IDOC) to submit Medicaid applications for incarcerated individuals pre-release under House Enrolled Act 1269 and allowed for Medicaid coverage to be suspended, instead of ended, for newly incarcerated individuals.

The researchers studied whether Indiana’s justice-involved population saw Medicaid enrollment gains as a result of these policies and whether later interagency streamlining improved the enrollment process.

There were three main surges in enrollment during the study period.

First, enrollment surged after Indiana implemented Medicaid expansion. At that time, enrollment jumped from eight percent of justice-involved individuals enrolled in Medicaid to 25 percent by March 2015.

Likelihood of enrollment increased nine percentage points during this time.

Then, enrollment increased again when the pre-release application policy went into effect mid-year in 2015. The Medicaid-insured population of justice-involved individuals jumped from 25 percent having Medicaid coverage to 45 percent having Medicaid coverage in a matter of four months.

After the pre-release application policy went into effect, enrollment during the 60 to 120 days after release dropped. Enrollment in the week after release did not decline, however.

Likelihood of enrollment rose 17 percentage points during this surge, though the slope of enrollment declined .06 percentage points per month.

The third time that enrollment surged was when the suspend-reinstate Medicaid policy went into effect.

In this case, overall enrollment was still at 40 to 50 percent of justice-involved individuals being enrolled in Medicaid. But the number of individuals who enrolled in the first week after release—as opposed to eight to 60 days or 61 to 120 days post-release—rose substantially.

Likelihood of enrollment rose another 12 percentage points during this time period and the trend of enrollment increased by .04 percentage points each month. The researchers deemed this upward trend to be statistically significant.

On the national scale, these results would mean that around 21 to 34 percent of released inmates could enroll on Medicaid through Medicaid expansion.

Indiana’s results were consistent with expectations based on prior literature.

The results reinforced policy recommendations that interagency coordination is critical to effectively securing Medicaid coverage for justice-involved individuals.

“However, it is important to note that we also observed a declining trend in enrollment per month after the initial implementation of the prerelease application policy,” the researchers acknowledged.

“It is possible this was a result of ‘process fatigue,’ wherein during this time Indiana was undergoing multiple business process changes to implement the House Enrolled Act 1269 mandate that were not yet at optimal efficiency.”

The researchers noted that the study’s structure did not allow for a control group and recognized that this, as well as other policies introduced during the course of the study or alternative individual or systemic elements, could have interfered with the results.

They also acknowledged that these results might be specific to Indiana’s system and not other state Medicaid programs.

The findings could support the idea that lack of expedient healthcare coverage drives justice-involved individuals to avoid primary care services and instead utilize emergency department services.

“Our results support recommendations calling for collaboration and data sharing within states and across agencies,” the researchers concluded.

“Future research on justice-involved adults is needed to examine the role of coverage in improving health outcomes such as chronic disease management and averting high-acuity health care services such as ED visits. Furthermore, a greater understanding of the role of health coverage on recidivism is needed.”

The coronavirus pandemic makes research like this even more valuable since incarcerated individuals are considered at high risk of contracting the virus. Some states have been attempting to empty their prisons in order to reduce the spread of the virus, but this could present challenges for newly released individuals who do not have healthcare coverage.

Indiana’s Medicaid program has come under scrutiny along with other states’ programs for receiving permission to have work requirements. The state has suspended the policy.