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.
Most of the state prison systems in the 31 states that expanded Medicaid have either not created large-scale enrollment programs or operate spotty programs that leave large numbers of exiting inmates -- many of whom are chronically ill -- without insurance.
Local jails processing millions of prisoners a year, many severely mentally ill, are doing an even poorer job of getting health coverage for ex-inmates, by many accounts. Jail enrollment is especially challenging because the average stay is less than a month and prisoners are often released unexpectedly.
Ex-inmates with the worst chances of getting insurance and care are in 19 states that did not expand Medicaid. Only a small number qualify for coverage. Enrollment efforts by prisons and jails are almost nonexistent.
Nationwide, 16 state prison systems have no formal procedure to enroll prisoners in Medicaid as they reenter the community, according to a survey by The Marshall Project. Nine states have only small programs in select facilities or for limited groups of prisoners, like those with disabilities. These 25 states collectively release some 375,000 inmates each year.
Failure to link emerging inmates to health insurance is a missed opportunity to improve health and save money by cutting recidivism as well as visits to the hospital emergency room, advocates say. Studies have showed Medicaid access in Florida and Washington cut return trips to jail
among the mentally ill by 16 percent.
"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.
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 Department 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, he has said
, "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 Bureau of Justice Statistics
(PDF), 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 dozen times the rate
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."