One-Third of People Involved With the Justice System Still Lack Health Insurance

About half of people involved with the justice system are newly eligible for health insurance through the Affordable Care Act. While coverage is rising, one-third still lack insurance.

Past research suggests that 70% of people involved with the justice system have a substance use disorder or a mental health issue, and are often untreated because of high rates of uninsurance in this group.

However, about half of people involved with the justice system are newly eligible for health insurance through the Affordable Care Act (ACA), and researchers at the University of Michigan Medical School and Institute for Healthcare Policy and Innovation report that health coverage for those recently involved with the justice system is rising. This is a notable shift that could signal future improvements in coverage for mental health and substance use disorders among the millions of people who struggle with these issues when they are released from prison.

The study, published in Journal of General Internal Medicine, found that 1 in 3 people with recent justice system involvement still lack health insurance, and those with private insurance lag in addiction treatment. Researchers led by Tyler N.A. Winkelman, MD, MSc, analyzed national data from 15,899 adults ages 19 to 65 who were on probation or parole or under arrest during the prior year (study period, 2008-2014). These individuals were compared with more than 218,000 adults who had no involvement with the justice system during the same time period.

The data show that during the first years after the ACA was enacted, the rate of health insurance coverage rose significantly among people who in the past year had been arrested or were on probation or parole. The study found that people who were recently involved with the justice system and who had private insurance or Medicaid were more likely to get treatment of serious mental illness or alcohol use disorders. Those who had Medicaid coverage were also more likely to obtain treatment for depression or illegal drug use.

Although the portion of justice-involved individuals who had insurance increased over time, people involved with the justice system still lagged behind adults who were not involved with the justice system with respect to getting health insurance coverage.

The investigators concluded that the provision of the ACA that mandates insurers to cover young adults on their parents’ plans had a larger effect on people involved with the justice system than on other adults under age 26.

“We were surprised by the magnitude of the effect—a 13 percentage point drop—which suggests that private health insurance reform can be an important tool to increase coverage in this group,” Winkelman said in a statement. The late teens and early twenties are peak years for the onset of mental health and substance use disorders, the researchers noted. They found that Medicaid expansion and the new private insurance exchanges also significantly reduced uninsurance for the justice-involved population.

A surprising finding, according to Winkelman, was that privately insured people with justice involvement received treatment for illicit drug use or depression less often than people with Medicaid. This may be due to Medicaid’s care-coordination services and relatively robust infrastructure for mental health and substance use treatment, he said.

New efforts to enroll people in health coverage during prison stays have been introduced in some states but not all states facilitate health insurance enrollment prior to release. Under law, people now in prison may not receive routine care paid for by Medicaid or Medicare, but they can receive coverage by those programs for hospital stays over 24 hours.