Journal of Urban Health

, Volume 95, Issue 4, pp 454–466 | Cite as

Medicaid Enrollment among Prison Inmates in a Non-expansion State: Exploring Predisposing, Enabling, and Need Factors Related to Enrollment Pre-incarceration and Post-Release

  • Catherine A. Grodensky
  • David L. RosenEmail author
  • Colleen M. Blue
  • Anna R. Miller
  • Steve Bradley-Bull
  • Wizdom A. Powell
  • Marisa E. Domino
  • Carol E. Golin
  • David A. Wohl


Prison inmates suffer from a heavy burden of physical and mental health problems and have considerable need for healthcare and coverage after prison release. The Affordable Care Act may have increased Medicaid access for some of those who need coverage in Medicaid expansion states, but inmates in non-expansion states still have high need for Medicaid coverage and face unique barriers to enrollment. We sought to explore barriers and facilitators to Medicaid enrollment among prison inmates in a non-expansion state. We conducted qualitative interviews with 20 recently hospitalized male prison inmates who had been approached by a prison social worker due to probable Medicaid eligibility, as determined by the inmates’ financial status, health, and past Medicaid enrollment. Interviews were transcribed verbatim and analyzed using a codebook with both thematic and interpretive codes. Coded interview text was then analyzed to identify predisposing, enabling, and need factors related to participants’ Medicaid enrollment prior to prison and intentions to enroll after release. Study participants’ median age, years incarcerated at the time of the interview, and projected remaining sentence length were 50, 4, and 2 years, respectively. Participants were categorized into three sub-groups based on their self-reported experience with Medicaid: (1) those who never applied for Medicaid before prison (n = 6); (2) those who unsuccessfully attempted to enroll in Medicaid before prison (n = 3); and (3) those who enrolled in Medicaid before prison (n = 11). The six participants who had never applied to Medicaid before their incarceration did not hold strong attitudes about Medicaid and mostly had little need for Medicaid due to being generally healthy or having coverage available from other sources such as the Veteran’s Administration. However, one inmate who had never applied for Medicaid struggled considerably to access mental healthcare due to lapses in employer-based health coverage and attributed his incarceration to this unmet need for treatment. Three inmates with high medical need had their Medicaid applications rejected at least once pre-incarceration, resulting in periods without health coverage that led to worsening health and financial hardship for two of them. Eleven inmates with high medical need enrolled in Medicaid without difficulty prior to their incarceration, largely due to enabling factors in the form of assistance with the application by their local Department of Social Services or Social Security Administration, their mothers, medical providers, or prison personnel during a prior incarceration. Nearly all inmates acknowledged that they would need health coverage after release from prison, and more than half reported that they would need to enroll in Medicaid to gain healthcare coverage following their release. Although more population-based assessments are necessary, our findings suggest that greater assistance with Medicaid enrollment may be a key factor so that people in the criminal justice system who qualify for Medicaid—and other social safety net programs—may gain their rightful access to these benefits. Such access may benefit not only the individuals themselves but also the communities to which they return.


Prison Healthcare Health coverage Medicaid Disability 



We thank the NC prison system administrators and inmates who made this project possible. This project was funded by the National Institutes of Health (R01 MD008979 and R21 MH099162). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The project was also supported by the University of North Carolina at Chapel Hill Center for AIDS Research (CFAR, NIH Funded program P30 AI50410) and the UNC Criminal Justice Working Group. Drs. Golin and Wohl were also supported by career development grants (K24 HD069204 and K24 DA037101, respectively).

Compliance with Ethical Standards

All study procedures were approved by the University of North Carolina at Chapel Hill’s Office of Human Research Ethics and the North Carolina Department of Public Safety’s Human Subjects Review Committee.


  1. 1.
    Mallik-Kane K, Visher CA. Health and prisoner reentry: how physical, mental, and substance abuse conditions shape the process of reintegration. Washington, DC: Urban Institute: Justice Policy Center; 2008.Google Scholar
  2. 2.
    Bandara SN, Huskamp HA, Riedel LE, McGinty EE, Webster D, Toone RE, et al. Leveraging the affordable care act to enroll justice-involved populations in Medicaid: state and local efforts. Health Affairs (Project Hope). 2015;34(12):2044–51.CrossRefGoogle Scholar
  3. 3.
    Center CoSGJ. Policy brief: opportunities for criminal justice systems to increase Medicaid enrollment, improve outcomes, and maximize state and local budget savings. New York, NY: Council of State Governments Justice Center; 2013.Google Scholar
  4. 4.
    Bainbridge AA. The affordable care act and criminal justice: intersections and implications. Washington, DC: Bureau of Justice Assistance, US Department of Justice; 2012.Google Scholar
  5. 5.
    Blair P, Griefinger R, Stone TH, Somers S. Increasing access to health insurance coverage for pre-trial detainees and individuals transitioning from correctional facilities under the Patient Protection and Affordable Care Act. Community-Oriented Correctional Health Services. 2011. (Exploring health reform and criminal justice: rethinking the connection between jails and community health).Google Scholar
  6. 6.
    Cuellar AE, Cheema J. As roughly 700,000 prisoners are released annually, about half will gain health coverage and care under federal laws. Health Affairs (Project Hope). 2012;31(5):931–8.CrossRefGoogle Scholar
  7. 7.
    Rosen DL, Grodensky CA, Holley TK. Federally-assisted healthcare coverage among male state prisoners with chronic health problems. PLoS One. 2016;11(8):e0160085.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Garfield R, Damico A. The coverage gap: uninsured poor adults in states that do not expand Medicaid. San Francisco, CA: Kaiser Family Foundation; 2017.Google Scholar
  9. 9.
    Stein JA, Andersen R, Gelberg L. Applying the Gelberg-Andersen behavioral model for vulnerable populations to health services utilization in homeless women. J Health Psychol. 2007;12(5):791–804.CrossRefPubMedGoogle Scholar
  10. 10.
    Toledo LA. Understanding Medicaid and its impact in North Carolina: a chart book. In: Center NCJCBT, ed. 2017. p. 1–27.Google Scholar
  11. 11.
    Rosen DL, et al. Implementing a prison Medicaid enrollment program for inmates with a community inpatient hospitalization. J Urban Health. 2017.Google Scholar
  12. 12.
    SocioCultural Research Consultants L. Dedoose ersion 7.0.23 web application for managing, analyzing, and presenting qualitative and mixed method research data. 2016. Accessed December 2016.
  13. 13.
    Maietta RC, Mihas P. Sort & sift, think and shift: let the data be your guide, in ResearchTalk Fall Seminar Series 2015. Chapel Hill, NC.Google Scholar
  14. 14.
    Glanz K, R.B, Viswanath KV. Health belief model. In: Health behavior and health education: theory research and practice. 4th ed. San Francisco, CA; 2008.Google Scholar
  15. 15.
    Fishbein M, Ajzen I. Predicting and changing behavior: the reasoned action approach. New York, NY: Psychology Press (Taylor & Francis); 2010.Google Scholar
  16. 16.
    Foundation KF. How might Medicaid adults with disabilities be affected by work requirements in section 1115 waiver programs? San Francisco, CA; 2018.Google Scholar
  17. 17.
    Foundation KF. Understanding the intersection of Medicaid and work. San Francisco, CA: Kaiser Family Foundation; 2018.Google Scholar
  18. 18.
    Fryling LR, Mazanec P, Rodriguez RM. Barriers to homeless persons acquiring health insurance through the Affordable Care Act. J Emerg Med. 2015;49(5):755–762.e752.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Kenney GM, Haley JM, Anderson N, Lynch V. Children eligible for Medicaid or CHIP: who remains uninsured, and why? Acad Pediatr. 2015;15(3 Suppl):S36–43.CrossRefPubMedGoogle Scholar
  20. 20.
    Wenzlow AT, Ireys HT, Mann B, Irvin C, Teich JL. Effects of a discharge planning program on Medicaid coverage of state prisoners with serious mental illness. Psychiatr Serv (Washington, DC). 2011;62(1):73–8.CrossRefGoogle Scholar
  21. 21.
    Morrissey JP, Domino ME, Cuddeback GS. Expedited Medicaid enrollment, mental health service use, and criminal recidivism among released prisoners with severe mental illness. Psychiatr Serv (Washington, DC). 2016;67(8):842–9.CrossRefGoogle Scholar
  22. 22.
    Cuddeback GS, Morrissey JP, Domino ME. Enrollment and service use patterns among persons with severe mental illness receiving expedited medicaid on release from state prisons, county jails, and psychiatric hospitals. Psychiatr Serv (Washington, DC). 2016;67(8):835–41.CrossRefGoogle Scholar
  23. 23.
    Schwartzapfel B. Out of prison, uncovered: Medicaid for ex-prisoners saves money and lives, but millions are released without it. The Marshall Report: Nonprofit Journalism about Criminal Justice. New York, NY; 2016.Google Scholar
  24. 24.
    Schwartzapfel B, Hancock J. Personal communication with author. 2017.Google Scholar

Copyright information

© The New York Academy of Medicine 2018

Authors and Affiliations

  • Catherine A. Grodensky
    • 1
  • David L. Rosen
    • 1
    Email author
  • Colleen M. Blue
    • 1
  • Anna R. Miller
    • 1
  • Steve Bradley-Bull
    • 1
  • Wizdom A. Powell
    • 1
  • Marisa E. Domino
    • 1
  • Carol E. Golin
    • 1
  • David A. Wohl
    • 1
  1. 1.University of North at Chapel Hill School of MedicineChapel HillUSA

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