In 2010, aiming to provide affordable and comprehensive healthcare to people who otherwise would not have access to essential services, the Affordable Care Act (ACA) was signed into law. But in an effort to “repeal and replace” the ACA, federal lawmakers are currently considering legislation that, if enacted, will  undercut these services, negatively affecting people with physical, behavioral, and cognitive disabilities. It will drastically cut funding that has been crucial for policymakers looking to reduce mass incarceration and increase safety for communities.

Medicaid expansion, a key provision of the ACA that extends eligibility to people at or below 138 percent of the federal poverty level ($11,490 for an individual and $23, 550 for a family of four), has been especially helpful to policymakers.  It has served as a critical tool for states and local governments to increase access to healthcare and supportive services, dramatically improving the community’s ability to assist people in need. Expansion of this program has increased access to important in-home and community-based services (such as personal care attendants and home healthcare); treatment for substance use disorders; and counseling services, among other programs and services that support reentry, prevent recidivism, and promote healthy, supportive, and safe communities.

If this aspect of the ACA is significantly altered, people who have been involved in the justice system are particularly at risk of losing key health and disability-related services. This is because evidence suggests that they are more likely to also have a disability or complex health needs:

• People with intellectual or developmental disabilities (I/DD) represent 4-to-10 percent of the prison population despite only making up 2 percent of the general population.
• Nearly 68 percent of people in jail and more than 50 percent of individuals in prison have a diagnosable substance use disorder compared to 9 percent of the general population.
• People incarcerated in state prisons are at least two to four times more likely to experience serious mental illness (such as schizophrenia, major depression, bipolar disorder, etc.) than people in the community.

Although Medicaid is either suspended or terminated for people once they are incarcerated, estimates show that at least 95 percent of all people incarcerated in state prisons—including those with intellectual and developmental disabilities, substance use disorders, and serious mental illnesses—eventually return to their communities. (While incarcerated, they receive healthcare from the correctional system.)

From rape crisis counseling to substance use treatment to coverage for basic healthcare following a period of incarceration, access to healthcare is vital to an individual’s successful life in the community after returning from a period of incarceration. The proposed cuts would almost certainly decrease the availability of these important programs, sending formerly incarcerated people back to communities with limited support, contributing to their challenges and preventing meaningful recovery upon reentry.

The proposed policy landscape for healthcare harkens back to the deinstitutionalization efforts of the late twentieth century, where states closed mental health asylums and institutions for people with developmental disabilities in large numbers in an effort to provide services to people in the community. These efforts were largely documented as failures, primarily because community-based supports were not properly resourced. Demonstratively, without these resources, states and local jurisdictions begin relying on other forms of institutionalization instead—often in the form of prisons and jails.  

Although there is sustained bipartisan support for reducing mass incarceration and improving safety outcomes, policymakers need also consider the effect  that any proposed healthcare legislation will have on people returning from prison and jail, including those who have disabilities, including behavioral health needs. By ensuring that such people have the tools they need to thrive in their own communities, among family, friends, and other supportive services, policymakers can avoid previous failures at deinstitutionalization while better ensuring inclusive, affordable, and comprehensive care for all.