The voices of Urban Institute's researchers and staff
October 18, 2013

How Medicaid expansion could improve public safety

October 18, 2013

Special thanks to Shebani Rao for her invaluable research and writing assistance. 

As debates rage in Washington over the Affordable Care Act (ACA), many Americans might be surprised —or even dismayed —to learn that former prisoners are among the beneficiaries of expanded health coverage.   But this could well result in an unexpected benefit: improvements in public safety across the board. That’s because providing access to health care, prescription medicines, and substance abuse treatment can keep former prisoners from reoffending.

Some ex-offenders have always been eligible for Medicaid, but many more will now qualify under the ACA.  What’s different now is that in most states Medicaid will be open to low-income adults in general —not just those who are disabled, pregnant, or parents eligible for income support.

My research about returning prisoners reentering society found that the vast majority of them experience challenging chronic health problems. Of those my colleagues and I surveyed, half of the men and two out of three women had physical health conditions such as diabetes, hepatitis, and HIV/AIDS; 15 percent of men and 30 percent of women had some type of mental illness; and about two-thirds reported substance abuse. Additionally, many of these individuals had a formidable combination of multiple physical health, mental health, and substance abuse problems.

After leaving prison, the health of these ex-offenders deteriorated. Their use of prescription medicines dropped in half, as did their participation in substance abuse treatment. Most of them were uninsured after release, and many did not receive routine treatment for their specific health conditions. Like other uninsured people, they resorted to costly emergency room visits and hospital care, ultimately at taxpayers’ expense.

Not surprisingly, the health problems returning prisoners faced were connected to a host of reentry challenges, including increased recidivism. Released prisoners with physical health problems were less likely to maintain employment and more likely to return to prison within a year of their release.

Those with substance abuse problems were more likely to turn to illegal activities for financial support—and, again, return to prison within a year. Returning prisoners with mental illnesses reported extensive housing instability, spotty employment, inconsistent family support, and more reoffending.

Access to physical and behavioral health care through Medicaid expansion may be a key step to helping former prisoners succeed in their communities. Expanding coverage can help these individuals continue their in-prison treatment and access health services immediately after release, which is an especially critical time in the reintegration process.  Together, Medicaid coverage and treatment might help to slow the costly “revolving door” of recidivism in the criminal justice system.

Research has found that mental health and substance abuse treatment can substantially reduce reoffending by released prisoners. Specifically, accessing services through Medicaid benefits has been found to improve recidivism outcomes for former inmates suffering from mental illness. Reduced recidivism through Medicaid expansion, in turn, can ultimately save costs for the criminal justice system.

By expanding former prisoners’ access to health services, we can expect their health outcomes to improve and reoffending to decrease. The resulting reductions in victimization, imprisonment, and reliance on emergency care could yield substantial cost savings to the community and taxpayers at large. As Medicaid becomes available to more ex-offenders, the potential health, public safety, and cost benefits of coverage can be achieved on a broad scale. 

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