“Prisoners are the community. They come from the community, and they return to it. Protection of prisoners is protection of our communities.” -Joint United Nations Program on HIV/AIDS, 1996
Under the Affordable Care Act, an estimated 4 million people who have spent time in jail will have better access to health coverage for conditions that might — if left untreated — result in higher health care costs and an increased risk of recidivism. That’s the conclusion of an analysis by researchers at the George Washington University School of Public Health and Health Services (SPHHS).
“Health reform gives people with a history of jail time access to continuous health care for the first time ever,” says lead author Marsha Regenstein, PhD, who is a professor of health policy at SPHHS. “The hope is that such coverage will help keep individuals and entire communities healthier and reduce the nation’s health care costs.” The report appears in the March issue of the journal Health Affairs.
Jails, unlike prisons, typically house offenders who have been detained or arrested by the police — often for misdemeanors or nonviolent crimes. In many cases, people who are mentally ill, have substance use problems or are homeless and picked up and sent to jail for a short period and then quickly released back into the community. Without follow-up care or treatment they are at risk of another arrest and the cycle repeats, according to the authors of the new report.
Counties, cities and other localities operate more than 3200 jails across the nation and they are responsible for providing some level of health care to inmates while they are incarcerated. “The Affordable Care Act doesn’t change that responsibility but it does mean that many in the jail population will be able to get health coverage before and after time spent in the local jail,” said co-author Sara Rosenbaum, JD, the Harold and Jane Hirsh Professor of Health Law and Policy at SPHHS.
Medicaid does not provide coverage for people serving time in jail. The Affordable Care Act does nothing to change that situation. However, under the ACA people with a history of a jail stay may be eligible for Medicaid coverage upon release — particularly if they live in a state that has opted to expand its Medicaid program.
According to the analysis an estimated one out of six people expected to enroll in Medicaid under the new state expansion programs will have spent some time in jail during the past year. To date, 25 states and the District of Columbia have expanded Medicaid programs to cover more of the low-income population.
And this report says another one out of ten people enrolling in health plans under the insurance Marketplaces will have a history of a recent jail stay. Under the ACA, people who are poor but still do not qualify for Medicaid can often purchase an affordable health plan by going to the online insurance Marketplaces.
The promise of continuous coverage would mean that people with serious mental illness or substance abuse might get medication and treatment that would help them stay off the streets — and possibly out of situations leading to an arrest in the future. Almost three-quarters of people incarcerated in jails meet the criteria for mental illness at the time of their booking and the same high number have problems related to alcohol or drug abuse, the authors note.
But such positive outcomes can be expected only if community jails, insurers, and health care providers work together to coordinate services so that people coming out of jails can sign up for Medicaid or a qualified health plan and then get an appointment quickly at the local clinic or health care provider, Regenstein said.
In some cases, jails identify chronic health problems and provide health care for inmates. But they rarely connect with or have ties to providers in the community, Regenstein says. Without those ties and the resulting treatment inmates can be released with an infectious disease or health problem that goes unaddressed and then worsens or even spreads to others.
While most jails still rely on paper records, the use of electronic information exchanges could help ensure a healthy and smooth transition to the community, the authors contend. Such electronic health records could follow the patient once they are released or vice versa. Providers in jail or in the community could then follow-up on a patient’s chronic condition such as diabetes or asthma and ensure that medications or treatments are available before, during or after a jail stay.
Finally, jails are realizing they must work closely with Medicaid offices and health insurance navigators in order to identify and enroll people who qualify for health plans. The challenge is that jails have limited staff or resources for this kind of outreach, the authors said. There are also many logistical barriers that make it hard for jail inmates to produce the kind of documentation they need to qualify for and enroll in a new health plan.
The authors conclude that the opportunities offered by the ACA for this population outweigh any barriers and could benefit not just individuals but entire communities. “Enrolling people who are to be released from jail will require substantial effort and resources,” says Rosenbaum. “However, this investment will pay off in terms of better health, reduced costs and possibly the reduced risk of additional jail time.”
Improving the availability and quality of health care for current and former jail inmates has major public health benefits that extend far beyond the correctional population. Jail inmates and the soon-to-be-released inmates are disproportionately inflicted with illness and tend to be sicker, on average, than the U.S. general population. The changing characteristics of the reentry population and their demographics have a direct impact on the prevalence of disease in the population. Chronic medical conditions, infectious diseases, mental illness, and substance abuse are common within jails and soon-to-be-released populations. Almost all jail inmates will return to their communities within weeks or months of entering the facility, bringing with them a host of health and social needs that must be addressed. Additionally, negative societal attitudes towards current and former inmates often make reentry into the community even more difficult and presents a significant barrier to providing adequate health care services to this population. Yet the public is largely unaware of the health needs of released inmates, and the risks and challenges they present to their communities are not being addressed explicitly, despite the fact that reentry directly affects almost every community in the country.
Communicable diseases are one major problem facing jails and communities. Owing to crowded conditions, jail inmates pass on their infections to other inmates, staff, and their own friends and families who visit them. Or they contract communicable diseases themselves and slip through shoddy screening and substandard treatment programs. Left untreated inside jail, inmates eventually leave, usually returning to the communities in which they were sentenced. Back home, they risk infecting families, friends, and—if they engage in violent crime—complete strangers.
Mental illness and substance abuse also run rampant in the nation’s jails. According to the Bureau of Justice Statistics, 75% of the female inmate population and 63% of the male inmate population in local jails suffer from mental illness. Among inmates with a mental illness, over two-thirds also have comorbid substance abuse disorders. Left untreated, psychiatric and substance use disorders significantly increase the risk of reoffending and rearrest, presenting a major problem for communities as well as former inmates attempting to reintegrate into society.
In addition, individuals with physical and mental health problems have poorer outcomes in employment, housing, and reintegration into society than those without such problem. Mentally ill men and women and substance-abusing women are more likely to be homeless upon release from jail, and individuals with substance abuse problems engage in more criminal behavior and are more likely to earn money through illegal activities. Having any type of health condition upon reentry is associated with engaging in criminal activity and having a higher likelihood of being re-incarcerated. Thus, in addition to the public health consequences, substandard health care among current and former jail inmates has negative implications for the local economy, public safety, and overall community stability.
The public health implications of substandard health care in our nation’s jails continue to grow as correction institutions, educators, and community leaders fail to properly address health care issues involving inmates. Prejudice plays a key role in erecting barriers that prevent inmates from receiving the same quality of health care that is afforded to free members of society. Politicians, with their “lock ’em up and throw away the key” attitudes, further exacerbate the problem.
Given the close association between correctional facilities and the community, it has become apparent that a tremendous public health opportunity exists within the penal system. The opportunity to intervene with a population at high risk for many physical and mental illnesses benefits individuals, their communities, and society at large with reduced disease rates, financial savings, improved public safety and better use of the health care system. The Affordable Care Act provides an opportunity to develop a system of continuing care to improve the health outcomes of current and former inmates, as well as the communities they will ultimately return to.
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