The latest Kaiser Health Tracking Poll finds that public opinion on the Affordable Care Act (ACA) remains more negative than positive, with 47 percent viewing the law unfavorably (closer to levels measured earlier this year after rising to 53 percent in July) and 35 percent having a favorable view. Partisan divisions on the law are as deep as ever, not only when it comes to overall opinion but also in the public’s perception of how the law has impacted their own families and the next steps they want Congress to take.

This poll takes a special look at registered voters’ views of the ACA and what role, if any, the law might be playing in the upcoming midterm election. The survey finds that health care is named as an important voting issue by about one in eight voters, ranking behind the economy and jobs, and clustered with several other issues such as foreign policy and national defense, dissatisfaction with government, immigration, and education. At the same time, the ACA is prominent among the issues voters report hearing about from candidates in their campaigns and advertising. And the messages they are hearing in political advertising are decidedly more anti-ACA than pro-ACA, particularly in states with competitive Senate races. This messaging in advertising may be a reflection of Republican candidates playing to their base, as the survey finds that most Republican voters want candidates to continue talking about the ACA, while most Democrats want them to focus on other issues. Two months out from Election Day, Republicans have a modest edge among the most enthusiastic voters. However, it does not appear that opposition to the ACA is a big driver of that enthusiasm, as these voters are no more likely than others to mention health care as an important factor in their vote.

More Continue to View ACA Unfavorably than Favorably

The latest Kaiser Health Tracking Poll finds that the public continues to be more likely to express an unfavorable view of the health care law (47 percent) than a favorable one (35 percent). However, after rising to 53 percent in July, the latest poll finds that the share with an unfavorable view fell back down closer to the shares reported earlier in the year.  The share not offering an opinion on the law increased to 19 percent this month, while the share with a favorable view remains similar to previous levels. Even as overall opinion remains more negative than positive, nearly twice as many Americans say they want their Congressional representative to work to improve the law (63 percent) rather than to repeal it and replace it with something else (33 percent).

When it comes to personal impact, a majority of the public (56 percent) says the law has not directly impacted them or their families. Of those who say the law has touched them directly, about twice as many report being hurt (27 percent) as report being helped (14 percent). Those who report being hurt by the law mainly say that it has increased the cost of their health care or insurance (16 percent), while those who say the law has helped them mainly say it has allowed someone in their family to get or keep health coverage (6 percent) or made it easier for them to get the health care they need (4 percent).

Party Identification Sharply Divides Opinion Of Health Care Law

Consistent with previous Kaiser Health Tracking Polls, opinions of the health care law including views overall, impression of personal impact and what Congress should do next are sharply divided along party lines. A majority of Democrats report a favorable opinion of the law (57 percent), while a majority of Republicans report an unfavorable opinion (74 percent), and independents fall in between the two, although more of them have an unfavorable than a favorable view (49 percent versus 30 percent). Intensity in opinion of the law lies with the Republicans, with about twice as many Republicans expressing a “very” unfavorable opinion of the law as Democrats expressing a “very” favorable opinion (57 percent versus 28 percent).

Just as opinion of the law in general is divided along party lines, reported personal impact is as well. Democrats (27 percent) are more likely than independents (11 percent) and Republicans (2 percent) to report that the law has directly helped them. And vice versa, Republicans are more likely to say that the law has directly hurt them (46 percent) than are independents (31 percent) and Democrats (10 percent).

The public’s preferences for next steps with the health care law also differ sharply by party identification, with a large majority of Democrats wanting their representative in Congress to work to improve the law (89 percent), and a majority of Republicans wanting them to work to repeal the law and replace it with something else (61 percent).  However, notable shares of both Republicans (35 percent) and those with an unfavorable opinion of the law (40 percent) say that they want their representative to work to improve the law.

Where Does Health Care Rank As A Voting Issue?

This month’s poll takes a special look at registered voters’ views of the ACA and what role, if any, the law might be playing in the upcoming midterm election. Like the public overall, registered voters are more likely to have an unfavorable view of the ACA than a favorable one (49 percent versus 35 percent). Opinion tilts even more negative among likely voters1  (51 percent versus 35 percent).

However, health care does not appear to be the dominant issue on voters’ minds when thinking about how to vote in November. Asked to name in their own words the two most important issues in deciding their vote for Congress, the most frequently-mentioned issue is the economy and jobs (21 percent). Thirteen percent of voters name health care as a top issue, including just 3 percent who specifically mention the Affordable Care Act. Those who view the law favorably are about equally likely to mention health care as a top issue in their vote as are those with an unfavorable view (12 percent versus 15 percent).

As a voting issue, health care is clustered with a number of other issues, including foreign policy/national defense/terrorism (13 percent), dissatisfaction with the way government is working (12 percent), immigration and border security (9 percent), and education (9 percent).

Looking at registered voters by party identification, the economy is the most frequently mentioned voting issue among Democrats, Republicans, and independents alike. While health care ranks second and is mentioned by a similar share of Democrats (15 percent) and Republicans (16 percent), it ranks further down the list and is mentioned by a smaller share of independent voters (9 percent). When Republicans mention health care as a top voting issue, they are more likely to mention the ACA or Obamacare by name (7 percent of Republicans versus 2 percent of Democrats), while Democrats are more apt to name other health care issues or health care more generally.

Other partisan differences are also apparent. For example, foreign policy, immigration, and government spending all receive more mentions among independents and Republicans than among Democrats, while Democrats and independents are more likely than Republicans to name dissatisfaction with government. Two issues make the top five list for Democrats but do not rank as high for other voters: education and crime/public safety.

Issues Are Only One Part Of Voters’ Decisions

In assessing how the health care law will influence voting decisions, it’s important to keep in mind that national issues like the ACA are only one part of the calculus for voters. While about a third (34 percent) of registered voters say specific national issues will make the biggest difference in how they vote for Congress, about a quarter each say their vote will be mostly based on the candidate’s character and experience (23 percent) or local or state issues (24 percent), and 11 percent say the candidate’s party affiliation will be the most important factor.

Voters Are Hearing Candidates Talk About Jobs, Immigration, And The ACA

While the ACA may not be top-of-mind for most voters when deciding how to vote, it is prominent among the issues voters report hearing about from candidates. About a third (32 percent) of registered voters say they’ve heard “a lot” from candidates about the health care law, and another one in five (19 percent) say they’ve heard “some” about the issue. Similar shares report hearing from candidates about immigration and the economy, while fewer say they’re hearing from candidates about education or state and local issues.

Voters who identify as Republican are somewhat more likely than Democratic voters to say they’re hearing “a lot” from candidates about immigration (41 percent versus 31 percent) and state and local issues (26 percent versus 17 percent), but for other issues, including the health care law, there is no partisan difference in how much voters report hearing from candidates.

Voters Report Seeing More Anti-ACA Than Pro-ACA Advertising

In addition to hearing candidates talk about the ACA, about half of voters (53 percent) report seeing some type of political or issue advertising related to the health care law in the past 30 days, including ads that were opposed to or in support of the law itself, as well as ads that tried to influence their vote for a particular candidate because of their position on the law. Overall, nearly three times as many voters say that most of the ads they saw were opposed to the law (20 percent) as say most of them were in support of the law (7 percent), while just under a quarter (23 percent) say they saw about equal numbers of both.

In states with competitive Senate races2 , an even larger share of voters reports seeing ads related to the law (71 percent), and the balance of negative over positive ads is even more lopsided (34 percent say they saw more ads opposed to the law while just 4 percent report seeing more ads in support).

Voters Are Divided On Whether Candidates Should Continue Talking About ACA

At this point in the campaign, voters are evenly divided on whether they want to hear candidates for Congress continue to talk about the ACA. About half (48 percent) of voters say they are tired of hearing candidates talk about the law and would rather they focus on other issues, while a similar share (47 percent) feel it’s important for candidates to continue the debate. The desire for continued debate is more on the side of the law’s opponents than its supporters; about six in ten Republicans and those with an unfavorable view of the law want candidates to keep up the debate, while similarly large shares of Democrats and those who view the law favorably say they should move on to other issues.

Despite the fact that voters in states with competitive Senate races report seeing more campaign advertising related to the law, they are not more likely than voters in other states to say they are tired of hearing candidates talk about the ACA (49 percent in states with competitive Senate races versus 48 percent in other states).

Republicans Have An Edge Among “Enthusiastic” Voters, But Not Necessarily Because Of ACA

As other polls have shown, Republicans have a modest edge when it comes to voter enthusiasm. While a majority of voters of all political stripes say their enthusiasm about voting this year is “about the same” as in previous Congressional elections, 27 percent of Republicans say they are “more enthusiastic” about voting this year than in the past, compared with 20 percent of Democrats and 18 percent of independents.

Overall, the survey finds that registered voters are fairly evenly divided between those who want to see the Democrats hold on to their majority in the Senate (43 percent) and those who would prefer to see the Republicans gain the majority (40 percent). This narrows to a dead heat among likely voters – 43 percent say they want a Democratic majority and 43 percent want a Republican one. However, Republicans have an edge among those who say they’re more enthusiastic about voting this year; half (50 percent) of these voters say they’d prefer to see the Republicans gain the majority in the Senate and 38 percent say they’d like the Democrats to hold on to their majority.

While the “more enthusiastic” voters may give Republicans an edge, opposition to the ACA does not seem to be the dominant factor driving their enthusiasm. These voters are no more likely than other voters to name health care as one of the most important issues in deciding their vote (14 percent name health care – including 6 percent who name the ACA specifically, ranking behind the economy at 21 percent and foreign policy/defense at 16 percent). Further, when asked to say in their own words why they’re more enthusiastic about voting this year, the most common responses relate to a desire to elect more Republicans or help Republicans gain control of the Senate (13 percent), followed by a general sense that participation is important (10 percent), a desire to change who’s in office or get rid of incumbents (10 percent), a general desire for change (8 percent), dissatisfaction with the way government is working (8 percent), and the overall direction of the country (8 percent). Just 3 percent of “more enthusiastic” voters mention the health care law as the main reason for their enthusiasm.

How Do Voters Say A Candidate’s Position On The ACA Will Affect Their Vote?

While the ACA may be just one factor in voters’ decisions, many say that a candidate’s position on the law – along with a variety of other issues – would make them more or less likely to vote for that candidate. Almost four in ten (38 percent) say that if a candidate voted for the health care law, they would be less likely to vote for that candidate, while 29 percent say they would be more likely to vote for them. The numbers are almost exactly opposite when it comes to a candidate who voted to repeal the law: 41 percent say they would be more likely to vote for that candidate and 30 percent say they would be less likely to vote for them. To put the ACA in context with other issues, nearly half (48 percent) of voters say they’d be more likely to vote for a candidate who supports increasing the minimum wage, and over four in ten (44 percent) say they’d be less likely to vote for a candidate who supports a path to citizenship for undocumented immigrants.

Not surprisingly, voters’ reactions to different candidate positions on the ACA divide sharply on party lines, and once again Republicans appear to have the edge in terms of enthusiasm. Just over half (53 percent) of Democrats say they would be more likely to support a candidate who voted for the ACA, but an even larger share of Republicans (72 percent) say they would be less likely to back such a candidate. Similarly, when asked how they would react to a candidate who voted to repeal the law, 68 percent of Republicans say they would be more likely to vote for them and 53 percent of Democrats say they would be less likely.

Among independent voters overall, about twice as many say they would be less likely to vote for a candidate who voted for the ACA as say they would be more likely to vote for such a candidate (40 percent versus 21 percent). But as previous Kaiser tracking polls have shown, independents who lean towards one party or another have views that look more like their partisan counterparts. Nearly half (46 percent) of independent voters who lean toward the Democratic party say they would be more likely to support a candidate who voted for the health care law, while two-thirds (67 percent) of Republican-leaning independents say they would be less likely to support such a candidate.

As other polls have shown, voters’ views on the ACA, nicknamed “Obamacare” for the president who championed its passage and signed it into law, often mirror their views on the president himself. And in fact, this survey finds that partisan divisions in voters’ reactions to a candidate who “supports President Obama” are very similar to a candidate who “voted for the health care law.” Just over half (52 percent) of Democratic voters say they’d be more likely to vote for a candidate who supports the president (almost identical to the 53 percent who say the same about a candidate who voted for the ACA), and 82 percent of Republican voters say they’d be less likely to vote for such a candidate (similar to the 72 percent who say they’d be less inclined to back a candidate who voted for the ACA).

This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted August 25- September 2, 2014, among a nationally representative random digit dial telephone sample of 1,505 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (753) and cell phone (752, including 424 who had no landline telephone) were carried out in English and Spanish by Princeton Data Source under the direction of Princeton Survey Research Associates International (PSRAI). Both the random digit dial landline and cell phone samples were provided by Survey Sampling International, LLC. For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2012 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, nativity (for Hispanics only), and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the July-December 2013 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margin of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margin of sampling errors for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

1. Likely voters are defined as those who say they are “absolutely certain” to vote or will “probably” vote in the Congressional election in November. ↩︎
2. States with competitive Senate races are those identified by the Cook Political Report ratings as “Toss Up,” “Lean Democrat,” or “Lean Republican as of Sept. 4: AK, AR, CO, GA, IA, KY, LA, MI, NC, NH, and WV (see http://cookpolitical.com/senate/maps). ↩︎

Introduction

Individuals transitioning into and out of the criminal justice system include many low-income adults with significant physical and mental health needs who face a variety of economic and social challenges. The Affordable Care Act (ACA) coverage expansions, particularly the Medicaid expansion, provide new opportunities to increase health coverage for this population, which may contribute to improvements in their ability to access care as well as greater stability in their lives and reduced recidivism rates. This brief provides an overview of the adult criminal justice-involved population and the potential impacts of the ACA on their health coverage. (For information on health coverage and care for youth in the juvenile justice system, see: https://www.kff.org/medicaid/issue-brief/health-coverage-and-care-for-youth-in-the-juvenile-justice-system-the-role-of-medicaid-and-chip/.)

The Criminal Justice System

The criminal justice system is comprised of a range of different types of correctional facilities (Figure 1). Correctional facilities include prisons, which typically house longer-term felons or inmates serving a sentence of more than one year, and jails, which house individuals awaiting trial or sentencing and those convicted of misdemeanors and serving shorter terms that are typically less than one year. There also are several forms of community-based corrections, including probation, parole, and halfway houses. Offenders in community corrections often are required to adhere to strict conditions and rules, and failure to comply with these requirements may lead to incarceration or re-incarceration.

Prisons are overseen by the federal government and states, while jails typically are governed by the local city or county. The federal correctional system consists of prisons overseen by the Federal Bureau of Prisons, which house individuals convicted of a federal crime and generally serving a term of more than one year. State correctional systems oversee prisons housing individuals convicted of state crimes and generally serving terms of more than one year. Each state governs its own prison system through a Department of Corrections. There are over 3,200 jails nationwide housing individuals awaiting trial or serving a short sentence for a misdemeanor, with most counties (2,977 out of 3,069) operating their own jails.¹ 

The Criminal Justice-Involved Population

About 2.3 million individuals are incarcerated in prison or jail, but millions more interact with the correctional system annually (Table 1). (See Appendix Table 1 for data by state.) About 1.5 million individuals were incarcerated in prisons as of the end of 2012. Over the course of the year, about 600,000 individuals are admitted to prison and a similar number are released.²  As of mid-year 2013, over 730,000 individuals were in jails.³  About six in ten of these individuals were not convicted and awaiting court action; the remaining four in ten were sentenced or convicted offenders awaiting sentencing.⁴  Given the shorter terms of jail inmates compared to prisoners, there is rapid churn among the jail population. Between July 2012 and June 2013, an estimated 11.7 million people were admitted to local jails and, on average, jails experienced a weekly turnover rate of 60%.⁵  The jail population is concentrated in large jails (that have an average daily population of 1,000 or more inmates), which house nearly half (48%) of all jail inmates but only account for 6% of all jail jurisdictions.⁶  An additional 4.8 million adults were under community supervision as of the end of 2012, and about 4.1 million adults entered and exited community supervision over the course of 2012.⁷  About 80% of adults under community supervision are on probation, while the remainder is on parole.

Adult males of color make up the majority of the incarcerated population. As of 2013, 99% of jail inmates were adults and 86% were male. Just over half of the jail population (53%) was people of color, including more than a third who were Black (36%) and 15% who were Hispanic (Figure 2).⁸  Among prisoners, more than nine in ten are male (93%) and two-thirds (66%) are people of color.⁹  These patterns reflect higher incarceration rates among people of color compared to Whites. Incarceration rates for Black men are over six times higher than the rate for White men and nearly two and half times higher than the rate for Hispanic men.¹⁰  American Indians also have higher rates of incarceration compared to Whites.¹¹ 

People involved with the criminal justice system are generally low-income and uninsured. Overall, data on the income and insurance status of people moving into and out of the criminal justice system are limited. However, survey data from 2002 show that nearly six in ten jail inmates reported monthly income of less than $1,000 prior to their arrest.¹²  Data also suggest that the population is largely uninsured. For example, a survey of San Francisco county jails found that about 90% of people who enter county jails have no health insurance.¹³  Another survey of inmates returning to the community from Illinois jails found that more than eight in ten were uninsured after returning to the community at 16 months post-release.¹⁴ 

The incarcerated population has significant physical and mental health needs. Chronic disease is prevalent among the population with higher rates of tuberculosis, HIV, Hepatitis B and C, arthritis, diabetes, and sexually transmitted disease compared to the general population.¹⁵  Over half of prison and jail inmates have a mental health disorder, with local jail inmates experiencing the highest rate (64%).¹⁶  These disorders include mania, major depression, and psychotic disorders.¹⁷  Prisoners and jail inmates who have a mental health disorder are more likely than those without a disorder to have been homeless in the year prior to their incarceration, less likely to have been employed prior to their arrest, and more likely to report a history of physical or sexual abuse. Moreover, the majority of inmates with a mental health disorder also have a substance or alcohol use disorder.¹⁸ 

Individuals moving into and out of the criminal justice system also face a variety of social challenges. Poverty, unemployment, lower education levels, housing instability, and homelessness are all more prevalent issues among criminal justice-involved population than the general population.¹⁹  This population also generally has higher rates of learning disabilities and lower rates of literacy.²⁰ 

Health Care for Incarcerated Individuals

Correctional facilities are required to provide health services to incarcerated individuals, but many inmates go without needed care. The provision of health care varies significantly across states and types of correctional facilities. Some larger prisons have infirmaries on-site, and many prisons hire independent doctors or contract with private or hospital staff to provide care, with the majority of prisons creating a hybrid system. In jails, health care is primarily provided through contracts with local health care providers, such as public hospitals or other safety-net providers, who come to the jails to provide services. As with large prisons, some large jails have on-site primary care, pharmacy, and mental health and substance abuse centers. Even though these services are available, data show that many inmates go without needed health care while incarcerated. For example, a 2009 study found that, among inmates with a persistent medical problem, approximately 14% of federal inmates, 20% of state inmates, and 68% of local jail inmates did not receive a medical examination while incarcerated.²¹  About two thirds of prison inmates and less than half of jail inmates who had previously been treated with a psychiatric medication had taken medication for a mental condition since incarceration.²² 

States have been facing rising costs in prison health care spending. As of 2011, state spending on correctional health care was about $7.7 billion, accounting for about a fifth of total prison expenditures.²³  Between 2007 and 2011, correctional health care spending rose in 41 states, with a median growth rate of 13 percent.²⁴  This growth reflects a combination of an increase in the prison population and higher per-inmate expenses due to an aging inmate population, the prevalence of physical and mental health needs, and challenges in delivering health care in prisons, such as distances from hospitals and providers.²⁵  However, in most states, spending peaked before fiscal year 2011 and has been declining since then due, in part, to a reduction in state prison populations.²⁶ 

Medicaid has historically played a very limited role in covering inmate health care costs. Prior to the ACA, Medicaid eligibility was limited to low-income people who fell into certain groups, including children, pregnant women, parents of dependent children, and elderly and disabled adults. Overall, eligibility for non-disabled, non-elderly adults was very limited, with adults without dependent children generally excluded from the program and income eligibility limits for parents remaining very low in most states.²⁷  As such, many inmates historically could not qualify for Medicaid since they did not fit into one of the categorical eligibility categories. Even for inmates who do qualify for Medicaid, federal law prohibits Medicaid payment for most health care services provided to individuals while incarcerated under a policy known as the “inmate exclusion” (see Box 1). Given these limitations, previously, few states pursued Medicaid financing for eligible prisoners’ health care services.²⁸ 

The ACA and the Criminal Justice-Involved Population

The ACA offers new opportunities to increase health coverage among individuals transitioning back into the community from prisons and jails. The ACA established new coverage options by expanding Medicaid eligibility to nearly all adults with incomes at or below 138% FPL ($16,105 for an individual in 2014). The federal government will cover 100% of the cost of coverage for individuals made newly eligible as a result of this expansion, phasing down to a 90% federal match as of 2020. The ACA also created new Health Insurance Marketplaces with premium tax credits available for moderate income individuals. In addition to these coverage expansions, the ACA also requires all states to implement streamlined, coordinated enrollment processes to connect eligible individuals to health coverage.

The ACA coverage expansions provide new coverage options for many individuals who interact with the criminal justice system. Although as enacted in the ACA, the Medicaid expansion would occur in all states, the Supreme Court ruling on the ACA effectively made the expansion a state option. As of August 2014, 28 states are implementing the expansion.³⁰  In states expanding Medicaid to low-income adults, many individuals who interact with the criminal justice system are newly eligible for the program. Moreover, in all states, some individuals being released from prison and jail may qualify for coverage under the new Marketplaces established by the ACA (see Box 2). However, in states not implementing the Medicaid expansion, many poor uninsured adults did not gain a new coverage option and will likely remain uninsured. While the coverage expansions increase coverage options for individuals transitioning through the criminal justice system, targeted outreach and enrollment efforts will be key for translating these new options into increased coverage, particularly since the population faces a broad range of enrollment barriers such as lack of knowledge about coverage options and lower literacy and education levels.³¹ 

Correctional facilities can play a key role in connecting eligible individuals to coverage and care to facilitate their reintegration back into the community. Correctional facilities can help connect eligible individuals to coverage by providing outreach and education about coverage options as well as direct enrollment assistance either through staff or by bringing in external enrollment assisters. Providing this assistance within jails may be challenging since there is often limited time to connect individuals with resources or support community re-entry given the short-terms of jail inmates. However, several states and localities have already launched initiatives to enroll individuals into coverage and facilitate connections to community providers as individuals transition back into the community (see Box 3).

Increased coverage among the criminal justice-involved population may lead to improved access to care and broader benefits, including reduced recidivism rates. As noted, individuals transitioning into and out of prisons and jails have significant physical and mental health needs. Upon release from prison and jail, individuals are often uninsured, making it difficult to access stable sources of care in the community to address these needs. Expanding health insurance to these individuals will likely facilitate their ability to access needed care and manage their ongoing conditions. Improved connections to services and better management of health conditions may also contribute to reduced rates of recidivism, particularly among individuals with mental health and substance abuse disorders. For example, in Michigan, rates of recidivism fell following implementation of an initiative that links newly released prisoners to a medical home in the community, helps them access needed medications and primary and specialty care, and assists them in obtaining their medical records upon release.³²  In addition, studies in Florida and Washington found that people with severe mental illness who were enrolled in Medicaid at jail release were more likely to access community mental health and substance abuse services than those without Medicaid, and that 12 months after release, Medicaid enrollees had 16% fewer detentions and stayed out of jail longer than those who either were not enrolled or had been enrolled for a shorter time.³³ 

Expanding health coverage among the criminal justice-involved population may contribute to offsetting savings for states. Although the Medicaid inmate exclusion policy limits Medicaid payments for most health care services provided to individuals while incarcerated in prison or jail, Medicaid reimbursement is available for care provided to eligible individuals admitted to an inpatient facility, such as a hospital, nursing home, or psychiatric center. Prior to the ACA, only a few states had pursued Medicaid reimbursement for these services given the limited share of the incarcerated population that could qualify for Medicaid. However, those that did pursue federal matching dollars for inmate inpatient services demonstrated state savings.³⁶  The Medicaid expansion offers greater potential savings to states from reimbursement for inpatient services provided to incarcerated individuals, since a larger share of the incarcerated population may qualify for Medicaid and because the federal government is providing states an enhanced federal matching rate for newly eligible adults. Several states have projected substantial state savings from obtaining Medicaid reimbursement for inpatient care provided to prisoners.³⁷  Increased coverage among the formerly incarcerated population as they return to the community may also contribute to other state and local savings through reductions in uncompensated care and savings in other indigent care programs.

Conclusion

Individuals moving into and out of the criminal justice population are a low-income population with significant physical and mental health needs. Historically, this population has had high uninsured rates and very limited access to Medicaid coverage given the program’s limited eligibility for adults prior to the ACA. The ACA’s Medicaid expansion and Marketplaces, coupled with targeted outreach and enrollment efforts, provide opportunities to increase coverage among this population that should help to improve their ability to access needed care and contribute to greater stability in their lives and reduced rates of recidivism. States expanding Medicaid may also reduce spending for their incarcerated population and achieve other state and local savings stemming from gains in coverage through Medicaid and the Marketplaces among formerly incarcerated individuals who are returning to the community.

1. James Stephan and Georgette Walsh, Census of Jail Facilities, 2006 (Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, December 2011), http://bjs.gov/content/pub/pdf/cjf06.pdf and National Association of Counties, County Intelligence Connections (CIC) database, 2012. Some states operate unified prison and jail systems; in these states, the state Department of Corrections oversees both the prisons and jails in the state. See Barbara Krauth, A Review of the Jail Function within State Unified Corrections Systems (Longmont, CO: LIS, Inc., US Department of Justice, National Institute of Corrections Information Center, September 1997), http://nicic.gov/library/014024 ↩︎
2. E. Ann Carson and Daniela Golinelli, Prisoners in 2012: Trends in Admissions and Releases, 1991-2012 (Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, December 2013), http://www.bjs.gov/content/pub/pdf/p12tar9112.pdf. ↩︎
3. Todd D. Minton and Daniela Golinelli, Jail Inmates at Midyear 2013 – Statistical Tables (Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, May 2014), http://www.bjs.gov/content/pub/pdf/jim13st.pdf. ↩︎
4. Ibid. ↩︎
5. Ibid. ↩︎
6. Ibid. ↩︎
7. Laura M. Maruschak and Thomas P. Bonczar, Probation and Parole in the United States, 2012, (Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Revised April 22, 2014) http://www.bjs.gov/content/pub/pdf/ppus12.pdf ↩︎
8. Todd D. Minton and Daniela Golinelli, Jail Inmates at Midyear 2013, op cit. ↩︎
9. E. Ann Carson and Daniela Golinelli, Prisoners in 2012, op cit. ↩︎
10. Ibid and Marla McDaniel et al., Imprisonment and Disenfranchisement of Disconnected Low-Income Men (Washington, DC: Urban Institute and the US Department of Health and Human Services, August 2013) http://www.urban.org/UploadedPDF/412986-Imprisonment-and-Disenfranchisement-of-Disconnected-Low-Income-Men.pdf ↩︎
11. Todd Minton, Jails in Indian Country, 2011 (Washington DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, September 2012), http://www.bjs.gov/content/pub/pdf/jic11.pdf ↩︎
12. Doris James, Profile of jail inmates, 2002 (Washington, DC: Department of Justice, Bureau of Justice Statistics, July 2004), http://www.bjs.gov/content/pub/pdf/pji02.pdf ↩︎
13. Wang EA, White MC, Jamison R, Goldenson J, Estes M, Tulsky JP. Discharge planning and continuity of health care: findings from the San Francisco County Jail. Am J Public Health. 2008;98(12):2182–4. ↩︎
14. Kamala Mallik-Kane, Returning Home Illinois Policy Brief Health and Prisoner Reentry (Washington, DC: Urban Institute, Justice Policy Center, August 2005), http://www.urban.org/UploadedPDF/311214_health_prisoner_reentry.pdf ↩︎
15. National Institute of Corrections, “Solicitation for a Cooperative Agreement—Evaluating Early Access to Medicaid as a Reentry Strategy,” Federal Register 76, no. 129 (2011): 39438-39443; Ingrid Binswanger, Nicole Redmiond, and LeRoi Hicks, “Health disparities and the criminal justice system: an agenda for further research and action,” Journal of Urban Health 89, no. 1 (2012): 98–107; and Laura Maruschak, Medical Problems of Prisoners (Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, April 2008), http://www.bjs.gov/content/pub/pdf/mpp.pdf. ↩︎
16. Doris James and Lauren Glaze, Mental health problems of prison and jail inmates, (Washington, DC:US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, September 2006), http://www.bjs.gov/content/pub/pdf/mhppji.pdf ↩︎
17. Ibid. ↩︎
18. Ibid. ↩︎
19. Kamala Mallik-Kane and Christy Visher, Health and prisoner reentry: how physical, mental, and substance abuse conditions shape the process of reintegration, (Washington, DC: Urban Institute, Justice Policy Center, February 2008), http://www.urban.org/UploadedPDF/411617_health_prisoner_reentry.pdf ↩︎
20. Caroline Wolf Harlow, Education and Correctional Populations, (Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, January 2003), http://www.bjs.gov/content/pub/pdf/ecp.pdf ↩︎
21. Wilper AP, Woolhandler S, Boyd JW, Lasser, KE, McCormick D, Bor DH, et al. The health and health care of US prisoners: results of a nationwide survey. American Journal of Public Health. 2009; 99(4):666-72. ↩︎
22. Ibid. ↩︎
23. State Prison Health Care Spending: An Examination,(Washington DC: Pew Charitable Trusts and John D. and Catherine T. MacArthur Foundation, July 2014), http://www.pewtrusts.org/en/research-and-analysis/reports/2014/07/08/state-prison-health-care-spending. ↩︎
24. Ibid. ↩︎
25. Ibid. ↩︎
26. Ibid. ↩︎
27. Martha Heberlein, Tricia Brooks, Samantha Artiga, and Jessica Stephens, Getting into Gear for 2014: Shifting New Medicaid Eligibility and Enrollment Policies into Drive, (Washington, DC: Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured, Georgetown Universtiy Center for Children and Families, November 2013), https://modern.kff.org/medicaid/report/getting-into-gear-for-2014-shifting-new-medicaid-eligibility-and-enrollment-policies-into-drive/ ↩︎
28. Managing Prisoner Health Care Spending, op cit. ↩︎
29. Subparagraph (A) in the matter after section 1905(a)(29) of the Social Security Act. ↩︎
30. State Health Facts, “Status of State Action on the Medicaid Expansion Decision, 2014,” The Henry J. Kaiser Family Foundation, https://modern.kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/, accessed July 10, 2014. ↩︎
31. Judith Solomon, The Truth about Health Reform’s Medicaid Expansion and People Leaving Jail (Washington, DC: Center on Budget and Policy Priorities, June 2014), http://www.cbpp.org/files/6-25-14health.pdf ↩︎
32. Vondie Woodbury and Peter Sartorius, Michigan Pathways Project links ex-prisoners to medical services, contributing to a decline in recidivism (Rockville, MD: Agency for Healthcare Research and Quality, August 2013), http://www.innovations.ahrq.gov/content.aspx?id=2134 ↩︎
33. Joseph Morrissey et al, “Medicaid Enrollment and Mental Health Service Use Following Release of Jail Detaineees with Severe Mental Illness,” Psychiatric Services 57, no. 6 (2006): 809-815 and “Joseph Morrissey et al, “The Role of Medicaid Enrollment and Outpatient Service Use in Jail Recidivism Among Persons with Severe Mental Illness,” Psychiatric Services 58, no. 6 (2007): 794–801. ↩︎
34. Personal communication with Cook County Health and Hospital Systems, April 2014. ↩︎
35. “Home,” Connections Correctional Healthcare Services. Accessed June 25, 2014. http://www.connectionscsp.com/connections-correctional-healthcare/ ↩︎
36. Managing Prisoner Health Care Spending, op cit. ↩︎
37. Ibid. ↩︎