Out of prison, but struggling for health care

On his release from prison in December 2013, Gregory Odeneal had secured a place to live. He had studied his responsibilities under Minnesota's supervised-release program, and he was prepared to start job hunting.

What he didn't have was health insurance. Which was a problem because he needed a physician's care for a worsening case of multiple sclerosis.

"The doctors won't see me if I don't have the insurance," he said in a recent interview.

It took Odeneal nearly two months to get approved for the state's Medicaid health insurance program for the poor, causing his treatment to be delayed and his symptoms to worsen.

Scores of inmates leave Minnesota's prisons every year, and many of them have costly chronic diseases such as diabetes and hepatitis, or mental illness and drug addictions — conditions that can undercut their re-entry into society. The Minnesota Department of Corrections has a Medicaid application program for departing inmates who have a disability, while others are given applications and encouraged to apply.

But it's unclear how many actually have health coverage on their release, and advocates say the state could do more — especially now that most prisoners are eligible for Medicaid under an expansion created by the 2010 Affordable Care Act.

"This is not an easy application process, and we are concerned that DOC is not putting enough specialized resources into it," said Meghan Kimmel, president of St. Paul-based Portico Healthnet, which helps people, including inmates, apply for health insurance.

"The need for this specialized assistance and follow-up is high, and correctional facilities are not designed to provide that," she said.

For those with a substance use disorder, the risk of death from an overdose in the two weeks after leaving prison is 10 times higher than in the general population, said Dr. Tyler Winkelman of the Minneapolis-based Hennepin Healthcare, who researches health issues in the criminal justice system.

"People need health insurance to help them get the treatment that they need," said Winkelman. "Substance use treatment can reduce the likelihood that someone would end up back in prison."

In several states, prison systems are pushing hard to get departing inmates enrolled in Medicaid, in part because it helps them make the transition back into society.

"This is certainly a trend that we are seeing ... across the country," said Alex Blandford, program director for behavioral health at the Council of State Governments Justice Center. "It is a really important part of a broader strategy to reduce recidivism."

Ohio, for example, has drawn national attention for its prison Medicaid sign-up program. In the past year, it enrolled 87 percent of the 13,200 departing inmates selected for Medicaid pre-enrollment. But Ohio takes the process one step further: Care coordinators from the state's Medicaid HMOs have Skype sessions with inmates to help them select doctors, clinics or treatment programs that they can see once they are released.

"People that are healthy are more likely to be able to find work," said Tom Betti, press secretary for the Ohio Department of Medicaid. "In the long run that saves taxpayer dollars. They are healthier, employed and not reincarcerated."

In 2004, Minnesota began enrolling departing prisoners in Medicaid if they had a disability that made them eligible for government health insurance. The Legislature provided funding for special release planners, which work with about 1,300 people a year.

"They will have their Medicaid number in hand, will have appointments set up and have prescriptions," said Nanette Larson, health services director at the Corrections Department.

After Medicaid eligibility expanded under the federal health law, Minnesota's prisons began providing inmates with paper applications for Medicaid, but they don't track how many succeeded in enrolling.

Until recently, as part of a pilot project serving the Stillwater and Shakopee prisons, Portico Healthnet tracked some applications to make sure they got accepted and helped resolve ones that were rejected.

Corrections officials say they are evaluating that program and might invite bids from Portico and similar nonprofit organizations to do more of that outreach.

Portico's Kimmel says it helps to have trained health "navigators" assist inmates with the application process. One mistake or one missed answer on the form could lead to a rejection by county case workers, who determine Medicaid eligibility.

For example, Portico has seen applications rejected when male applicants didn't answer a question about being pregnant.

"When we tell this to [male] inmates, everyone starts laughing," said Kimmel. "But we are not making joke — you have to answer that question."

Portico still has arrangements to assist prisoners without intensively tracking their applications. It also provides outreach to jails in Hennepin and Ramsey counties.

"The judges are in support of it, as is the County Board," said Gail Moerke, who coordinates transition services in Ramsey County. "If they don't have health insurance they are going to avoid [seeking care] and they don't get the help they need."

Odeneal said that before he was discharged in 2013, no one in the prison system gave him an application for Medicaid.

"They just said it was pretty much go to the county," said Odeneal, who had been convicted of rape in 2009. In addition, the terms of his release required him to find a job, and he didn't want to take time away from that to visit clinics or fill out county paperwork.

"I had to look for a job instead of going to the doctor," he said. Meanwhile, the weakness on the right side of his body got worse and Odeneal was constantly fatigued.

After talking with his case officer, Odeneal got permission to focus on getting health coverage. But even after he was approved for Medicaid, there were glitches in his coverage that led to further treatment delays. Eventually, he was able to use the insurance, and one doctor told him that the delay in treatment had made his condition worse.

"I used to be an athlete," he said. "But now it is tough to walk a flight of stairs."