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Prison inmates suffer from a heavy burden of physical and mental health problems and have considerable need for healthcare and coverage after prison release. The Affordable Care Act may have increased Medicaid access for some of those who need coverage in Medicaid expansion states, but inmates in non-expansion states still have high need for Medicaid coverage and face unique barriers to enrollment. We sought to explore barriers and facilitators to Medicaid enrollment among prison inmates in a non-expansion state. We conducted qualitative interviews with 20 recently hospitalized male prison inmates who had been approached by a prison social worker due to probable Medicaid eligibility, as determined by the inmates' financial status, health, and past Medicaid enrollment. Interviews were transcribed verbatim and analyzed using a codebook with both thematic and interpretive codes. Coded interview text was then analyzed to identify predisposing, enabling, and need factors related to participants' Medicaid enrollment prior to prison and intentions to enroll after release. Study participants' median age, years incarcerated at the time of the interview, and projected remaining sentence length were 50, 4, and 2 years, respectively. Participants were categorized into three sub-groups based on their self-reported experience with Medicaid: (1) those who never applied for Medicaid before prison (n = 6); (2) those who unsuccessfully attempted to enroll in Medicaid before prison (n = 3); and (3) those who enrolled in Medicaid before prison (n = 11). The six participants who had never applied to Medicaid before their incarceration did not hold strong attitudes about Medicaid and mostly had little need for Medicaid due to being generally healthy or having coverage available from other sources such as the Veteran's Administration. However, one inmate who had never applied for Medicaid struggled considerably to access mental healthcare due to lapses in employer-based health coverage and attributed his incarceration to this unmet need for treatment. Three inmates with high medical need had their Medicaid applications rejected at least once pre-incarceration, resulting in periods without health coverage that led to worsening health and financial hardship for two of them. Eleven inmates with high medical need enrolled in Medicaid without difficulty prior to their incarceration, largely due to enabling factors in the form of assistance with the application by their local Department of Social Services or Social Security Administration, their mothers, medical providers, or prison personnel during a prior incarceration. Nearly all inmates acknowledged that they would need health coverage after release from prison, and more than half reported that they would need to enroll in Medicaid to gain healthcare coverage following their release. Although more population-based assessments are necessary, our findings suggest that greater assistance with Medicaid enrollment may be a key factor so that people in the criminal justice system who qualify for Medicaid-and other social safety net programs-may gain their rightful access to these benefits. Such access may benefit not only the individuals themselves but also the communities to which they return.

In 2011, North Carolina (NC) created a program to facilitate Medicaid enrollment for state prisoners experiencing community inpatient hospitalization during their incarceration. The program, which has been described as a model for prison systems nationwide, has saved the NC prison system approximately $10 million annually in hospitalization costs and has potential to increase prisoners' access to Medicaid benefits as they return to their communities. This study aims to describe the history of NC's Prison-Based Medicaid Enrollment Assistance Program (PBMEAP), its structure and processes, and program personnel's perspectives on the challenges and facilitators of program implementation. We conducted semi-structured interviews and a focus group with PBMEAP personnel including two administrative leaders, two "Medicaid Facilitators," and ten social workers. Seven major findings emerged: 1) state legislation was required to bring the program into existence; 2) the legislation was prompted by projected cost savings; 3) program development required close collaboration between the prison system and state Medicaid office; 4) technology and data sharing played key roles in identifying inmates who previously qualified for Medicaid and would likely qualify if hospitalized; 5) a small number of new staff were sufficient to make the program scalable; 6) inmates generally cooperated in filling out Medicaid applications, and their cooperation was encouraged when social workers explained possible benefits of receiving Medicaid after release; and 7) the most prominent program challenges centered around interaction with county Departments of Social Services, which were responsible for processing applications. Our findings could be instructive to both Medicaid non-expansion and expansion states that have either implemented similar programs or are considering implementing prison Medicaid enrollment programs in the future.