Well before #DefundThePolice went viral, abolitionist activists and scholars had been calling for the redirection of funds from the criminal legal system into a broad set of nonpunitive community resources. Their work has suggested that greater public investment in health care and social welfare could reduce policing in disadvantaged communities. Prior research has illustrated the expansive role police currently play in responding to social problems and health emergencies that could be addressed in other ways. To test this premise, we embarked on a study that asked whether a greater investment in social programs might reduce community reliance on police.
We specifically wanted to measure the capacity for health insurance policy to impact exposure to policing, and we set out to do so using a natural experiment generated by the Medicaid expansion provision of the Affordable Care Act. By examining the effects of Medicaid expansion on arrests in 3,035 U.S. counties (96.5% of all counties), we were able to quantitatively examine this long-standing argument.
The ACA was signed into law by President Barack Obama in 2010, and its goal was to broaden health insurance coverage in the United States through a combination of mandates, subsidies, health insurance exchanges, market reforms, and the expansion of Medicaid. The law produced historic gains — the total uninsured population declined from 48 million in 2010 to 28 million in 2016 — much of which were made through Medicaid expansion.
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Medicaid, a national public health insurance program for people with low income, is the principal source of long-term care coverage for Americans. Financed mostly by the federal government, the ACA’s Medicaid expansion aimed to cover more people by expanding the eligibility criteria. But following the U.S. Supreme Court decision that upheld the law’s constitutionality, the court also allowed states to opt out of expanding coverage to people up to age 64 and with incomes below 138% of the federal poverty level. At the close of 2021, 38 states and Washington, D.C. had expanded Medicaid, with 12 states abstaining from the program.
This partial expansion generated a large body of research on health outcomes and health care utilization, but no published studies had examined whether broadening health insurance coverage, and specifically Medicaid expansion, affected the level of criminal system contact in a diverse and comprehensive sample of communities, nor had they examined whether expanded coverage affected particular types of police encounters, such as arrests for drug possession. We wanted to see if — and how — Medicaid expansion had affected policing.
Police officers are routinely tasked with responding to a wide variety of community concerns that include health crises, and policing routes millions of people with behavioral health disorders, including substance use problems, into treatment and/or institutionalization. High rates of police contact reflect the failure of primary prevention policies to meet the basic needs of marginalized people, particularly related to health, substance use problems, poverty, and interpersonal conflict. According to the Prison Policy Initiative, almost 400,000 people are in jail or prison for a drug charge. In the United States, approximately 1 million of the more than 10 million arrests police make per year are for drug-related charges. Alongside these practices, limited health insurance coverage suppresses participation in community-based behavioral health services and treatment.
The enormous footprint of the criminal legal system — and the significant precarity and health burdens of the people it affects — presents expanded health insurance coverage as a potentially critical measure for reducing levels of police contact in U.S. communities.
The enormous footprint of the criminal legal system — and the significant precarity and health burdens of the people it affects — presents expanded health insurance coverage as a potentially critical measure for reducing levels of police contact in U.S. communities.
Two key hypotheses emerge from existing research on criminalization, social inequality, and health policy. One contends that arrests would decline as a result of broader insurance coverage — that is, greater health care access among those with untreated health care needs, chief among them mental health and substance use disorder treatment, would reduce the likelihood that police would arrest individuals presenting mental health problems or involved in drug-related activity or other criminalized behaviors. The financial stability gained by increased access to health insurance could also reduce risk of arrest.
But a substantial body of research posits that health policy reforms could result in either minimal change or even increased criminalization of people with behavioral health conditions. In this account, accessing health care services could heighten the level of surveillance of participants, either due to the spatial concentration of policing near health care institutions serving low-income populations or data system integration across social service and criminal justice institutions.
Because arrests are a local phenomenon driven by many contextual factors, we chose to test these hypotheses by studying arrest rates in U.S. counties. Using FBI Uniform Crime Reporting Program data provided by data scientist Jacob Kaplan, we compared county-level arrests before and after Medicaid expansion during the period of 2014 (when major provisions of the ACA took effect) and 2016. We then compared these rates to those in counties in non-expansion states. In addition to changes in overall arrest rates, we also studied changes in violent, drug, and low-level arrests. Given our hypothesis about the relationship between behavioral health conditions (especially substance use disorders), insurance coverage, and the risk of arrest, we were particularly interested in how ACA Medicaid expansion affected drug arrests.
Our results show that Medicaid expansion had a striking effect on arrests. We estimated a 20 to 32 percent negative difference in the rate of arrest in counties in expansion states compared to counties in non-expansion states, an effect that was persistent in all three years of expansion, controlling for a wide range of confounding factors. The largest negative differences were in drug arrests — our findings suggest a 25 to 41 percent negative difference in the three years following Medicaid expansion relative to non-expansion counties. We also observed a 19 to 29 percent negative difference in arrests for violence during this period, and a decrease in low-level arrests between 24 to 28 percent in expansion counties compared to non-expansion counties.
This evidence supports the hypothesis that expanding insurance coverage reduced the level of criminalization experienced within communities. It was also evident in a diverse set of police encounters, including violent and drug arrests.
This evidence supports the hypothesis that expanding insurance coverage reduced the level of criminalization experienced within communities. It was also evident in a diverse set of police encounters, including violent and drug arrests.
These results suggest that Medicaid expansion may have been particularly important in providing insurance coverage for individuals with substance use problems and reducing their contact with the criminal legal system; the ACA took effect during a period when drug overdose deaths sharply increased, and prior research has shown that Medicaid expansion was associated with fewer opioid overdose deaths at the county level.
In addition to Medicaid, our analyses addressed a range of factors that could have influenced arrests. One prominent example is the opioid epidemic — opioid-related deaths quadrupled between 1999 and 2015, which overlaps precisely with the period of Medicaid expansion under the Affordable Care Act. To account for this and other potential confounders, we controlled a wide range of both county-level and state-level measures. We observed an increase in overall arrest rates and drug arrests during this period, but we were unable to fully assess whether this could be explained by changes in criminalized behaviors, as arrest rates could have changed due to shifts in criminalized behavior in the population, shifts in policing, or a combination of both. But while rates of drug arrest increased in both non-expansion and expansion states after 2014, the rate of increase in expansion states appeared to be less steep.
This suggests that in counties that rely on policing to respond to individuals with health problems, insurance coverage creates new avenues for individuals to seek care, receive treatment, and avoid arrest. This demonstrates just one way that social policy can meaningfully reduce the footprint of the criminal legal system, prevent cumulative disadvantage, and improve health for marginalized and chronically policed populations.
Medicaid expansion demonstrates just one way that social policy can meaningfully reduce the footprint of the criminal legal system, prevent cumulative disadvantage, and improve health for marginalized and chronically policed populations.
That said, we cannot rely solely on social and health policy to reduce police arrests. Several years after its passage, the ACA remains a precarious policy. Federal courts struck down its insurance mandate in 2018 and 2019; the U.S. Supreme Court, which ultimately reversed those rulings, has entertained myriad additional challenges to it. Congress, for its part, has yet to extend pandemic-era relief that made ACA premiums more affordable to the neediest patients. More importantly, even the largest public investments in health and social welfare wouldn’t change policing practices or criminal justice policies. Although ACA Medicaid expansion was associated with fewer arrests compared to states that did not expand Medicaid, overall arrest rates increased following ACA expansion, even in states that adopted the expansion provision.
Under historic conditions of mass criminalization, with police reform high on the agenda at all levels of government, policymakers should note that broad health policy reforms can meaningfully reduce contact with the criminal legal system. But they cannot create enduring change on their own. A far-reaching set of social welfare and criminal system policy reforms will also be necessary for these effects to be fully realized, and for them to be transformative and long-lasting.
Image: Dima Mukhin/Unsplash
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