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Health Care on the Line: How the Affordable Care Act kept me out of prison

Health Care on the Line: How the Affordable Care Act kept me out of prison

Picture of Chandra Bozelko
Pictures of people helped by the Affordable Care Act occupy the seats of Democratic senators boycotting a Senate Judiciary Commi
Pictures of people helped by the Affordable Care Act occupy the seats of Democratic senators boycotting a Senate Judiciary Committee meeting on the nomination of Judge Amy Coney Barrett to the Supreme Court.
(Photo by Hannah McKay/Getty Images)

Editors’ Note: As the case against Affordable Care Act goes before the U.S. Supreme Court this week, the Center for Health Journalism is sharing a series of stories about the impacts of this transformative law.

During the confirmation hearings of Amy Coney Barrett, the newest Supreme Court Justice, Democratic senators displayed poster-size photos of people who could lose their health insurance if the Supreme Court rules the Affordable Care Act is unconstitutional in Texas v. California. 

One of those photos could have been my release mugshot, taken on March 18, 2014 as I left prison after more than six years inside. 

When I came home, I held in one hand prescriptions for four medications and, in the other, an order from the Court Support Services Division that I had to engage in “mental health treatment,” meaning psychotherapy, as a condition of my probation.

I didn’t have a job so employer-based coverage was not an option, and a market-based plan through Obamacare was out of my reach. I had only $14.00 from my job in the prison kitchen, one that had paid $1.75 a day, so I could not afford even a minimal, subsidized premium.

Even in that state of need, I was much better off than many of the approximately 600,000 people who leave correctional custody every year. I lived with my parents so I wasn’t homeless and they covered other expenses for me, like food and utilities. Many people use their meager prison earnings, if they have any, to cover all their expenses. Medication and therapy lose their priority when someone’s looking simply to survive.   

One of the key provisions of the Affordable Care Act,  Medicaid expansion — insurance for childless low-income individuals who can’t afford premiums and have little to no access to employer coverage — went into effect less than three months before I needed it. Medicaid was my only option if I wanted to remain free.

To date, 38 states and the District of Columbia have expanded Medicaid. Of the 10 states that incarcerate people at the highest rates, six have not expanded Medicaid. Two of them, Missouri and Oklahoma, plan to do so next year if the Supreme Court doesn’t get in the way and strike down the law.

A 2017 paper by a graduate student in economics at the University of Illinois found that the greater the Medicaid expansion, the greater the reduction in crime. Medicaid expansion reduced homicide, aggravated assault, robbery and car theft in statistically significant ways, saving society around $400 million.

         RELATED: Health Care on the Line: The ACA is my lifeline

         Health Care on the Line: How the ACA helped LGBT Americans heal

         Health Care on the Line: What Americans will do for health insurance

         Health Care on the Line: When will Washington listen to health care's forgotten voices?

The states that expanded Medicaid and assured that inmates going home had access to health care reported significant reductions in reoffending. In one notable example, Michigan cut recidivism rates by more than half — from 46% to 21.8% — after it made physical and mental health care more accessible through Medicaid expansion.

A nationwide survey found that when Medicaid coverage is available after release from prison, it deters both violent and public order crimes committed by people who had reoffended several times before. It’s not a small reduction either: crime among people historically likely to reoffend declined by 31% to 40%. 

The prevalence of mental illness diagnoses in correctional settings is 3 to 12 times the rate in the community. About 65% of incarcerated people have substance use disorders, although only 11% get treatment. That’s to be expected. Behavioral health issues were rarely covered before the passage of the Affordable Care Act and about 90% of people entered custody without any health insurance anyway.

Letting them leave without it is correctional malpractice. In addition to preventing crime by helping people get the care they need, Medicaid prevents unnecessary incarceration that results from poverty.

Indeed, if I hadn’t complied with the conditions of my probation to engage in psychotherapy because I couldn’t afford it, I could have been returned to custody without ever committing a crime. Approximately 95,000 people are re-incarcerated on technical violations of their parole or probation, two legal statuses that are often dependent upon receiving a certain type of mental health care. Medicaid allows people to comply with the requirements and honor their commitments. It also helped me keep my ulcerative colitis in remission and my blood pressure from climbing as I struggled to resettle myself.

Prior to the ACA, the path of returning citizens was, all too often, a cul-de-sac; it turned them right back into the problems they faced before incarceration. Access to care bends that curve so people can stay straight.  

What the Democratic senators were trying to demonstrate at Coney Barrett’s hearing but didn’t explicitly say is that the Supreme Court can use principles of equity in deciding cases. Equity isn’t just faceless, abstract concepts of fairness and justice.  Equity is about people getting what they need to survive or succeed — access to resources and assistance — based on where they are and where they’re headed. 

Supreme Court opinions have included equitable analysis in the past and the justices should do the same with respect to the ACA. The Court’s opinion on this law will have real-world consequences far beyond health care. Dismantling the ACA and its Medicaid expansion may eliminate the best way we have to reduce recidivism in this country.



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One family member has enjoyed the extended age coverage under my insurance such that there was not financial ruin. Another family member will leave prison soon. ACA may be a help, but this may have more to do with administration of ACA at the state level. It was not helpful prior to prison for many of their needs.

But Obamacare/ACA was based on a number of assumptions that have not been correct. Before we assume that new reforms will help, it is important to examine policy changes from the perspective of the Americans most behind in health access, local health care spending, and health care dollars retained locally.

About 40% of Americans are found in 2621 counties lowest in health care workforce with 75% of the rural population and 32% of the urban population. These map out as the Red Counties in the 2016 election plus the rural counties bluest of the Blue Counties with Native American, African American, and border Hispanic population majorities.

Based on economic impacts of the physicians in these counties, only about 13% of health spending goes to these counties. Every dollar taken for health insurance may only return 10 cents on the dollar. We already know that Medicaid is one of the worst plans. High deductible is poorly supportive for primary care. And the ACA plans were certainly not the best. These are the problems that have existed before, during, and after ACA.
Consider the disparities caused with many more billions forced out by mandated health insurance with few returning. Dollars, jobs, economics, and social determinants are in decline specific to these counties because of ACA. Not surprisingly the debt loads of local providers have been increasing.

There is little question that ACA has been a benefit
1. To health insurance corporations
2. To places with concentrations of workforce. Systems and larger practices can benefit from the higher payments for procedural, technical, hospital, and subspecialized care.

But consider these 2621 counties where 90% of locally available services are lowest paid generalist and general specialty services.

Hopefully you can see through to understand that the financial design is what shapes levels of workforce which are a major determinant of health access. The practices and hospitals in these counties have long been paid 15 - 30% less. This chronic inequity was not addressed and their situation was made worse by health reforms focused on micromanagement as the ultimate good.

For example the HITECH to ACA to MACRA to value based designs have forced some 30 – 50% of the practices (many cannot afford to pay for these changes) to adopt digitalization, innovation, regulation, and reorganization. These practices have had to pay about 1 billion dollars a year more out of the primary care budgets. Each year additional percentage points of the revenue generated by a physician or physician assistant or nurse practitioner have been shaved away leaving less and less to invest in the delivery team members.

These practices in the 2621 counties lowest in health care workforce had 60,000 primary care physicians in 2008. They had 38 billion as their share of primary care spending in 2008 but now have less than 30 billion to invest in primary care delivery each year due to stagnant revenue. Full consideration of the usual cost of delivery increases and regulatory costs and lost productivity would likely reveal worse. COVID will be finishing off more.

These counties need about 45% of primary care to address the complex needs of this 40% of the population but only has 25% of the primary care workforce that received 20% of primary care spending, with even less remaining to spend on primary care after ACA and other cost of delivery increases. Mental health and women's health and basic surgical services in these counties have similar 45% of demand, 40% pop, 25% workforce 20% of spending issues.

Do you see the folly of asking for more integration, coordination, outreach, consultants, or specialized team members when the practices have the most complex patients in places with the lowest levels of mental health, women's health, and social support levels?

Most of what is published or promoted in recent years has little relevance at all for the health care in these counties.

Each new innovation and regulation has been costly with impacts on budgets, productivity, revenue, burnout, and turnover. The impacts hit hardest where the financial design is worse and where practices are smaller - also specific to the populations with the most limited workforce and access.

Until the designers understand that their assumptions about health insurance as access are wrong, the abuses for tens of millions will continue.

1. The assumption that Americans most behind in health access lacked for health insurance coverage is not correct. They lack access predominantly because the financial design for their local health care has always been the worst - and was made even worse with ACA. ACA wanted to cut costs and reduce utilization. Not surprisingly this played out poorly for most Americans with their underutilization often due to insufficient local workforce and insurance policy barriers.

2. The assumption that health insurance expansion is a universal improvement even in places that lack health care workforce is incorrect. These 2621 counties lowest in health care workforce with 40.2% of the population had 40.6% of the uninsured. They have the Medicaid, Medicaid, High Deductible, and worst private insurance - the result of worst employers. Similarly they do not lack for employment any more, their employers offer lower pay and benefits including most limited health insurance

3. The assumption that health outcomes are about clinical interventions by hospitals, practices, and providers - They are not. Genetic, social determinant, relationship, situation, environment, and other determinants predominantly shape health outcomes.

The current CMS director admitted that the Innovation Center has been able to significantly influence outcomes in 5 of 54 attempts and only 3 are replicable. But she wants to do more? And she wants the practices to go at risk and put more skin in the game.

This is a primary example of leadership that fails to understand what remains of health care for most Americans – especially the Red Counties and the most tragic situations in the Bluest of the Blue rural counties.
Managed care groupthink assumptions flowed to Dartmouth Assumptions and Orsag to ACA and MACRA and now to value based designs.

As Kip Sullivan points out
1. ACA has been a mess with questionable health outcomes results
2. Pay for performance has failed to do more than impact process as the Annals of Internal Medicine evidence based review indicated
3. Primary care medical home demonstrations have failed times 3
4. MedPAC, Rand and other consultants and advisors have advised CMS of some of the problems arising from its designs to no avail
5. Poor definitions of the interventions with vague and changing metrics, measurements, and outcomes definitions all indicate policy designs “not ready for prime time.”

My studies indicate that readmission penalties hit the hospitals in these 2621 counties hardest. The top penalty in year 2 of 1 to 2% went to 14% of the hospitals in these counties compared to 9% for rural hospitals, 5% overall, and 3% for urban.

STAR Ratings of hospitals are also biased.

In fact there is little that CMS has done other than to reinforce existing discrimination by design.

The consistent themes
1. The designers do not understand the consequences of their designs
2. Our nation does not value Basic Health Access (and other areas) specific to most Americans most behind
3. The designers assume that insurance manipulations or practice or hospital manipulations can fix poor and declining outcomes – they cannot.

And the final take home:

These 2621 counties lowest in health care workforce have been growing fastest decade after decade and should become a majority of the US population by 2060. The counties highest in health care workforce with 10% of the population are stagnant (except in Texas due to Hispanic population increases). The counties with 20% higher in health care workforce concentrations have slow growth more like the 0.6% annual population growth of the nation. The middle concentration 30% of the US population and the lowest concentration counties are growing fastest.

Our health care design is creating worsening deficits of workforce, health care dollars, and health access where most Americans most need care.

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Soon after the Sept.23 Throne Speech promised universal medication coverage, the drug companies reacted with threats of abandoning Canadian research and development (R&D) if the federal government does restrain the industry’s drug prices.

R&D costs are typically cited by the profitable industry to justify its exorbitant prices and resistance to universal pharmacare coverage.

I believe that this corporate resistance is why every Canadian federal government to date has not implemented such much-needed coverage, even after promising to do so.

Not only does this make medication affordability much harder, but many low-income outpatients who cannot afford to fill their prescriptions end up back in the hospital system thus costing far more than if their generic-brand medication was covered.

Wouldn't logic say that we cannot afford to maintain such an absurdity that costs Canada billions extra annually?

(And considering it’s a potential life-and-death issue, why has our news-media not pursued it far more than it has? Or is there an over-reliance on Big Pharma advertisement revenue?)

I seriously doubt it’s coincidental that the absence of universal medication coverage also keeps the pharmaceutical industry’s profits soaring.

Without doubt, its Ottawa lobbyists—who immediately went into full gear talking our government out of implementing a universal generic-brand medication coverage plan—are very much worth their bloated salaries.


The Center for Health Journalism’s 2023 National Fellowship will provide $2,000 to $10,000 reporting grants, five months of mentoring from a veteran journalist, and a week of intensive training at USC Annenberg in Los Angeles from July 16-20. Click here for more information and the application form, due May 5.


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