A connection between the nation’s highest incarceration and refusal to expand Medicaid? (Capitol Update)

Steve Lewis served as Speaker of the Oklahoma House of Representatives from 1989-1991. He currently practices law in Tulsa and represents clients at the Capitol.

The latest state-by-state comparison for incarceration rates drew headlines in Oklahoma because we are now number one in incarceration. Rounding out the top ten after Oklahoma are Louisiana, Mississippi, Georgia, Alabama, Arkansas, Texas, Arizona, Kentucky and Missouri. A quick view at the list suggested the question of whether there is a correlation between incarceration rates and Medicaid expansion, so I decided to look.

I found that six of the ten highest incarcerating states have refused to expand Medicaid coverage: Oklahoma, Mississippi, Georgia, Alabama, Texas and Missouri. Louisiana adopted a “demonstration” version of expansion like the Arkansas plan, effective July 1, 2016. Since then it has dropped from Number one to Number two. Arkansas, on March 4, 2014 adopted its private option version of Medicaid expansion. Arizona adopted a private option version of Medicaid expansion but 42 percent of the state’s 773,000 uninsured are eligible but not enrolled in Medicaid due to certain barriers; Kentucky had one of the more successful transitions to Medicaid expansion although it recently changed to a private option plan.

So, six of the ten states highest in incarceration have not adopted Medicaid expansion. Three of the other four states have a private option version of expansion, which suggests something less than full-throated support. Kentucky has now gone that route. So, what does this prove? Health care and criminal justice are both complex topics, so it’s dangerous to draw conclusions without a lot more research than I’m capable of. Certainly, there are reasons beyond failure to expand Medicaid that will explain the high incarceration rates in these states. Kentucky, for example is one of only six states that, like Oklahoma, still has jury sentencing in criminal cases.

Medicaid expansion makes substance use disorder and mental health treatment available to thousands of people — namely women without children and men —  who do not otherwise have a way to get treatment. Everyone, regardless of political stripe these days says a major driver of the incarceration rates is lack of available treatment. Governor Fallin and legislators have wrangled for four or five years with “criminal justice reform” and struggled to find money to provide treatment. I would argue that common sense says the correlation between lack of treatment and incarceration is significant. One answer for the problem seems obvious: accept our own federal treatment dollars that are available under Medicaid expansion. It’s a shame that stubbornness by some and political fear by others keeps an acknowledged solution from being available to those who become incarcerated — and to their families and their victims.

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Steve Lewis served as Speaker of the Oklahoma House of Representatives from 1989-1990. He currently practices law in Tulsa and represents clients at the Capitol.

3 thoughts on “A connection between the nation’s highest incarceration and refusal to expand Medicaid? (Capitol Update)

  1. https://www.brookings.edu/blog/up-front/2018/01/03/new-evidence-that-access-to-health-care-reduces-crime/

    “Another barrier to treatment access is cost: many people who need treatment don’t have health insurance, and so the care they need — even when available nearby — is unaffordable. (And without paying customers, it’s tough for treatment facilities to stay open.) Heifei Wen, Jason Hockenberry, and Janet Cummings looked at the effects of increasing treatment access via state Medicaid expansions. Between 2001 and 2008, several states expanded Medicaid access to low-income adults without children (the population most at risk for criminal activity) via
    so-called HIFA waivers.

    “The authors found that when Medicaid expanded, both violent and property crime rates fell. The authors argue that the effect is driven primarily by increasing access to substance abuse treatment: they find that Medicaid expansions increased the number of people receiving such treatment by 20 percent. It’s possible that Medicaid expansions affect criminal behavior through other channels as well — for instance, it also increases access to mental health care and reduces financial instability. But assuming that substance abuse treatment was the main driver of effects on crime in this setting, the authors estimate that a ten percent increase in such treatment (at an annual cost of $1.6 billion) yielded an annual benefit of $2.9 to 5.1 billion in avoided crime. That’s a big return on investment.

    “A new paper by Jacob Vogler considers the effects of Medicaid expansions in more recent years (through 2015), due to the Affordable Care Act. He emphasizes the benefits of access to health insurance for low-income adults as a package: that is, he does not try to tease apart whether effects are due to access to substance abuse treatment or something else. Indeed, since substance abuse and mental health problems are often intertwined, it seems reasonable to assume that treatment for one is effectively treatment for both, and reducing stress and financial pressures associated with healthcare costs surely matters too. At the same time, increasing access to health care including prescription drugs might help fuel addiction (particularly opioid addiction), and this could increase crime as a result. This appears unlikely, but it could counteract some of the crime-reduction benefits; the net effect is what matters, and this is what Vogler looks at.

    “He finds that Medicaid expansions have reduced violent crime by 5.8 percent and property crime by 3 percent. As one might expect, effects were larger in places that had higher pre-expansion uninsured rates among individuals subsequently eligible for Medicaid (that is, where more people were affected by the policy change). Vogler estimates that the ACA’s Medicaid expansions resulted in cost savings of $13.6 billion due to the reduction in crime.”

  2. This article is irresponsible. At the very least, this is just an opinion couched inappropriately in statistical vernacular. A correlation is a statistical tool and significant findings cannot be determined without a statistical test. Also, the full-throated phrase in paragraph 3 should be full throttled.

  3. I agree that the threats to Medicaid are driving incarceration rates and that seems so baffling until one considers who relies on Medicaid the most…and that is NOT individuals and families in need, but (I say) instead the well heeled mental hospitals which seem hell bent on keeping their beds bursting full and the Medicaid funds dangerously strained. When something needful is running out there is always a mad scramble for the dregs. So many of these inmates are broke or near broke that they have this insurance which seems to be so often shunned at the regular therapists offices…so as a result people often can’t get the ongoing psychological support they need. Then many avoidable crises are not avoided and then patients will sometimes completely by accident stumble upon one of these lockup places and then get locked up, just for the “crime” of showing up unaware of their true mission, which is to lock people in, through fair means or foul… to cash in on Medicaid. I know this sounds unbelievable and I would be surprised to hear a story like this too, until it happened to me. I thought the place was just another outpatient clinic and I got next to no information on the phone when I was looking for a therapist and the next thing I knew was I was being locked into one of these places based on my lack of informed consent and basic information. Call me a liar and I will prove I am telling the truth. So I developed a theory after all that trauma and illegality imposed on me: That these places exist, as do the now dwindling outpatient clinics/therapists for the poor…as just another branch of the POLICE DEPARTMENT, in that the more people who are siphoned off into this brutal medical mismanagement racket, the easier it is for the POLICE DEPARTMENT who should not be handling emotional distress cases when there is no criminality involved…to make things easier for themselves. Any educated person knows that when you can get some basic kindness and support when in emotional trouble, then things will never escalate to make it look like the troubled person would ever want to “hurt” anyone, but at the nuthouse they are OBSESSED with trying to make people look dangerous to others, I guess in order to reinforce the idea that they should be locked up in the first place, when the real reason is to MILK THE MEDICAID unto oblivion if necessary. Guaranteed-income jobs are so wonderful aren’t they??? So the police department likes the idea of mental hospitals and the clinics probably love it, because they won’t have to work for less than they want to charge patients per hour. And the general public seems to love them because after all if so many people are locked up that makes for a safer and saner community at large, where if only the poor are suffering then who has to care? Then of course if a person is unable to fight for the right to prove they are not dangerous then they will be arrested and so that is driving incarceration rates in the real lockup. I would bet my life that rates of incarceration are rising steeply in both places and they probably both parallel each other closely. The less poor in the nuthouse and the more poor in the joint. I mean the prisons can’t cash in on the Medicaid but they can get full time workers for next to nothing and what political official in this backward state would ever find that morally reprehensible and dangerous for the community and general economy? Does anyone ever consider how that will and does destroy all the values Americans once held dear? What will happen to these people who shouldn’t be there in the first place, when and if they are sprung? In the nuthouse they are only interested in your not coming back, regardless if that has anything to do with what was/is hurting you, so what will happen is that once sprung, things will easily revert back to baseline and the statewide Medicaid funds are that much less adequate, and there is more blaming the poor for all this and more reactionism against meaningful and fair medical coverage for anyone who can’t afford it personally. Never mind more general conviction that people who get locked up in either place must have deserved it after assuming that operating procedures are legitimate because we are taught everywhere to simply believe that vicious lie. IT IS A VICIOUS LIE. After it happened to me I managed to get the chief OK MEDICAID FRAUD investigator on the phone and he told me bluntly that he didn’t care if there was official Medicaid fraud run by these oppressive institutions (the OK nuthouses). So if that guy didn’t care who else world? It is obviously way more lucrative in OK to run these free-labor workhouses to make up for the lack of a true economy here, and way more convenient to lock up people in the “thought-change” institutions, regardless of their drain on Medicaid, if people can be brainwashed that the ghastly structural inequality and resulting oppression and unemployment and underemployment and lack of real community and progressivism in OK…is the fault of the people suffering the fallout. Not true. This picture will always emerge in mercenary monopolistic undemocratic states like OK. The rich love it so it stays like this.

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