When the Affordable Care Act (ACA) was passed in 2010, COCHS was one of the first organizations to recognize that people who are at risk of justice system involvement would qualify for Medicaid coverage. Medicaid coverage became available to individuals whose income is at or below 138 percent the Federal Poverty Level (FPL). COCHS as well as other organizations have published many articles and papers that explain what the ramifications of these change are for the justice involved and their healthcare providers.
Medicaid Expansion and The Inmate Exclusion
In 2012, when the Supreme Court of the United States upheld the ACA, it was not widely understood that it had made Medicaid expansion optional for states. Nevertheless, the vast majority of states expanded and more states continue to expand. However, at the time of the passage of the ACA, there were many erroneous claims that the Medicaid expansion was for "felons". These claims ignored the fact that people covered by Medicaid lose coverage when they go behind bars. This loss of coverage is known as the inmate exclusion. States enforce the inmate exclusion by suspending or terminating Medicaid benefits.
Before Medicaid expansion, justice involved individuals with Medicaid coverage made up a relatively small percentage of people cycling in and out of jails, as Medicaid was restricted to pregnant women and children, caretaker relatives, people over age 65, and people with disabilities. After Medicaid expansion, the bulk of the expansion population is comprised of childless adults which includes a sizeable subset with criminal justice involvement. COCHS is enthusiastic about Medicaid expansion as it is seen as way to treat the health challenges such as behavioral health issues and substance use disorder (SUD) that so often lead people to have involvement with the justice system. A study from Washington State showed a decrease in arrests and costs following treatment for SUD.
The Opioid Epidemic, Medicaid, and The Inmate Exclusion
The opioid epidemic started a re-appraisal of Medicaid's inmate exclusion. The inmate exclusion causes interruptions in care for people with SUD or opiate use disorder (OUD) cycling in and out of jails. Treating individuals with Medication-Assisted Treatment (MAT) while incarcerated could have promising impact on health and recidivism, as the studies from Washington State have indicated. Many sheriffs and wardens are in favor of allowing Medicaid coverage to be used within jails and prisons, as a way to insure that there are the resource available to provide treatment.
There have been proposals to modify or abolish the inmate exclusion. Two different bills have been introduced in congress that in various ways end the inmate exclusion. United States Senator Jeff Merkley (D-OR) introduced a bill that would preserve Medicaid benefits for an inmate who is in jail awaiting trial. United States Representative Annie Kuster (D-NH) and United States Senator Cory Booker (NJ-D) have introduced a bill to eliminate the inmate exclusion. Others have argued that it might be more prudent to go through a waiver process to modify the inmate exclusion in order to understand the implications and complexities of Medicaid coverage within corrections.
Medicaid Administrative Claiming
Another source of Medicaid reimbursement available to jurisdictions that could impact health care delivery to the justice involved population is Medicaid Administrative Claiming (MAC). 96 percent of Medicaid expenditures cover traditional direct services; the other 4 percent, however, cover non-service functions including funding matches to states and localities for administrative expenses related to Medicaid. There is also targeted case management (TCM) which is an optional Medicaid service. It is different from MAC as it covers a whole range of case management services including social, educational and other services such as vocational training or housing.