Background: A large proportion of justice-involved individuals have mental health issues and substance use disorders (SUD) that are often untreated due to high rates of uninsurance. However, roughly half of justice-involved individuals were estimated to be newly eligible for health insurance through the Affordable Care Act (ACA).
Objective: We aimed to assess health insurance trends among justice-involved individuals before and after implementation of the ACA's key provisions, the dependent coverage mandate and Medicaid expansion, and to examine the relationship between health insurance and treatment for behavioral health conditions.
Design: Repeated and pooled cross-sectional analyses of data from the National Survey on Drug Use and Health (NSDUH).
Participants: Nationally representative sample of 15,899 adults age 19-64 years between 2008 and 2014 with a history of justice involvement during the prior 12 months.
Main measures: Uninsurance rates between 2008 and 2014 are reported. Additional outcomes include adjusted treatment rates for depression, serious mental illness, and SUD by insurance status.
Key results: The dependent coverage mandate was associated with a 13.0 percentage point decline in uninsurance among justice-involved individuals age 19-25 years (p < 0.001). Following Medicaid expansion, uninsurance declined among justice involved individuals of all ages by 9.7 percentage points (p < 0.001), but remained 16.3 percentage points higher than uninsurance rates for individuals without justice involvement (p < 0.001). In pooled analyses, Medicaid, relative to uninsurance and private insurance, was associated with significantly higher treatment rates for illicit drug abuse/dependence and depression.
Conclusion: Given the high prevalence of mental illness and substance use disorders among justice-involved populations, persistently elevated rates of uninsurance and other barriers to care remain a significant public health concern. Sustained outreach is required to reduce health insurance disparities between individuals with and without justice involvement. Public insurance appears to be associated with higher treatment rates, relative to uninsurance and private insurance, among justice-involved individuals.
Keywords: criminal justice; health policy; healthcare reform; vulnerable populations.