Decarcerating America

by Ernest Drucker

  The introduction of mental health managed care in the 1980s led to indirect cost-shifting from health care to jails. As people with mental illness were incarcerated, their managed care coverage was terminated as they moved out of the domain of community mental health care and into the separate universe of the criminal justice system. With the health of these individuals no longer under their purview, providers and insurers realized system-level cost savings as a consequence.20 Community-based models were not adequately financed, nor were they structured to address the integrated health and social needs of people with mental illness and their families.21 Advances in psychosocial treatment, medication-assisted addiction treatment, psychopharmacology, and mental health services over the past two decades have introduced opportunities for considerable improvement, but coverage and capacity have remained out of reach.

  The segmentation and starvation of behavioral health care in the specialty model gained some relief with the passage of a mandate for parity coverage with medical and surgical care in 2008 legislation. This mandate was reinforced by the Affordable Care Act in 2010, which named behavioral health care as one of ten essential health benefits for coverage. Because the act also expanded coverage, individuals could actually gain access to behavioral health care via the parity requirement, and meet their treatment needs. Medicaid expansion began generating improvements in the quality of behavioral health care delivered by safety net providers, including the integration of behavioral health care with medical care and medical-legal partnerships and community-based services to address the social determinants of health.22

  A series of studies tracked the effect of enrollment in Medicaid upon release from jail on behavioral health care and subsequent rearrest among justice-involved people with serious mental illness. This research was conducted several years before the 2010 Affordable Care Act and examined Medicaid coverage linked to disability benefits for people with serious mental illness. Investigators found that the group with Medicaid at release was more likely to use community-based services, to access them quickly, and to participate for longer periods of time. Importantly, they also experienced less reincarceration: a 16 percent reduction in the average number of subsequent detentions.23

  Despite the expansion of coverage and the reinforcement of parity provided by the Affordable Care Act, the problem of behavioral health care capacity has remained a barrier to treatment on demand, especially for substance use disorders. In 2016, the Comprehensive Addiction and Recovery Act and the subsequent 21st Century Cures Act responded to this gap with investments to improve treatment access and quality and to augment community mental health services.

  Another study describes the effect of expanding publicly funded substance use disorder treatment on treatment utilization and arrest rates in a jail-involved population. From 2005 to 2009, Washington invested in a massive treatment expansion on the basis of projected cost savings in medical and long-term care, which the study found were subsequently realized. The expansion also resulted in significantly lower arrest rates in the year following treatment, with arrests declining by 17 to 33 percent across three differently insured groups under the expansion.24

  Taken together, the effects documented in these studies suggest that, in combination, coverage for people with behavioral health conditions and capacity expansion for care and treatment will both reduce incarceration as a preventive effect, and reduce the potential for recidivism after reentry. Whether national legislative efforts to develop this foundation in recent years will succeed in broadening access and improving quality remains to be seen, but certainly they affirm meaningful progress in this regard.

  Supportive Services to Address the Social Determinants of Health

  Community health workers improve the cultural competence of the health care structure and support participants in addressing their priority needs. The growing professionalization of this role within the health care system acknowledges the specific, invaluable expertise of the care provider with lived experience similar to that of the person being helped, something that is especially relevant to the experiences of former prisoners with community reentry. These roles extend the practical influence of community health care beyond the clinic walls, recognizing and responding to the influence of social factors on health outcomes. In other words, they can address and reduce the risk of reincarceration head-on. For the formerly incarcerated, the creation of the community health worker role also offers an employment opportunity, important because extended unemployment in the period after incarceration is a significant risk factor for reincarceration.25

  The involvement of reentry community health workers in health care delivery for justice-involved individuals, such as with the transitions clinic model, can dramatically reduce recidivism among patients. At a program site of the Michigan Prisoner Reentry Initiative, a community health worker program that focuses on recent parolees with serious medical needs, the recidivism rate declined by half in the five years after the program began.26 Outcomes such as this affirm the intrinsic value of provider lived experience for attending to the social determinants of health. In the community health center model, community health workers could help to reverse the local effects of hyperincarceration and prove invaluable for shrinking the criminal justice system.

  Since the 1990s, states have had the opportunity to allocate Medicaid funding for case management services to particular populations, such as the seriously mentally ill. With the Affordable Care Act, eligible populations for this care coordination model, called Medicaid health homes, were expanded to include people with any one of a number of chronic health conditions, including diabetes, hypertension, and asthma, and also including substance use disorders. By allocating health care dollars to fund supportive services for low-income individuals, this arrangement introduced a pathway for strengthening the social safety net. Justice-involved individuals with one of the targeted chronic health conditions could gain invaluable case management assistance from this model.

  In another model, supportive services can operate as the connective tissue in a structural network of health care providers, to promote care coordination and facilitate engagement and retention in care. The Affordable Care Act offered several mechanisms for structuring such a network, one example being the accountable care organization (ACO). This approach allowed the network to accrue and reinvest the cost savings it realized in patient care, such as through patient-level reductions in emergency department visits. An ACO serving a community characterized by hyperincarceration could choose to invest cost savings into reentry case management as a supportive service of the network, for example, or into hiring community health workers as network staff. Evidence suggests this approach would reduce both recidivism and emergency department visits by the justice-involved individuals it served, while improving their engagement in health care.

  In short, supportive services could improve reentry, reduce recidivism, and facilitate diversion away from the criminal justice system entirely. With a community-oriented approach in their design and implementation, these features can be leveraged to reduce hyperincarceration in communities and prevent individual-level justice involvement. Coverage will ensure access to services, treatment, and care. And services, treatment, and care—especially for mental health and substance use disorders—could reduce recidivism, bolster reentry services, and provide options for diversion and deflection away from the criminal justice system.

  Contexts and Futures

  Much of the content described here emerged in part from the 2010 Affordable Care Act, a watershed moment for U.S. health care. Although the act captured some of the best among the accumulated policies and initiatives from the past thirty years for strengthening the U.S. health care structure, it did not go far enough. It did not achieve universal coverage, although it made a significant dent in the problem of the uninsured. And while the act offered innovative models for building supportive services, these were not widely nor uniformly adopted by states. Behavioral health care in
the United States remains woefully sparse and still suffers from a lack of integration with general health care. The evidence base for substance use disorder treatment remains thin. While the gains made by the act were tremendously important for strengthening and improving the U.S. health care system, there is still considerable distance to travel if we are to reach a public health vision.

  At the time of this writing in 2017, the future of the 2010 Affordable Care Act is deeply uncertain. Whether and how the act will be repealed and replaced remains unknown. Even worse are the threats to convert the federal Medicaid program to a block grant for states, effectively undoing the federal standards currently set for services and care delivered with these funds, and restricting the dollars supporting them in what will most certainly result in cuts to care. In spite of this political jousting, optimism about improvements and developments in the future might be found in the positive experiences of Americans with the recent health care reforms. The effectiveness of the explicit public health vision adopted by the Affordable Care Act’s version of health care reform has not been lost on the many millions who have gained coverage and on the many thousands who accessed behavioral health care or benefited from care coordination services. If the stories of constituents mean anything in federal policy making, these experiences could help to generate an even better health care approach for coverage, behavioral health care, and services in the future. It is possible that, in the contested political landscape of U.S. health care, we may finally land on a national single-payer plan quite soon.

  The case for health care as a vehicle for decarceration is located in the structural context of public systems and in the sociohistorical context of class and race in the United States. Making this case a reality demands an cross-sectoral perspective on public systems and a belief that this type of vision can be realized with coordinated leadership. In the mirrored worlds of policy making and policy advocacy, where actors prefer to “stay in their lane” and operate within their system silos, meaningful work across the divides can be difficult to accomplish. Finding the best mix of stakeholder involvement, telling compelling stories to the audiences that will have the most impact, and assuring all sides that they will benefit from working together to achieve this kind of change—these elements represent important challenges to making the cross-sectoral vision a reality. At its best, this vision is still a threat to the structural status quo.

  The inequities characterizing both the health care system and the criminal justice system in the United States emerge from the nation’s sociohistorical conflict with race and class—its categorical allegiance to the former, and its cultural denial of the latter. The case for health care as a mechanism for decarceration rests principally on these issues of civil rights and status. This vision expresses hopeful potential for the impact of focused and sustained public-health-oriented health care investments directed to hyperincarcerated communities, which are low-income and predominantly Black and Latino.

  But could this same framework also protect other groups from vulnerability to criminalization in the future? At the time of this writing, the federal government is launching a massive national campaign to deport thousands, perhaps millions, of undocumented immigrants from the country. Even in self-proclaimed sanctuary cities, where safety net providers are strictly prohibited from requesting immigration documents from patients, health care utilization has already dropped off. Despite assurances from local authorities, people are understandably fearful that public health care providers will be legally obliged to cooperate with immigration law enforcement. If these fears do not come true, then the health care decarceration vehicle could offer some relief. This group would benefit from inclusion in universal coverage and the availability of relevant supportive services, such as the medical-legal partnership model at community health centers. While this arrangement could help to prevent detentions and deportations, it is still too early to predict how the current situation will evolve.

  Over the past decade, the term “mass incarceration” joined popular discourse in the United States, and some intimations of a public reckoning with our practice as the world’s leading jailer occurred. It remains to be seen whether the political will is strong enough to pursue meaningful action for reversing this practice and for repairing the damage it has done. What is certain, however, is that the construction of a health care system truly grounded in a public health vision could play a central part in this shift. The combined effect of the three features presented here could actually generate a lot of the systemic change necessary to accomplish decarceration. Taken together, and designed and implemented to achieve health and social equity, they could produce a health care system that advances and secures the social safety net and reduces the now-habituated overreach and reliance on the criminal justice system to address health and social problems.

  None of this will happen without intent. An engaged citizenry must voice their demands and expectations for an improved and expanded national health care system, and their commitment to considerable public investments ensuring its sustainability. Advocates and scholars can produce imaginative and thoughtful ideas for leveraging the health care system to promote decarceration, and policy makers and public officials have to orchestrate the pathways and structures for getting there. The commitment to decarceration must become rooted deep in U.S. policy, business, and culture. We have seen a vision for how health care could be a vehicle for building some of this foundation now, and we have an obligation to ensure it remains strong and grows.

  Notes

  1. Throughout this chapter, the terms mental illness and addiction are used for ease of understanding, instead of the standard clinical terminology, mental health condition and substance use disorder, respectively. These terms, in the general vernacular, are sometimes used pejoratively; such meaning is not intended in any part of this text.

  2. L. Wacquant, “The Body, the Ghetto and the Penal State,” Qualitative Sociology 32 (2009): 101–29.

  3. P. Farmer, Pathologies of Power: Health, Human Rights, and the New War on the Poor (Berkeley: University of California Press, 2003).

  4. L. Wacquant, “The New ‘Peculiar Institution’: On the Prison as Surrogate Ghetto,” Theoretical Criminology 4, no. 3 (2000): 377–89.

  5. T. Skocpol, Health Care Reform and the Turn Against Government (New York: Norton, 1996).

  6. E.A. Wang, M.C. White, R. Jamison, J. Goldenson, M. Estes, and J.P. Tulsky, “Discharge Planning and Continuity of Health Care: Findings from the San Francisco County Jail,” American Journal of Public Health 98, no. 12 (2008): 2182–4.

  7. K. Patel, A. Boutwell, B.W. Brockmann, and J.D. Rich, “Integrating Correctional and Community Health Care for Formerly Incarcerated People Who Are Eligible for Medicaid,” Health Affairs 33, no. 3 (2014): 468–73; J.D. Rich, R. Chandler, B.A. Williams, D. Dumont, E.A. Wang, F.S. Taxman, S.A. Allen, J.G. Clarke, R.B. Greifinger, C. Wildeman, F.C. Osher, S. Rosenberg, C. Haney, M. Mauer, and B. Western, “How Health Care Reform Can Transform the Health of Criminal Justice–Involved Individuals,” Health Affairs 33, no. 3 (2014): 462–67.

  8. National Research Council, The Growth of Incarceration in the United States: Exploring Causes and Consequences (Washington, DC: National Academies Press, 2014).

  9. B. Western and B. Petit, “Incarceration and Social Inequality,” Daedalus, Summer 2010, 8–19.

  10. A.E. Cuellar and J. Cheema, “Health Care Reform, Behavioral Health, and the Criminal Justice Population,” Journal of Behavioral Health Services and Research 41, no. 4 (2014): 447–59; Patel et al., “Integrating Correctional and Community Health Care.”

  11. S.N. Bandara, H.A. Huskamp, L.E. Riedel, E.E. McGinty, D. Webster, R.E. Toone, and C.L. Barry, “Leveraging the Affordable Care Act to Enroll Justice-Involved Populations in Medicaid: State and Local Efforts,” Health Affairs 34, no. 12 (2015): 2044–51.

  12. S.A. Somers, E. Nicolella, A. Hamblin, S.M. McMahon, C. Heiss, and B.W. Brockmann, “Medicaid Expansion: Considerations for
States Regarding Newly Eligible Jail-Involved Individuals,” Health Affairs 33, no. 3 (2014): 455–61.

  13. J. Guyer, D. Bachrach, and N. Shine, “Medicaid Expansion and Criminal Justice Costs: Pre-expansion Studies and Emerging Practices Point Toward Opportunities for States,” State Health Reform Assistance Network, November 2015, 1–8.

  14. K.A. Chari, A.E. Simon, C.J. DeFrances, and L. Maruschak, “National Survey of Prison Health Care: Selected Findings,” National Health Statistics Reports no. 96, National Center for Health Statistics, 2016.

  15. R.L. Trestman and R.H. Aseltine Jr., “Justice-Involved Health Information: Policy and Practice Advances in Connecticut,” Perspectives in Health Information Management, Winter 2014, 1–11.

  16. D. Cloud, M. Dougherty, R.L. May II, J. Parsons, P. Wormeli, and W.J. Rudman, “At the Intersection of Health and Justice,” Perspectives in Health Information Management, Winter 2014, 1–4.

  17. B. Butler and J. Murphy, “The Impact of Policies Promoting Health Information Technology on Health Care Delivery in Jails and Local Communities,” Health Affairs 33, no. 3 (2014): 487–92.

  18. E.A. Wang, C.S. Hong, L. Samuels, S. Shavit, R. Sanders, and M. Kushel, “Transitions Clinic: Creating a Community-Based Model of Health Care for Recently Released California Prisoners,” Public Health Reports 125, no. 2 (2010): 171–77.