What Second Chance? The Uncertain Future of Post-Prison Health Care

In the four months since President Trump signed the First Step Act, the product of a landmark bipartisan effort that many have called one of the most important justice reforms in years, about 500 individuals have been released from federal prison.

“America is a nation that believes in redemption,” the president boasted at the White House signing ceremony, as he celebrated a law that expands the “good time credits” allowing more federal inmates to apply for early release.

But for many of those returning citizens, “redemption” may prove a mixed blessing.

Thanks to White House policies that may effectively reduce access to post-incarceration health coverage immediately upon release, returning citizens aged 50 and over could face special hurdles in obtaining care.

In a pointed irony, the president’s stance on the Affordable Care Act (ACA) may stymie reentry efforts for older individuals who need medical and mental healthcare to successfully reintegrate after they leave prison, effectively undercutting this new and promising era of decarceration.

Although the Trump administration has yet to make good on its promise to repeal the ACA, many states over the past two years already have taken advantage of changes that have weakened the law—specifically the program’s incentives to expand access to Medicaid.

If more states add restrictions, advocates suggest, it may be more difficult for an influx of older, early-release inmates to receive needed medical care upon reentry.

“Are we prepared?” asked Charmaine Clarke-Shabazz, a Farmingdale State College professor, social worker and substance abuse counselor, who recently earned a doctoral degree for her research into the lived experiences of older former incarcerees.

“No we are not, definitely.”

The challenge is complicated by the health concerns of incarcerated populations. Starting at age 50, inmates in federal and state correctional facilities are categorized as “elderly.” The physical and mental toll of incarceration seems to result in prisoners aging faster by as many as 10 to 15 years.

Self-reported health conditions found in Bureau of Justice Statistics prison surveys indicate that elderly incarcerated individuals suffer from multiple chronic health conditions, including depression and other mental health disorders. Compared with people living in the community, researchers have observed chronic illnesses among the inmate population that are more commonly seen in individuals a decade or two older.

The federal First Step Act “good time” credit provision is expected to save a total of 27,126  total “bed years” of incarceration over the next two decades. That, according to the U.S. Sentencing Commission, translates to just as many inmates exiting federal correctional facilities over the next two decades, if all those eligible offenders earned and retained the maximum amount of good time credit allowed under the new First Step Act “good time” provision. 

Even before the new legislation, the need to prepare older former inmates with chronic conditions for reentry was on the federal Bureau of Prisons (BOP) radar. According to a May 2015 report from the Department of Justice Office of Inspector General (OIG), release preparation programs rarely included courses that specifically addressed the needs of aging inmates.

In response to an OIG recommendation, BOP formed a working group that identified additional resources focused on eldercare needs to include in the Release Preparation Plan for all inmates.

As states respond to calls for reform, the need for healthcare interventions for returning citizens may become more apparent to policymakers. Of the more than 600,000 inmates released from state facilities each year, roughly 10 percent depart at age 50 or older.

Some states have greater numbers.

In Illinois, for example, people aged 50 or older represented 15 percent of the 22,639 individuals exiting prisons in fiscal year 2017 into mandatory supervised release

The number of inmates in Illinois aged 50 years and older leaving the state’s two dozen facilities in 2018 came to 2,846. This was a slight drop after small, but steady increases and a high of 3,408 in 2017. However about one-third of older, justice-involved individuals have been returning to Illinois prisons within three years after release. For example, the three-year recidivism rate for those who exited in 2015 was 30 percent.

Like a majority of federal prisoners, who were incarcerated in their youth for lengthy terms imposed by mandatory minimum and three strikes laws for drug-related offenses, many exiting state facilities often return to impoverished communities without reentry programs targeted to their demographic.

Federal Share in Medicaid Drops to 90% in 2020

Currently, the federal government pays 93 percent of the total of costs for expanding Medicaid to childless adults without employer-sponsored healthcare and incomes below 138 percent of the federal poverty level. In 2019 it will provide about $62 billion in funding to pay for the additional individuals in the states that have expanded eligibility. In 2020, the federal share will drop to 90 percent.

Those opposed to expanding Medicaid say that even a 10 percent state share will increase spending dramatically.

Policy analysts at Pew Charitable Trusts have said that the costs born by the community when incarcerated individuals return to their communities are part of the notion of enrolling people into Medicaid. Under this federal-state partnership, communities can share the costs as people return, and through that coverage they can preserve care continuity and prevent uncoordinated and unnecessarily expensive cases of emergency room care.

Before ACA’s Medicaid expansion, many inmates returned to urban communities with a few weeks’ supply of their medications and no immediate options for enrolling in health coverage.

“Those who left prisons and jails were generally exiting without health insurance,” Maria Schiff, a researcher on the project team that produced the October 2017 Pew report Prison Health Care Costs and Quality.

“Many of these individuals would use emergency department care, which is what uninsured people largely do.“

The numbers of older prisoners returning to their communities may increase as individuals complete their long sentences, or begin to benefit from policy reforms such as the First Step Act and possible future state sentencing reforms encouraged by the White House.

Additionally, some states have already launched multi-year initiatives aimed at reducing the prison population. In 2015 Illinois launched an effort to reduce its prison population by 25 percent by 2025.

Compassionate Care

Growing advocacy for compassionate care for older inmates, as well as of concerns over the increasing cost of health care in prisons, means such reforms could soon be mirrored in changes to state corrections policies.

While most of the attention to re-entry has focused on getting younger inmates back into the workforce, there is relatively little research on the most effective ways of reintegrating older inmates who have been locked away for lengthy sentences and largely forgotten.

Clarke-Shabazz and other researchers say communities need sufficient policies and resources in place to help exiting prisoners navigate post-incarceration health needs which range from maintaining treatment for chronic illnesses, depression and the effects of long-term institutionalization found in older inmates and returning citizens.

To date, here has been little independent research into how health status upon reentry and access to continuity of care impacts reintegration among those who have served lengthy sentences and are returning to communities after age 50.

In a March 2018 paper, The Health of America’s Aging Prison Population, a team of researchers reviewed more than 12,000 studies on older inmates, and found only 21 with original research that offer a glimpse into their health status. Only a handful featured national data.

“We wanted to characterize the physical health, mental health, and cognitive health of older prisoners, people who were in prisons for a really long time,” said Alden Gross, an epidemiologist on a team that included mental and physical health researchers along with an attorney.

“We used 50 and older as a cut off. But the paper ended up being a critique on the quality of research that’s coming out of prisons.”

Based upon their review of literature, the researchers concluded “unhealthy lifestyles among incarcerated individuals and inadequate health care lead to earlier onset and more rapid progression of many chronic conditions that are prevalent among community-living older adults.”

But Gross, who studies cognitive aging, said none of the studies was designed to investigate this aspect of health among inmates.

“There have been one or two studies with a national representative sample, but those were back in the 1990’s,” Gross said. “So we really didn’t find a lot of good data.

“In terms of comparing younger prisoners with older prisoners, comparing older prisoners with older adults in the general population—all these different types of comparisons need to be made, and we need high quality data in order to make them.”

Even so, some previous studies of younger inmates have linked medical and mental health care access to reentry success. In a pre-ACA study of 1,100 inmates, average age 36, Health and Prisoner Reentry: How Physical, Mental and Substance Abuse Conditions Shape the Process of Reintegration, found that most returning prisoners didn’t have health insurance in the months after release and didn’t pursue care for ongoing health challenges.

“Employment outcomes might be improved if health issues were addressed early in the postrelease period so that health conditions would not deteriorate, researchers Kamala Mallik-Kane and Christy A. Visher concluded in this 2008 study.

They also found that “returning prisoners with mental health conditions experienced reentry difficulties across a range of domains: they had poorer housing and employment outcomes and reported higher levels of post-release criminal involvement.”

Study of 26 Returning Citizens in NYC

For her doctoral studies in social welfare at Stony Brook University, Clarke-Shabazz investigated the lived experiences of 26 former inmates aged 50 and older who had returned to the five boroughs of Manhattan after lengthy and multiple sentences in New York’s federal and state correctional facilities.

The timing of Clarke-Shabazz’s research coincided with efforts to expand Medicaid eligibility. New York was among three dozen states that began expanding its Medicaid enrollment to include former inmates and connect them to care after release. Policy experts say the Medicaid expansion available to former inmates marked a change in how prisons approached their role in returning the incarcerated back to communities.

“Prior to the Affordable Care Act extension there was far less state interest in connecting people to services, except for a handful of populations like those who are HIV positive,” said Schiff, of Pew Charitable Trusts.

“States that expanded at the beginning are largely still in process of trying to perfect that process for everybody and make sure the process is finished by the time the person walks out of the gate.”

Schiff said that this is an important intervention, primarily because the healthcare concerns that many people have within the first couple of weeks or months after release includes overdose from a substance abuse disorder. Moreover, Medicaid has more of a challenge trying to locate the person once he or she leaves prison, Schiff added.

In Ohio the state correctional system even began partnering with its health department to enroll soon-to-be released inmates into Medicaid as part of its pre-release planning. As of February 2017, two years after it launched, 10,000 departing inmates were able to leave one of Ohio’s 27 prisons with a Medicaid card and seek medical care upon release back into their communities.

Even as Clarke-Shabazz’s work features a small cohort and doesn’t represent a national sample, the two-hour interviews she conducted with each study participant offer a glimpse into the medical and mental health challenges of former inmates a year or more after their reentry that may reflect the lives of older justice-involved individuals returning to other urban communities after lengthy periods of incarceration.

Attributing it to the ACA, participants in Clarke-Shabazz’s study told her that they found it easy to obtain coverage to continue care they were receiving while incarcerated upon their return to their communities.

But many of the individuals she interviewed had unresolved trauma for which they weren’t receiving treatment. She found that reentry agencies focusing more on connecting returning citizens to substance abuse programs over mental health care programs. She found that lengthy periods of incarceration have left many inmates so institutionalized that they still acted like they were in prison long after release.

“You have people telling you ‘I’ve been out of prison for more than a year and I never cover when I’m sleeping, I still shower in my underwear.’ These are serious mental health issues and post-traumatic stress disorder,” Clarke-Shabazz said.

At an April 1 White House event celebrating passage of the First Step Act, there seemed to be several success stories of older returning citizens who attended the event at the president’s invitation. But Clarke-Shabazz’s research offers a more nuanced story about older former inmates and their post-release challenges.

One of her interview subjects, identified as “Wilson,” 58, had been considered a successful example of reintegration: He found employment with a state agency and secured his own apartment, which he shared with his girlfriend.

‘I Am Not Crazy’

“When he was asked if he had any mental health issues, Wilson quickly replied, ‘No, I am not crazy.’”

But, as Clarke-Shabazz reported in her 2017 dissertation, Reentry Experiences of Elderly Ex-Offenders: Wasted Lives, “He….cried frequently during his interview when talking about his experiences in prison and about his past, [and] added, ‘at one point I was contemplating suicide….I had nobody to talk to.’ “

“He was not willing to seek out professional help, even though he acknowledged he needed someone to speak with about his emotions and thoughts.”

Some of her interviewees exhibited anti-social behavior that made it obvious to onlookers that they have experienced incarceration, making reentry more difficult.

According to Clarke-Shabazz, incarceration had altered the physical behavior of her interviewees as well as how they spoke and interacted while they communicated with her. Some of her interviewees responded passively while others were overly aggressive.

“In the prison system, you don’t say too much—just answer what is asked,” she said. “If you exhibit that behavior with your parole officer, you can get in serious trouble. He’s asking you questions and you’re giving him one-word answers. You can be deemed as hiding things from them.”

Few of her interviewees received mental health counseling while they were incarcerated, and she reported that her cohort of largely African-American males were unwilling to admit to needing mental healthcare services.

Despite hinting at experiences of sexual violence, former inmates also were reluctant to admit that they experienced this violence and that they needed counseling to deal with it, Clarke-Shabazz said.

Another theme that presented itself throughout all 26 interviews, Clarke-Shabazz observed, was the feeling of despair among participants that they wasted their lives, and even that, she says requires some post-incarceration counseling.

In her dissertation, she added:

Many cried openly during interviews when discussing the lives they could have had if they choose a different path and the many years wasted in prison. They ruminated over the time lost from their children and family members. They also express guilt over the emotional stress they caused their families. The department of corrections policy of releasing inmates to shelters had many feeling undervalued, demoralized and stigmatized.

 While the data is still thin on the impact that access to medical and mental care might have on successful re-entry and reintegration for older adults, Clarke-Shabazz says policymakers need to prepare for the return of these individuals because their reentry impacts not only the formerly incarcerated themselves, but also their families and the communities to which they return.

“It is still a cost to communities in terms of the actors who have to pay for these chronic illnesses and whatever they need to receive their health,” Clarke says.

“It’s also on the family members who probably have to take care of them. Many of them can barely take care of themselves and have issues with mobility and so forth. Just imagine when you have thousands of elderly coming into a community where it’s really hard to get an assigned general practitioner.

“They can go to an emergency room but that comes at a higher cost.“

Cassie M. Chew is a 2019 Journalists in Aging fellow based in Washington, D.C.  This article was written with the support of the Gerontological Society of America, Journalists Network on Generations and the Retirement Research Foundation.