In the enduring quest to discover what can prevent criminals from reoffending, a new holy grail is emerging: health-care services.
Excitement is stirring inside the justice system, as corrections officials work to link inmates who are leaving custody with health services in their communities, courtesy of President Obama’s Affordable Care Act (ACA). The idea is to enroll thousands of ex-offenders in Medicaid, the federal-state health insurance program for the poor, thus making them eligible for treatment for mental health issues, substance abuse, and chronic medical problems that most have never before consistently received on the outside.
The hoped-for result: a reduction in the share of those who reoffend, and a drop in incarceration costs related to securing public safety.
“This is a huge opportunity,” says Kamala Mallik-Kane, who studies correctional systems, inmates, and health policy at the nonprofit Urban Institute. “The unprecedented step of connecting these newly eligible people to health insurance has incredible potential to change the trajectory of inmates to reintegrate back into society and not back into the justice system.”
The ACA, or “Obamacare,” makes Medicaid available for the first time to a broad class of poor men previously ineligible for it – with Uncle Sam footing most of the bill. So far 25 states and the District of Columbia have opted in, and many of their correctional systems are taking the lead to enroll inmates leaving jails or prisons, which are full of people who are disproportionately poor, minority, and male.
Shawn Sells is one such offender. Upon his most recent discharge from a Connecticut jail, in January, he encountered a new step in the otherwise familiar process: a two-page Medicaid application. It marked the first time that Mr. Sells, who has been in and out of custody on sex and drug offenses for many of his 47 years, had health insurance.
But as Sells’s unfolding story reveals, it is much too soon to know if the excitement among justice experts is justified. No state or county expects to see, this early, a sea change in its correctional systems, recidivism rates, or health-care costs. And it’s not known, for instance, at what rate ex-offenders who enroll in Medicaid actually use health services in their communities.
Many experts, moreover, are wary of the notion that health reform and access to Medicaid for formerly imprisoned men can truly transform America’s criminal-justice system.
“Medicaid enrollment for inmates is not the silver bullet,” says Paul Howard, a senior fellow at the Manhattan Institute, a conservative think tank and director of its Center for Medical Progress.
He suggests that Medicaid, a $265 billion federal expenditure in 2013, is not yielding adequate results for the cost – and that it’s time to take “a long and hard look” before expanding it to serve even more people. “Extending those benefits to a historically transient and difficult population with a whole host of social-issues challenges will not change their approach to health care or [their] behaviors,” warns Mr. Howard.
Enthusiasts for Medicaid sign-ups for ex-inmates build their hopes on research indicating that recidivism rates fall when prisoners and ex-prisoners receive mental health treatment. A 2010 study by David Mancuso of the Washington State Institute of Public Policy, a state-based policy think tank, found that for state residents enrolled in Medicaid and receiving substance abuse treatment, arrest rates dropped by as much as 33 percent compared with rates for those who didn’t receive treatment, leading to lower correctional costs and better public safety.
In any case, about 8 million prisoners leave America’s prisons and jails every year. Since the rollout of Obamacare last October, ex-offenders account for about 1 million of the 6 million new Medicaid beneficiaries enrolled in expansion states.
Better care inside than out
While incarcerated, prisoners have a constitutionally protected right to health care, with costs usually covered by the state (even if they have their own health insurance). Typically, privately contracted health companies or public hospital systems provide such care. Most jails and prisons have on-site clinics – in some cases, even full-service hospitals.
While some say the quality of prisoner care could be better, it’s more robust than what usually greets indigent ex-inmates on the outside. In many states, inmates who’ve been diagnosed with chronic conditions receive a small supply of medication upon release, but often no medical provider or insurance for refills – creating a gap in their health care. Correctional health professionals across the United States share stories of inmates who get rearrested so they can get medication.
Sells, who struggles with substance abuse, was back in jail as of early July for a probation violation. Sells is what the criminal-justice community calls a “frequent flier” for his intense cycling within the system and for the drain on public resources to keep him healthy and to prevent him from committing new crimes.
Substance abuse or mental health issues afflict the vast majority of prison inmates in the US. More than 1 million incarcerated people suffer from mental illness, the Department of Justice estimated in 2006 – almost half the total in custody. As for substance abuse, the picture is even bleaker, affecting between 60 and 80 percent of all inmates, found a 2013 report of the US Office of National Drug Control Policy.
Here’s one lens through which to view the scope of the problem: No mental health hospital in the US dispenses more medication than the Los Angeles County jails or the Cook County Jail in metro Chicago. Thirty-five percent of Cook County Jail inmates self-report mental health issues.
The ACA has changed the calculus, say criminal-justice professionals, who previously saw no way to rectify the health-care disconnect as inmates left custody. Pilot Medicaid-enrollment programs now exist in Rhode Island, Connecticut, Illinois’s Cook County, California’s Alameda County (Oakland area), and Maryland’s Montgomery County (Baltimore area).
For states and local governments leaping on the Medicaid-for-inmates bandwagon, it’s a win-win. Exiting prisoners receive a core benefits package that includes coverage for mental health and substance abuse disorders, and states or counties get a big influx of federal dollars that can help offset their own health spending.
Take Cook County, with an annual public health budget of $500 million in uncompensated care (of which $47 million is spent on inmates in custody). Since the county jail started enrolling exiting inmates for Medicaid last fall, federal dollars have come gushing into county coffers – to the tune of $632.48 per new patient per month. The public health system, moreover, has seen an 11 percent drop in the number of patients lacking health insurance – and ex-inmates are believed to have contributed to that decline. [Editor's note: The original version has been altered to clarify that $500 million represents just the uncompensated portion of the county's public health budget.]
“The Affordable Care Act has given [the county’s] public health system a level of financial stability that we have not seen in decades,” says Steven Glass, executive director of managed care for Cook County Health and Hospitals System. “Because of that stability we are able to provide care services to the broad community as well as the inmates leaving Cook County Jail.”
Connecticut at the forefront
The strongest case study might be Connecticut, which has one of the most comprehensive approaches to Medicaid enrollment in the nation. The state runs all its jails and prisons, making change easier to administer uniformly. It has four jails and 11 prisons, holding almost 17,000 inmates. Here, a person making less than about $15,800 a year qualifies for Medicaid.
The link is obvious between greater access to health care and lower recidivism rates, say state officials. “If you don’t feel well, you don’t act well,” says James Dzurenda, state correction commissioner. “The Affordable Care Act gives our released offenders access to health care, which is critical to release offenders back into the community safely, increase public safety, and ultimately reduce victimization.”
The New Haven Correctional Center, a jail that Mr. Dzurenda oversees, holds as many as 800 people. Inside the main facility, across from the dorms, sit the jail’s medical clinics, a series of gray rooms painted by inmates to denote the different sections. “Mental health” and “X-rays” pattern one door. One-quarter of patients here receive medication daily to treat an array of ailments – diabetes, mental illness, pain.
“In jail we see patients that are not taking care of themselves,” says Dr. Kathleen Maurer, correctional medical director for Connecticut, as she led a tour of the jail. “For many, this is the first time they are seeing the doctor.”
Upon release, an inmate fills out a Medicaid enrollment form, which is faxed through a secure line to the state Department of Social Services. There, the Department of Correction pays for five dedicated entitlement specialists to process benefits for inmates leaving the system.
Last year, Connecticut processed 7,794 Medicaid applications from state criminal-justice agencies. In the same period, state prison population and arrest rates dropped by about 3.4 percent, according to reports from the state Office of Policy and Management.
The next step here is to shift to electronic record keeping by the end of 2015, so that health professionals can track patients’ medical histories whether individuals are inside or outside the criminal-justice system.
“The Affordable Care Act will allow us to work with providers on the outside so we can better understand how to manage [inmates’] health needs,” said Dr. Maurer.
Jails are a natural place in which to try to enroll as many people as possible for Medicaid, simply because of the size of the population passing through, say many criminal-justice workers. The numbers, called “the churn,” are bleak: 11.6 million people were admitted into America’s 3,000-plus jails in 2012. Eighty-seven percent of them were male, and 6 in 10 were in pretrial detention.
“What is the opportunity to stop the churn?” asks Tracie Gardner, director of New York State policy at Legal Action Center, a group that fights discrimination against people with histories of addiction, HIV/AIDS, or crime. “Jails can be the place. We know from specialized programs focusing on HIV and mental health in jails that you actually can use that time to do an assessment – to get people connected to a kind of care, and create a continuity of care with their provider outside.”
Not a silver bullet
Enrolling in Medicaid does not guarantee an ex-inmate will instantly turn over a new leaf, of course. Moreover, the cumulative effect promises to be difficult to tease out: None of the programs now in place track inmates after they reenter the community, so there is no way to tell if ex-offenders are actually using the health insurance.
Often, ex-inmates stick with their former habits of heading directly to emergency rooms for care, driving up public health costs, according to a recent study of former prisoners in Rhode Island.
And some of those who work in the field say the additional paperwork surrounding Medicaid enrollment is simply too burdensome to be worth the while. “We do not have resources to do the enrollment right now,” says Joe Goldenson, medical director of jail health services at the San Francisco Department of Public Health.
Back in Connecticut, Sells reflects on how his view is changing as he nears age 50. Staying in “the game” is becoming less important, while medical care is becoming more so, he said before he was reincarcerated.
“Having my medical,” he said, “puts me on the right track to think about getting my life back in order.”
To help inmates transition into the health-care system on the outside, some clinics target their services to men and women returning home from prison and jail.
“Just because someone has insurance does not mean they are going to take the next step,” said Emily Wang, cofounder and director of Transitions Clinic Network, 11 clinics across the US that treat people leaving custody. “How do we keep prisoners engaged and find primary care providers they trust so they can see the real benefits of insurance?”
Researchers have found that former inmates who have primary care doctors go to the emergency room less often than those who don’t. The patients work with a community specialist, someone who has experience with or ties to incarceration. The approach is similar to that of “health homes,” which provide intense care coordination for clients with two or more chronic health conditions.
So far, many hope that linking ex-inmates to community health services will be a milestone in the annals of American criminal justice. “We do know that 95 percent of our patients [in Connecticut] are insured, in large part because of ACA and because of the work of the [state] Department of Correction,” says Dr. Wang. “Let’s not lose the momentum.”