Medicaid Enrollment among Prison Inmates in a Non-expansion State: Exploring Predisposing, Enabling, and Need Factors Related to Enrollment Pre-incarceration and Post-Release

Abstract

Prison inmates suffer from a heavy burden of physical and mental health problems and have considerable need for healthcare and coverage after prison release. The Affordable Care Act may have increased Medicaid access for some of those who need coverage in Medicaid expansion states, but inmates in non-expansion states still have high need for Medicaid coverage and face unique barriers to enrollment. We sought to explore barriers and facilitators to Medicaid enrollment among prison inmates in a non-expansion state. We conducted qualitative interviews with 20 recently hospitalized male prison inmates who had been approached by a prison social worker due to probable Medicaid eligibility, as determined by the inmates' financial status, health, and past Medicaid enrollment. Interviews were transcribed verbatim and analyzed using a codebook with both thematic and interpretive codes. Coded interview text was then analyzed to identify predisposing, enabling, and need factors related to participants' Medicaid enrollment prior to prison and intentions to enroll after release. Study participants' median age, years incarcerated at the time of the interview, and projected remaining sentence length were 50, 4, and 2 years, respectively. Participants were categorized into three sub-groups based on their self-reported experience with Medicaid: (1) those who never applied for Medicaid before prison (n = 6); (2) those who unsuccessfully attempted to enroll in Medicaid before prison (n = 3); and (3) those who enrolled in Medicaid before prison (n = 11). The six participants who had never applied to Medicaid before their incarceration did not hold strong attitudes about Medicaid and mostly had little need for Medicaid due to being generally healthy or having coverage available from other sources such as the Veteran's Administration. However, one inmate who had never applied for Medicaid struggled considerably to access mental healthcare due to lapses in employer-based health coverage and attributed his incarceration to this unmet need for treatment. Three inmates with high medical need had their Medicaid applications rejected at least once pre-incarceration, resulting in periods without health coverage that led to worsening health and financial hardship for two of them. Eleven inmates with high medical need enrolled in Medicaid without difficulty prior to their incarceration, largely due to enabling factors in the form of assistance with the application by their local Department of Social Services or Social Security Administration, their mothers, medical providers, or prison personnel during a prior incarceration. Nearly all inmates acknowledged that they would need health coverage after release from prison, and more than half reported that they would need to enroll in Medicaid to gain healthcare coverage following their release. Although more population-based assessments are necessary, our findings suggest that greater assistance with Medicaid enrollment may be a key factor so that people in the criminal justice system who qualify f...

Application of Andersen’s behavioural model of health services use: a scoping review with a focus on qualitative health services research

“…Other authors claimed that the model does not cover all factors of healthcare utilisation, such as psychosocial factors, 22 and would be less suitable for studies on HIV 89 or healthcare coverage. 93 …”

“…Other authors claimed that the model does not cover all factors of healthcare utilisation, such as psychosocial factors, 22 and would be less suitable for studies on HIV 89 or healthcare coverage. 93 Not all critics proposed model modifications, but some of the identified limitations may lead to modifications of or additions to the BMHSU. Based on their findings, some authors (n=12) identified additional factors not covered by the model that impact healthcare utilisation, 23 39 54 90 or competing priorities 23 39 (table 2).…”

Postrelease mortality among persons hospitalized during their incarceration

“…Yet as a Medicaid nonexpansion state, there are few options to continue health care for low-income people re-entering the community. Despite a prison-based program that facilitates Medicaid enrollment (based on nonexpansion eligibility criteria) to pay for community hospitalization during incarceration [25], some qualitative evidence suggests that there may be substantial barriers to retaining and continuing Medicaid enrollment postrelease [18]. And only a small proportion of those hospitalized in our study (<3%) were old enough to eligible for Medicare.…”

“…When incarcerated persons are released from prison and return to their communities, they often face an array of economic and social challenges [17]. Those returning citizens who have serious health conditions have the additional burden of accessing and paying for health care [4,18]dand lack of care can result in greater morbidity and mortality. In this study, we examined the postrelease mortality among people who had a community hospitalization during their imprisonment.…”

Emergency department utilization by people living with HIV released from jail in the US South

“…However, conflicting data exist, and some studies have shown no benefit of intensive management interventions over control groups on post-release outcomes, though these programs had very high linkage to care in the control arm and high recidivism rates, making post-release outcomes more challenging to interpret (MacGowan et al, 2015;Wohl et al, 2011Wohl et al, , 2017. The expansion of Medicaid is an important tool for improving care delivery for individuals leaving jail or prison (Guyer, Serafi, Bachrach, & Gould, 2019), though individuals released in states which have not expanded Medicaid, particularly low-income individuals, face additional barriers (Grodensky et al, 2018;Washington Post Editorial Board, 2019). Ending the Medicaid exclusion for people under correctional supervision would allow for continuous access to mental health and substance abuse treatment which is associated with lower rates of recidivism (Pew Charitable Trusts, 2011) and could impact healthcare utilization.…”