Administration officials moved Thursday to improve low Medicaid enrollment for emerging prisoners, urging states to start signups before release and expanding eligibility to thousands of former inmates in halfway houses near the end of their sentences.

Health coverage for ex-inmates "is critical to our goal of reducing recidivism and promoting the public health," said Richard Frank, assistant secretary for planning for the Department of Health and Human Services.

Advocates praised the changes but cautioned that HHS and states are still far from ensuring that most people leaving prisons and jails are put on Medicaid and get access to treatment.

"It's highly variable. Some states and jurisdictions are having a lot of success" enrolling ex-prisoners, said Kamala Mallik-Kane, a researcher at the Urban Institute who has studied the process. "Others of them have initiatives in place that aren't reaching the kinds of numbers that are making a dent."

The 2010 health law made nearly all ex-prisoners eligible for Medicaid in states that chose to expand the state and federal insurance program for the poor. Many welcomed the chance to cover a group with high rates of chronic disease, mental illness and substance abuse problems.

But prisons and jails, burdened with ineffective computers, understaffing and complicated Medicaid enrollment procedures, have been slow to sign up released inmates.

Federal and state prisons let out more than 600,000 people a year. Millions more cycle through jails. But a study published in Health Affairs found prisons and jails nationwide enrolled only 112,520 emerging inmates between late 2013 up to January 2015.

In Maryland, often cited for progressive social policy, the prison system is enrolling fewer than one in 10 released inmates, Kaiser Health News reported this week.

Much of HHS' guidance repeats existing policy, reminding states that those on probation or parole are eligible for Medicaid and urging states to keep prisoners' names in the Medicaid computers while they're locked up. (That eases re-enrollment.)

Inmates are generally ineligible for Medicaid while incarcerated. Prison and jail medical systems care for them.

HHS is "providing encouragement and a nudge" to states to improve sign-ups as well as money to upgrade enrollment computers, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied ex-inmate enrollment. "They understand that this is a technology issue."

Making up to 96,000 halfway-house inmates eligible for Medicaid is new policy, designed to connect people with care before they're fully released. Prisoners often move to halfway houses or home detention near the end of their terms, closely supervised but frequently allowed to shop, apply for jobs and see a doctor.

Under the new policy, "if you have a fair amount of freedom of movement" in a halfway house, "you're not considered an inmate" for Medicaid purposes, said Sarah Somers, an attorney for the National Health Law Program, an advocacy group. "That will be very helpful for a lot of people who are trying to transition out of incarceration."

Nathan Sharpe recently spent two months in a home detention program in West Baltimore between leaving prison and being fully released. He wanted to get a checkup to make sure there was no lasting damage from a stabbing he received last summer in Maryland's Jessup Correctional Institution.

But he had to wait until home detention ended last week to be covered by Medicaid, he said.

"That helps a lot" if people like him could get on Medicaid after they first leave prison, he said. "People can get the health care they need sooner. I've been out a week now and I still haven't been able to see a doctor because I don't have my card."

Ex-inmates have extremely high rates of HIV and hepatitis C infection, diabetes, mental illness and substance abuse problems. They are especially vulnerable after they leave the prison medical system and before they connect with community doctors.

One study in Washington state showed that ex-inmates were a dozen times more likely to die than the general population in the first two weeks after their release.

Immediate Medicaid coverage "can mean the difference between life in the community and recidivism and even life and death," Michael Botticelli, the White House's director of national drug control policy, told reporters.

HHS has been urging states to enroll ex-inmates in Medicaid for years. But the Affordable Care Act's Medicaid expansion made many more of them eligible for coverage, giving policymakers a new reason to promote sign-ups, advocates said.

So far 31 states and the District of Columbia have expanded Medicaid under the law.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Jay Hancock is on Twitter: @jayhancock1.

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