Best Practices: Helping ex-inmates get Medicaid

Like inmates throughout the country, most people entering the Louisville Metro Jail lack health insurance and many suffer from long-untreated chronic conditions.

At least partly as a result, some people, particularly those with serious mental illness and drug or alcohol addiction, keep getting re-arrested and returning to jail, increasing costs to taxpayers.

Louisville Metro Corrections Director Mark Bolton saw an opportunity when Kentucky expanded Medicaid in 2014 to cover low-income adults. With support from Mayor Greg Fischer, Bolton hired a full-time Medicaid enrollment staffer in December 2014 to sign up people during the jail intake process. That way, they could more readily access needed care, including behavioral care and medication-assisted addiction treatment, after release.

Then last year, Bolton launched a related program for “familiar faces”—those who are homeless, suffer from mental illness and/or addiction, and repeatedly are picked up on public nuisance-type charges. On release, they are given a backpack containing medications, basic clothing items, hygiene supplies and bus tickets, and staffers transport them to shelters or clinics. It's based on a program begun at Cook County Jail in Chicago.

Nationally, 42% of state prison inmates report both mental health and substance-abuse disorders, research shows. Other studies have found that providing good services to released inmates charged with minor crimes can reduce re-arrest and re-incarceration rates by 90%.

Nevertheless, thousands of people eligible for Medicaid are leaving jails and prisons without being signed up for coverage, increasing the chances of poor health outcomes and a return to incarceration, experts say.

Some local jails, including those in Chicago, Tucson, Ariz., and Albuquerque, have launched initiatives to increase the number of inmates who have Medicaid when they are released. But there are tough challenges, including poor coordination between local jail authorities and state Medicaid agencies, lack of funding to hire enrollment assisters, and chaotic conditions during jail intake, said Maureen McDonnell of the Chicago-based not-for-profit Treatment Alternatives for Safe Communities. In addition, there is sometimes political opposition to offering public health insurance to accused lawbreakers.

“Typically, these programs start with a motivated jail director, county commissioner or county behavioral health director who sees the writing on the wall about how many people have substance abuse and mental health conditions,” said McDonnell, who advises jail officials around the country in starting Medicaid enrollment programs. “The current national focus on mental health and substance abuse is helping a lot.”

At the Louisville Metro Jail, Medicaid connector Janeane Louden sits in the booking area and starts a Medicaid application for everyone in the line who does not have health insurance. In addition, she solicits referrals from staffers in other parts of the jail system and visits secure parts of the facility herself to talk to inmates and fill out applications. “You have to be willing to go beyond your four walls and think of different ways to reach out and enroll people,” she said.

Signing up inmates isn't enough, because many have never had insurance and don't understand its value or how to use the healthcare system. “Young people say, 'I don't need insurance,' ” she said. “I tell them about the importance of checking up on high blood pressure and diabetes.”

Bolton said his jail still has a long way to go in boosting the number of inmates signed up for Medicaid and connecting them with services. The program has enrolled only about 2,000 of the 30,000 people admitted to the jail over the past year. Part of the problem is that some people are admitted while in the midst of full-blown psychotic episodes and aren't able to communicate effectively.

Because of the jail's work, “More people have Medicaid when they leave jail, and that opens the door to a range of services that are tough to fund and provide unless someone has Medicaid,” said Anthony Zipple, CEO of Seven County Services, a major provider of behavioral and addiction services in Louisville.

But the jail's enrollment program will face a fresh complication if Kentucky's new Republican governor, Matt Bevin, shuts down Kynect—the state-run insurance exchange through which Medicaid sign-ups are processed—and shifts to the federal exchange. “Any time you do a system transition, it creates some level of disruption, and you have to work really hard to make sure it doesn't interfere with people's access to treatment,” Zipple said.

This matters to thousands of people leaving the Louisville Metro Jail. In a video produced by Kynect, an inmate explained how signing up for Medicaid has helped him. “All my medical issues stem from abusing drugs for 20 years,” he said. “I have bad teeth. Now that I have (Medicaid), they'll start the process of rebuilding what I destroyed over the years.”