BY: The Exoneration Project

Insure or Imprison?

By Eva Nagao

If you are incarcerated at any point in your life, you are likely unhealthier both before, during, and after your incarceration when compared to an individual who does not experience imprisonment. Prisons are disproportionately filled with low-income[1] individuals and ethnic and racial minorities. Excluding prisoners from adequate healthcare (i.e. the Medicaid Inmate Exclusion Policy) perpetuates these racial and socioeconomic disparities. [2]

1 in every 10 black men are in jail or prison on any given day, and have a 1 in 3 chance of being imprisoned in their lifetime. For black men in our country, prison is a health crisis. [3]

A lot has been made of studies that show young black men experience reduced mortality while incarcerated, but these studies also show that while survival rates may temporarily improve due to the absence of high-risk factors (i.e. gun violence), the mental and long-term health of individuals–and their families—generally worsens. Compared with the non-incarcerated population, all prisoners have increased prevalence of infectious disease, sexually transmitted disease, chronic medical conditions, substance abuse disorders, mental health disorders, and high rates of Vitamin D deficiency.

Inmates are the only people in the United States that we are legally required to provide healthcare to[4] and yet prison health facilities are some of the only health facilities that do not adhere to federal healthcare (i.e. Medicaid) standards.[5] This is a public health problem, and an especially disconcerting one since prison health clinics provide many Americans with their first contact with healthcare workers. In fact, an estimated 40% of chronic medical conditions are diagnosed during incarceration.[6]

As the prison population ages, older inmates are even more likely to have chronic conditions. In the last two decades there was a 200% increase in the number of prisoners older than 55, and the medical care of the elderly and incarcerated is 2-3 times that of the average inmate.[7]

Patients with chronic conditions are often released without care plans or prescriptions,[8] and because former inmates are at a disproportionately high risk of mental health problems, discontinued care often leads to re-hospitalization or re-incarceration. One study found that, within the first two weeks of release from prison, former inmates are 12.7 times more likely to die, primarily from drug overdoses, heart attacks, homicides, and suicides.[9] Given that jails and prisons are acting as our nation’s mental health hospitals but lack this crucial follow-up care, it is unsurprising that nearly 70% of individuals reoffend within three years after release.[10]

Since Medicaid was passed in 1965, the number of incarcerated people in federal and state prisons has increased 700%.[11] In the same time period, the share of total income going to the top 1% of earners has more than doubled.[12] For the first time since the inception of Medicaid, poor, sick Americans are spending less money on healthcare than the wealthiest 20% of Americans.[13] Analysis suggests that U.S. life expectancy would have increased over 50% more (and that infant mortality would have fallen almost 40% more) in the decades following the passage of Medicaid if incarceration levels had stabilized in the mid-1980s.[14] It’s expensive to be poor, more expensive to be poor in poor health, and expensive for everyone to incarcerate the poor and unhealthy.

It should be no surprise that today, the wealthiest 1 percent of Americans live 10 to 15 years longer than the poorest 1 percent.[15]

Before the passage of the Affordable Care Act (“Obamacare” or the ACA) in 2014, most states restricted Medicaid eligibility to disabled people, pregnant women, poor adults with children, and poor children. 32 states[16] now extend Medicaid to individuals under 65 years of age with incomes up to 138% of the federal poverty level (around $11,770 for an individual, and $27,180 for a family of three).[17] In total, the Medicaid program serves more than 70-million low-income people, and serves as the largest payer for nursing home services in the country. Before the ACA, four-fifths of inmates were uninsured at their release, and many were unable to pay for their care.  Unfortunate as it is that inmates are excluded from Medicaid coverage while incarcerated, signing individuals up for benefits upon release has certainly saved lives.

Both the current House and Senate bills advocate the roll back of Medicaid eligibility, as well as significant cuts in federal funding that currently guarantee states can support comprehensive health care coverage to all low-income people applying for Medicaid.[18] According to the Congressional Budget Office (CBO), the proposals in both the House and Senate bills would force at least 49 million people into the ranks of the uninsured.[19] Jails and prisons across the United States have been working hard to enroll prisoners in the ACA upon their release, hoping to alleviate the healthcare crises that lead so many into their care. Healthcare that is only available to the rich impoverishes us all. We cannot roll back Medicaid, and in fact, should expand the continuum of quality care for our most vulnerable population, prisoners. The choice is simple: insure or imprison.


[1] On average, incarcerated people have a median annual income of $19,185 prior to incarceration, which is 41% less than non-incarcerated people in similar age groups. See Rabuy, B, Kopf, D. Prisons of Poverty: Uncovering the pre-incarceration incomes of the imprisoned. Prison Policy Initiative Reports 2015 available online here.

[2] Individuals in solitary confinement, approximately 100,000 people in the U.S. on any given day, of any race, gender or age do not experience reduced mortality as a consequence of incarceration. It should also be noted that besides young black men, no other group of prisoners experiences improved health outcomes while in prison. See Wildeman, C, Wang E.  Mass incarceration, public health, and widening inequality in the USA. The Lancet 2017; 389.

[3] See Nellis, A. The Color of Justice; Racial and Ethnic Disparity in State Prisons. The Sentencing Project 2016 available online here.

[4] See Estelle v. Gamble 429 U.S. 97 (1976)

[5] “In some larger American jails, abuse of mentally ill inmates is routine. Since the 1980s, virtually every correctional facility of a certain size has been under a federal consent decree to improve conditions.” See Ford, M. America’s Largest Mental Health Hospital is a Jail. The Atlantic 2015 available online here.

[6] See Bor, J, Cohen, G, and Galea, S. Population health in an era of rising income inequality: USA 1980-2015. The Lancet 2017; 389.

[7] Ibid.

[8] Even after the ACA , 19% of non-elderly adults in the U.S. who received prescriptions would not afford to fill them. See Dickman, S, Himmelstein, D, and Woolhandler, S. Inequality and the heath-care system in the USA. The Lancet 2017; 389.

[9] See Khazan, O. The Prison Health Paradox. The Atlantic 2017 available online here.

[10]  See Gaffney, A, McCormick, D. The Affordable Care Act: implications for health-care equity. The Lancet 2017; 389.

[11] See Public Safety, Public Spending: Forecasting America’s Prison Population 2007-2011. Pew Charitable Trusts 2017 available online here.

[12] “The share of incomes going to the wealthiest 10% increased from 33% of total earnings in 1978 to 50% in 2014—a level of inequality not seen since before the Great Depression.” See Winkelman, T, Young, A, and Zakerski, M. Inmates are excluded from Medicaid – here’s why it makes sense to change that. Michigan Institute for Healthcare Policy and Innovation at the University of Michigan. 2017 available online here.

[13] See Dickman, et al.

[14] See Winkelman, et al.

[15] Ibid.

[16] 19—mostly southern states with large minority populations–opted out of the ACA’s Medicaid expansion to include impoverished individuals. Studies suggest the opt-outs will lead to thousands of unnecessary deaths annually. See Gaffney, et al.

[17] “An additional 5–6 million undocumented immigrants do not have insurance because the ACA specifically excluded them from its coverage expansion.” See Dickman, et al.

[18] Sebelius, K, Pollack, R. A Health Care War on the Poor. Health Affairs Blog 2017 available online here.

[19] Ibid.