The Medicaid expansion component of the Affordable Care Act (ACA) provides several opportunities for policy, data and funding linkages that offer states the promise of more efficient care delivery and improved health outcomes.
Perhaps nowhere is this possibility greater than at the nexus of the public health and criminal justice systems.
The ACA expands Medicaid eligibility to include adults without children who have incomes up to 133 percent of the federal poverty level (FPL).
Most people involved in the criminal justice system fall into this category of adults: young, lower-income, non-disabled males who did not previously qualify for the Medicaid program.
This article focuses on new opportunities for states to address the health care needs of people involved in the criminal justice system — either those awaiting jail time, about to be released or involved in post-release programs.
A population with challenging needs
Historically, the justice-involved population is among the largest group without health insurance.1
Also, people moving in and out of the criminal justice system face a variety of social challenges — poverty, unemployment, lower education levels, lower literacy rates and homelessness — which contribute to their health care needs often being undertreated or untreated.
The incarcerated population is much more likely than the general public to:
- Suffer from mental health or behavioral conditions
- Have substance abuse disorders (SUD) related to alcohol or drugs2
- Suffer a higher level of chronic diseases such as diabetes, asthma, hypertension, arthritis, cancer, HIV, hepatitis B and C and tuberculosis3
Many face care needs in all three categories. As has been widely documented in the justice system, co-occurring disorders ─ mental health, substance use disorder, and physical health conditions ─ are “more often the rule than the exception in justice settings.” 4
Medicaid eligibility can provide access to health care coverage that can be used to address the health care needs of this population.
Not only are these individuals now eligible for a broad range of medical and social services, but states and local municipalities can leverage high federal matching rates to create specialized programs to serve the at-risk criminal justice population and help reduce recidivism.
Opportunities for state involvement
At a time of almost unprecedented innovation in the delivery and payment for health care services, opportunities for states to positively impact the health of the non-incarcerated, justice-involved population abound.
They involve a combination of policy, technology and care coordination efforts that fall under two main categories:
- Jail diversion programs (JDP) provide access to health care and social support services that can either reduce jail time or prevent it altogether.
JDPs are intended for low-level offenders charged with nonviolent misdemeanors, nonviolent crimes related to substance abuse, or nonviolent offenses related to mental illness.
Under the ACA, states can receive federal matching rates to create specialized programs to serve at-risk populations that are not traditionally viewed as “health” programs, so long as they hold the potential to improve health outcomes and reduce costs.
These can include jail diversion programs that focus on reducing or preventing substance abuse.
A number of reports suggest that jail diversion program focused on those individuals with substance abuse issues or behavioral health problems actually reduce criminal justice costs and improve health outcomes and access to needed health care services.5,6
They also reduce substance abuse and lead to improved mental health, without threatening public safety.
- Collaborative partnerships between Medicaid and the criminal justice system improve health and social services for those offenders who:
- Are awaiting incarceration
- Require inpatient hospitalization while incarcerated
- Are about to be released, or involved in post-release programs (probation, work-release programs, parole, etc.)
Federal law generally prohibits states from using Medicaid funds to pay for inmates’ health care. However, Medicaid can cover inpatient care for otherwise eligible inmates who are released from jail and admitted to hospitals for a day or longer — the so-called inpatient exception.
While the ACA does not change the restriction on using Medicaid funds for inmate care, it significantly increases the number of inmates who are eligible for the inpatient exception.
It does so by expanding general Medicaid eligibility to single adults, thereby offering the potential to treat inmates more holistically and in ways that may reduce future health complications and costs.
Within these major categories, states can take the following specific steps to improve the health of the justice-involved population:
- Suspend Medicaid benefits rather than terminate them. When individuals are incarcerated, most states terminate Medicaid benefits. Problems arise, however, as inmates are about to be released.
Administrative delays — and in some cases state regulations — often result in a gap of several weeks before coverage resumes, a critical time period, especially for former inmates struggling with mental illness or substance abuse issues.
This is often the case regardless of how long an individual is incarcerated — a one-month stay in prison could result in many months without health care upon release (during which time former inmates must rely on expensive emergency room treatment or simply go without care).
The sooner that coverage begins or resumes — preferably on day one of release — the sooner at-risk former inmates can receive services that will provide stability when they re-enter society.
Such an approach offers treatment to individuals immediately rather than waiting for their issues to become more acute, therefore improving overall health and reducing costs.
- Determine eligibility and facilitate enrollment. Based on income levels, the vast majority of people in jails and on probation or parole will be eligible for Medicaid services under the ACA.
State agencies can implement “presumptive eligibility” so that individuals can start receiving services immediately upon release until formal eligibility is determined.
With proper training, corrections and supervision agencies, working with Medicaid, could quickly (and electronically) determine eligibility and enroll these at-risk individuals in health coverage.
Enrollment in Medicaid (or health exchange) coverage should be a step in pretrial processing for discharge and prerelease “re-entry” planning.
Policy experts point out that the first step in this effort is to identify the location of enrollment, which can include:- At the county jail during initial intake
- At the county jail post-arraignment and pretrial
- At the county jail, prerelease; through the probation department’s initial assessment
- Other places in between
Studies in Florida and Washington found that people with severe mental illness who were enrolled in Medicaid at jail release were more likely to access community mental health and substance abuse services than those without Medicaid.7
Those studies also found that 12 months after release, Medicaid enrollees had 16 percent fewer detentions and stayed out of jail longer than those who were not enrolled, or enrolled for a shorter time.8
In a 2014 report from the National Association of State Mental Health Program Directors, Peter Koutoujian, sheriff of Middlesex Co. in Massachusetts, noted that approximately 85 percent of their sentenced population is struggling with addiction and/or mental illness.
For this population, he states “Leaving the jail with health care coverage and a mental health care provider can mean the difference between maintaining a healthy path of rehabilitation, or reoffending due to a lack of mental health treatment.”9
- Implement creative models of care. For programs to be successful, they need to link justice-involved people to community-based, patient-centered care. States have the opportunity to be creative in this effort, including:
- Treating the justice-involved population at clinics in the underserved and crime-heavy neighborhoods in which they live
- Focusing on substance abuse treatment, which affects so many former inmates
- Establishing health homes that meet the unique needs of this population, such as treatment for serious and persistent mental illness
- Coordinating care efforts by providing transitional and primary care with case management to former inmates with chronic health needs — among them diabetes, hypertension, HIV and behavioral problems
Community-based care is the best way to engage this population and focus on their specific health and attendant social service needs.
A recent Washington study showed that increased funding over five years of substance abuse treatment for disabled justice-involved Medicaid adults increased their engagement and coincided with a 50 percent reduction in growth rates of medical and long-term care costs.10
Implemented on a wide scale, community-based care holds the promise of improved outcomes, reduced costs and lower recidivism rates.
- Look beyond “traditional” health care. As mentioned above, under the ACA, states can receive federal matching rates to create specialized programs to serve at-risk populations that are not traditionally viewed as “health” programs.
In addition to JDPs, these can also include other programs such as housing stabilization for high-risk, chronically homeless individuals with wrap-around physical, behavioral and social support services.
Supportive housing, especially, has proven to be a net cost-saver for the justice-involved population.
One study showed that providing housing and support services resulted in a 73 percent reduction in total emergency-related costs, a 34 percent decrease in emergency room costs, a 66 percent reduction in inpatient costs and an 82 percent reduction in detox visits.11
Such housing could be provided in conjunction with a jail diversion program, or be a standalone program that could also focus on newly released inmates, providing transitional housing until they could become full-fledged members of society and stand on their own.
- Use technology and analytics to collaborate, link programs and measure success.
Each approach to serving the justice-involved population requires technology and analytics to link disparate programs and agencies — corrections, courts, Medicaid, behavioral health, social services, housing, law enforcement — and to measure success on an ongoing basis.
Justice system officials and public health officials can, where possible, use technology and share data to:- Track inmate movement to determine when health coverage should start or resume and what services they will require
- Streamline and automate enrollment
- Match inmate needs and issues with care programs, facilities and providers
- Help ensure care coordination.
Individuals moving in and out of the criminal justice system are mostly uninsured, low-skilled, low-income individuals facing significant physical and mental health issues.
There is no doubt that these individuals present among the biggest challenges for states as they work to improve overall population health and reduce both health and incarceration costs.
Expanded Medicaid eligibility under the ACA offers states a unique opportunity for their criminal justice and health agencies to connect and address the physical, behavioral, and social health needs of justice-involved individuals.
1 Gates A, Artiga S, Rudowitz R. Health coverage and care for the adult criminal justice-involved population. Kaiser Commission on Medicaid and the Uninsured. kff.org/uninsured/issue-brief/health-coverage-and-care-for-the-adult-criminal-justice-involved-population. Published Sept. 5, 2014, Accessed Oct. 4, 2017.
2 James D, Glaze L. Mental health problems of prison and jail inmates. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. September 2006.
3 Gates et al.
4 Peters R, Wexler HK, Lurigio AJ. Co-occurring substance use and mental disorders in the criminal justice system: A new frontier of clinical practice and research. Psychiatric Rehabilitation Journal; 2015, 38(1):1. apa.org/pubs/journals/features/prj-0000135.pdf.
5 The TAPA Center for Jail Diversion. What can we say about the effectiveness of jail diversion programs for persons with co-occurring disorders? Substance Abuse Mental Health Services Administration; 2004.
6 Steadman, HJ, Naples M. Assessing the effectiveness of jail diversion programs for persons with serious mental illness and co-occurring substance use disorders. Behavioral Sciences and the Law. 2005;23(2):163–170.
7 Morrissey J, Steadman H, Dalton K, Cuellar A, Stiles P, Cuddeback G. Medicaid enrollment and mental health service use following release of jail detainees with severe mental illness. Psychiatric Services; 2006; 57(6):809–815.
8 Morrissey JP, Cuddeback GS, Cuellar AE, Steadman HJ. The role of Medicaid enrollment and outpatient service use in jail recidivism among persons with severe mental illness. Psychiatric Services; June 2007; 58(6):794–801.
9Miller J, Glover R. Strategies to enroll uninsured people with mental health conditions under the Affordable Care Act. National Association of State Mental Health Program Directors. nasmhpd.org/sites/default/files/NASMHPDEnrollment%20Issue%20Paper%20__January%202014.pdf. Published Jan. 2014. Accessed Oct. 4, 2017.
10 Mancuso D, Nordlund DJ, Felver BEM. The impact of substance abuse treatment funding reductions on health care costs for disabled Medicaid adults in Washington State. Olympia (WA) Department of Social and Health Services. April 2013. RDA Report No. 4.88. dshs.wa.gov/sesa/rda/research-reports/impact-substance-abuse-treatment-funding-reductions-health-care-costs-disabled-medicaid-adults-washington-state. Accessed Oct. 8, 2017.
11 Perlman J, Parvensky J. Denver housing first collaborative: Cost benefit analysis and program outcomes report. Colorado Coalition for the Homeless. 2006.