Jails and Detention Centers
At midyear 2010, nearly 750 000 individuals were incarcerated in county and city jails in the United States on a single day; of these, 61% were awaiting court action on the current charge (e.g., the pretrial population).19 In 2010, 12.9 million people were admitted to these types of facilities, making them a prime population to target for Medicaid enrollment and services on release. This policy development offers a wide range of possibilities for increasing access to community health care, reducing recidivism, improving the reentry process, and engaging criminal justice agencies in Medicaid enrollment.
The size of the jurisdiction’s jail or detention center may affect the opportunities for intervention, because this population has a wide range of average weekly turnover (51.5%-136.7%). Overall, smaller jails see greater turnover than larger jails (Table 1), so the time needed for enrollment and other reentry planning will need to be tailored to the length of time an individual is incarcerated.
Prison and Community Corrections
Those released from prison are also likely to benefit from the expansion of Medicaid to childless adults starting in 2014. Although 1.6 million adults were incarcerated in federal and state prisons in 2009, 730 000 were released that year (21% higher than releases in 2000).20 A recent study has estimated that as many as one third (33.6%) of those released from prisons annually could enroll in Medicaid after the expansion becomes effective.21Of the nearly five million people already involved in community corrections, most are on active supervision (which may require participation in some type of treatment).22 (“Community corrections” refers to the supervision of criminal offenders in the resident population, as opposed to confining them to secure correctional facilities; the two main types of community corrections supervision are probation and parole.) Hence, opportunities also exist to expand Medicaid enrollment for those reentering from prisons and those already in the community but still in need of services. Those able to access adequate treatment may be at reduced risk of probation violation or re-arrest for behaviors related to untreated mental health problems or addictions.
The new Medicaid enrollment guidelines include a number of changes that should make it much easier to enroll in the program than the current process.23 In general, the new system is designed to enable individuals to apply independently (including via a home computer connection), although many of those in the homeless population will want or need assistance in doing so. Improvements include moving to a modified adjusted gross income, faster determination timelines, electronic verification of information, more flexible residency and address options, limited use of paper documentation, a 12-month renewal process, and application assistance if needed.
These improvements should make applying for Medicaid (and reenrollment) easier for both clients and those assisting them. Because under the new system an application can be submitted online with electronically verified information, personnel working in jails and prisons now have a greater opportunity to participate in the enrollment process as part of reentry standard operating procedures.
HEALTH STATUS OF THE CRIMINAL JUSTICE POPULATION
A wide body of literature has focused on the health status of those involved with the criminal justice system, who demonstrate poorer health than the general population, increased rates of chronic and infectious disease, and very high rates of behavioral health disorders.24,25
Chronic and Infectious Disease
One report on medical problems of jail inmates found that half of women (53%) and one third of men (35%) reported a current medical problem; the most commonly reported conditions were arthritis (19% and 12%, respectively), hypertension (14% and 11%, respectively), asthma (19% and 9%, respectively), and heart disease (9% and 6%, respectively). 26 One study conducted in Maryland jails found that nearly 7% tested positive for HIV, and the prevalence of HCV reached nearly 30% and that of hepatitis B reached just more than 25%.27 Overall, persons released from criminal justice venues (both jails and prisons) have been found to represent 17% of the total AIDS population, 13% to 19% of those with HIV, 12% to 16% of those with hepatitis B, 29% to 32% of those with HCV, and 25% of those with tuberculosis.28 These conditions pose important public health implications, as well as significant fiscal expenditures for criminal justice agencies responsible for providing needed health care.
Behavioral health conditions are particularly prevalent in a criminal justice setting. One study found that 64% of those in jail have some form of mental illness,29 and another study found serious mental illnesses in nearly 15% of the men and 31% of the women, which is more than three to six times those rates found in the general population.30 Other research has found that 10% to 15% of those in state prisons also have severe mental illness.31 The prevalence of substance use is even higher. More than two thirds of jail inmates are dependent on or have abused alcohol or drugs (with men and women having similar rates).32 The rates of substance abuse among jail inmates can be as much as seven times that of the general public.33 Often, mental illness and substance abuse are co-occurring conditions in this population. In jails, an estimated 72% of individuals with serious mental illness have a substance use disorder.34 In prisons, individuals with co-occurring disorders ranged from 3% to 11% of the total incarcerated population. 35 Clearly, addressing mental health and substance use disorders must be a priority for both community health care providers and the criminal justice system.
ESSENTIAL HEALTH SERVICES
The ACA requires Medicaid coverage for the newly eligible population to include 10 categories of services: ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.1
Many of those who have criminal justice system involvement-and those individuals who might experience homelessness-will have access to insurance that covers a wide range of health care services, particularly behavioral health care. Increasing the availability of ongoing communitybased health care services has the potential to improve health and stabilize behavior, thereby decreasing the risks of (re)arrest, incarceration, and homelessness. It is possible that those who do enter the justice system could have improved health status, and those who leave could be better connected to community care that helps maintain stability after release. As one example, a Washington State study found that rates of rearrest were 21% to 33% lower in three groups treated for chemical dependency than among other adults needing, but not receiving, treatment. This reduction saved $5000 to $10 000 for each person treated.36,37 At the same time, future funding for services targeted to this population such as mental health and substance abuse treatment grants, Services in Supportive Housing, and Ryan White HIV/ AIDS programs are uncertain. Framing the conversation in terms of cost savings and a larger public health interest may help engage a broader range of support among public policymakers.