Christian Heiss, MPH, CPH, and Shannon M. McMahon, MPA, CHCSDecember 13, 2014
For many people with mental illness — who lack access to health services and an adequate support system — jail has become a de facto home. Of the approximately 10 million individuals nationally who cycle in and out of local jails each year, roughly 14.5 percent of men and 31 percent of women have serious mental illness and more than 50 percent have a diagnosable substance use disorder. In New York City, the number of individuals in jail with mental illness has grown from 29 percent in 2010 to 38 percent in 2014, causing increasing concern for public health and safety. These trends are mirrored across the country (e.g., Cook County, Illinois and Los Angeles).
Research shows that increased access to health care services can help keep individuals away from the revolving door of repeat arrests. In Washington State, arrest rates are 21 to 33 percent lower among adults who receive substance abuse treatment compared with those who do not get treatment, leading to significant savings to local law enforcement, jail, court, state corrections departments, and potential victims. Yet, in the recent past, 90 percent of people who entered county jails had no health insurance, in large measure because there was not a coverage option for this group. Those with coverage were often dis-enrolled while in jail. Thus, the vast majority of individuals leaving jail lacked access to needed health services upon release.
Affordable Care Act Opens up Coverage Options for Jail-Involved
New health insurance coverage options that became available in 2014 under the Affordable Care Act (ACA) have the potential to dramatically change this landscape — particularly in states that have already or are considering expanding Medicaid. The ACA provides the option to expand Medicaid coverage for adults without dependent children up to 138 percent of the federal poverty level ($16,105 annual income for a single adult), along with federal support for marketplace coverage for individuals between 100 and 400 percent of the federal poverty level.
Many individuals with criminal justice involvement — who are disproportionately young, male, minority and poor — are potentially eligible for these new coverage options. Providing access to health coverage will support adults coming out of jail with mental illness and other chronic health issues not only with much-needed medical and behavioral health services, but also with housing and social supports to help them lead more stable lives. Adults who are eligible for Medicaid can enroll year-round. For those eligible for coverage via the ACA’s new health insurance marketplaces, recently proposed regulations allow individuals reporting a change in life circumstances — including those being released from prison or jail — to enroll in coverage through a marketplace outside of designated annual enrollment periods.
New Pathways for State and Local Government Collaboration
To take advantage of expanded health insurance coverage options, state Medicaid agencies and state and local corrections systems are collaborating in new ways to reach and enroll individuals with criminal justice involvement into health coverage. As discussed at a recent meeting of state and federal partners, hosted by the Center for Health Care Strategies (CHCS) and Community Oriented Correctional Health Services (sponsored by the Robert Wood Johnson Foundation and Flowers Community Initiatives), following are two key pathways to connect former inmates to much-needed care:
- Collaborative eligibility and enrollment processes for implementation in jail settings (e.g., state and local partnerships) that help facilitate the eligibility process for individuals and help them get enrolled in Medicaid upon release.
- Jail-based, pre-release care coordination that helps those who are Medicaid-eligible secure appropriate mental health and substance abuse services upon release and ensure continuity of care as individuals transition from jail to the community. Health homes and targeted case management are service delivery and payment models for states to consider for this type of work.
In New Mexico, the state Medicaid agency and Bernalillo County (which includes the state’s most populous city, Albuquerque) are launching a new effort whereby detention center staff will support both of the pathways described above. Detention center coordinators will work with inmates prior to release to connect them with medical and mental health and substance use services as well as enroll them in a health plan. To gauge the effectiveness of the effort, state officials will examine Medicaid enrollment, correctional expenditures, and any potential reductions in recidivism rates. CHCS is facilitating this effort with support of the Robert Wood Johnson Foundation’s State Health Reform Assistance Network.
In New York City, Mayor Bill de Blasio’s recently released Action Plan on Behavioral Health and the Criminal Justice System outlines numerous ways for the city’s Department of Health and Human Services and Department of Corrections to focus on treatment versus jail time for people with mental illness. Among the many recommendations, the Mayor’s report includes better training for first responders to direct individuals to treatment rather than jail when appropriate, as well as the establishment of “drop-off centers” for people who simply need 24-hour respite care, case management, and/or supervised withdrawal detox services. The plan also recommends enhancing discharge services to ensure that individuals who are released are connected both to new Medicaid coverage options and to health homes to coordinate additional services as needed, including behavioral health, housing, employment, parenting, substance use treatment, etc.
In Minnesota, Hennepin Health, a county-based program that offers medical, behavioral health, and social services for low-income Hennepin County residents, was recently awarded State Innovation Model funding to improve outcomes for individuals with criminal-justice involvement. Hennepin’s “accountable community for health” will bring together Hennepin County health and correction agencies with community-based organizations to ensure health care coverage, improve health outcomes, reduce homelessness, increase employment, and reduce repeat visits to local jails and adult correctional facilities.
Health Coverage Offers Promise to Curb Recidivism
A recent New York Times editorial aptly lauding New York City’s bold move to revamp health and social service access for former inmates with mental illness, cautioned that jail should not be the “housing of last resort” for this vulnerable population. New health insurance coverage facilitated by the ACA — particularly Medicaid in states that have elected to expand coverage — provides an unprecedented opportunity to avoid this scenario by connecting individuals leaving jails to physical and behavioral health services and social supports in their communities. Doing so can smooth reintegration for people with mental illness, help them transition into healthier lifestyles, and ultimately, curb recidivism.
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