A Cycle of Punishment: Health Care Disparities in the Justice System

By Marianella Herrera

What you can do:

  1. Reach out to your representative about repealing the Medicaid Inmate Exclusion Policy. Find your representative here: https://www.house.gov/representatives/find-your-representative
  2. Visit the Prison Policy Initiative to read more about the health crisis across the United States at https://www.prisonpolicy.org/health.html
  3. Donate to local transition programs that help formerly incarcerated individuals bridge the coverage gap created during their time in prison.

The punitive nature of the American criminal justice system has elicited much debate into just what exactly constitutes enough punishment for an individual to have paid their supposed dues to society. After all, the very basis of the system, however morally backward, implies a process of otherization: making individuals who have transgressed against behavioral or social norms separate from the mainstream. Some may argue that time served within the carceral state is more than enough to satisfy this sentiment, while others may see the logic behind additional repercussions, such as disenfranchisement or the economic hardships many released individuals face due to their prior convictions. Yet, there seems to be no plausible justification for stripping an individual’s right to vote in a democracy, nor one for ostracizing workers in a laughably capitalistic nation. This trend, therefore, proves a societal inclination to favor long-lasting consequences for those who have committed crimes, with health care injustices being but one other example of this tendency.

Although guaranteed health services under the Eighth Amendment, many incarcerated individuals report poor quality of care and low access to treatment while in prison. [1] These inadequacies only serve to exacerbate the rampant mental health crisis in the justice system, as well as the increased rates of infectious diseases and substance usage compared to the general population. Furthermore, “upon reentry into society, prompt and continuous management of these conditions often falls by the wayside as individuals who have been incarcerated face challenges enrolling in health insurance coverage [and] finding a primary care physician…” [2] According to a study conducted by the Prison Policy Initiative in 2014, incarcerated individuals had a median annual income of about $19,000 prior to their incarceration, which is 41% less than their non-incarcerated counterparts. [3] This suggests that many individuals who go through the justice system are uninsured, for they fall just above the 138% federal poverty line eligibility for Medicaid and/or employer-based insurance. This is corroborated by research conducted by Kamala Mallik-Kane on the health of males returning to Chicago following time spent in state prison: “81% were without any health insurance [and] the situation remained similar 16 months after release, with 85 percent of respondents being uninsured.” [4]

How, then, does the justice system compensate for the fact that many of the individuals within it enter and leave without health care? Nearly all incarcerated individuals technically qualify for Medicaid in states that expanded the program under the Affordable Care Act, but under the Medicaid Inmate Exclusion Policy, they are ineligible. Even for enrolled individuals, 42 states, as well as the District of Columbia, suspend Medicaid benefits for incarcerated populations, rather than terminate eligibility as of 2019. [5] The policy “does not prohibit individuals from being enrolled in Medicaid while incarcerated; however, even if they are enrolled, Medicaid will not cover the cost of their care,” unless the individual is noted as an inpatient at a health care center. [6] 

This leads to an interesting cycle of burden placed upon the individual returning to society. Since Medicaid does not cover the cost of their care, and many facilities charge copays for health care services, these individuals incur outstanding fees that are paid following release, instantly generating financial debt. Furthermore, the re-enrollment process following Medicaid suspension is not as immediate as the federal government would have one believe; not only does this gap increase risk of recidivism, as well as a host of other personal health-related issues, but “family members who rely on those benefits are placed at risk due to the prolonged interruption of funding.” [7] What’s more, there is no differentiation between those being detained prior to conviction and those that have been convicted and are serving a sentence. This means that “an innocent individual who is held in jail due to their inability to pay will likely face a gap in health care coverage upon release until they are able to re-enroll.” [8] More often than not, these individuals will be low-income people of color, thus reinforcing the health disparities among such communities.

We only have to ask ourselves why such a system persists. Why are incarcerated individuals still perceived as less deserving? Why are there such glaring loopholes in health care coverage? 

To answer the former, political scientists Anne Schneider and Helen Ingram posit that “social constructions influence the policy agenda… [and] the rationales that legitimate policy choices.” [9] The incarcerated population, falling under Schneider and Ingram’s deviant category, is at the receiving end of punitive measures because the general public approves of such treatment and politicians know they will not receive any backlash for upholding law and order. It stands to reason that many people believe, as I previously mentioned, that there are consequences to breaking the law and these consequences are only limited to the imaginations of those concocting them.

To answer the latter, one only needs to examine the importance of free and available health care for all. A fictional dichotomy seems to exist between basic services and basic rights; the American public appears to believe that such basic services are only achieved through collective effort and in order to enjoy them, one must actively participate in providing the service to others as much as it is provided to them. A deeply entrenched meritocracy has formed in our society in which there are people who are deemed deserving and undeserving. American health care is at this very crossroads. Take Social Security, for example. No one seems to mind paying for the program because they know that when the time comes, they will enjoy the same benefits on someone else’s tax dollar. Medicaid, on the other hand, seems like a one-way street to some since they do not witness the utility themselves. In order to move well beyond the ostracization of incarcerated individuals and the host of injustices they face, society must realize the bubble of arrogance it has placed around itself and strive to move towards a reality where punishment is demobilized and empathy is uplifted.

Works Cited:

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661478/#bib5


[3] https://www.prisonpolicy.org/reports/income.html

[4] https://www.urban.org/sites/default/files/publication/42876/311214-Returning-Home-Illinois-Policy-Brief-Health-and-Prisoner-Reentry.PDF

[5] https://www.kff.org/medicaid/state-indicator/states-reporting-corrections-related-medicaid-enrollment-policies-in-place-for-prisons-or-jails/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

[6] https://www.kff.org/uninsured/issue-brief/health-coverage-and-care-for-the-adult-criminal-justice-involved-population/

[7] https://www.naco.org/resources/featured/naco-nsa-joint-task-force-report-addressing-federal-medicaid-inmate-exclusion-policy#:~:text=The%20Medicaid%20Inmate%20Exclusion%20Policy%20shifts%20the%20full%20cost%20of,and%20delivering%20safety%2Dnet%20services.[8] https://www.naco.org/sites/default/files/documents/Medicaid-One-Pager_3-11-20.pdf