摘要：Juvenile justice and Medicaid agencies share an interest in serving delinquent youths, many of whom have a relatively poor health status. However, many state and local Medicaid policies result in these youths having no insurance coverage, making access to needed services difficult. A nationally representative survey of state and community juvenile justice and Medicaid agencies was conducted to assess Medicaid policies. Evidence from the survey suggests that in some areas delinquent youths are actively disenrolled from Medicaid benefits, and in others little effort is made to connect them to Medicaid coverage. Discrepancies between justice agency and Medicaid agency responses point to poor communication and coordination. Overall, the survey identified several opportunities for policy intervention to enhance access to services for justice-involved youths. ALL TOO OFTEN, PUBLIC agencies serve overlapping populations but pursue their missions without coordinating their efforts. One example is juvenile justice agencies and Medicaid programs, both of which serve youths who may have violated the law. These youths typically have poor physical and mental health status, with higher-than-average rates of substance abuse and psychiatric disorders as well as acute and chronic medical conditions. 1 – 7 High rates of illness, especially psychiatric disorders, may lead to higher medical costs and increased recidivism for juvenile justice, while poor care may exacerbate expenditures and case management services for Medicaid agencies. Thus, both systems have a shared interest in serving the health needs of these high-risk youths. In fact, however, the policy of the federal Medicaid program is to discontinue Medicaid benefits for incarcerated youths, which often means the loss of insurance coverage and more difficulty accessing services upon release. 8 By federal law, state juvenile justice systems must provide timely and appropriate physical and mental health services to justice-involved youths, specifically those held in correctional facilities. Youths may be held in detention or commitment correctional facilities, depending on the stage of court processing. In 1999, juvenile courts handled nearly 1.7 million delinquency cases. Approximately 336 000 of these cases (20%) resulted in the youths being detained in a justice facility while awaiting further court processing. 8 In approximately 155 000 cases (9%), the youths were judged delinquent and placed in a commitment facility to serve a longer sentence. Typically, detained and committed youths are housed in separate facilities. The facilities vary considerably in size and ownership, with some being publicly and others privately operated. Youths held in detention and those placed in correction facilities face the potential loss of Medicaid insurance benefits because federal law prohibits such benefits for incarcerated individuals. Medicaid is a federal–state partnership in which states design and administer their programs within broad federal guidelines. One federal stipulation is that no federal Medicaid funds can be used to pay for health care services to “inmates of a public institution.” 9 Technically, states may not claim federal Medicaid matching funds for services provided to incarcerated youths. One way to comply with this rule is to drop incarcerated youths from the Medicaid benefit rolls entirely. There are only limited instances when Medicaid federal matching funds are available for services provided—for example, if a youth is transferred to a medical facility for inpatient services or if a youth has been “sentenced” to a community setting, such as probation, but is awaiting release from the detention facility. The practice of dropping inmates from benefit rolls and discontinuing Medicaid benefits has been the subject of considerable policy debate. 9 – 12 Beneficiaries whose benefits are terminated are likely to face delays in reenrollment upon release because they face the burden of reapplying for eligibility. One concern is that without health insurance benefits, many individuals also will not receive timely health care after release. Without insurance, they may be deterred from seeking services or have more difficulty locating providers willing to treat their illness. Lack of timely care, in turn, could lead to flare-ups in medical or mental heath conditions, which could translate into higher health care costs and possibly higher rates of rearrest and diminished public safety. The federal government has issued policy statements clarifying the exclusion of detainees and others in public institutions. Specifically, recognizing the difficulties for individuals in reapplying for benefits, the federal Medicaid program has encouraged states to “suspend” rather than “terminate” Medicaid benefits while a beneficiary is in a public institution. 13 While this distinction may seem subtle, suspension would lead to more rapid reinstatement of Medicaid benefits for detainees than termination. Other alternatives for states to ease the transition to Medicaid benefits include assisting inmates with their applications, processing them prior to release, or giving special priority to applications from former inmates. In practice, both justice and Medicaid agencies must work in concert to fully implement either disenrollment or reenrollment policies. Because the agencies have very different missions and priorities, such coordination may not be common or complete. The impact of Medicaid disenrollment policies on youths depends on the manner in which, and the extent to which, the policy is implemented. Lost in the policy debate has been the question of whether Medicaid disenrollment and reenrollment of justice-involved youths is common practice and, if so, in what form. A recent national survey of states and a representative sample of communities attempted to answer these questions. The study hypothesized that state and local Medicaid and justice agencies have very different understandings of Medicaid policies, indicating a lack of communication between policymakers and those on the front lines who implement them. We summarize (1) responses to key questions about Medicaid disenrollment policies and practices, (2) agency efforts to enroll justice-involved youths in Medicaid rather than disenroll them, and (3) the use of Medicaid financing for services to youths in preadjudication detention facilities.
