Stacey McHoul left jail in Baltimore last summer with a history of heroin use and depression and only a few days' worth of medicine to treat them. When the pills ran out, she started thinking about hurting herself.
"Once the meds start coming out of my system, in the past, it's always caused me to relapse," she said. "I start self-medicating and trying to stop the crazy thoughts in my head."
Jail officials gave her neither prescription refills nor a Medicaid card to pay for them, she said. Within days she was back on heroin — her preferred self-medication — and sleeping in abandoned houses in Baltimore's Sandtown-Winchester neighborhood.
Thousands leave jail or prison every year without access to the coverage and care they are entitled to, jeopardizing their own health and sometimes public health. Many are mentally ill or struggle with drug abuse, others have chronic illnesses such as diabetes, high blood pressure, AIDS and hepatitis C. Most return to poor communities such as Sandtown, which erupted in violence a year ago after Freddie Gray died from spinal injuries suffered in police custody.
Advocates for ex-convicts held high hopes for the Affordable Care Act's Medicaid expansion, which promised to deliver insurance to previously excluded single adults starting in 2014, including almost everyone released from prisons and jails.
Maryland's prison agency, which three years ago said it was "well positioned" to enroll released inmates in Medicaid, is signing up under 10 percent of those who leave prisons and jails every year, according to state data. Few states that have expanded the federally supported program for low-income residents under the health law are doing any better, specialists say.
Officials of the Maryland Department of Public Safety and Correctional Services say they do the best they can with limited resources, enrolling the most severely ill in Medicaid while letting most former inmates fend for themselves.
"We are battling, every one of us," to maximize coverage, said prison medical director Dr. Sharon Baucom, pointing to efforts to train sign-up specialists, get Medicaid insurance for hospitalized inmates and share information on mentally ill inmates with social service and health care agencies.
"There are hand-offs that could be improved," she said. "With the resources that we currently have, and the process that we have in place, we could do more and we just need some more help."
Coverage under Medicaid was seen as an unprecedented chance to transform health care for ex-inmates by connecting them to treatment, reducing expensive emergency-room visits, controlling disease, and putting them on a path to rehabilitation and reintegration into society.
Up to 90 percent of those leaving prisons and jails are eligible for Medicaid in states such as Maryland that expanded Medicaid, experts say.
Some 12,000 of Maryland's 21,000 prison inmates are designated at any given time as chronically ill with serious medical conditions and behavioral problems, according to prison officials. But given limited means and requirements to connect exiting prisoners with transportation, shelter and employment, the system focuses on enrolling the very sickest, Baucom said.
"It's a shame to have to make that call," she said.
Dr. Rosalyn Stewart saw what happened to many chronically ill ex-offenders when she ran a recently completed pilot program to enroll former inmates in Medicaid and get them treatment and shelter.
"People frequently ran out of their medications and did not have access to the care they needed," said Stewart, a professor at the Johns Hopkins University School of Medicine.
Last year, McHoul, 40, spent two short stays in Baltimore's Women's Detention Center. Jail officials never told her that a hospital had enrolled her in Medicaid between her first incarceration and the second, she said.
After neither stay did she have more than two weeks' supply of any medication, including Depakote, a mood stabilizer, she said.
"It was whatever was left in the blister pack," said McHoul, who is now in a Baltimore drug treatment program. "It's like, 'Here's your supply. Sign this that we gave them to you. See you later.'"
State policy is to give exiting prisoners 30 days' worth of medicine. But a court ordered McHoul's release shortly after she was arrested the second time, which did not give the jail enough time to prepare medications, a corrections spokesman said.
From January 2014, when the Medicaid expansion took effect, through this March, Maryland released nearly 16,000 people sentenced to prison or jail, according to state data. Thousands more cycle in and out of jails each year without being convicted.
However, the corrections department said it enrolled only 1,337 released inmates in Medicaid during those 27 months. Another 1,158 prisoners joined Medicaid over that time when they were hospitalized. (Medicaid covers inmates if they spend 24 hours as hospital inpatients; most return to prison.)
Monique Wright, 35, got out of the Jessup Correctional Institution last fall and began suffering acute head and neck pain caused by scoliosis, a spinal curvature. Without Medicaid coverage or a doctor, she sought emergency care at Johns Hopkins Bayview Medical Center.
"It's the paperwork" that keeps prison officials from making sure people like her have Medicaid upon release, Wright said. "They don't want to do the paperwork. They don't have the staff to do the paperwork."
Advocates wonder why the corrections system is so poor at enrolling what is "literally a captive audience."
"They've had them housed for the past 10, 15 years," said Andre Fisher, a case manager for ex-inmates at Druid Heights Community Development Corp., a nonprofit in West Baltimore. "What's so hard about it?"
Enrolling inmates in Medicaid can take weeks, prison officials said. Sometimes the card does not arrive until after they are out. Computer problems slowed sign-ups in late 2014.
"If you do the checkoff list, we've checked off everything we can do," said Baucom, noting efforts to increase enrollment and cooperate with the Maryland Motor Vehicle Administration to get inmates state IDs, which they sometimes need to apply for Medicaid.
If it is hard for the prison system to enroll inmates, it is even harder for the individuals to enroll themselves. Those who emerge without Medicaid face a maze of applications, bus trips, phone calls and queues if they want to sign up. Many don't bother.
Lack of identification cards and other hindrances can mean weeks-long delays at a time when released prisoners are especially vulnerable.
"If you're the diabetic that hasn't been compliant with your medication, you need your medication now," said Henrietta Sampson, director of treatment coordination at Powell Recovery Center, a Baltimore addiction recovery agency that works with ex-inmates. "You can't wait two weeks because you may drop dead."
Neighborhoods are at risk when former inmates with chronic illness return.
"You really need to think about this as a public health issue," said Scott Nolen, director of drug treatment programs for the Open Society Institute — Baltimore, a nonprofit that works on criminal justice policy. "There is transmission of communicable diseases that happens in prison, in confined spaces. And now those folks are coming back into communities, and we want to make sure they get health care."
In few places is the burden greater than in Sandtown-Winchester. The Justice Policy Institute, a nonprofit, called Sandtown "ground zero for the use of incarceration" in Baltimore last year. The institute estimates that nearly one resident in 30 is in prison.
At the same time, three West Baltimore ZIP codes, including Sandtown, showed the highest rates of HIV infection in Baltimore in 2014, according to hospital data from the Maryland Health Services Cost Review Commission obtained and analyzed by Kaiser Health News and Capital News Service.
Few independent experts expect Maryland — let alone most other states — to come anywhere close to full enrollment of emerging inmates any time soon.
"It's fair to say we're just at the tip of the iceberg" in prisoner enrollment, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied the process. "Maryland is always an innovator. If Maryland is still at the cutting edge of how to do this, many areas of the country don't have any of these types of programs in place."
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation. KHN reporter Shefali Luthra and Capital News Service reporters Catherine Sheffo, Daniel Trielli, Naema Ahmed and Marissa Laliberte contributed to this article.