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Maryland officials signing up ex-offenders for Medicaid

As Congress threatens to upend the Affordable Care Act, Maryland is stepping up its efforts to add people leaving state prisons and jails to the government health insurance rolls.

Officials are working to enroll former inmates in Medicaid, the state-federal health insurance plan for the poor. The state Department of Public Safety and Correctional Services, which runs prisons in Maryland and Baltimore City's jail system, is signing up about 150 people a month.

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And come July, officials can move even more quickly. Maryland has the federal government's permission to assume that everyone in the state correctional system is eligible for Medicaid and enroll them at the time they are released.

These ex-offenders have disproportionately high rates of addiction and chronic disease, but typically have had no means to get treatment.

"We really wanted to think about a way to create a safety net backstop for people leaving the correctional system," said Shannon McMahon, deputy secretary for health care financing at the Maryland Department of Health and Mental Hygiene.

Maryland joins a small number of states taking more aggressive steps to boost health insurance for ex-offenders and is the only state to offer everyone so-called presumptive eligibility. The coverage, initially used to ensure pregnant women could access hospital care, is instant and lasts for a couple of months. Health care providers can then help patients pursue continuing enrollment.

Observers and advocates say the move, allowed under the federal law also called Obamacare, could lead to healthier communities and reduced recidivism, particularly among ex-offenders who seek addiction treatment.

State officials won't say what they would do if the federal law is repealed after this year, as President Donald Trump and congressional leaders have said they plan to do.

"The Affordable Care Act is the law of the land, and until that changes we're business as usual," McMahon said.

She said Maryland's spiking rate of overdoses from opioids, including prescription painkillers and heroin, spurred health officials to seek federal approval to offer the blanket Medicaid eligibility.

The system has already added about 260,000 Marylanders to the Medicaid rolls under the federal health law, increasing the program enrollment to more than 1.2 million.

More people in correctional facilities, specifically childless men, have qualified for Medicaid since passage of the federal health law, yet no state has been particularly good at enrolling them, according to Steve Rosenberg, president of Community Oriented Correctional Health Services, an advocacy group for those leaving correctional systems.

Correctional officials have been working with the state Motor Vehicle Administration and federal Social Security Administration to get more offenders official identification, which has been one of many barriers to enrollment, said Gerard Shields, a corrections spokesman.

On an annual basis, enrollment amounts to about 10 percent of the 5,000 or so sentenced inmates leaving the state system and the 5,000 pretrial detainees leaving the jail system. A recent study in California found about two-thirds of people leaving that state's system qualified for Medicaid.

The enrollment efforts come as the GOP-lead Congress is working to repeal and replace Obamacare, including the Medicaid expansion. A major concern for conservatives is the costs.

The federal government now pays the bulk of the $2.6 billion in Medicaid expansion costs in Maryland, while the state and federal governments evenly split the remainder of the $10.2 billion budget. A new state legislative analysis found that repeal of the health law would cost Maryland about $2 billion in the next fiscal year in Medicaid funding.

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The Hogan administration hasn't said whether there are contingency plans to make up the funding or other money lost if the health law is repealed. But McMahon noted that the Republican governor, who inherited the Medicaid expansion from the previous Democratic administration, has generally been seeking ways to get more people treatment as opioid overdoses have lead to record fatalities.

The health department also won federal approval to use Medicaid money to pay for residential drug treatment, which had been banned.

For now, the administration will continue with plans to launch the correctional program in July.

Health and corrections officials say the ex-offender population is most vulnerable to overdose right after release, though little addiction treatment is offered in jails and prisons.

Surveys show nationally, and locally, 60 percent to 80 percent of those booked into jails have a drug or alcohol use problem. Many also have mental health issues and chronic health conditions such as HIV or hepatitis.

Rosenberg said arrests also are often connected to substance abuse, and many cycle in and out of jail. Just 4 percent of those arrested nationally end up convicted and sent to prison.

"We are arresting a lot of people for symptoms of behavioral health issues," Rosenberg said. "It's costly. Now we can say, 'Hey we've seen you four times in the last several months but you're eligible for Medicaid and treatment, do you want to go?'"

Not even Rosenberg, however, thinks all those offered Medicaid will take it even if the paperwork problems are eliminated. Some ex-offenders are culturally unaccustomed to the health care system, and others may fear that enrolling in insurance would connect them to past debts, such as child support payments.

Kamala Mallik-Kane, a researcher in the Urban Institute's Justice Policy Center, said only about 10 percent enter jail with insurance, usually if they have a disability. A small number qualify through Medicare, insurance for seniors, or through the Veterans Administration.

Enrolling people in Medicaid has been particularly difficult in jails, where short stays stymied efforts to complete applications. Under a pilot program in Connecticut, however, officials worked with the Medicaid program to aggressively enroll pretrial detainees. They found that many did see doctors, fill prescriptions and obtain behavioral health care within one month of release.

Several studies have shown that better health reduces recidivism, she said, meaning Maryland's push to cover more people from the correctional system could save money and improve community health.

"Substance abuse relapse and poor health can often lead to incarceration," she said. "Health care can disrupt the trajectory."

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