By Marvin Swartz, MD
The United States has the largest prison population in the world, with over 2.3 million people incarcerated. It is estimated that 8% to 20% of the prison population has a severe mental illness and persons with mental illness are three times more likely to be incarcerated, compared with the general population. One key element of successful re-entry of incarcerated persons with severe mental illness is ongoing mental health treatment after release. But how to pay for needed treatment, including sometimes expensive medications?
Almost all incarcerated persons with severe mental illness depend on Medicaid coverage or by unreimbursed charity care if uninsured. Medicaid coverage is usually be suspended after only a month in jail or prison. After 12 months of suspension, coverage can be completely terminated. According to a recent survey two-thirds of the states terminate Medicaid benefits and about one-fifth suspend benefits after 12 months. Given that the average duration of a prison sentence is over 2 years, most prison inmates have either lost or been suspended from Medicaid before they are released.
Enrollment in some form of health insurance upon release is crucial for access to effective care. Several states have initiated successful programs to expedite enrollment or re-enrollment of persons eligible for Medicaid on their release and follow up studies have shown a marked uptick in access to treatment as a result.
North Carolina has two distinct opportunities to close coverage gaps on re-entry. One is to launch a state-wide program to expedite Medicaid re-enrollment and assist previously eligible unenrolled persons to enroll in Medicaid upon leaving prison. Some North Carolina counties have made a start on this, but a state-wide program is needed. In a growing number of states case managers are deployed to reach into prisons to assist in this process.
The second major opportunity would come with Medicaid expansion. States that have expanded Medicaid to adults with incomes below 138 percent of the federal poverty level, have created a significant opportunity to provide coverage to people after their release from jail or prison. A recent study estimated that with the implementation of health reform, up to 33.6 percent of inmates released annually could enroll in Medicaid.
The revolving door for justice-involved persons with severe mental illness is pernicious. North Carolina could make great strides in closing the revolving door by closing these coverage gaps.
[Marvin S. Swartz, M.D., is Professor in the Department of Psychiatry and Behavioral Sciences at Duke and a Faculty Member at the Wilson Center for Science and Justice at the Duke School of Law. Dr. Swartz has been extensively involved in research and policy issues related to the organization and care of mentally ill individuals at the state and national level.]