Up close shot of an orange prison jumpsuit

Prison Health Care is Broken Under the Medicaid Inmate Exclusion Policy

By Sarah Wang

Incarcerated individuals need health care, but punitive policies make securing access to care particularly difficult among this population, which numbers about 2.1 million as of 2021.

As a first step to protecting incarcerated individuals’ right to health, Congress should repeal the Medicaid Inmate Exclusion Policy (MIEP).

The MIEP, established in 1965, prohibits Medicaid from covering incarcerated individuals, despite any prior eligibility. Through the MIEP, two populations are affected: first, jail inmates, defined as those convicted or accused of a crime, and second, prison inmates, defined as those convicted or awaiting trial. In other words, both convicted individuals and those still presumed innocent are stripped of their access to the federal health insurance program for low-income individuals.

The Supreme Court’s ruling in Estelle v. Gamble (1976), affirmed that incarcerated individuals have the constitutional right to health care. Incarcerated individuals need health care more than ever in light of the COVID-19 pandemic, which has disproportionately affected those within correctional facilities.

In this context, policy efforts like the Humane Correctional Health Care Act (H.R.3514) are particularly critical.

The Humane Correctional Health Care Act (H.R.3514), introduced in May of 2021, would repeal the Medicaid Inmate Exclusion Policy and thus provide incarcerated individuals with Medicaid access. This policy would be particularly significant in states that have expanded Medicaid under the Affordable Care Act (ACA), because justice-involved populations largely intersect with those made eligible for Medicaid in expansion states (namely, people who earn less than 138% of the federal poverty level). A similar bill was introduced in the Senate in October 2019, the Equity and Pretrial Medicaid Coverage Act (S.2628).

The MIEP overburdens county and local jails financially and jeopardizes public health. Legislation like H.R. 3514 and S.2628 would support states and counties in delivering quality health care.

Inmates need more health care, with chronic disease rates among inmates being more than double the general public. For example, among inmates, the rate of HIV is five to seven times higher than the general public. With the prison population aging, demands on health care increase. Incarcerating older prisoners with chronic illnesses costs two to three times more than young inmates.

Pushing legislation like H.R. 3514 and S.2628 would save county and state jails billions of dollars. Specifically, states that have expanded Medicaid could save $4.7 billion each year. This is because currently, county and local jails are burdened with the majority of health care expenses for their incarcerated populations. The only time that Medicaid can match health care costs for an incarcerated individual is when he or she is hospitalized for in-patient care for 24 hours or longer in a facility off the correctional facility grounds.

To manage health care costs, many correctional facilities nationwide charge prisoners unaffordable copays. In another measure aimed at minimizing health care costs, jails and prisons offer low-quality care that inadequately follows established clinical guidelines. They fail to deliver medical exams for chronic diseases to about 20 percent of state prisoners and 70 percent of jail inmates. When incarcerated individuals receive care, providers are often unfamiliar with their medical history, an obstacle to chronic disease treatment. While hospitals and clinics abide by the Center for Medicaid & Medicare Services guidelines, jails and prisons do not. Repealing the MIEP would establish firmer guidelines by making jails and prisons abide by federal guidelines. Additionally, repealing the MIEP could help incarcerated individuals feel more equipped to manage their health needs with health insurance instead of emergency care reliance. Further, the MIEP perpetuates racial and socioeconomic disparities, because low-income ethnic and racial minorities are disproportionately incarcerated.

Repealing the MIEP also would help ensure access to treatment of mental health concerns that influence recidivism. Mental health is a serious issue among incarcerated individuals: incarcerated individuals have far higher rates of major depression, substance abuse, and schizophrenia than the general population. Despite many factors leading to recidivism, treating mental health and substance use disorder is often cost-effective and associated with lower recidivism rates.

Legislation like H.R. 3514 is necessary to combat the restrictions put in place by the MIEP. Currently, overburdened county and local jails provide inadequate care for incarcerated individuals with high rates of comorbidities, mental health issues, and COVID-19. Repealing the MIEP can significantly improve health care access for incarcerated individuals.

Sarah Wang is a recent graduate of University of California Irvine with a BA in public health policy.

The Petrie-Flom Center Staff

The Petrie-Flom Center staff often posts updates, announcements, and guests posts on behalf of others.

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