He had to see a doctor. He had only a month’s worth of pills to control his delusions and mania. He was desperate for insurance coverage.

But the state failed to enroll him in Medicaid, although under the Affordable Care Act Indiana had expanded the health insurance program, making most ex-inmates eligible. Left to navigate an unwieldy bureaucracy on his own, he came within days of running out of the pills that ground him in reality.

“I have a serious mental disorder, which is what caused me to commit my crime in the first place,” said Ernest, who asked reporters to use only his middle name to protect his privacy. “Somebody should have been pretty concerned.”

The health law was expected to connect Ernest and almost all other ex-prisoners for the first time to Medicaid coverage for the poor, cutting expensive visits to the emergency room, improving their prospects of rejoining society and reducing the risk of spreading communicable diseases that flourish in prisons.

But Ernest’s experience is repeated millions of times across the country, an examination by The Marshall Project and Kaiser Health News shows.

“I hate to say it — it’s a captive audience. You have somebody there! You know they’re going to be released in a few weeks,” said Monica McCurdy, who as head of a clinic for Project HOME in Philadelphia constantly sees homeless, recently released prisoners without Medicaid coverage. “Why not do the handoff that’s needed to prevent this person winding up in the ER? It defies common sense.”

Health Risks Soar After Prison Release

Before the Affordable Care Act, state Medicaid programs covered mainly children, pregnant women and disabled adults, which included only a small number of ex-offenders. That’s still generally the case in the 19 states that didn’t expand Medicaid.

Radio story by Jake Harper, Side Effects Public Media, a news collaborative covering public health.

President-elect Donald Trump has vowed to repeal the health act and replace it with something else, leaving the law’s Medicaid expansion and eligibility for ex-prisoners in doubt. Rep. Tom Price, Trump’s pick to head the Departmetn of Health and Human Services — which oversees Medicaid — has been one of Obamacare’s most vociferous critics in Congress.

But some analysts expect parts of the law to survive, perhaps including Medicaid expansion managed more directly by states than by Washington.

Even some Republicans have supported the idea, suggesting that revoking Medicaid coverage from millions of new recipients would be difficult. Republican Gov. John Kasich expanded Medicaid in Ohio in part for ex-inmates, , “to get them their medication so they could lead a decent life.”

Other parts of the health law received more attention, but advocates saw giving Medicaid coverage to ex-inmates as one of its most transformative aspects. Illness for illness, inmates are the sickest people in the country.

They have far higher rates of HIV, hepatitis and tuberculosis than the general population. They’re also more likely to have high blood pressure, diabetes and asthma. More than half are mentally ill, according to the , with up to a quarter meeting criteria for psychosis. Between half and three-quarters have an addiction problem.

Prisons and jails have their own doctors, but their responsibility to provide care stops upon an inmate’s departure. Inmates generally aren’t eligible for Medicaid while imprisoned.

No time is more critical than the days immediately after release. One study showed that in the first two weeks, ex-prisoners die at a of the general population. Heart disease, drug overdose, homicide and suicide are the main causes.

But even in states that expanded Medicaid, the most vulnerable and sometimes dangerous ex-inmates are often left on their own.

Ernest went to prison for shooting and killing his daughter amid a psychotic religious delusion. Re-enacting the biblical story of the sacrifice of Isaac, he thought God would intervene to save the girl. News reports from the time say police found him naked, carrying the child’s lifeless body through the streets of an Indianapolis suburb.

Indiana expanded Medicaid under the health law in February 2015 and set up a system to enroll all eligible prisoners upon release. Yet when Ernest got out in August 2015, he was not enrolled in Medicaid, let alone connected to doctors.

Prison officials say they applied for Medicaid on Ernest’s behalf, but Medicaid records show he applied when he got home. It’s not clear where the system failed.

“It is important that the offenders have some accountability in the process,” said Douglas Garrison, a spokesperson for the Indiana Department of Correction. “The IDOC has worked diligently to ensure released offenders are receiving coverage.”

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled.

“Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Failure to sign up ex-inmates for health care is a common occurrence in states that expanded Medicaid under the health law, even in places such as Indiana where agencies have provided enrollment assistance.

No Enrollment For Thousands Of Chronically Ill

Two-thirds of the 9,000 chronically ill prisoners released each year by Philadelphia’s jails aren’t getting enrolled as they leave, said Bruce Herdman, medical director for the jails. The city lacks even the $2 million necessary to supply a month’s worth of medication for released inmates with prescriptions, he said.

“They give you like two weeks’ supply of medication,” said Ricky Platt, 49, who left the Philadelphia jail in 2015, quickly ran out of Zoloft antidepressants and became homeless. “They don’t give you any resource of where to go or get a doctor and get your prescription filled or anything.”

Emergency doctors at Thomas Jefferson University Hospital in Philadelphia often see released inmates with kidney failure who are at risk of dying if they don’t receive dialysis almost immediately, said Dr. Priya Mammen, one of the hospital’s emergency physicians.

“We’re kind of the go-to spot for many people, but particularly for people who have been released from prison,” she said. “Either in the first week we see them or when their prescriptions run out.”

Kara Salim, 26, got out of the Marion County, Indiana, jail in 2015 with a history of domestic-violence charges, bipolar disorder and alcoholism — and without Medicaid coverage. As a result, she couldn’t afford the fees for court-ordered therapy.

Without therapy she wasn’t allowed to see a psychiatrist for her medications. Without medication she spiraled downward, eventually threatening suicide at a court hearing. When court officers tried to bring her to a psychiatric hospital, she erupted, kicking and scratching them and landing back in jail, with new felony charges: battery against a public safety officer.

“I wish I could tell you she’s the exception,” said Sarah Barham, an addiction counselor with Centerstone, an Indiana nonprofit.

Medicaid enrollment requires resources that many prison systems and local jails — often overcrowded and operating in crisis mode for years — lack or have been reluctant to commit.

“Most of the county sheriffs don’t have the proper staff they need to even run the jails,” said Bill Wilson of the Indiana Sheriffs’ Association. Many jails are making an effort, but in some places “pulling the resources out to enroll an inmate in Medicaid is not something the sheriff’s able to do.”

In Minnesota, only those eligible for special release planning programs are offered assistance in applying; as a result, fewer than 1,000 of the 6,800 prisoners the state released last year applied for Medicaid, according to corrections officials there. Minnesota is one of seven states — Alaska, Hawaii, Arizona, Montana, Louisiana and Illinois are the others — that expanded Medicaid but have not implemented a large-scale enrollment program.

In many states, even prerelease registration requires a follow-up visit to a local Medicaid or welfare office to “activate” the coverage on release. Obtaining a phone, paying for minutes and navigating bus lines to state offices can be daunting for newly released inmates who often struggle with basic needs such as food and shelter.

Indiana officials applied for Medicaid on behalf of more than 7,000 state prisoners from March through September — nearly 90 percent of those released. (Many of the others were released to other states or deported, officials said.) Yet only a little more than half called to activate their coverage when they got home, according to state data. The state said in recent weeks it eliminated the requirement to activate coverage with a call.

Released prisoners also often need to reestablish identification by applying for Social Security cards and birth certificates. That can take weeks or months. Sometimes there’s another step: enrolling in one of the private, managed care networks that many states hire to administer Medicaid benefits.

In the chaotic days and weeks after release, red tape can mean the difference between joining Medicaid or remaining cut off from community caregivers.

William Santee, 46, released from Pennsylvania state prison this year, has diabetes, high cholesterol and high blood pressure. He learned about Medicaid enrollment requirements and the need to visit a welfare office from workers at a homeless shelter.

The prison “didn’t tell me about where to go or anything like that,” he said. “They don’t consider that their responsibility.” Waiting in line and completing the welfare-office paperwork took five hours.

Getting The Details Right

Almost as critical as successful enrollment is choosing a Medicaid plan that covers medicines and services ex-inmates need. Jail and prison workers are rarely equipped to wade through such details.

“That’s a huge issue for us,” said Susan Jo Thomas of Covering Kids and Families, a nonprofit that helps enroll people in Medicaid in Indiana. “You finally get a person to the place where they are ready … to go into detox, but if they have aligned with an insurance company that doesn’t cover the medicine that program uses, then you have a problem.”

In some extreme cases bureaucratic rules clash, leaving ex-prisoners stranded between agencies. In Indiana and several other states, corrections departments consider prisoners in work release programs, who report to jobs during the day, to be free. That means they’re not eligible for care from the prison system.

Medicaid, on the other hand considers them still incarcerated. So they can’t enroll in community health coverage, either.

“We got all excited when Obamacare came out, because everybody’s going to be covered,” said Peggy Urtz, who runs an Iowa work release facility for women. Instead, she said, the women “are going to ERs when they’re ill and racking up medical bills. We have good providers, well experienced in working with women, and they can’t go to them because they don’t have insurance.”

A few states and localities reap praise for innovative and comprehensive attempts to enroll emerging prisoners in Medicaid.

Ohio recently finished phasing in Medicaid registration at all state prisons and is one of the few states giving inmates a managed-care insurance card as they leave, said John McCarthy, that state’s Medicaid director. Chicago’s huge Cook County jail puts prisoners on the Medicaid books as they enter, rather than before they leave, to sidestep the common problem in jails of unpredictable release dates.

More often the process looks like what was happening one recent Friday in Indiana’s Marion County jail, where Lt. Debbie Sullivan was trying to rouse sleepy women to sign up for health insurance.

The document she distributed was three pages long, authorizing a Medicaid application on inmates’ behalf. It asked for names, addresses, birth dates and Social Security numbers. The handwritten information would later be entered into computers — a recipe for transposed digits and misspelled names.

“The program remains a work in progress,” said Katie Carlson, a spokeswoman for the Marion County Sheriff’s Office, which runs the jail. “It has proven a daunting task to enroll, track and provide meaningful information on both Medicaid and health care.”

Experts say such sessions require a half hour or more to get the details right and answer questions about picking the right plan and following up with doctors and insurance officials after release.

Sullivan’s knowledge of the women’s next steps was minimal. In response to questions, she simply told them to contact their local social service office when they get out. She walked out of the block with about 30 signed applications. It was over in 15 minutes.

“Thank you ladies!” she called on her way out, as the heavy steel door slammed behind her.

This article is published in partnership with , a nonprofit news organization covering the U.S. criminal justice system, NPR, and , a news collaborative covering public health.

Graphic by Yolanda Martinez. Marshall Project interns Deonna Anderson, Josiah Bates, Jonathan Gomez and Rachel Siegel contributed research.

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A new report released Tuesday shows the consequences of this system can be deadly. Beyond access to classes and job training, the disparities extend to HIV care, too.

While state prisons provide routine HIV testing and treatment and a well-respected, federally funded program to link inmates to medical care on release, HIV care in the jails is “limited, haphazard and in many cases, non-existent,” concluded the.

Of the state’s 104 jails, only five provide routine HIV testing, researchers found. And for inmates who are HIV-positive, treatment is often delayed and inconsistent. “Some days they would give me all of my pills, other days only some of them and once it stopped for a week when they ran out. Another time they gave me somebody else’s meds,” one man told researchers about his time in Orleans Parish Prison.

After Marvin Auguillard was diagnosed with HIV in East Baton Rouge Parish Prison in 2008, he continued to cycle in and out of several of Louisiana’s prisons and jails, mostly on a series of forgery and theft charges. Still, his 2012 stint at the Orleans Parish Prison in New Orleans stands out. (Some of the facilities, like Orleans Parish’s, refer to themselves as prisons, but in practice they are akin to county jails.)

Several former jail inmates reported their family members had to bring their medications from home because they were told the medication was too expensive. Given the price of HIV medications — which can cost — and other related specialty care, many jail administrators were frank with the researchers, telling them they do not offer testing because caring for people who turn out to be positive is too expensive.

About nationwide — some 30,000 people — are infected with HIV. Because the risk factors for going to jail and for becoming infected with HIV often overlap — addiction, poverty, being — the rate of HIV in prison nationally is some than in the general population. In Louisiana, 3.5 percent of the state’s prisoners are infected.

The problem doesn’t affect just prisoners; it’s a public health concern as well. In recent years, a major push in HIV has been “” — people whose HIV is well-controlled are substantially less likely to infect others. A cornerstone of this philosophy is ready access to HIV testing, with regular and uninterrupted treatment for those who are positive.

Gaps in access to HIV medication can lead to resistance to the first-line medications, making treatment more difficult and expensive in the future.

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One 12-week treatment course can . With a constitutional obligation to provide medical care to inmates, prison officials—whose health-care budgets are a zero-sum proposition—are struggling to treat even a fraction of those with the disease.

“Hepatitis C is a progressive disease—it could take 30 years to progress to advanced liver cancer,” says Dr. Jagpreet Chhatwal, a radiologist at Harvard Medical School and the study’s senior author. “If you compare that to the average time spent inside prison, which is three to five years, it would make sense these people would be part of the community when this started happening.”

Transmitted primarily by injection drug use, hepatitis C afflicts 17% of prisoners, compared to 1% of the general population. Public health advocates have for years described testing and treatment of hepatitis C in prison as a “public health opportunity.” Given high rates of the disease, “testing, education, and, when appropriate, treatment of prisoners should be a cornerstone of the public health response to the hepatitis C epidemic in the United States,” argued three correctional and public health physicians in a medical journal (and last year).

That’s not how things panned out. Because the most serious complications of hepatitis C can take decades to emerge, cash-strapped correctional officials have been reluctant to treat seemingly healthy inmates whose medical problems won’t show themselves until long after they are released. What’s more, first-generation treatments took up to a year, caused serious side-effects, and were only effective about half the time for most patients. Even prisons with dedicated treatment programs were treating out of the hundreds of thousands of prisoners with hepatitis C.

Now, new hepatitis C medications can cure 90% of patients in as few as 12 weeks; from the major medical societies recommend treating all patients with hepatitis C—and single out incarcerated people as a group for whom treatment could have the secondary benefit of preventing transmission to others. But still prison administrators in most states have been slow to offer testing or treatment in any substantial numbers. (In and , prisoners have filed class-action lawsuits to gain access to the drugs.)

“There is an incentive for prisons to put their head in the sand,” says Emory Medical School’s Anne Spaulding, one of the co-authors of the paper. “The more cases you find with aggressive screening, the more cases you might need to treat.”

This new paper, which appears in the medical journal Annals of Internal Medicine, found that universal screening—and treatment of any prisoner whose liver disease is found to be moderate or severe—could avert $760 million in spending on liver transplants and other medical care over thirty years. At least 80% of that spending would have been in the general population. “That’s the whole motivation of this paper, showing if we start treating people in prison, the whole society benefits,” says Chhatwal. Because the benefits would accrue to society at large, and not to the prison, Chhatwal suggests that state and federal governments should step up and provide supplemental funding to manage hepatitis C in prisons. The paper put the first-year cost of implementing the screening and treatment programs at $1.1 billion across the state and federal systems—about 12 percent above what they’re spending on health care now. “Cost effective” is not the same as cost saving: “It means something will cost additional money, but it’s worth spending,” Chhatwal said.

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