By Robert B. Barnett Jr., J.D.
The expansion of Medicaid permitted by the Affordable Care Act (ACA) has helped states develop a range of promising approaches to providing care to people leaving jail or prison, according to a Commonwealth Fund issue brief. Although state approaches vary, the brief noted that successful programs typically have (1) data exchanges to know when a person is leaving jail or prison, (2) "in-reach" services to help inmates establish a relationship with a primary care provider before being released, (3) strategies for addressing non-healthcare considerations, such as finding a home and food, that affect health, (4) a peer support specialist to help navigate health care and social service resources, and (5) health providers with training and expertise in working with former inmates.
Given that 33 states and the District of Columbia have expanded Medicaid to all adults with incomes below 138 percent of the federal poverty level, opportunities exist for improving the way our society integrates just-released inmates into the health care system. The hope is that the programs will not only help the released inmates but will also benefit society by lowering recidivism rates and reducing emergency room visits. States estimate that high percentages of inmates are Medicaid-eligible upon their release (New York estimates 80 percent, while Colorado estimates 90 percent). Given the potentially high costs associated with people who cycle in and out of hospitals, homelessness, and prisons, some states are trying to seize the opportunity to improve health outcomes for just-released inmates.
Medicaid enrollment. Once upon a time, Medicaid coverage was terminated when an individual entered prison. Today, states are suspending or reclassifying coverage to enable them to obtain coverage immediately upon release. Even if an inmate is not enrolled at the time of incarceration, states are permitting inmates to enroll while incarcerated, including at the initial intake. In some states, Medicaid enrollment is part of the release planning process, which typically occurs at least 30-45 days before the release date.
Data exchanges. Arizona uses an automated data exchange system to identify when a Medicaid beneficiary is released. It now shares the data daily with managed care plans to support better care delivery. In New York City, health homes exchange data with the New York City agency responsible for inmate health services in city jails to identify release dates. Once a date is determined, the health homes initiate outreaches, which include a staff member visiting the former inmate in the home to begin health care planning.
In-reach. Ohio enrolls eligible inmates into Medicaid 90 days before their release and asks them to select a Medicaid managed care plan. The selected plan then conducts in-reach with inmates to assess their needs and identify a primary care provider. Special considerations are given to inmates with serious illnesses. New Mexico requires that Medicaid managed care plans coordinate care for those inmates who are released, which includes returns to tribal communities and reservations. Plans are required to designate a contact person for communications with prisons, jails, and detention centers. Recidivism rates have dropped to 16 percent from 57 percent in three years, and emergency room use has dropped by 64 percent.
Social considerations. For many released inmates, finding food, housing, and job are more immediate concerns than finding health care. In New York City, the Brooklyn Health Home network employs 400 community-based care managers who spend 70-80 percent of their time working directly with clients, including finding housing, filling out applications, and providing medical treatment navigation. Brooklyn Health Home has established formal relationships with housing organizations and has trained its care managers on housing applications.
Peer support. The Transitions Clinic Network, which operates in several states, uses community health workers with a history of incarceration to reach out to parole officers, hospital emergency rooms, faith-based organizations, and homeless encampments to help provide primary care to inmates who are leaving prison. These workers make referrals to physical and behavioral health services, accompany the individual to appointments, provide advice on housing and employment, and help them obey release conditions. On average, they meet with each patient five times in nonclinical encounters. One study found a 50 percent reduction in hospital emergency room visits.
Special training. In Albuquerque, care managers who go to prisons are provided the same training as correctional officers, which allows them greater freedom of movement within the prison. In San Francisco, where the first Transitions Clinic was established, the Network has worked with a local community college, the City College of San Francisco, to develop a post-prison community health worker certificate program. The course is now available online for community health workers around the country.
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