Q&A: Obamacare is changing the health outlook for inmates, and some of the best stories are local

This is the second part of a two-part interview that offers context and tips for reporters covering the health of some of California’s most vulnerable populations. Find the first part here. — Ed.

Last week, we caught up with Shannon McConville, a researcher with the Public Policy Institute of California, who discussed new ways for journalists to cover health reform. This week, McConville explores her recent research on jail inmates and the role of the Affordable Care Act in extending health coverage to this vulnerable population.

Health reform has provided a new opportunity for California to enroll its jail population in health coverage, as McConville details in the new PPIC report she published with colleague Mia Bird. This population is composed largely of low-income single adults who have much higher rates of infectious disease and mental health and substance abuse needs. While inmates receive health care services from county jail systems while they’re incarcerated, very few have coverage after they’re released. The ACA provides an opportunity to change that.

Q: Why did you decide to look into this inmate population?

A: We were interested in the overlap between the Affordable Care Act and the criminal justice system in the California context. The public safety realignment of 2011, which shifted supervision of lower-level felons from the state to the counties, created a situation where county jails are now responsible for a larger group of California’s correctional population. This shift toward local responsibility increased incentives for county justice systems to invest in reentry programming, or coordinated services and supports designed to help former inmates transition back into the community and avoid further contact with the criminal justice system. Now that the ACA provides options for public insurance coverage through Medi-Cal, California’s Medicaid program, it’s easier to extend health insurance to this group.

Q: How has the ACA’s insurance expansion affected these populations?

A: In addition to the ACA’s expansion of Medicaid eligibility to much of the currently uninsured jail population, California also recently signed into law Assembly Bill 720, which facilitates the use of jails as sites of health insurance enrollment. Increasing enrollment levels for the jail population could reduce corrections cost as well as improve public health and safety.

Q: How does increasing health care enrollment reduce costs and help public health?

A: The jail population has substantial health needs, and inmate health care plays an important role in driving up correctional costs. More than a quarter of the average costs of prison incarceration per inmate in California comes from health expenditures, according to the Legislative Analyst’s Office (LAO) reports. Even though the federal “inmate exception” rule does not allow counties to get reimbursed through Medi-Cal for health services provided within the jail system, Medi-Cal can cover the cost of inpatient hospital care for inmates who are offsite for more than 24 hours.

Given how often jail inmates cycle in and out of custody, access to health care could also help manage chronic conditions, indirectly reducing the costs of in-custody care.

Along with costs, there are also significant public health benefits from increasing insurance coverage for the jail population. Since there are high rates of infectious disease among those cycling between jails and the community, diagnosis and treatment can help maintain their health as well as the health of their families and the overall community.

Q: You write that “Health insurance enrollment could also help reduce the likelihood that individuals will cycle back into the corrections system.” Why is that?

A: Individuals enrolled in Medi-Cal can receive coverage for substance abuse and mental health services. Substance abuse treatment can substantially reduce recidivism, studies show. In California, for example, a recent cost-benefit analysis of substance abuse treatment in 13 California counties found that the intervention substantially reduced recidivism, as well as corrections and health care costs. Similar research conducted in Washington demonstrated that treatment for chemically dependent individuals reduced recidivism.

Q: Your paper mentions the 2013 state law that facilitates enrollment assistance within jails that removed many barriers to enrolling these populations. What other efforts have been made to enroll these populations?  

A: Well since ACA implementation and the passage of AB 720, most county correctional systems have created enrollment assistance programs to connect people in county jails and probation to available health insurance. There was also money allocated by the state (AB 82) to target outreach and enrollment to particularly hard to reach groups including people with substance use or mental health conditions, people who are homeless, and people under county and state correctional supervision.  Those funds are distributed to local agencies to support enrollment activities and based on the most recent state progress report they have reached more than 1 million people and provided enrollment assistance for Medi-Cal to nearly 105,000.

Q: Are there any figures on how many inmates are being enrolled through the correctional systems?

A: Right now we don’t have any comprehensive information on enrollment numbers for correctional populations specifically, although one of the goals of our ongoing research project at PPIC is to better understand enrollment outcomes for this group. There is another report that just came out that provides some enrollment data for select counties.

Q: Were any of your findings surprising?

A: In our most recent work, we really took a deeper look at who is still uninsured in California in a post-ACA environment to see how they compared to what we knew about the jail population.  We found quite a bit of overlap. And what we found was that these young, disadvantaged men still had really high likelihoods of being uninsured, even though the coverage expansions under the ACA that opened up Medi-Cal to poor, single adults should have really benefitted this group. We will likely need to find alternative ways to connect some hard-to-reach people to available insurance coverage – and county jails and probation departments could play an important role.

Q: Your research used the Jail Profile Survey (JPS) to assess health services provided in county jail systems and trends in jail-based health care over the past decade. Tell us more about the JPS. Are there any other data resources you’d recommend?

A: The JPS is a monthly survey conducted by the Board of State and Community Corrections (BSCC). This is an independent agency that is tasked with providing oversight and technical assistance to the state’s local correctional systems. They have been collecting data on county jails for more than two decades and it is all available online. Two relatively new examples in California are the California Health and Human Services Open Data Portal and the OpenJustice portal from the California Department of Justice. Both sites provide information and data visualization tools.

Q: Do you have any suggestions on how health journalists can cover vulnerable populations like these?

A: I’ve seen articles on a national level about health coverage for correctional populations. Obama is trying to do high-level stuff such as the Roadmap to Reentry. But I think some of the best ways to cover these topics would be at a county or regional level. Most of the programs are being implemented by local entities, such as the local sheriff or county probation departments in the case of enrollment assistance programs, and in many cases the correctional agencies partner with other county agencies and local service providers to connect people to health coverage and needed services.

[Photo by Bart Everson via Flickr.]