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Insurance is Not Enough: Addressing the Health and Social Needs of the Criminal Justice-Involved

An inmate stands in his cell at Men's Central Jail in Los Angeles, California (REUTERS/Jason Redmond).

Editorial note: This blog was adapted from an article in the March 2014 Health Affairs, "Integrating Correctional And Community Health Care For Formerly Incarcerated People Who Are Eligible For Medicaid." 

Under the Affordable Care Act, up to 13 million adults have the opportunity to obtain health insurance coverage through an expansion of the Medicaid program. As many as 2.86 million or 22%, of them will be justice-involved – people who are incarcerated, on probation, or on parole. This expansion is a promising step forward since nearly 90% of individuals released from prison lack health insurance coverage.

However, health insurance coverage alone is not sufficient to effectively link any individual to proper community-based health care. Much like a driver's license does not guarantee access to a vehicle or intricate knowledge of the highway system, an insurance card does not ensure the availability of a provider or a patient’s ability to successfully navigate the health care system.

This is especially true for the justice-involved population.

These individuals are at far greater risk for disease, and have higher rates of physical and behavioral health issues, including infectious disease and substance use. The Bureau of Justice Statistics has reported substance abuse rates in excess of 80%, while nearly 50% of all jail inmates exhibit symptoms of co-occurring mental illness and substance abuse or dependence. Justice-involved people also generally have higher rates of learning disabilities and lower literacy, making it even more difficult to navigate the health care system.

To further complicate their already challenging situation, these individuals also suffer from pervasive social issues, such as poverty, unemployment, unstable housing and homelessness, and varying degrees of personal and family problems. As a result, once they return to the community seeking health care will often rank low on a list of competing priorities, including securing employment and housing, and reestablishing family and community relationships with limited financial resources and social support. Therefore, we must acknowledge that successfully connecting these individuals to health care resources will help mitigate further risk and accommodate their unique spectrum of physical, social and mental health needs.

Further, we must acknowledge that if not addressed the lingering disparity between disease burden and access to care will continue to drive health care costs, worsen health outcomes, and perpetuate the unfortunate marginalization of a high-risk, high-need population. While it is critical to better understand insurance enrollment strategies for prison populations, it is also critical to better anticipate their health care needs and prepare the delivery system to meet those needs efficiently and effectively.

Successful Models of Care
Several care models have been particularly effective in linking justice-involved people to community-based care. Three unifying themes characterize these successful models of care:

  • Effectively reach individuals and establish a consistent source of care to improve individual and population health
  • Increase access to substance abuse treatment to reduce health care costs
  • A link to consistent health care after release from jail results in lower recidivism (or reincarceration), particularly for those with behavioral health care needs (e.g., mental illness, chronic disease)

Project Bridge and the Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS) (Rhode Island): Project Bridge personnel go into prisons, identify HIV-infected inmates before they are released, and link them to a hospital-based clinic for their post-release care. Using an intensive case management system, Project Bridge successfully retained former prisoners in post-release medical care by providing support services for their nonmedical challenges.

Transitions Clinic (currently operating in ten U.S. cities): Transitions Clinics are located in neighborhoods with high concentrations of formerly incarcerated people and provide transitional and primary care with case management to former inmates with chronic health needs. The clinics provide referrals to community organizations for necessary social support services, and case management from trained community health workers who were previously incarcerated. The model depends on robust information exchange and has been shown to successfully engage this population in post-release care by addressing both transitional and primary health care needs.

Michigan Prisoner Reentry Initiative Michigan (statewide): This statewide program offers coordinated care for recently released prisoners, specifically by using community health workers to connect former prisoners with serious medical needs to a patient-centered medical home. An analysis of 2,000 people in the program found that the recidivism rate for people who had been on parole for two years fell from 46% in 2007 to 24% in 2012. The state saved an average of $31,000 annually for each prisoner who did not return to prison.

Policy Implications
Despite the growing evidence base and the tremendous progress made by these programs, barriers to engaging justice-involved people in consistent health care must be addressed in future public policy. Here we present four recommendations for policymakers, Medicaid agencies, criminal justice institutions, clinicians, and other stakeholders who collectively seek to achieve better care for justice-involved populations.

New competencies: Effective engagement of justice-involved individuals will require new competencies across all settings, and requires a broad understanding of their complex and interrelated health, legal, social, and economic needs. Providers in both criminal justice and community-based health care settings need to be exposed to different competencies across medical and behavioral health fields and understand this population’s simultaneous health, legal, and socioeconomic challenges. Some emerging models of care such as Accountable Care Organizations (ACOs) and patient-centered medical homes are addressing these issues, but efforts should be broadened to include the larger health care delivery system.

Robust collaboration: Effective engagement will also require collaboration between criminal justice personnel, community health care providers, and social support services. The programs mentioned here indicate that linkage to care, information exchange, and coordination between corrections and community health care settings are feasible and cost-effective. Policy makers at the local, state, and federal levels have key roles to play in reducing the barriers necessary to share information and coordinate care across these settings. At a minimum, policy makers need to facilitate the development of partnerships among corrections professionals, health plans, and community providers.

Systemic barriers: Many people who leave the criminal justice system—and their new health care providers— must wait for weeks, if not months, for accurate copies of their medical records. While new systems are attempting to reconcile these issues, regulatory alignments and policy guidance are also needed to ensure the appropriate transfer of information between the criminal justice and community health care domains.

Wide-ranging benefits: Policy makers should recognize the opportunities for cost savings by coordinating services across health care and the correctional health sectors. By reducing barriers to collaboration across clinical and nonclinical settings, we can expect a number of benefits for clinically and socially complex subpopulations.

Overall, we see great potential for collaboration between criminal justice and community-based health care systems. Such collaboration is essential to achieving the clinical and cost objectives of a high-value health care system that serves the greatest possible number of people— including those who have been involved in the criminal justice system. By learning from and building on the evidence and the models of care that have been developed, as well as identifying the necessary elements of their transformation, the nation’s expansion of access can result in better care and overall improvement in other determinants of health among formerly incarcerated people, including employment and recidivism.

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