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

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.

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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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