When advocates discuss expanding Oklahoma’s Medicaid welfare program to include able-bodied adults, they typically suggest beneficiaries will be financially struggling individuals just trying to get by.

But at this week’s meeting of the special, bicameral Healthcare Working Group, lawmakers discussed how Medicaid expansion would impact a very different group: People who have just re-entered society after being convicted of crimes that sent them to prison.

Under Oklahoma’s existing Medicaid program, ex-convicts are typically eligible for Medicaid coverage only if they are aged, disabled, or pregnant.

“If a state were to increase access to health care to 138 percent of the poverty level, it would capture a lot of these discharged people, is that correct?” asked Rep. Marcus McEntire, a Duncan Republican who is co-chair of the group.

“Based on conversations I’ve had with my counterparts in other states, yes, at least for a period of time once they discharge,” said Clint Castleberry, director of health services for the Oklahoma Department of Corrections.

Under federal law, state lawmakers can expand the Oklahoma’s Medicaid program to include able-bodied individuals earning up to 138 percent of the federal poverty level. It is estimated that Medicaid expansion would add 628,000 able-bodied adults to state welfare rolls and directly cost Oklahoma taxpayers $374 million annually with additional funding coming from federal tax payments.

With more than 26,000 individuals currently in Oklahoma prisons, and most of those individuals expected to be released at some point, a significant share of those who could qualify for taxpayer-funded health care coverage through Medicaid expansion would be those who have spent time behind bars.

“If an inmate is being discharged, and there’s no mental-illness issue, there’s no disability issue, they have health-care coverage in prison, but when they get out there’s none?” asked Rep. Trish Ranson, D-Stillwater. “That’s correct?”

“That is possible,” Castleberry said.

“So then if we were to do a Medicaid expansion, that could capture several individuals in that category up to the point of the 138 percent poverty level,” Ranson said. “So they get out of prison, they get a job. Then that could be a transition to the point where once they have a job then hopefully they will be able to afford it.”

“Other states that have qualified discharging individuals through the poverty level, that does establish a continuum of care for them up to a certain point in time to where they’re employed and begin to move financially beyond that qualifying instance,” Castleberry said.

Some lawmakers suggested that giving former inmates taxpayer-funded health coverage would cause them to commit fewer crimes upon their release, including Rep. Cynthia Roe, a Lindsay Republican and nurse.

“I had a couple of distressing situations when I was working at the Lindsay hospital in that we had a couple of inmates—I can specifically remember even the exact rooms they were laying in, because it had such an impact—that they literally violated their parole to come back to prison because they had diagnoses of cancers,” Roe said. “That bothers me a lot that somebody would choose to go back to prison just to get treatment for the cancer they could not get treatment for. So if we had some sort of expansion that could possibly include these inmates that have had cancer diagnoses or some other devastating diagnoses that might not qualify (today) because they’re not technically disabled, they’re not 65, could some sort of expansion include these inmates so they’re not deliberately violating their parole just to go to prison and get treatment?”

“I think there’s a lot of moving parts to that,” Castleberry said. “Assuming whatever that expansion was, in terms of what that eligibility criteria is, theoretically there could be a safety net there.”

McEntire told lawmakers that a 2018 study, based on inmate self-reporting, suggested that having some form of insurance coverage made former convicts less likely to commit additional crimes and return to prison.

“They report that having the cost relief on health care was really important for them not going back in,” McEntire said.

Department of Corrections officials said Ohio, which expanded its Medicaid program to include able-bodied adults, has created a program that helps link convicts to Medicaid upon release. Ohio officials claimed the program would save millions on emergency room visits by those individuals once they were no longer behind prison walls.

Similarly, the state of New York is seeking a waiver to allow it to enroll inmates in Medicaid during the last 30 days before an inmate’s release in order to increase the likelihood of those individuals retaining Medicaid coverage after rejoining society. The New York proposal would be the first of its kind in the nation. As with Ohio, New York officials claimed that providing Medicaid coverage would save state expenses for the provision of routine care in emergency rooms.

However, two reports that examined Medicaid expansion in Oregon found it did not reduce emergency room use and one report found Medicaid recipients were actually more likely to use the emergency room for routine health care than were the uninsured.

If Oklahoma chose not to expand Medicaid to able-bodied adults, McEntire asked if the state could obtain a waiver that allowed expansion of the program only for ex-convicts.

“What if we were to change in our waiver the eligibility requirements for incarcerated folks who have been discharged?” McEntire asked. “I’m just curious. Or would that be discriminatory?”

“You’re basically getting into the field of partial expansion, and other states have not been successful in their efforts for that,” said Audra Cross, legislative liaison for the Oklahoma Health Care Authority, which administers the Medicaid program.

The overall recidivism rate—the share of convicts who commit additional crimes and are returned to prison after their release—is at or under 25 percent in Oklahoma today, Castleberry said. Janna Morgan, chief mental health officer for the Department of Corrections, said the recidivism rate for former inmates with mental illness is almost double that amount, but said treatment reduces that rate. However, she said the recidivism rate only falls back to about 25 percent even when mentally ill ex-convicts have access to support programs.