This project, Leaving Prison and Connecting with Medical Care, aimed to evaluate the impacts of two changes to Wisconsin Medicaid policy on health care access, health outcomes and reincarceration for formerly incarcerated individuals. Incarcerated populations have high rates of hepatitis C virus (HCV) and opioid use disorder (OUD), and untreated HCV and OUD lead to severe health and social consequences. Medicaid coverage could reduce adverse health outcomes and reincarceration in former prisoners by improving access to treatment. In 2014, Medicaid eligibility was extended to all poor adults, and in 2015, pre-release Medicaid enrollment assistance was introduced within state prisons, though there has been little research done to assess the effects of these changes on criminal justice-impacted individuals.
The project successfully achieved its goals, demonstrating that expanded eligibility and pre-release enrollment assistance increased the number of Medicaid applications before and enrollments at the time of release. The policies improved coverage for both the general population and those with histories of substance use, and they were associated with a 2.5 percent decline in reincarcerations and a 5.2 percent increase in employment procurement. Additionally, the changes to Medicaid policy significantly increased the likelihood of outpatient visits post-release for individuals with substance use histories, although overall substance use disorder-related care remained low.
The Challenge
Incarcerated populations have high rates of hepatitis C virus (HCV) and opioid use disorder (OUD), with the Wisconsin Department of Corrections reporting a 12.5 percent prevalence, particularly among women. Untreated HCV and OUD lead to severe health and social consequences, including increased risk of cirrhosis, liver cancer, overdose and recidivism. Medicaid coverage could reduce adverse health outcomes and reincarceration in former prisoners by improving access to treatment. Historically, most Medicaid programs did not offer coverage to low-income, non-disabled adults unless they were custodial parents, thereby excluding the majority of adults released from prison. However, in 2014 the Affordable Care Act authorized the expansion of Medicaid eligibility to all poor adults, increasing coverage for adults with criminal justice system involvement.
Prompt connection to health care is important for individuals reentering the community, especially those with HCV or OUD as they require expeditious access to continued treatment to prevent adverse outcomes. In 2015, pre-release Medicaid enrollment assistance was introduced within state prisons. While evidence suggests that these two significant changes to Wisconsin Medicaid policy have increased coverage and facilitated timely access to healthcare, there has been no research on the effect of pre-release Medicaid enrollment assistance on treatment use for OUD and HCV. This represents an evidentiary gap as policymakers consider how to promote Medicaid coverage for criminal justice system-impacted adults.
Project Goals
The primary goal of this project was to evaluate the impacts of the two changes to Wisconsin Medicaid policy on health care access, health outcomes and reincarceration for formerly incarcerated individuals. Because these policy changes provide opportunity to evaluate potential health gains attributable to the expansion of Medicaid to criminal justice system populations, the secondary goal of the project was to quantify the influence of area-level OUD and HCV treatment and prevention resources on the relationship between Medicaid and post-incarceration health care use. These goals were addressed through three specific aims:
Assess the incremental effects of expanded Medicaid eligibility and the addition of pre-release, onsite Medicaid enrollment assistance on the likelihood of Medicaid enrollment and the likelihood of reincarceration.
Identify the change in OUD and HCV treatment use, hospitalization and emergency department visits for drug overdose and mortality associated with the prison-based Medicaid enrollment program combined with expanded Medicaid eligibility, relative to expanded Medicaid eligibility alone.
Apply a novel research tool under development at the University of Wisconsin to identify the moderating roles of area-level OUD and HCV treatment and prevention resources between Medicaid and post-incarceration health care use.
Results
This project successfully achieved its goals of evaluating the impact of the changes to Wisconsin Medicaid policy and the relationship between Medicaid and post-incarceration health care use. Expanded Medicaid eligibility and pre-release enrollment assistance led to a significant increase in the likelihood individuals applied for and enrolled in Medicaid at the time of release. The policies improved Medicaid coverage equally for the general population and those with a history of substance use. Furthermore, having Medicaid coverage upon release was associated with a 2.5 percent decline in reincarceration rates at six months and a 5.2 percent increase in employment likelihood.
The presence of a prison-based Medicaid enrollment assistance program significantly increased the likelihood of outpatient visits within 30 days post-release for individuals with a history of substance use. However, the overall levels of substance use disorder-related outpatient care remained low and there was no observed reduction in hospital-based care. Factors such as sex and race were significant predictors of post-release outpatient care use, with females more likely than males and white individuals more likely than Black individuals to seek care. Overall, these results demonstrate the importance of Medicaid coverage for improving health outcomes and reducing reincarceration.
