Medicaid expansion may reduce deaths among formerly incarcerated, but racial inequities persist
November 21, 2024
Expanding Medicaid coverage could lead to fewer deaths among those who were formerly incarcerated, but new findings from a JAMA Network Open study show significant racialized inequities in this reduction.
The study, led by researchers at the UNC Gillings School of Global Public Health, compared mortality data from formerly incarcerated populations in Rhode Island, a state that adopted Medicaid expansion in 2014, and North Carolina, which adopted it in 2023. Results show that expanding access to Medicaid for people who were formerly incarcerated was associated with lower mortality due to drug overdoses, homicides and deaths from all causes. But those reductions were mostly experienced by white people than in all other racially minoritized groups combined, and Black people experienced no mortality reductions in the health results examined by the researchers.
The reduction in all-cause deaths among white people was three times higher than those in Black, Hispanic, Native American, and Asian American and Pacific Islander groups combined and six times higher than Black people alone.
Dr. Shabbar Ranapurwala
“We had hoped that Medicaid expansion would actually reduce health inequities, but the finding that the all-cause mortality among Black formerly incarcerated people did not change at all was really surprising,” said Shabbar Ranapurwala, PhD, the study’s senior author and associate professor of epidemiology at the Gillings School. “Medicaid expansion helps people – that is clear – but our study suggests that Medicaid expansion doesn’t reach everyone, and that’s a big barrier in reducing health inequities.”
Pasangi Perera
“Another surprise was that Medicaid expansion did not produce a change in suicide mortality, even though we expected that access to health care would increase mental health care access and therefore prevent suicide deaths,” added Pasangi Perera, MS, the study’s first author and doctoral student at the Gillings School.
Public health experts have hypothesized that expansion of Medicaid coverage, a provision of the Affordable Care Act (ACA) first enacted in 2014, could reduce deaths among people who were formerly incarcerated by increasing access to medications for opioid use disorder, health care and mental health care. Because Medicaid expansion is a voluntary process based on state decisions, statewide adoption has occurred at different times across the United States. Some, like R.I. expanded Medicaid immediately, while others, like N.C., expanded last year. According to the U.S. Government Accountability Office, expansion of Medicaid under the ACA made health care available to 80-90% of people who were formerly incarcerated who might have been previously ineligible in those states.
This new study is the first to examine the association between Medicaid expansion and mortality in these vulnerable populations, who have historically faced racialized health inequities, stigma, and lack of access to housing, employment and health care – all of which increase the risk of poorer health quality and death.
“While R.I. is a much smaller state than N.C. and the general population makeup is different than N.C., the age and sex distribution of formerly incarcerated people in R.I. is almost identical to that in N.C.,” Perera explained. “Similarly, almost half of all incarcerated individuals in both states are racially minoritized people. The main difference is that in N.C., the incarcerated racially minoritized people are mostly Black, and in R.I. they are mostly Hispanic. But race is a social construct, not biologic, and when looking at biologic factors, such as age and sex, the two populations are very comparable.”
“When we planned the study, there were very few groups in the country who had as good data access as we did in N.C., and RI was the best among them,” said Ranapurwala. “We did reach out to other states like Kentucky and Arkansas that have similar general populations like N.C., but there were limitations to data access and linkage in both of those states.”
The research team used data on formerly incarcerated populations (ages 18 and older) from the departments of corrections in R.I. and N.C., collected between 2009-2018, and linked them to state death certificate data collected between 2009-2019. They used a method called controlled interrupted time series analysis to assess the impact of the Medicaid expansion intervention in 2014 on mortality among these populations in R.I. The team measured mortality, or death, due to all causes, opioid overdose, overdoses involving multiple substances, suicides and homicides. They also measured re-incarceration separately in the study.
They found that in R.I., there were 72 fewer deaths due to all-cause mortality per quarter after Medicaid expansion. They saw similar decreases in deaths due to drug overdose and homicide but no change in suicide-related deaths. They also saw decreases in re-incarceration rates, and all-cause mortality decreased the most among those who were re-incarcerated. People over age 30 saw the greatest reduction in mortality.
When examining the results by race, the team found that white individuals experienced the highest decrease in all areas of mortality, while Black individuals did not experience any substantial decrease. All-cause mortality among white individuals was three times higher than all other groups combined.
The findings underscore the importance of additional public health-related efforts that can address racialized inequities among formerly incarcerated populations, even within the context of Medicaid expansion and other broad health policy improvements.
“While there are limitations in this study that we detail toward the end of the manuscript, almost all of those limitations are overcome by corresponding strengths of our study,” said Perera.
“The inequitable impact of Medicaid expansion is concerning,” Ranapurwala added. “Our study shows us that the promise of Medicaid expansion in preventing harmful outcomes is being realized among the most vulnerable populations, but factors related to structural racism limit the reach of that promise of health care for all.”
Ranapurwala says the team is currently planning and developing research studies that can increase the reach of Medicaid expansion to racially minoritized individuals by using community-based strategies to increase adoption of Medicaid expansion.
This study was funded by the UNC Injury Prevention Research Center through a grant funded by the National Center for Injury Prevention and Control (R49CE003092).
Contact the UNC Gillings School of Global Public Health communications team at sphcomm@unc.edu.
