The Affordable Care Act:
Implications for Public Safety and
Corrections Populations
Susan D. Phillips, Ph.D.
September 2012

For further information:
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This report was written by Susan D. Phillips, Ph.D., research analyst
at The Sentencing Project.
The Sentencing Project is a national non-profit organization engaged
in research and advocacy on criminal justice issues.
The work of The Sentencing Project is supported by many individual
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Wallace Global Fund
Working Assets/CREDO
Copyright @ 2012 by The Sentencing Project. Reproduction of this
document in full or in part, and in print or electronic format, only by
permission of The Sentencing Project

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

M

any people in correctional institutions have faced barriers obtaining
needed health and behavioral health care services in the community
either prior to their incarceration or upon reentry following
incarceration. One-third to three-quarters of men booked into jails in ten major cities
in 2010 were not covered by any type of health insurance. 1 This is largely because of
high rates of unemployment and narrow Medicaid eligibility criteria. Unemployment
limits access to employer-based health plans and the ability to purchase private
insurance or pay health costs out-of-pocket. Additionally, people who have been
incarcerated face enduring barriers to employment both because of legal barriers and
the stigma associated with having a felony conviction. Consequently, they also face
enduring challenges obtaining employer-based health insurance. 2, 3 Medicaid is an
alternative for some individuals, but only for those who meet income requirements
and who are also either pregnant, have dependent children, or are severely disabled. 4
The Affordable Care Act
The Affordable Care Act (ACA) signed into law by the President in 2011 potentially
can aid individuals who are at risk for incarceration and those who have been
incarcerated through provisions that allow states to expand eligibility for Medicaid.
The ACA creates new mechanisms for uninsured people to obtain coverage for
physical and behavioral health care. First, by 2014 each state must have a health
insurance exchange that will act as a regulated health insurance marketplace whereby
uninsured individuals with incomes between 133% and 400% of the federal poverty
limit can purchase coverage. Individuals will receive tax credits on a sliding scale to
offset the cost of this coverage. 5
Second, states have the option to expand Medicaid coverage to all individuals under
age 65 with incomes below 133% of the federal poverty level who are not otherwise
covered by Medicaid. 6 Additionally, prevention, early intervention, and treatment of
mental health problems and substance use disorders will be considered essential
health benefits.

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

To help states expand Medicaid coverage, the federal government will cover 100% of
expenditures for the newly eligible population from 2014 to 2016, with the amount
of federal funds decreasing yearly to 90% by 2020 and thereafter. 7 Many people at
risk for being incarcerated and many who will be released from correctional facilities
will be among those who are newly eligible for Medicaid in states that opt to expand
eligibility. 8
States are now in the process of planning and carrying out the implementation of the
ACA. Groups concerned with high rates of incarceration and, in particular, with its
accompanying racial disparities, will want to follow these decisions. What follows is a
brief introduction to the implications the ACA has for:
(1) lowering the number of people cycling through the criminal justice system
because of behaviors stemming from addictions and mental illness;
(2) lowering correctional health care expenditures through improved continuity
of care; and
(3) reducing racial disparities in incarceration related to disparities in health care
access.

HEALTH ISSUES AND CORRECTIONAL POPULATIONS
Approximately 10 million people spend time in correctional facilities at some point
each year. They are more likely than are people in the general population to have
behavioral health problems (i.e., mental health problems and addictions),
communicable diseases (e.g., tuberculosis, Hepatitis C, and HIV infection), and
chronic illnesses (e.g., diabetes, asthma, and hypertension). 9, 10 Many of these
individuals lack access to treatment for these problems outside of jails and prisons.
About half of all people in jails and prisons have mental health problems and about
65 percent meet medical criteria for alcohol or other drug abuse and addiction. 11,12
Because mental illness and substance abuse are associated with behaviors that can
lead to incarceration and recidivism, barriers to community care play an indirect role

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

in people cycling in and out of correctional facilities. At the same time, the cost of
locking up a record number of people limits the funds jurisdictions might otherwise
have available for treatment services. 13
In the case of medical problems, people enter correctional facilities with more acute
health care needs than they might otherwise because of limited access to care in the
community. Jails and prisons are constitutionally required to provide medical care to
these individuals. 14 Therefore, county and state governments – the entities that bear
fiscal responsibility for health care services for most people who are incarcerated –
are indirectly paying for deficiencies in access to community-based health care at a
time when correctional health services are one of the fastest growing areas of county
and state budgets. 15,16
Cycling In and Out of Correctional Facilities
Beginning in 2014, Medicaid will cover treatment for mental illness and substance
abuse and, in states that opt to expand Medicaid eligibility, this coverage will be
available to many people who are at risk for being incarcerated as well as people
being released from correctional facilities. 17 By covering behavioral health care, more
service providers can offer and be reimbursed for these services, resulting in more
individuals having access to treatment. This is particularly important in the case of
people at risk for criminal justice system involvement because of the high prevalence
of mental illness and substance abuse within this population and the role these
problems play in behaviors leading to arrest and recidivism.
The expansion of Medicaid means that states can essentially use federal Medicaid
funds to increase treatment services that could reduce incarceration and recidivism
and, in doing so, potentially lower associated local and state corrections expenditures.
Research shows a direct relationship between county levels of funding for drug and
alcohol services and courts sentencing people to intermediate sanctions rather than
jail or prison. 18 Other evidence suggests that drug treatment significantly reduces
criminal activity, incarceration, and recidivism. 19 Accordingly, states and local

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

governments that cover costs for jails and prisons can potentially benefit indirectly
from expanded Medicaid eligibility through fewer people entering jails and prisons
for crimes related to substance abuse and mental health problems and from
decreases in recidivism rates. Pre-release and reentry programs might also be better
able to connect people who are leaving jail or prison with community-based
intervention services.
The ACA and Correctional Health Care
The cost of correctional health care is borne by local and state governments and is
one of the fastest growing areas of county and state budgets. 20,21 Once the ACA is
implemented, local and state governments will continue to bear the costs for
correctional health care. 22 However, with more people having access to communitybased care before entering correctional facilities, jails and prisons may see a decline in
the acuity of health care problems.
Individuals will not be covered by health insurance plans purchased through
exchanges while serving time in jail or prison, but pretrial detainees who are
otherwise eligible may enroll and individuals who are already enrolled will remain
insured up until they are sentenced to incarceration. As is currently the case, federal
Medicaid funds cannot be used to pay for care for individuals while they are
incarcerated except in certain limited instances in which people are hospitalized and
temporarily not considered to be incarcerated under Medicaid rules. 23 However,
Medicaid eligibility can be suspended rather than terminated while people are serving
jail and prison sentences to avoid them having to go through the lengthy process of
reapplying when released. Also, eligible individuals who are not enrolled can apply
for Medicaid while incarcerated so that coverage for needed services is in place when
they are released.
The ACA specifically requires states to conduct targeted outreach to facilitate the
enrollment of underserved populations in Medicaid. Probation and parole agencies,
jails, and prisons are in a position to identify individuals who are newly eligible for

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

Medicaid in states that elect to expand coverage. 24 Involving these entities in
designing processes for enrolling individuals and for connecting them with
community-based care upon release is important for improving the continuity of care
between community- and corrections-based care and, in turn, maximizing the
investment local and state governments make in correctional health care.
The ACA and Incarceration Disparities
African Americans and other minority groups experience serious health problems
(e.g., heart disease, stroke, cancer) 25 and certain serious mental illnesses at higher
rates than whites. 26 These disparities arise from multiple interrelated factors, some
individual (e.g. drug use, genetics) and some societal. The societal factors include
higher rates of poverty, lower socioeconomic status, greater exposure to
environmental toxins, and stress related to discrimination. 27
In addition to having greater health care needs, members of minority groups also
experience greater disparities accessing physical and mental health treatment. This is
partly because members of minority groups are significantly less likely than are
whites to have health insurance. Although minority groups make up one-third of the
U.S. population, they are more than half of the 50 million people who were
uninsured prior to the ACA. 28, 29 , 30
As has been well documented, members of minority groups are overrepresented in
correctional populations. For example, in 2010, African American males were
incarcerated at seven times and Hispanic males at nearly three times the rate of
whites. 31
The ACA is not a panacea – it will not eradicate the societal factors that contribute
to excessive poor health among African Americans and other minorities, nor will it
eradicate other biases within the criminal justice system that contribute to disparate
rates of incarceration. It does, however, pose an opportunity to level at least one
dimension of the playing field – access to treatment for mental illness and addiction

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

– two problems that increase the likelihood of arrest and recidivism. In doing so, it
may help reduce racial/ethnic disparities in incarceration.

PROSPECTS FOR IMPROVED ACCESS TO HEALTH CARE
States are in the process of planning and carrying out the implementation of the
ACA. The extent to which the ACA will benefit individuals at risk for involvement
in the criminal justice system and correctional populations will depend on decisions
States make about:
(1) expanding Medicaid to all individuals with incomes below 133% of the
poverty level,
(2) outreach to disadvantaged groups involved in or at risk for involvement in
the criminal justice system,
(3) optimizing strategies for improving the coordination and continuity between
community- and corrections-based care, and
(4) capitalizing on coverage for mental health and substance abuse treatment to
divert people from the criminal justice system to the health care system.
For More Information
Many health care policy analysts, correctional health care organizations, and
governmental associations are tracking the implementation of the ACA, including
the evolving interpretation of its specifics by the Department of Health and Human
Services (the federal agency responsible for promulgating rules and regulations). The
following websites provide a starting point for criminal justice practitioners and
advocates who are interested in learning more about the implications of the ACA for
public safety and correctional populations:

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

•

Community Oriented Correctional Health Services
http://www.cochs.org/health_reform

•

Council of State Governments
http://reentrypolicy.org/jc_publications/faqs-implications-of-the-federallegislation-on-justice-involvedpopulations/FAQs_Federal_Health_Legislation_on_Justice_Involved_Popul
ations_REV.pdf

•

Health Care Reform GPS
www.healthreformgps.org

•

The Henry J. Kaiser Family Foundation
http://www.kff.org/healthreform

•

National Association of Counties
http://www.naco.org/programs/csd/Documents/Health%20Reform%20I
mplementation/County-Jails-HealthCare_WebVersion.pdf

•

National Commission on Correctional Health Care:
http://www.ncchc.org/pubs/CC/healthcarereform.html

•

National Institute of Corrections
http://nicic.gov/Library/024963

•

Pew Center on the States
http://www.pewstates.org/projects/stateline/headlines/medicaidexpansion-seen-covering-nearly-all-state-prisoners-85899375284

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

•

Robert Wood Johnson Foundation
http://www.rwjf.org/healthreform

•

Substance Abuse and Mental Health Services Administration
http://www.samhsa.gov/healthreform/index.aspx

•

U.S. Department of Human Services
http://www.healthcare.gov/law/resources/index.html

Office of National Drug Control Policy (2011). 2011 Annual Report: Arrestee Drug Abuse
Monitoring Program II. Washington, DC. http://www.whitehouse.gov/sites/default /files/
email files/ adam_ii_2011_annual_rpt_web_version_corrected.pdf
2 Visher, C., Debus, S. & Yahner, J. (2008). Employment after prison. A longitudinal study of
releases in three states. Urban Institute, Justice Policy Center.
http://www.urban.org/UploadedPDF/411778_employment_after_prison.pdf.U
3 Kulkarni, S.P., Bladwin, W., Lightstone, A.S., Gelberg, L. & Biamant, A.L. (2010). Is
incarceration a contributor to health disparities? Access to care of formerly incarcerated
adults. Journal of Community Health, 35, 268-274.
4 Kaiser Commission on the Uninsured (2012).Who benefits from ACA Medicaid expansion?
ttp://www.kff.org/medicaid/quicktake_aca_medicaid.cfm
5 Blair, P. & Greifinger, R. G. The health care reform law: What does it mean for jails? National
Commission on Correctional Health Care
http://www.ncchc.org/pubs/CC/healthcarereform.html
6 Urban Institute Health Policy Center (2012). Supreme Court decision on the Affordable Care
Act: What it means for Medicaid. http://www.urban.org/publications/412605.html
7 Ibid. 4
8 Substance Abuse and Mental Health Services Administration (2012). Health reform.
http://www.samhsa.gov/healthreform/healthReform.aspx
9 Maruschak, L.M. (2006). Medical problems of jail inmates (NCJ 210696). Washington, DC:
Bureau of Justice Statistics.
1

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

James, D. J. & Glaze, L.E. (2006). Mental health problems of prison and jail inmates (NCJ
213600). Washington, DC: Bureau of Justice Statistics.
11 Karberg, J. C. & James, D.J. (2005). Substance abuse, dependence, and treatment of jail
inmates (NCJ 209588). Washington, DC: Bureau of Justice Statistics.
12 The National Center on Addiction and Substance Abuse at Columbia University (2010).
Behind bars II: Substance abuse and America’s prison population. NY: Author.
http://www.casacolumbia.org/articlefiles/575-report2010behindbars2.pdf
13 Stevenson, B. (2011). Drug policy, criminal justice and mass imprisonment. Global
Commission on Drugs. http://www.globalcommissionondrugs.org/wpcontent/themes/gcdp_v1/pdf/Global_Com_Bryan_Stevenson.pdfPolicy Center
14 Estelle v. Gamble, 429 US 97 (1976).
15 Angelotti, S. & Wycoff, S. Michigan’s prison health care: Costs in context. Lansing, MI:
Senate Fiscal
Agency.http://www.senate.michigan.gov/sfa/Publications/Issues/PrisonHealthCareCosts/Pri
sonHealthCareCosts.pdf
16 Puleo, T. & Chedekel, L. (2011). Dollars and lives: The cost of prison health care. New
England Center for Investigative Reporting. http://necir-bu.org/investigations/taxpayer-watchseries/dollars-and-lives-the-cost-of-prison-health-care-2/
17 Blair, P. & Greifinger, R. G. The health care reform law: What does it mean for jails?
National Commission on Correctional Health Care
http://www.ncchc.org/pubs/CC/healthcarereform.html
18 Johnson, B. D. & DiPietro, S. M. (2012). The power of diversion: Intermediate sanctions and
sentencing disparity under presumptive guidelines. Criminology, 50, 811–850.
19 Mitchell, O., Wilson, D. B. & MacKenzie, D.L. (2007). Does incarceration-based drug
treatment reduce recidivism? A meta-analytic synthesis of the research. Journal of
Experimental Criminology, 3,353-375.
20 Ibid. 15
21 Ibid. 16
22 Ibid. 17
23 Association of State Correctional Administrators. Policy: Resolutions, regulations & legal
issues/The impact of health care reform on correctional health.
http://www.asca.net/articles/910.
24 Ibid. 23
25 Health and Human Services. A nation free of health disparities: HHS action plan to reduce
racial and ethnic health disparities.
http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
26 Miranda, J., McGuire, T.G., Williams, D.R. & Wang, P. (2008). Mental health in the context of
health disparities. American Journal of Psychiatry, 165.
27 Williams, D. R., Yu, Y., Jackson, J. S. & Anderson, N.G. (1997). Racial differences in physical
and mental health: Socio-economic status, stress and discrimination. Journal of Health
Psychology, 2, 335-351.
28 Lillie-Blanton, M. (2008). Addressing disparities in health and health care: Issues for
reform. Testimony before the House Ways and Means Committee.
http://www.kff.org/minorityhealth/upload/7780.pdf
10

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THE AFFORDABLE CARE ACT | IMPLICATIONS FOR PUBLIC SAFETY AND CORRECTIONS POPULATIONS

Hausmann, L. R., Jeong, K., Bost, J.E. & Ibrahim, S.A. (2008). Perceived discrimination in
health care and health status in a racially diverse sample. Medical Care, 46, 905-914.
30 Collins, K.S., Tenney, K. & Hughes, D. L. (2002). Quality of health care for African
Americans, The Commonwealth Fund.
http://www.commonwealthfund.org/Publications/Other/2002/Mar/Quality-of-Health-Carefor-African-Americans--A-Fact-Sheet.aspx
31 Guerino, P., Harrison, P.M. & Sabol, W. J. (2011). Prisoners in 2010. Washington, DC:
Bureau of Justice Statistics.
29

FURTHER READING AVAILABLE AT www.sentencingproject.org:
Mentally Ill Offenders in the Criminal Justice System: An Analysis and
Prescription
Reducing Racial Disparity in the Criminal Justice System: A Manual for
Practitioners and Policymakers

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