More local and state officials are working to ensure that low-income residents stay on Medicaid when they go to jail.
Federal law bars Medicaid recipients from accessing their full federal health benefits while incarcerated. But officials from both parties have pushed for two key changes to ensure little or no disruption of health benefits for pretrial detainees who have not been convicted of a crime and make up most of the 612,000 people held in America’s county jails.
In recent years, officials have increasingly implemented a stopgap measure to help inmates more seamlessly reactivate their Medicaid coverage upon release from jail or prison.
And a bipartisan coalition of county sheriffs, commissioners and judges are now lobbying federal lawmakers to change a long-standing policy and let pretrial detainees retain coverage while in custody.
The National Association of Counties and the National Sheriffs’ Association, which are supporting the effort, estimate that it would cost the federal government in excess of $3 billion a year.
“Just because you’ve been in jail for a short period of time, that shouldn’t automatically knock you off the [Medicaid] rolls,” David Davis, the Democratic sheriff of Bibb County, Georgia, told Stateline. “You then have to go through enrollment all over again.”
Some county officials say the policy is discriminatory, allowing people who can post bond to retain their benefits, but denying coverage to indigent individuals. They also say the policy collectively burdens local and state governments with billions of dollars in additional health care costs.
Beyond that, some officials say the denial of federal health benefits to pretrial detainees disrupts inmate medical care, a key factor that can increase their chances of landing behind bars again.
“Jail is not a hotel stay, nor is it vacation,” said Brett Clark, Republican sheriff of Hendricks County, Indiana. “But this issue is a hurdle and a barrier for folks who need to get into treatment programs.”
Concern regarding what’s known as the Medicaid Inmate Exclusion Policy — which dates to 1965 — has grown as sheriffs, jailers and wardens have seen limited budget increases for a jail population that’s one of sickest and most vulnerable in the nation.
Once someone is booked in jail, city and county governments are required to pay for the costs of their health care until that person is released. If convicted, federal or state officials typically pick up the tab for medical treatment through the remainder of the sentence. But the disruption to medical care is linked to high risks of mortality, medication lapses and recidivism.
The only time inmates can use their Medicaid benefits is when a practitioner orders a hospital admission that lasts longer than 24 hours.
In a statement, the Centers for Medicare and Medicaid Services told Stateline it encourages states to shift from terminating Medicaid enrollment for pretrial detainees — which forces people to reapply after their release — toward suspending enrollment.
The number of states that suspend enrollment, making it easier for inmates to reactivate their Medicaid benefits, has more than tripled, from 12 to more than 40, during the past six years.
In Washington, sheriffs and police chiefs now provide booking data to the state’s health authority, which allows it to reinstate Medicaid coverage to returning residents automatically.
In New York, the state health department has applied for a federal waiver to reactivate inmate Medicaid benefits 30 days before their release.
However, 1 in 6 states — including Missouri and Wisconsin — still terminate Medicaid enrollment, according to the Kaiser Family Foundation. And reapplying can take weeks or months.
Officials in those states lack the technology to make similar changes, or, in some cases, misunderstand the exclusion policy, according to the Council of State Governments Justice Center.
But officials in some of those states, including Utah and Idaho, say they’re now transitioning to suspending enrollment instead of terminating and reactivating it.
“Medicaid has never been a popular program with our state policymakers,” said Karen Crompton, director of Utah’s Salt Lake County Human Services. “Now, some local officials are pushing Congress to make changes to the Medicaid Inmate Exclusion Policy.”
The issue of jail health care, aside from addiction treatment, was largely left out of the recent federal criminal justice changes — including the First Step Act, which broadly seeks to reduce recidivism, in part by increasing access to addiction treatment.
Last fall, four Democratic senators introduced legislation to prevent pretrial detainees from losing their federal health benefits. (A companion House bill is expected in the near future.)
U.S. Sen. Sherrod Brown of Ohio, one of the sponsors, told Stateline that the measure would help counties and states further combat the opioid and mental health epidemics, while also keeping law enforcement officers safer.
At least two Republicans — U.S. Rep. Earl “Buddy” Carter of Georgia and U.S. Sen. Bill Cassidy of Louisiana — have expressed concerns about the price tag potentially attached to the bill.
But some county officials from both sides of the aisle say such financial concerns are misguided, and, in some cases, are fueled by stigma against inmates.
“The federal government is getting a break here,” said Nancy Sharpe, a Republican county commissioner in Arapahoe County, Colorado. “These people are entitled and already on the rolls. Counties are instead picking up the cost for something the federal government should be paying for.”
‘Unfair Burden on Jails’
Since the late 1970s, America’s 3,160 local jails have been required to provide “adequate” medical treatment to inmates, according to standards that emerged from the landmark ruling in Estelle v. Gamble and subsequent cases.
But the federal government doesn’t cover local jail or state prison health costs.
Greg Champagne, the Republican sheriff of Louisiana’s St. Charles Parish, said the federal policy denying pretrial detainees access to their health benefits violates their constitutional rights under the Fifth and 14th Amendments.
To understand why, the sheriff offered an example of two inmates arrested on charges of drunken driving. The one who has the money to make bail retains federal health benefits, but the second, who can’t make bail, loses those benefits.
“We shouldn’t treat someone differently because they don’t have the money for bail,” Champagne said.
A report from the National Association of Counties, which represents over 2,400 U.S. counties, notes that the Social Security Act prohibits Medicaid spending for “inmates of a public institution.”
But Blaire Bryant, an associate legislative director for the association, said the 55-year-old federal policy never distinguished between detainees who are still considered innocent and people who are convicted and sentenced to state or federal prison.
“Pretrial detainees, but for their housing status, would be still on their medical benefits,” said Bryant, who has led the group’s efforts to lobby to end the Medicaid exclusion for pretrial detainees. “And it places an unfair burden on jails.”
In a 2017 policy brief, University of Michigan researchers argued states and counties could apply for matching funds for Medicaid-covered services if the federal exclusion policy were repealed.
For decades, most states instead kicked anyone booked in jail who couldn’t post bond off their Medicaid rolls. Not only does this force pretrial detainees to use county-funded health care, which is typically more limited than their Medicaid coverage, it also disrupts care after release, Bryant said.
Local and state officials, recognizing this issue, have sought to reduce disruption upon release by suspending inmate participation in the federal health program. This bureaucratic tweak allows jails to help inmates approaching their release date to get their Medicaid reinstated faster.
Democratic Sheriff Jerry Clayton, who oversees the Washtenaw County jail in Ann Arbor, Michigan, devotes staff to help with the paperwork needed to re-enroll inmates near release.
Clark, the Hendricks County sheriff, said his staff’s effort to suspend Medicaid enrollment — and later reactivate it — can reduce the risk of recidivism and save taxpayer dollars.
Sharpe, the Arapahoe County commissioner, said current policy requires the county to spend nearly a quarter of its annual jail health care budget — $1.2 million — on pretrial detainees who lose access to Medicaid benefits.
Because Arapahoe, and not the federal government, covers this expense, inmates receive fewer services such as counseling and workforce training, Sharpe said.
Clayton in Washtenaw County budgets roughly $1 million for inmate health care each year. Of that, one-tenth is spent on pretrial detainees. But the sheriff says a single inmate booked with a serious medical condition — like someone in need of dialysis or HIV care — could potentially gobble up the full budget.
“If someone needs significant surgery, the hospital bill can be in the hundreds of thousands of dollars,” Clayton said. “We’re always one or two inmates away from blowing our budget. It’s an untenable position.”
Counties, States Urge Federal Action
Faced with growing awareness of the problem, Republican and Democratic local officials have turned to lawmakers in Washington, D.C., to change the Social Security Act to allow pretrial detainees to keep their federal health benefits.
The costs are “a burden to bear for rural and less affluent counties — areas that are predominately Republican,” U.S. Sen. Jeff Merkley of Oregon told Stateline. “The cost is a big issue, and the complexity of the administrative burden. I think both things will lead to Republican support.”
Despite the support for the bill from the county and sheriff associations, Clayton fears the lobbying effort over a potential $3.3 billion annual price tag will be a hurdle in getting the bill passed.
Helen Stone, a Republican commissioner in Chatham County, Georgia, said that she’s repeatedly lobbied the office of her U.S. congressman, Carter, the Republican who has expressed concerns about the potential price tag, but has so far been met with “reluctance.”
Carter told Stateline that county officials must collect more data to provide him and other lawmakers with a fuller understanding of the issue’s national scope.
Cole Avery, a spokesman for Cassidy, the Louisiana Republican who expressed similar concerns, told Stateline that the senator is interested in a form of the policy that could make it to the president’s desk.
For that to happen, he believes a bill with a “narrowed scope” that focuses solely on mental health and addiction would have a better chance of advancing through the Senate.
Clark, for his part, said that stigma toward inmates, and the broader indifference toward investing in jail conditions, may dampen widespread support for the federal bill. Some Americans think that a “tough on crime” attitude requires a more punitive approach to inmates, he said.
“No sheriff sees this as weak on crime,” Clark said. “We see this as smart on crime. It’s always a challenge to see the big picture.”
Without changes at the federal level, Miami-Dade County Judge Steve Leifman said, counties will find little-to-no relief for rising jail costs, which will limit their ability to improve hospitals, roads and schools.
But several local officials told Stateline that legislation is only the first phase of the fight to change this policy. If the bill hits roadblocks in Congress, the county and sheriff associations may potentially file a lawsuit to challenge the policy’s constitutionality.
“What we’re doing now doesn’t make sense,” said Michael Adkinson, Republican sheriff of Walton County, Florida, which suspends Medicaid benefits. “It’s not saving money. It’s cost-shifting.”