Health coverage for ex-prisoners: a quiet but important benefit of health reform

"If I'm trying to sell health reform, the smiling waitress with two kids, the laid-off steel worker, and the 7th grader with cancer work better on the campaign posters. Yet for many reasons � some obvious, some not � the health and well-being of ex-prisoners has a disproportionate impact on us all." - Harold Pollack

I began my public health career on a Yale postdoctoral fellowship. One of my formative experiences there was to accompany colleagues on the Community Health Care Van, a needle exchange-based mobile clinic for street drug users. I helped people complete basic paperwork.

A weathered middle-aged guy stepped onto the van. When I asked what brought him there, he pulled back his shirt to reveal a chalky-white oozing crater in his shoulder. That festering infection was my rude introduction to the life realities of injection drug users.

Most of these women and men suffered greatly. Most were uninsured. Facing complex illnesses, addiction, and severe life challenges, many nonetheless consumed enormous health system resources as they cycled through correctional facilities, became emergency department frequent-fliers, and required heavy use of other safety-net services.

We demonstrated that Community Health Care Van services reduced patients' emergency department use. We could have done more for these patients and their loved ones if we could have provided reliable primary care, appropriate drug treatment, and other services requiring insurance coverage.

This won't matter politically, but the Affordable Care Act will quietly improve public health by expanding coverage for hundreds of thousands of ex-prisoners and others under the control of the criminal justice system. Most of these men and women are on parole or probation. A nice Health Affairs paper by Alison Evans Cuellar and Jehanzeb Cheema runs the numbers. Roughly half of the 700,000 people released every year from correctional institutions will gain coverage or improved care under health reform.

Why we should care about ex-cons

Yeah I know. Ex-prisoners aren't the most cute and cuddly people who need insurance coverage. If I'm trying to sell health reform, the smiling waitress with two kids, the laid-off steel worker, and the 7th grader with cancer work better on the campaign posters. Yet for many reasons � some obvious, some not � the health and well-being of ex-prisoners has a disproportionate impact on us all.

For one thing, a large percentage of Americans with HIV/AIDS, tuberculosis, hepatitis C, and other infectious diseases pass through the gates of our jails and prisons every year. Engaging these men and women into care � and keeping them safe and healthy � yields huge public health benefits.

Many ex-prisoners suffer from severe mental illness. As states and localities implement punishing cuts to the medical safety net, frightening numbers of people have limited access to appropriate care, sometimes with tragic results.

There's suggestive evidence that ex-prisoners with health insurance may be less likely to continue prior drug use. They are also less likely to re-offend. Many ex-prisoners have serious drug problems. Absent insurance coverage, many find themselves on long waiting lists for treatment programs. Many women with drug problems require access to reproductive health services to avoid unintended pregnancies.

Nowhere to turn

Right now, many ex-offenders are ineligible for public insurance coverage. The panhandler at the train station with a heroin problem is simply poor. He isn't a vet. He isn't a mom. Addiction and substance abuse are not qualifying conditions for federal disability programs. If he has a history of violent or drug felonies, he may be barred from important aid programs. If he was enrolled in Medicaid prior to incarceration, he might well have been automatically disenrolled upon entry to jail or prison.

The Affordable Care Act improves this situation. Most important, poor people qualify for Medicaid even if they don't match the specific categories of various assistance programs. If your income falls below 133 percent of the federal poverty line, you are eligible. This is a boon for poor people. It is also a boon for mental health and drug treatment centers, and other safety-net providers. These facilities now have a reliable source of payment for their indigent patients. Many ex-prisoners will also benefit from affordability credits and protections provided under the new state health insurance exchanges.

Much practical work remains to be done. Many prisoners serve their time in relative health. They then disappear until they get rearrested or face some crisis that requires costly care. Many offenders lead chaotic lives. Some are homeless or have no fixed address. They aren't always fastidious if they are asked to return three times to the welfare office with different forms. Enrollment and retention procedures for both Medicaid and for the new exchanges must be carefully designed in light of these realities, to ensure that ex-prisoners are actually covered.

I'll bet less than one percent of the American public has thought about this difficult � often thankless � activity on behalf of an easily despised population. It's still important to protect public health and to relieve suffering. It's another reason to support health care reform.