Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.
The Affordable Care Act (ACA) is anticipated to expand coverage to 44 million Americans. As John Iglehart noted in his introduction to the March issue of Health Affairs, expansion of Medicaid through the ACA will open an important door for a particularly vulnerable population – those who are cycling in and out of the criminal justice system.
Although Medicaid does not cover standard health care for inmates during incarceration, expansion of Medicaid to single and childless adults has meant that prisons and jails can start enrolling inmates (a substantial portion whom meet these criteria) so they are covered upon release.
The ACA also allows Medicaid to pay for inmates’ care for hospital stays longer than 24 hours. Such changes have important implications for a group of inmates that is not often the focus of health policy dialogue – incarcerated pregnant women.
A Particularly Vulnerable and Costly Group: Pregnant Prisoners
Nationwide, 75 percent of incarcerated women are of reproductive age, and about 6-10 percent of female prisoners are pregnant during their incarceration. Incarcerated women fare worse than incarcerated men, and their reproductive health care needs, including access to contraception and abortion services, often go unmet. Inmates who are pregnant face additional risks. Compared with similar women that are not incarcerated, pregnant inmates have more risk factors and worse birth outcomes, for both mothers and babies.
Hospitals spend more on providing maternity and newborn care than any other type of health care service, and 48 percent of all births in the United States are funded by state Medicaid programs, including those to many pregnant inmates on furlough. When pregnant inmates give birth, costs are generally paid by the county or state that administers the facility in which they are incarcerated.
In 2010, the average vaginal delivery for a Medicaid patient with no complications cost $9,131, and cesarean deliveries, which are more frequent among women with complications during pregnancy or during labor, cost about 50 percent more ($13,590). Average medical costs for the first year of a baby’s life are more than 10 times greater for those born preterm ($49,033) than for those born on time ($4,551).
Pregnant incarcerated women generally have increased rates of complicated and preterm deliveries, and the costs of these complications are not lost on corrections officials. When interviewed last year, several of Minnesota’s county jail administrators reported requesting furloughs for pregnant women prior to delivery, so that the jail did not incur the costly medical expenses associated with the birth. Evidence (and common sense) suggests that there are better ways to address these cost concerns, and the ACA now provides at least two ways that county jails can improve access and continuity of care for incarcerated pregnant women.
The Way Forward: How the ACA May Improve the Health of Pregnant Prisoners
First, fear of high hospital bills no longer ought to be an implicit decision criterion regarding furlough or release dates for pregnant prisoners. Under the ACA, expanded Medicaid coverage can now pay for inmates’ hospital stays beyond 24 hours. Typical hospital stays for labor and delivery are between 48-72 hours, so this change is likely to improve continuity of care for pregnant inmates by decreasing incentives to furlough pregnant women just before delivery to avoid incurring costs of childbirth-related care.
A cost-neutral situation for county jails with respect to the expenses of childbirth for incarcerated women will allow for greater coordination and collaboration, ensuring that prenatal records are available at the time of delivery, that known risk factors are addressed, and that hospital discharge plans can be formulated and implemented in cooperation with both health care providers and corrections professionals.
Secondly, expanded Medicaid coverage in many states will allow for greater access to insurance coverage among prisoners upon their release. As highlighted in a New York Times article this week, jails and prisons are increasingly assisting inmates with enrollment so that they have coverage when they are released, an effort that may be intended to prevent medical emergencies or functional decline associated with recidivism for prisoners with substance use disorders or other mental health conditions.
These conditions, which occur more frequently among prisoners than among the general population, also present a particular concern among reproductive-age women because of potential adverse effects during pregnancy. Pregnant inmates who are released before giving birth may benefit from being connected with Medicaid or other programs for which they may be eligible. Also, low-income incarcerated women may have greater access to family-planning and preconception care following release from jail or prison because of Medicaid expansion and enrollment efforts. Improved preconception health is a national public health goal with important implications for maternal and infant health, especially for vulnerable populations.
In addition, the ACA will facilitate more extensive training for corrections staff and connections with community agencies that are enrolling inmates, allowing for greater attention to the particular needs of reproductive-age women, pregnant women, and mothers of young children.
Given both the frequency and substantial costs of unplanned or complicated pregnancies and adverse birth outcomes among incarcerated women, county, state, and federal officials in corrections, health, and human services departments should work together to ensure access to health insurance and continuity of care for incarcerated women. Tailored investments in prenatal education, support, and high-quality maternity care in this setting can strengthen communities by improving the health of some of our nation’s most vulnerable children and families.
Funding support. The first author’s time was supported in part by the University of Minnesota’s Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Program (5K12HD055887) funded through the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD) and administered by the University of Minnesota Powell Center for Women’s Health. The second author’s time was support in part by the National Center for Advancing Translational Sciences of the National Institutes of Health (UL1TR000114).The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.