Health Insurance Trends and Access to Behavioral Healthcare Among Justice-Involved Individuals-United States, 2008-2014

Abstract

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.

Conflict of interest statement

Compliance with Ethical Standards Funders This research was funded with support from the Robert Wood Johnson Clinical Scholars Program, the University of Michigan, and Ann Arbor VA Healthcare System. Conflict of Interest All authors declare no conflicts of interest.

Figures

Figure 1.

Uninsurance rates following the dependent coverage mandate in September 2010* by age group and justice-involvement history (*2010 estimates do not include data from quarter 4)

Figure 2.

Uninsurance rates by criminal justice involvement among adults 19–64, United States, 2008–2014

Figure 3

Type of insurance among justice-involved individuals age 19–64, United States, 2013 to 2014. (*p < 0.001)

Figure 4.

Adjusted* treatment rates for behavioral health disorders by insurance status among justice-involved individuals, 2008–2014. (*Adjusted for age, race, gender, and survey wave; †p = 0.057;‡p < 0.05; §p < 0.001)