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Hidden in the Fine Print...Is Something Very Good

The fine print of health reform is a strange mix of technical fixes, interest-group giveaways, and essential provisions that would be considered major legislation if they weren’t embedded in a 1,990 page bill. Some of these pages address the havoc that our fragmented financing system imposes on the public health system. Severely disadvantaged populations pose major, largely overlooked challenges in health reform. Criminal offenders may represent the most troubled and costly of these populations. These men and (increasingly) women face an unbelievable array of health problems. One not so random example: An estimated 29 to 43 percent of all Americans infected with hepatitis C are released from jail or prison each year.

Youth who commit crimes bring a huge array of physical and mental health problems, and face high risks from many of the same behaviors that get them in legal trouble. Heath difficulties include the obvious psychiatric and substance use disorders. Detained kids have skin infections and other mundane issues requiring primary care. In one study of Washington State, two-thirds of incarcerated youth had bad teeth. A gritty New York Times story recently highlighted the prevalence of survival sex work among teen runaways, who form a large subpopulation of the juvenile justice system. Not surprisingly, sexually-transmitted infections and unintended or high-risk pregnancies are widespread.

Juvenile offenders need health insurance to address these issues. Many are Medicaid-eligible and indeed were on the rolls before they were locked up. Yet for various reasons, states often intentionally or implicitly disenroll these youth from Medicaid upon incarceration--thus leaving them without health insurance when they are discharged. This is precisely the moment they most need help—and precisely the moment when the social costs of poor follow-up and blocked access to medical and psychiatric services are most extreme. For many of these youth, their first medical visit after leaving a juvenile detention center occurs in a hospital emergency department or a county jail. This is not smart social policy.

Section 1729 of the House Bill--"Preserving Medicaid coverage for youths upon release from public institutions"--seeks to address these issues. The core paragraphs read:

During the period such youth is incarcerated in a public institution, the State shall not terminate eligibility for medical assistance under the State plan for such youth.

…[O]n or before the date such youth is released from such institution, the State shall ensure that such youth is enrolled for medical assistance under this title, unless and until there is a determination that the individual is no longer eligible to be so enrolled.

Even within the small community of dedicated health wonks, few people know this section exists. Much of the fine print of health reform is the usual sausage-making. Then there are passages like Section 1729 that do credit to their authors. Commonsense humanity is easily missed when it comes packaged in dry bureaucratic language embedded in major legislation. It’s worth taking a moment to point this out.