At the Intersection of Health, Health Care and Policy Cite this article as: Matthew J. Bechelli, Michael Caudy, Tracie M. Gardner, Alice Huber, David Mancuso, Paul Samuels, Tanya Shah and Homer D. Venters Case Studies From Three States: Breaking Down Silos Between Health Care And Criminal Justice Health Affairs, 33, no.3 (2014):474-481 doi: 10.1377/hlthaff.2013.1190
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10.1377/hlthaff.2013.1190 HEALTH AFFAIRS 33, NO. 3 (2014): 474–481 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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Matthew J. Bechelli (mbe [email protected]) is a research associate at Community Oriented Correctional Health Services, in Oakland, California. Michael Caudy is a postdoctoral research fellow in the Center for Advancing Correctional Excellence, George Mason University, in Fairfax, Virginia. Tracie M. Gardner is director of state policy at the Legal Action Center, in New York City. Alice Huber is deputy director of the Research and Data Analysis Division, Washington State Department of Social and Health Services, in Olympia. David Mancuso is director of the Research and Data Analysis Division, Washington State Department of Social and Health Services. Paul Samuels is director and president of the Legal Action Center. Tanya Shah is assistant commissioner of the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene. Homer D. Venters is assistant commissioner for correctional health services, New York City Department of Health and Mental Hygiene.
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By Matthew J. Bechelli, Michael Caudy, Tracie M. Gardner, Alice Huber, David Mancuso, Paul Samuels, Tanya Shah, and Homer D. Venters
Case Studies From Three States: Breaking Down Silos Between Health Care And Criminal Justice The jail-involved population—people with a history of arrest in the previous year—has high rates of illness, which leads to high costs for society. A significant percentage of jail-involved people are estimated to become newly eligible for coverage through the Affordable Care Act’s expansion of Medicaid, including coverage of substance abuse treatment and mental health care. In this article we explore the need to break down the current policy silos between health care and criminal justice, to benefit both sectors and reduce unnecessary costs resulting from lack of coordination. To draw attention to the hidden costs of the current system, we review three case studies, from Washington State, Los Angeles County in California, and New York City. Each case study addresses different aspects of care needed by or provided to the jail-involved population, including mental health and substance abuse, emergency care, and coordination of care transitions. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of the two systems. ABSTRACT
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n 2009 the Robert Wood Johnson Foundation Commission to Build a Healthier America issued a report calling for leaders across all sectors to break down the policy silos within and around health care to improve health and achieve better value for the nation’s health expenditures.1 Indeed, it has been widely observed that lack of coordination, both within the health care sector and across sectors with overlapping interests, has impeded progress in improving population health and reining in health care costs. Sectors outside of health care with converging interests include education, early childhood, and community development, where a body of research has demonstrated links with health and health care.2 Another sector with implications for health care is criminal justice, particularly with respect to the nation’s 3,300 county and local jails, which are obligated to provide health care to the 11.6 million people who cycled through them
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in 2012.3 The jail-involved population—defined as people with a history of arrest in the previous year—has high rates of chronic illness and of mental health and substance use disorders.4 Jail-involved people also tend to be poor and uninsured, although since January 1, 2014, a sizable percentage of this population is believed to be newly eligible for Medicaid coverage under the Affordable Care Act (ACA).5 Against this backdrop, the question arises as to whether significant progress can be made in managing and reducing health care costs without taking into consideration the health care needs of the jail-involved population. In this article we make the case that it cannot. Using three case studies, we attempt to draw attention to the hidden costs of our current siloed system.
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Substance Abuse Treatment In Washington State Our first case study suggests that there are potentially significant cost savings from providing substance abuse treatment for jail-involved people residing in the community—one example of breaking down silos. In Washington State, changes over the past decade in public funding for substance abuse treatment provide a “natural experiment” for estimating the impact of such treatment on health care costs, including savings estimated for low-income adults newly eligible for Medicaid under the ACA. The characteristics of the population of lowincome adults newly eligible for Medicaid closely parallel those of the jail-involved population. Our analysis of the Washington State experience, reported in more detail below, found extensive overlap between the jail-involved population and the Medicaid expansion population. The analysis also demonstrated the impact of providing substance abuse treatment on criminal justice outcomes for this population. Population Characteristics In 2006 approximately 159,000 adults were booked at least once into a county or local jail in Washington State. Of those people, 32,000 had Medicaid coverage at some time in the year. This group was made up primarily of people with Medicaid coverage related to Supplemental Security Income (SSI) benefits—for people who are blind, are disabled, and have very low incomes. Another 15,000 had state-only coverage at some time in the year but never enrolled in Medicaid. This group was made up of people receiving coverage related to Washington State’s General Assistance program, which became part of the state’s Medicaid expansion population in January 2014. Finally, 112,000 had no Medicaid or other statefunded medical coverage in the year. The vast majority of people in this group would qualify for Medicaid under the ACA.6 Estimating Health Care Savings We examined changes in state funding for substance abuse treatment starting in 2005, and we report on estimated savings in health care and criminal justice costs associated with these treatment services. We focused primarily on populations with relatively high rates of criminal justice involvement who were enrolled in General Assistance and related state-funded programs prior to the Medicaid expansion under the ACA. The five-year period from state fiscal year 2005 to state fiscal year 2009 saw a major expansion of substance abuse treatment funding for adults enrolled in the General Assistance and Medicaid programs in Washington State. In January 2014 adults enrolled in General Assistance became part of the Medicaid expansion population.
The substance abuse treatment expansion was funded primarily by anticipated savings in medical and long-term care costs,7 which evaluation studies found were realized.8 The evaluation studies combined intent-to-treat and differencein-differences features to infer the impact of changes in substance abuse treatment funding on medical and nursing home expenditures for the affected Medicaid populations. To identify the subset of populations potentially in need of substance abuse treatment, this approach used data from health care encounters that indicated the presence of a substance use disorder. We then compared changes in per member per month health care costs for General Assistance and SSI clients with substance abuse problems, relative to changes in per member per month costs for the balance of the population without substance abuse problems. The key question was whether changes in treatment access for at-risk clients were associated with changes in rates of growth in health care spending in that population, relative to the trends experienced by the balance of the covered population—people who did not need substance abuse treatment. Exhibit 1 illustrates the findings for Medicaid beneficiaries with SSI. In the pre-expansion period, average annual per member per month medical costs grew more rapidly for beneficiaries with substance abuse problems than for those without such problems (10.8 percent versus 6.9 percent). During the expansion period, this pattern was reversed, with costs growing more slowly for adults with substance abuse problems than for those without such problems (1.4 percent versus 3.8 percent). The relative changes in medical cost trends were driven by underlying relative changes in inpatient hospital costs. We observed the same pattern of relative changes in medical service use for the General Assistance population. Overall, the health care savings associated with substance abuse treatment for the General Assistance population that is now part of the state’s Medicaid expansion population under the ACA were $162 per member per month. It is important to note that short-run medical cost offsets associated with substance abuse treatment would be much lower for people who are younger and healthier than the General Assistance population. However, over the longer term, the presence of ongoing untreated substance abuse increases the likelihood that a person will develop a level of chronic disease burden that would qualify him or her for SSI-related Medicaid coverage. These findings indicate the importance of funding substance abuse treatment as a strategy for containing medical care cost growth for people enrolled in Medicaid, MARCH 2014
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Exhibit 1 Change In Medical Expenditures Paid By Medicaid For Adults With Supplemental Security Income (SSI) In Washington State, State Fiscal Years 2004–09 Average annual percent change in Medicaid per member per month medical expenditures for adults with SSI who: State fiscal years 2003–04 (pre-expansion period) 2004–09 (expansion period
Needed substance abuse treatment 10.8 1.4
Did not need substance abuse treatment 6.9 3.8
SOURCE Authors’ analysis of data from the Washington State Department of Social and Health Services, Research and Data Analysis Division. NOTE In state fiscal years 2005–09 there was a major expansion of substance abuse treatment funding for adults enrolled in Washington State’s Medicaid program.
including those who are newly eligible and jailinvolved. Estimating Criminal Justice Cost Savings For low-income adults who make up the adult Medicaid expansion population, criminal justice involvement represents another area where substance abuse treatment has significant beneficial impacts. Exhibit 2 summarizes the estimated impact of substance abuse treatment on rates of arrest for low-income adults in Washington State in 2006. These adults were people enrolled in the state’s General Assistance program, people enrolled in a state-funded medical coverage program for individuals unable to work because of a substance abuse problem (the Alcoholism and Drug Addiction Treatment and Support Act program), and other low-income adults receiving publicly funded substance abuse treatment. The vast majority of these populations are eligible for Medicaid under the ACA. Exhibit 2 shows that criminal justice cost savings associated with access to substance abuse treatment are significant. Arrest impact analyses use a difference-in-differences regression model that controls for baseline differences in arrest rates between treated clients and the untreated comparison groups. Among clients with General Assistance medical coverage in 2006, those receiving substance abuse treatment experienced a 33 percent lower rate of arrest in the following year on a regression-adjusted basis, compared to General Assistance clients who needed but did not receive substance abuse treatment. We translated this relative reduction into a mean treatment effect size using the criminal justice cost-benefit model developed by the Washington State Institute for Public Policy. Based on the institute’s cost-benefit model, the present value per treated client of the impact on costs to crime victims and criminal justice systems from reduced criminal activity among Gen476
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eral Assistance clients receiving treatment in 2006 was $18,393. In many cases, these lifetime savings result from engagement in substance abuse treatment for a period of years and with multiple treatment episodes. For the General Assistance treatment group, the average per client cost of substance abuse treatment for the period 1998–2007 was $6,504. Some clients will continue with treatment in the future, which will both contribute to more persistent beneficial impacts in reducing criminal activity and add somewhat to the overall average cost of treatment. The benefits in reduced criminal recidivism and lower health care expenditures demonstrate that substance abuse treatment is a cost-effective use of public resources. This is so even before beneficial impacts on other outcomes—such as employment, housing stability, and reduced mortality risk—are considered. Policy Implications The vast majority of jailinvolved individuals who are not currently enrolled in Medicaid or covered by other statefunded insurance are likely to meet the income eligibility requirements for the Medicaid expansion. Many of them are also very likely to be in need of substance abuse treatment: In 2002 nearly 69 percent of jail inmates reported regular use of illegal drugs.9 A key question is how many of these people will enroll in Medicaid expansion coverage. The answer will largely depend on how local jails and the Washington State Department of Corrections facilitate enrollment. The business case for that facilitation is supported by the evidence that timely access to substance abuse treatment services reduces criminal recidivism.
Emergency Department Admissions In Los Angeles Our second case study explores the effects that siloed processes may have on the cost of providing needed medical care for people who have been arrested but not yet booked into jail. Courts have ruled that people in this situation have a constitutionally protected right to health care for serious medical needs.10 Reflecting this right, law enforcement agencies provide arrestees in need of medical attention with access to evaluation and treatment so as to obtain medical clearance for booking them into detention. This is commonly referred to as the “safe-to-detain process.” The Los Angeles Sheriff’s Department (LASD) operates Los Angeles County’s jail system. The arresting deputy decides whether medical treatment is necessary based on the arrestee’s selfreport and the deputy’s own observations (for example, whether the arrestee is bleeding or be-
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Exhibit 2 Estimated Cost Savings Associated With The Impact Of Substance Abuse Treatment For Low-Income Adults On Arrest Rates, Washington State, 2006 Population receiving treatment
Treatment impact on arrest rate (%)a
Cost of treatment, 1998–2007 ($)
Discounted value of impact of treatment ($)
General Assistance program beneficiaries
−33
6,504
18,393
Alcoholism and Drug Addiction Treatment and Support Act program beneficiaries
−18
6,295
10,647
Other low-income adults
−17
3,678
9,490
SOURCE Authors’ analysis of data from the Washington State Department of Social and Health Services, Research and Data Analysis Division. NOTE Beneficiaries of General Assistance are unemployable. aRegression adjusted.
having erratically; deputies do not measure blood pressure or perform other clinical tests). If treatment is necessary, the deputy transports the arrestee to a hospital emergency department (ED) and supervises him or her at the facility until a safe-to-detain assessment is performed and medical clearance is obtained. We measured the time spent by sheriff’s deputies during the safe-to-detain process and performed a preliminary examination of the process’s efficiency. We also explored whether the process could lead to ED overuse, which has been shown to contribute to unnecessary medical spending.11 This study was not intended to yield comprehensive or definitive results, but rather to indicate the need for further research and to highlight potential areas for improvement in the LASD’s process. Analyzing Safe-To-Detain Assessments Three of the LASD’s twenty-three patrol stations agreed to record data on safe-to-detain assessments during September 2012. For each arrestee taken to an ED, a deputy completed a survey that captured the relevant LASD personnel time, the reasons for the ED visit (according to the patient’s self-report and the deputy’s observations), and whether the patient was admitted to the hospital or released from the ED for booking. The stations also reported their total bookings and total arrests (including people who were released rather than booked) for the month. Collectively, the three stations reported that 136 individuals were escorted to EDs during the month, representing 5.5 percent of total arrests and 7.0 percent of total bookings. The stations spent 374.7 hours on safe-to-detain assessments. Deputies spent an average of approximately 2.8 hours on each assessment, including transportation and supervision at an ED. Of the 136 ED visits, only four (2.9 percent) resulted in hospital admissions. Nationwide, 13.3 percent of ED visits resulted in hospital admissions in 2010.12 The low admission rate for
arrestees could indicate overuse of the ED for nonurgent complaints. However, lack of admission by itself is not proof of overuse. For example, patients with acute exacerbations of chronic conditions such as asthma might require EDlevel services but not admission to a hospital. Understanding Low ED Admissions A closer examination of the reasons reported for the ED visits offers a possible explanation for the observed low admission rate.Whereas 28.7 percent of the ED visits in the LASD sample had an injury or acute medical complaint as the primary reason for the visit, 36.8 percent had only chronic conditions with no indication of acute symptoms as the reason. Excluding cases that reported potentially acute symptoms, the percentage of the LASD cases for which hypertension, diabetes, asthma, or a need for medication was the primary reason for the ED visit was considerably higher than the percentage for the United States as a whole (Exhibit 3).13 (Other chronic conditions listed as primary reasons for ED visits included hepatitis C, chronic pain, and unspecified chronic medical conditions.) It should be noted that medical signs and symptoms that might indicate higher acuities might not have been reported on the LASD survey. Nevertheless, the reported low admission rate and high rate of visits for chronic conditions could indicate that many of the arrestees in the sample might not have required acute care. However, under the LASD’s current policies and procedures, a lower-acuity treatment provider is not available for the safe-to-detain process. As a result, deputies might have no choice but to transport arrestees with valid but low-acuity medical needs to the ED. Based on the results of this study, it appears that the LASD’s safe-to-detain process might lead to the overuse of the ED for nonurgent reasons, possibly because of the lack of alternative treatment options. Future research could confirm this phenomenon by analyzing clinical data such MARCH 2014
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Exhibit 3 Primary Reason For Emergency Department (ED) Visits, Los Angeles Sheriff's Department (LASD) Study Sample And United States
SOURCE Authors’ analysis of data from Community Oriented Correctional Health Services; and National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 emergency department public-use data file (Note 13 in text). NOTE “Medication” refers to the need for medication.
as triage acuities, doctors’ notes, and discharge diagnoses. We did not collect detailed information about the services provided to the patients in this sample, which made it difficult to estimate medical costs.Whatever the cost, however, it is likely that hospitals are not compensated for the care they provide to LASD arrestees. Neither the LASD nor Los Angeles County is responsible for paying for ED visits for arrestees who have not been arraigned (following the precedent of a 2007 California court decision),14 and justice-involved people historically have a high likelihood of being uninsured.15 Budget And Staff Impact The LASD likely also bears significant costs resulting from the safe-to-detain process. The finding that 7.0 percent of detainees were escorted to an ED might not seem indicative of a large-scale problem. However, the 374.7 hours that the three stations collectively spent on the process during the month represents 2.3 full-time-equivalent staff positions. With LASD deputies’ salaries ranging from $57,552 to $79,680 per year (not including benefits), the current safe-to-detain process represents a use of substantial department resources.16 Policy Implications The LASD’s safe-todetain process might be seen as a product of having the health care and criminal justice systems in separate silos. The department’s booking process is designed to efficiently transition arrestees into custody, not to provide efficient and high-quality health assessments. Because EDs are open at all hours and must accept all patients, 478
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they have been a convenient way to incorporate health assessments for a predominantly uninsured population into the booking process. The fact that neither the LASD nor the county has to pay for these services is likely an additional incentive for relying exclusively on EDs. This study should not be considered as conclusive evidence that the LASD’s safe-to-detain process leads to unnecessary ED use. However, the results indicate that all the parties involved pay a price for the current siloed approach: The LASD spends costly hours transporting and supervising arrestees; hospital EDs spend time on nonurgent cases and likely provide uncompensated care; and some patients receive treatment in inappropriate settings. Health plans may soon begin paying a greater price as well, as more arrestees gain health care coverage through the ACA. This study’s findings indicate a need for further research and an exploration of alternatives to the current safe-todetain process.
Health Homes In New York State Our third case study discusses the potential benefits of breaking down silos to better coordinate reentry to the community from jail and health care services for people leaving jail. The health homes program launched by the New York State Department of Health in 201117 has the potential to help people released from local and county jails transition back into their communities by connecting them with needed health care services, including mental health care and substance abuse treatment. The health homes program was designed to improve care coordination and service integration for the subset of Medicaid enrollees with complex medical, behavioral, and long-term care needs who require a high volume of costly inpatient care. Each health home is actually a network of providers that work together to coordinate delivery of all services for these highneed, high-cost beneficiaries. Initially, the state’s Department of Health identified nearly one million eligible beneficiaries based on their medical histories and assigned them to one of four clinical categories: people with developmental disabilities, recipients of long-term care, people with behavioral health conditions, and people with multiple chronic conditions. Twenty-four health homes have begun enrolling patients and implementing the care coordination model. The first wave of activity focuses on patients with mental health, substance abuse, or chronic medical problems. Providing timely case management to patients returning to the community from jail or prison
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To achieve better clinical outcomes, health homes will need to match justiceinvolved patients with the services they require.
could prove important to the success of the health homes program. To provide this management would require initiating contacts between health care providers inside correctional settings and those in health homes and maintaining continuity of care from in-jail services to community-based care. This transition is a key one, since patients leaving either jail or prison experience high rates of mortality in their first weeks after incarceration.18,19 More than half of New York City jail inmates with a Medicaid number documented in the jail’s electronic health record system also appeared on New York State’s first health homes list. More broadly, there appears to be substantial overlap between the health home and criminal justice populations.20 The two most common diagnoses among patients in the New York City jail system are substance use disorders (for approximately 40 percent of patients) and mental health problems (approximately 35 percent).21 Incarcerated patients frequently return to their communities with no connection to mental health and substance disorder treatment resources, compounding the need for coordinated services.22,23 The health homes approach to reducing health care costs and improving quality could be a good one for the justice-involved population. In the New York City jail system, transitional case management for patients living with HIV has been shown to improve clinical outcomes (patients’ viral loads and CD4+ cell counts) and decrease the use of EDs.24 This approach, which has been used in other US correctional settings, is associated with cost-effectiveness, improved clinical outcomes, and reduced recidivism.25–27 Three issues need to be addressed for health homes to work for patients who are incarcerated. First, there must be a mechanism for ascertaining the health home and Medicaid status of peo-
ple who are jailed, as well as the jail status of patients who are enrolled in health homes. In New York City, the Department of Health and Mental Hygiene, which oversees correctional health care, has begun to address this issue by partnering with a single health home to collaboratively manage the cases of health homes patients as they transition back to the community.28 However, with twenty-four health homes in New York State, a single match point is necessary to enable providers in correctional facilities and community-based settings to identify and locate patients. One promising idea is to link the unique state identification number of each incarcerated person with his or her Medicaid number in a central matching repository. This would facilitate health home enrollment as well. The New York City Department of Health and Mental Hygiene’s partnership with the health home will provide service linkages for inmates who are eligible to enroll in a health home. The department’s staff will work to coordinate care as the patient moves from the jail back to the health home on release, including the transfer of health information with the patient’s consent and in compliance with privacy laws. Evaluation metrics include the use of ED and inpatient services after incarceration. Second, to achieve better clinical outcomes, health homes will need to match justice-involved patients with the services they require. The high rate of mental health and substance use disorders among the justice-involved population means that access to treatment services for these problems will need to be expanded substantially. Jailed patients with mental illness and substance use disorders also have high rates of chronic medical problems.29 Therefore, the capacity to treat hypertension, asthma, HIV, hepatitis, and diabetes involves the capacity to treat depression, bipolar disease, and substance use disorders.30–32 Successful coordination and delivery of this level of comprehensive care will require tight integration within the health home networks. Third, health homes will need to show results. Health homes are predicated on the notion that comprehensive case management of high-needs patients will result in better care and reduced costs. Key metrics for patients who have been incarcerated will include postrelease mortality, morbidity, use of health homes services (versus ED or inpatient services), and return to jail or prison.
Conclusion The silos separating health care from criminal justice result in inefficiencies that impose significant costs on both systems. Washington State’s M A R CH 20 1 4
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Health experience indicates that a well-designed package of Medicaid services addressing the needs of the jail-involved population can more than pay for itself in terms of both improved public safety and reduced public expenses. The study of the LASD’s safe-to-detain process provides insights into how much existing silos cost both systems. And the health homes program in New York
State suggests what can be done to create greater connectivity between the two systems, especially as implementation of Medicaid expansion under the ACA proceeds. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of these systems. ▪
The views expressed in this article do not necessarily reflect those of the New York City Department of Health and Mental Hygiene.
NOTES 1 Robert Wood Johnson Foundation Commission to Build a Healthier America. Beyond health care: new directions to a healthier America; recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America: executive summary [Internet]. Princeton (NJ): RWJF; 2009 Apr [cited 2014 Jan 15]. Available from: http://www.rwjf.org/content/dam/ farm/reports/reports/2009/ rwjf40483/subassets/rwjf40483_1 2 Braveman P, Egerter S. Overcoming obstacles to health in 2013 and beyond [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; [cited 2014 Jan 15]. Available from: http://www.rwjf.org/content/dam/ farm/reports/reports/2013/ rwjf406474 3 Minton TD. Jail inmates at midyear 2012—statistical tables [Internet]. Washington (DC): Department of Justice, Bureau of Justice Statistics; 2013 May [cited 2014 Jan 21]. Available from: http://www.bjs.gov/ content/pub/pdf/jim12st.pdf 4 Greifinger RB. Thirty years since Estelle v. Gamble: looking forward, not wayward. In: Greifinger RB, editor. Public health behind bars: from prisons to communities. New York (NY): Springer; 2007. p. 1–12. 5 Regenstein M, Rosenbaum S. What the Affordable Care Act means for people with jail stays. Health Aff (Millwood). 2014;33(3):448–54. 6 Mancuso D, Felver BEM. Health care reform, Medicaid expansion, and access to alcohol/drug treatment: opportunities for disability prevention [Internet]. Olympia (WA): Washington State Department of Social and Health Services; 2010 [cited 2014 Jan 15]. Available from: http://www.dshs.wa.gov/pdf/ms/ rda/research/4/84.pdf 7 Estee S, Nordlund DJ. Washington State Supplemental Security Income (SSI) cost offset pilot project: 2002 progress report [Internet]. Olympia (WA): Washington State Department of Social and Health Services; 2003
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Feb [cited 2014 Jan 15]. Available from: http://www.dshs.wa.gov/pdf/ ms/rda/research/11/109.pdf Mancuso D, Felver BEM. Bending the health care cost curve by expanding alcohol/drug treatment [Internet]. Olympia (WA): Washington State Department of Social and Health Services; 2010 Sep [cited 2014 Jan 15]. Available from: http:// www.dshs.wa.gov/pdf/ms/rda/ research/4/81.pdf Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Substance abuse treatment for adults in the criminal justice system [Internet]. Rockville (MD): SAMHSA; 2005 [cited 2014 Jan 15]. (Treatment Improvement Protocol [TIP] Series, No. 44). Available from: http://www .ncbi.nlm.nih.gov/books/ NBK64145/ The US Supreme court ruled in Estelle v. Gamble (429 U.S. 97 [1976]) that deliberate indifference to a sentenced inmate’s serious medical needs would constitute a violation of that inmate’s Eighth Amendment protection from cruel and unusual punishment. Other courts have ruled that arrestees’ rights are protected instead by the due process clauses of the Fifth and Fourteenth Amendments. However, the criterion of deliberate indifference to a serious medical need has been applied to Fifth and Fourteenth Amendment petitions—for example, City of Revere v. Mass. Gen. Hosp. (463 U.S. 239 [1983]), Gibson v. County of Washoe Nevada (290 F.3d 1175 [2002]), and Loe v. Armistead (582 F.2d 1291 [1978]). Delaune J, Everett W. Waste and inefficiency in the U.S. health care system [Internet]. Cambridge (MA): New England Healthcare Institute; 2008 Feb [cited 2014 Jan 15]. Available from: http://media .washingtonpost.com/wp-srv/ nation/pdf/healthreport_092909 .pdf National Center for Health Statistics.
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National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables [Internet]. Hyattsville (MD): NCHS; [cited 2014 Jan 15]. Available from: http:// www.cdc.gov/nchs/data/ahcd/ nhamcs_emergency/2010_ed_ web_tables.pdf National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 emergency department public-use data file [Internet]. Hyattsville (MD): NCHS; [cited 2014 Jan 15]. Available for download from: ftp://ftp.cdc.gov/ pub/Health_Statistics/NCHS/ Datasets/NHAMCS/ Sharp Healthcare v. County of San Diego (2007) 68 Cal.Rptr.3d 152, 156 Cal.App.4th 1301. Wang EA, White MC, Jamison R, Goldenson J, Estes M, Tulsky JP. Discharge planning and continuity of health care: findings from the San Francisco County Jail. Am J Public Health. 2008;98(12):2182–4. Los Angeles County Department of Human Resources. Class and salary listings, as of January 1, 2014 [Internet]. Los Angeles (CA): The Department; [cited 2014 Jan 15]. Available from: http://ceo.lacounty .gov/pdf/alpha.pdf Patchias EM, Detty A, Birnbaum M. Implementing Medicaid health homes in New York: early experience [Internet]. New York (NY): United Hospital Fund. 2013 Feb 8 [cited 2014 Jan 21]. Available from: http:// www.uhfnyc.org/publications/ 880881 Lim S, Seligson AL, Parvez FM, Luther CW, Mavinkurve MP, Binswanger IA, et al. Risks of drugrelated death, suicide, and homicide during the immediate post-release period among people released from New York City jails, 2001–2005. Am J Epidemiol. 2012;175(6):519–26. Spaulding AC, Allen SA, Stone A. Mortality after release from prison. N Engl J Med. 2007;356(17):1785. Correctional Health Services of the New York City Department of Health
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and Mental Hygiene worked with the New York State Department of Health to match a series of consecutive patients in jail against people on the state health homes lists. There were 2,055 unique Medicaid identification numbers for the patients in jail. These numbers were matched to the population eligible for a state health home in 2011. Of the 2,055 people, 1,121 people appeared on both lists. New York City Department of Health and Mental Hygiene, Correctional Health Services, internal data, 2013 Jun 1. Dinwiddie GY, Gaskin DJ, Chan KS, Norrington J, McCleary R. Residential segregation, geographic proximity, and type of services used: evidence for racial/ethnic disparities in mental health. Soc Sci Med. 2013;80:67–75. Alegría M, Canino G, Ríos R, Vera M, Calderón J, Rusch D, et al. Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatr Serv. 2002;53(12): 1547–55. Teixeira P, Jordan AO. Health out-
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comes for HIV-positive inmates released from NYC jails. Paper presented at: American Public Health Association Annual Meeting; 2012 Oct 27–31; San Francisco, CA. Spaulding AC, Pinkerton SD, Superak H, Cunningham MJ, Resch S, Jordan AO, et al. Cost analysis of enhancing linkages to HIV care following jail: a cost-effective intervention. AIDS Behav. 2013;17(Suppl 2):S220–6. Agency for Healthcare Research and Quality. Innovations exchange: Michigan Pathways project links exprisoners to medical services, contributing to a decline in recidivism [Internet]. Rockville (MD): AHRQ; [cited 2014 Jan 15]. Available from: http://innovations.ahrq.gov/popup .aspx?id=2134&type=1&isUpdated= True&isArchived=False&name= print Wang EA, Hong CS, Shavit S, Sanders R, Kessell E, Kushel MB. Engaging individuals recently released from prison into primary care: a randomized trial. Am J Public Health. 2012;102(9):e22–9. New York City Department of Health and Mental Hygiene, Correctional
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Health Services, memo of understanding with Bronx Lebanon Health Home, effective 2013 Sep 1. Binswanger A, Krueger PM, Steiner JF. Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. J Epidemiol Community Health. 2009;63(11): 912–9. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):1–14. Nordentoft M, Wahlbeck K, Hällgren J, Westman J, Osby U, Alinaghizadeh H, et al. Excess mortality, causes of death, and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland, and Sweden. PLoS One. 2013;8(1): e55176. Mukku VK, Benson TG, Alam F, Richie WD, Bailey RK. Overview of substance use disorders and incarceration of African American males. Front Psychiatry. 2012;3:98.
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10.1377/hlthaff.2013.1190 HEALTH AFFAIRS 33, NO. 3 (2014): 474–481 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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Matthew J. Bechelli (mbe [email protected]) is a research associate at Community Oriented Correctional Health Services, in Oakland, California. Michael Caudy is a postdoctoral research fellow in the Center for Advancing Correctional Excellence, George Mason University, in Fairfax, Virginia. Tracie M. Gardner is director of state policy at the Legal Action Center, in New York City. Alice Huber is deputy director of the Research and Data Analysis Division, Washington State Department of Social and Health Services, in Olympia. David Mancuso is director of the Research and Data Analysis Division, Washington State Department of Social and Health Services. Paul Samuels is director and president of the Legal Action Center. Tanya Shah is assistant commissioner of the Bureau of Primary Care Access and Planning, New York City Department of Health and Mental Hygiene. Homer D. Venters is assistant commissioner for correctional health services, New York City Department of Health and Mental Hygiene.
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By Matthew J. Bechelli, Michael Caudy, Tracie M. Gardner, Alice Huber, David Mancuso, Paul Samuels, Tanya Shah, and Homer D. Venters
Case Studies From Three States: Breaking Down Silos Between Health Care And Criminal Justice The jail-involved population—people with a history of arrest in the previous year—has high rates of illness, which leads to high costs for society. A significant percentage of jail-involved people are estimated to become newly eligible for coverage through the Affordable Care Act’s expansion of Medicaid, including coverage of substance abuse treatment and mental health care. In this article we explore the need to break down the current policy silos between health care and criminal justice, to benefit both sectors and reduce unnecessary costs resulting from lack of coordination. To draw attention to the hidden costs of the current system, we review three case studies, from Washington State, Los Angeles County in California, and New York City. Each case study addresses different aspects of care needed by or provided to the jail-involved population, including mental health and substance abuse, emergency care, and coordination of care transitions. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of the two systems. ABSTRACT
I
n 2009 the Robert Wood Johnson Foundation Commission to Build a Healthier America issued a report calling for leaders across all sectors to break down the policy silos within and around health care to improve health and achieve better value for the nation’s health expenditures.1 Indeed, it has been widely observed that lack of coordination, both within the health care sector and across sectors with overlapping interests, has impeded progress in improving population health and reining in health care costs. Sectors outside of health care with converging interests include education, early childhood, and community development, where a body of research has demonstrated links with health and health care.2 Another sector with implications for health care is criminal justice, particularly with respect to the nation’s 3,300 county and local jails, which are obligated to provide health care to the 11.6 million people who cycled through them
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in 2012.3 The jail-involved population—defined as people with a history of arrest in the previous year—has high rates of chronic illness and of mental health and substance use disorders.4 Jail-involved people also tend to be poor and uninsured, although since January 1, 2014, a sizable percentage of this population is believed to be newly eligible for Medicaid coverage under the Affordable Care Act (ACA).5 Against this backdrop, the question arises as to whether significant progress can be made in managing and reducing health care costs without taking into consideration the health care needs of the jail-involved population. In this article we make the case that it cannot. Using three case studies, we attempt to draw attention to the hidden costs of our current siloed system.
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Substance Abuse Treatment In Washington State Our first case study suggests that there are potentially significant cost savings from providing substance abuse treatment for jail-involved people residing in the community—one example of breaking down silos. In Washington State, changes over the past decade in public funding for substance abuse treatment provide a “natural experiment” for estimating the impact of such treatment on health care costs, including savings estimated for low-income adults newly eligible for Medicaid under the ACA. The characteristics of the population of lowincome adults newly eligible for Medicaid closely parallel those of the jail-involved population. Our analysis of the Washington State experience, reported in more detail below, found extensive overlap between the jail-involved population and the Medicaid expansion population. The analysis also demonstrated the impact of providing substance abuse treatment on criminal justice outcomes for this population. Population Characteristics In 2006 approximately 159,000 adults were booked at least once into a county or local jail in Washington State. Of those people, 32,000 had Medicaid coverage at some time in the year. This group was made up primarily of people with Medicaid coverage related to Supplemental Security Income (SSI) benefits—for people who are blind, are disabled, and have very low incomes. Another 15,000 had state-only coverage at some time in the year but never enrolled in Medicaid. This group was made up of people receiving coverage related to Washington State’s General Assistance program, which became part of the state’s Medicaid expansion population in January 2014. Finally, 112,000 had no Medicaid or other statefunded medical coverage in the year. The vast majority of people in this group would qualify for Medicaid under the ACA.6 Estimating Health Care Savings We examined changes in state funding for substance abuse treatment starting in 2005, and we report on estimated savings in health care and criminal justice costs associated with these treatment services. We focused primarily on populations with relatively high rates of criminal justice involvement who were enrolled in General Assistance and related state-funded programs prior to the Medicaid expansion under the ACA. The five-year period from state fiscal year 2005 to state fiscal year 2009 saw a major expansion of substance abuse treatment funding for adults enrolled in the General Assistance and Medicaid programs in Washington State. In January 2014 adults enrolled in General Assistance became part of the Medicaid expansion population.
The substance abuse treatment expansion was funded primarily by anticipated savings in medical and long-term care costs,7 which evaluation studies found were realized.8 The evaluation studies combined intent-to-treat and differencein-differences features to infer the impact of changes in substance abuse treatment funding on medical and nursing home expenditures for the affected Medicaid populations. To identify the subset of populations potentially in need of substance abuse treatment, this approach used data from health care encounters that indicated the presence of a substance use disorder. We then compared changes in per member per month health care costs for General Assistance and SSI clients with substance abuse problems, relative to changes in per member per month costs for the balance of the population without substance abuse problems. The key question was whether changes in treatment access for at-risk clients were associated with changes in rates of growth in health care spending in that population, relative to the trends experienced by the balance of the covered population—people who did not need substance abuse treatment. Exhibit 1 illustrates the findings for Medicaid beneficiaries with SSI. In the pre-expansion period, average annual per member per month medical costs grew more rapidly for beneficiaries with substance abuse problems than for those without such problems (10.8 percent versus 6.9 percent). During the expansion period, this pattern was reversed, with costs growing more slowly for adults with substance abuse problems than for those without such problems (1.4 percent versus 3.8 percent). The relative changes in medical cost trends were driven by underlying relative changes in inpatient hospital costs. We observed the same pattern of relative changes in medical service use for the General Assistance population. Overall, the health care savings associated with substance abuse treatment for the General Assistance population that is now part of the state’s Medicaid expansion population under the ACA were $162 per member per month. It is important to note that short-run medical cost offsets associated with substance abuse treatment would be much lower for people who are younger and healthier than the General Assistance population. However, over the longer term, the presence of ongoing untreated substance abuse increases the likelihood that a person will develop a level of chronic disease burden that would qualify him or her for SSI-related Medicaid coverage. These findings indicate the importance of funding substance abuse treatment as a strategy for containing medical care cost growth for people enrolled in Medicaid, MARCH 2014
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Exhibit 1 Change In Medical Expenditures Paid By Medicaid For Adults With Supplemental Security Income (SSI) In Washington State, State Fiscal Years 2004–09 Average annual percent change in Medicaid per member per month medical expenditures for adults with SSI who: State fiscal years 2003–04 (pre-expansion period) 2004–09 (expansion period
Needed substance abuse treatment 10.8 1.4
Did not need substance abuse treatment 6.9 3.8
SOURCE Authors’ analysis of data from the Washington State Department of Social and Health Services, Research and Data Analysis Division. NOTE In state fiscal years 2005–09 there was a major expansion of substance abuse treatment funding for adults enrolled in Washington State’s Medicaid program.
including those who are newly eligible and jailinvolved. Estimating Criminal Justice Cost Savings For low-income adults who make up the adult Medicaid expansion population, criminal justice involvement represents another area where substance abuse treatment has significant beneficial impacts. Exhibit 2 summarizes the estimated impact of substance abuse treatment on rates of arrest for low-income adults in Washington State in 2006. These adults were people enrolled in the state’s General Assistance program, people enrolled in a state-funded medical coverage program for individuals unable to work because of a substance abuse problem (the Alcoholism and Drug Addiction Treatment and Support Act program), and other low-income adults receiving publicly funded substance abuse treatment. The vast majority of these populations are eligible for Medicaid under the ACA. Exhibit 2 shows that criminal justice cost savings associated with access to substance abuse treatment are significant. Arrest impact analyses use a difference-in-differences regression model that controls for baseline differences in arrest rates between treated clients and the untreated comparison groups. Among clients with General Assistance medical coverage in 2006, those receiving substance abuse treatment experienced a 33 percent lower rate of arrest in the following year on a regression-adjusted basis, compared to General Assistance clients who needed but did not receive substance abuse treatment. We translated this relative reduction into a mean treatment effect size using the criminal justice cost-benefit model developed by the Washington State Institute for Public Policy. Based on the institute’s cost-benefit model, the present value per treated client of the impact on costs to crime victims and criminal justice systems from reduced criminal activity among Gen476
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eral Assistance clients receiving treatment in 2006 was $18,393. In many cases, these lifetime savings result from engagement in substance abuse treatment for a period of years and with multiple treatment episodes. For the General Assistance treatment group, the average per client cost of substance abuse treatment for the period 1998–2007 was $6,504. Some clients will continue with treatment in the future, which will both contribute to more persistent beneficial impacts in reducing criminal activity and add somewhat to the overall average cost of treatment. The benefits in reduced criminal recidivism and lower health care expenditures demonstrate that substance abuse treatment is a cost-effective use of public resources. This is so even before beneficial impacts on other outcomes—such as employment, housing stability, and reduced mortality risk—are considered. Policy Implications The vast majority of jailinvolved individuals who are not currently enrolled in Medicaid or covered by other statefunded insurance are likely to meet the income eligibility requirements for the Medicaid expansion. Many of them are also very likely to be in need of substance abuse treatment: In 2002 nearly 69 percent of jail inmates reported regular use of illegal drugs.9 A key question is how many of these people will enroll in Medicaid expansion coverage. The answer will largely depend on how local jails and the Washington State Department of Corrections facilitate enrollment. The business case for that facilitation is supported by the evidence that timely access to substance abuse treatment services reduces criminal recidivism.
Emergency Department Admissions In Los Angeles Our second case study explores the effects that siloed processes may have on the cost of providing needed medical care for people who have been arrested but not yet booked into jail. Courts have ruled that people in this situation have a constitutionally protected right to health care for serious medical needs.10 Reflecting this right, law enforcement agencies provide arrestees in need of medical attention with access to evaluation and treatment so as to obtain medical clearance for booking them into detention. This is commonly referred to as the “safe-to-detain process.” The Los Angeles Sheriff’s Department (LASD) operates Los Angeles County’s jail system. The arresting deputy decides whether medical treatment is necessary based on the arrestee’s selfreport and the deputy’s own observations (for example, whether the arrestee is bleeding or be-
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Exhibit 2 Estimated Cost Savings Associated With The Impact Of Substance Abuse Treatment For Low-Income Adults On Arrest Rates, Washington State, 2006 Population receiving treatment
Treatment impact on arrest rate (%)a
Cost of treatment, 1998–2007 ($)
Discounted value of impact of treatment ($)
General Assistance program beneficiaries
−33
6,504
18,393
Alcoholism and Drug Addiction Treatment and Support Act program beneficiaries
−18
6,295
10,647
Other low-income adults
−17
3,678
9,490
SOURCE Authors’ analysis of data from the Washington State Department of Social and Health Services, Research and Data Analysis Division. NOTE Beneficiaries of General Assistance are unemployable. aRegression adjusted.
having erratically; deputies do not measure blood pressure or perform other clinical tests). If treatment is necessary, the deputy transports the arrestee to a hospital emergency department (ED) and supervises him or her at the facility until a safe-to-detain assessment is performed and medical clearance is obtained. We measured the time spent by sheriff’s deputies during the safe-to-detain process and performed a preliminary examination of the process’s efficiency. We also explored whether the process could lead to ED overuse, which has been shown to contribute to unnecessary medical spending.11 This study was not intended to yield comprehensive or definitive results, but rather to indicate the need for further research and to highlight potential areas for improvement in the LASD’s process. Analyzing Safe-To-Detain Assessments Three of the LASD’s twenty-three patrol stations agreed to record data on safe-to-detain assessments during September 2012. For each arrestee taken to an ED, a deputy completed a survey that captured the relevant LASD personnel time, the reasons for the ED visit (according to the patient’s self-report and the deputy’s observations), and whether the patient was admitted to the hospital or released from the ED for booking. The stations also reported their total bookings and total arrests (including people who were released rather than booked) for the month. Collectively, the three stations reported that 136 individuals were escorted to EDs during the month, representing 5.5 percent of total arrests and 7.0 percent of total bookings. The stations spent 374.7 hours on safe-to-detain assessments. Deputies spent an average of approximately 2.8 hours on each assessment, including transportation and supervision at an ED. Of the 136 ED visits, only four (2.9 percent) resulted in hospital admissions. Nationwide, 13.3 percent of ED visits resulted in hospital admissions in 2010.12 The low admission rate for
arrestees could indicate overuse of the ED for nonurgent complaints. However, lack of admission by itself is not proof of overuse. For example, patients with acute exacerbations of chronic conditions such as asthma might require EDlevel services but not admission to a hospital. Understanding Low ED Admissions A closer examination of the reasons reported for the ED visits offers a possible explanation for the observed low admission rate.Whereas 28.7 percent of the ED visits in the LASD sample had an injury or acute medical complaint as the primary reason for the visit, 36.8 percent had only chronic conditions with no indication of acute symptoms as the reason. Excluding cases that reported potentially acute symptoms, the percentage of the LASD cases for which hypertension, diabetes, asthma, or a need for medication was the primary reason for the ED visit was considerably higher than the percentage for the United States as a whole (Exhibit 3).13 (Other chronic conditions listed as primary reasons for ED visits included hepatitis C, chronic pain, and unspecified chronic medical conditions.) It should be noted that medical signs and symptoms that might indicate higher acuities might not have been reported on the LASD survey. Nevertheless, the reported low admission rate and high rate of visits for chronic conditions could indicate that many of the arrestees in the sample might not have required acute care. However, under the LASD’s current policies and procedures, a lower-acuity treatment provider is not available for the safe-to-detain process. As a result, deputies might have no choice but to transport arrestees with valid but low-acuity medical needs to the ED. Based on the results of this study, it appears that the LASD’s safe-to-detain process might lead to the overuse of the ED for nonurgent reasons, possibly because of the lack of alternative treatment options. Future research could confirm this phenomenon by analyzing clinical data such MARCH 2014
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Exhibit 3 Primary Reason For Emergency Department (ED) Visits, Los Angeles Sheriff's Department (LASD) Study Sample And United States
SOURCE Authors’ analysis of data from Community Oriented Correctional Health Services; and National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 emergency department public-use data file (Note 13 in text). NOTE “Medication” refers to the need for medication.
as triage acuities, doctors’ notes, and discharge diagnoses. We did not collect detailed information about the services provided to the patients in this sample, which made it difficult to estimate medical costs.Whatever the cost, however, it is likely that hospitals are not compensated for the care they provide to LASD arrestees. Neither the LASD nor Los Angeles County is responsible for paying for ED visits for arrestees who have not been arraigned (following the precedent of a 2007 California court decision),14 and justice-involved people historically have a high likelihood of being uninsured.15 Budget And Staff Impact The LASD likely also bears significant costs resulting from the safe-to-detain process. The finding that 7.0 percent of detainees were escorted to an ED might not seem indicative of a large-scale problem. However, the 374.7 hours that the three stations collectively spent on the process during the month represents 2.3 full-time-equivalent staff positions. With LASD deputies’ salaries ranging from $57,552 to $79,680 per year (not including benefits), the current safe-to-detain process represents a use of substantial department resources.16 Policy Implications The LASD’s safe-todetain process might be seen as a product of having the health care and criminal justice systems in separate silos. The department’s booking process is designed to efficiently transition arrestees into custody, not to provide efficient and high-quality health assessments. Because EDs are open at all hours and must accept all patients, 478
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they have been a convenient way to incorporate health assessments for a predominantly uninsured population into the booking process. The fact that neither the LASD nor the county has to pay for these services is likely an additional incentive for relying exclusively on EDs. This study should not be considered as conclusive evidence that the LASD’s safe-to-detain process leads to unnecessary ED use. However, the results indicate that all the parties involved pay a price for the current siloed approach: The LASD spends costly hours transporting and supervising arrestees; hospital EDs spend time on nonurgent cases and likely provide uncompensated care; and some patients receive treatment in inappropriate settings. Health plans may soon begin paying a greater price as well, as more arrestees gain health care coverage through the ACA. This study’s findings indicate a need for further research and an exploration of alternatives to the current safe-todetain process.
Health Homes In New York State Our third case study discusses the potential benefits of breaking down silos to better coordinate reentry to the community from jail and health care services for people leaving jail. The health homes program launched by the New York State Department of Health in 201117 has the potential to help people released from local and county jails transition back into their communities by connecting them with needed health care services, including mental health care and substance abuse treatment. The health homes program was designed to improve care coordination and service integration for the subset of Medicaid enrollees with complex medical, behavioral, and long-term care needs who require a high volume of costly inpatient care. Each health home is actually a network of providers that work together to coordinate delivery of all services for these highneed, high-cost beneficiaries. Initially, the state’s Department of Health identified nearly one million eligible beneficiaries based on their medical histories and assigned them to one of four clinical categories: people with developmental disabilities, recipients of long-term care, people with behavioral health conditions, and people with multiple chronic conditions. Twenty-four health homes have begun enrolling patients and implementing the care coordination model. The first wave of activity focuses on patients with mental health, substance abuse, or chronic medical problems. Providing timely case management to patients returning to the community from jail or prison
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To achieve better clinical outcomes, health homes will need to match justiceinvolved patients with the services they require.
could prove important to the success of the health homes program. To provide this management would require initiating contacts between health care providers inside correctional settings and those in health homes and maintaining continuity of care from in-jail services to community-based care. This transition is a key one, since patients leaving either jail or prison experience high rates of mortality in their first weeks after incarceration.18,19 More than half of New York City jail inmates with a Medicaid number documented in the jail’s electronic health record system also appeared on New York State’s first health homes list. More broadly, there appears to be substantial overlap between the health home and criminal justice populations.20 The two most common diagnoses among patients in the New York City jail system are substance use disorders (for approximately 40 percent of patients) and mental health problems (approximately 35 percent).21 Incarcerated patients frequently return to their communities with no connection to mental health and substance disorder treatment resources, compounding the need for coordinated services.22,23 The health homes approach to reducing health care costs and improving quality could be a good one for the justice-involved population. In the New York City jail system, transitional case management for patients living with HIV has been shown to improve clinical outcomes (patients’ viral loads and CD4+ cell counts) and decrease the use of EDs.24 This approach, which has been used in other US correctional settings, is associated with cost-effectiveness, improved clinical outcomes, and reduced recidivism.25–27 Three issues need to be addressed for health homes to work for patients who are incarcerated. First, there must be a mechanism for ascertaining the health home and Medicaid status of peo-
ple who are jailed, as well as the jail status of patients who are enrolled in health homes. In New York City, the Department of Health and Mental Hygiene, which oversees correctional health care, has begun to address this issue by partnering with a single health home to collaboratively manage the cases of health homes patients as they transition back to the community.28 However, with twenty-four health homes in New York State, a single match point is necessary to enable providers in correctional facilities and community-based settings to identify and locate patients. One promising idea is to link the unique state identification number of each incarcerated person with his or her Medicaid number in a central matching repository. This would facilitate health home enrollment as well. The New York City Department of Health and Mental Hygiene’s partnership with the health home will provide service linkages for inmates who are eligible to enroll in a health home. The department’s staff will work to coordinate care as the patient moves from the jail back to the health home on release, including the transfer of health information with the patient’s consent and in compliance with privacy laws. Evaluation metrics include the use of ED and inpatient services after incarceration. Second, to achieve better clinical outcomes, health homes will need to match justice-involved patients with the services they require. The high rate of mental health and substance use disorders among the justice-involved population means that access to treatment services for these problems will need to be expanded substantially. Jailed patients with mental illness and substance use disorders also have high rates of chronic medical problems.29 Therefore, the capacity to treat hypertension, asthma, HIV, hepatitis, and diabetes involves the capacity to treat depression, bipolar disease, and substance use disorders.30–32 Successful coordination and delivery of this level of comprehensive care will require tight integration within the health home networks. Third, health homes will need to show results. Health homes are predicated on the notion that comprehensive case management of high-needs patients will result in better care and reduced costs. Key metrics for patients who have been incarcerated will include postrelease mortality, morbidity, use of health homes services (versus ED or inpatient services), and return to jail or prison.
Conclusion The silos separating health care from criminal justice result in inefficiencies that impose significant costs on both systems. Washington State’s M A R CH 20 1 4
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Health experience indicates that a well-designed package of Medicaid services addressing the needs of the jail-involved population can more than pay for itself in terms of both improved public safety and reduced public expenses. The study of the LASD’s safe-to-detain process provides insights into how much existing silos cost both systems. And the health homes program in New York
State suggests what can be done to create greater connectivity between the two systems, especially as implementation of Medicaid expansion under the ACA proceeds. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of these systems. ▪
The views expressed in this article do not necessarily reflect those of the New York City Department of Health and Mental Hygiene.
NOTES 1 Robert Wood Johnson Foundation Commission to Build a Healthier America. Beyond health care: new directions to a healthier America; recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America: executive summary [Internet]. Princeton (NJ): RWJF; 2009 Apr [cited 2014 Jan 15]. Available from: http://www.rwjf.org/content/dam/ farm/reports/reports/2009/ rwjf40483/subassets/rwjf40483_1 2 Braveman P, Egerter S. Overcoming obstacles to health in 2013 and beyond [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; [cited 2014 Jan 15]. Available from: http://www.rwjf.org/content/dam/ farm/reports/reports/2013/ rwjf406474 3 Minton TD. Jail inmates at midyear 2012—statistical tables [Internet]. Washington (DC): Department of Justice, Bureau of Justice Statistics; 2013 May [cited 2014 Jan 21]. Available from: http://www.bjs.gov/ content/pub/pdf/jim12st.pdf 4 Greifinger RB. Thirty years since Estelle v. Gamble: looking forward, not wayward. In: Greifinger RB, editor. Public health behind bars: from prisons to communities. New York (NY): Springer; 2007. p. 1–12. 5 Regenstein M, Rosenbaum S. What the Affordable Care Act means for people with jail stays. Health Aff (Millwood). 2014;33(3):448–54. 6 Mancuso D, Felver BEM. Health care reform, Medicaid expansion, and access to alcohol/drug treatment: opportunities for disability prevention [Internet]. Olympia (WA): Washington State Department of Social and Health Services; 2010 [cited 2014 Jan 15]. Available from: http://www.dshs.wa.gov/pdf/ms/ rda/research/4/84.pdf 7 Estee S, Nordlund DJ. Washington State Supplemental Security Income (SSI) cost offset pilot project: 2002 progress report [Internet]. Olympia (WA): Washington State Department of Social and Health Services; 2003
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Feb [cited 2014 Jan 15]. Available from: http://www.dshs.wa.gov/pdf/ ms/rda/research/11/109.pdf Mancuso D, Felver BEM. Bending the health care cost curve by expanding alcohol/drug treatment [Internet]. Olympia (WA): Washington State Department of Social and Health Services; 2010 Sep [cited 2014 Jan 15]. Available from: http:// www.dshs.wa.gov/pdf/ms/rda/ research/4/81.pdf Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Substance abuse treatment for adults in the criminal justice system [Internet]. Rockville (MD): SAMHSA; 2005 [cited 2014 Jan 15]. (Treatment Improvement Protocol [TIP] Series, No. 44). Available from: http://www .ncbi.nlm.nih.gov/books/ NBK64145/ The US Supreme court ruled in Estelle v. Gamble (429 U.S. 97 [1976]) that deliberate indifference to a sentenced inmate’s serious medical needs would constitute a violation of that inmate’s Eighth Amendment protection from cruel and unusual punishment. Other courts have ruled that arrestees’ rights are protected instead by the due process clauses of the Fifth and Fourteenth Amendments. However, the criterion of deliberate indifference to a serious medical need has been applied to Fifth and Fourteenth Amendment petitions—for example, City of Revere v. Mass. Gen. Hosp. (463 U.S. 239 [1983]), Gibson v. County of Washoe Nevada (290 F.3d 1175 [2002]), and Loe v. Armistead (582 F.2d 1291 [1978]). Delaune J, Everett W. Waste and inefficiency in the U.S. health care system [Internet]. Cambridge (MA): New England Healthcare Institute; 2008 Feb [cited 2014 Jan 15]. Available from: http://media .washingtonpost.com/wp-srv/ nation/pdf/healthreport_092909 .pdf National Center for Health Statistics.
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National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables [Internet]. Hyattsville (MD): NCHS; [cited 2014 Jan 15]. Available from: http:// www.cdc.gov/nchs/data/ahcd/ nhamcs_emergency/2010_ed_ web_tables.pdf National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 emergency department public-use data file [Internet]. Hyattsville (MD): NCHS; [cited 2014 Jan 15]. Available for download from: ftp://ftp.cdc.gov/ pub/Health_Statistics/NCHS/ Datasets/NHAMCS/ Sharp Healthcare v. County of San Diego (2007) 68 Cal.Rptr.3d 152, 156 Cal.App.4th 1301. Wang EA, White MC, Jamison R, Goldenson J, Estes M, Tulsky JP. Discharge planning and continuity of health care: findings from the San Francisco County Jail. Am J Public Health. 2008;98(12):2182–4. Los Angeles County Department of Human Resources. Class and salary listings, as of January 1, 2014 [Internet]. Los Angeles (CA): The Department; [cited 2014 Jan 15]. Available from: http://ceo.lacounty .gov/pdf/alpha.pdf Patchias EM, Detty A, Birnbaum M. Implementing Medicaid health homes in New York: early experience [Internet]. New York (NY): United Hospital Fund. 2013 Feb 8 [cited 2014 Jan 21]. Available from: http:// www.uhfnyc.org/publications/ 880881 Lim S, Seligson AL, Parvez FM, Luther CW, Mavinkurve MP, Binswanger IA, et al. Risks of drugrelated death, suicide, and homicide during the immediate post-release period among people released from New York City jails, 2001–2005. Am J Epidemiol. 2012;175(6):519–26. Spaulding AC, Allen SA, Stone A. Mortality after release from prison. N Engl J Med. 2007;356(17):1785. Correctional Health Services of the New York City Department of Health
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and Mental Hygiene worked with the New York State Department of Health to match a series of consecutive patients in jail against people on the state health homes lists. There were 2,055 unique Medicaid identification numbers for the patients in jail. These numbers were matched to the population eligible for a state health home in 2011. Of the 2,055 people, 1,121 people appeared on both lists. New York City Department of Health and Mental Hygiene, Correctional Health Services, internal data, 2013 Jun 1. Dinwiddie GY, Gaskin DJ, Chan KS, Norrington J, McCleary R. Residential segregation, geographic proximity, and type of services used: evidence for racial/ethnic disparities in mental health. Soc Sci Med. 2013;80:67–75. Alegría M, Canino G, Ríos R, Vera M, Calderón J, Rusch D, et al. Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatr Serv. 2002;53(12): 1547–55. Teixeira P, Jordan AO. Health out-
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comes for HIV-positive inmates released from NYC jails. Paper presented at: American Public Health Association Annual Meeting; 2012 Oct 27–31; San Francisco, CA. Spaulding AC, Pinkerton SD, Superak H, Cunningham MJ, Resch S, Jordan AO, et al. Cost analysis of enhancing linkages to HIV care following jail: a cost-effective intervention. AIDS Behav. 2013;17(Suppl 2):S220–6. Agency for Healthcare Research and Quality. Innovations exchange: Michigan Pathways project links exprisoners to medical services, contributing to a decline in recidivism [Internet]. Rockville (MD): AHRQ; [cited 2014 Jan 15]. Available from: http://innovations.ahrq.gov/popup .aspx?id=2134&type=1&isUpdated= True&isArchived=False&name= print Wang EA, Hong CS, Shavit S, Sanders R, Kessell E, Kushel MB. Engaging individuals recently released from prison into primary care: a randomized trial. Am J Public Health. 2012;102(9):e22–9. New York City Department of Health and Mental Hygiene, Correctional
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Health Services, memo of understanding with Bronx Lebanon Health Home, effective 2013 Sep 1. Binswanger A, Krueger PM, Steiner JF. Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. J Epidemiol Community Health. 2009;63(11): 912–9. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):1–14. Nordentoft M, Wahlbeck K, Hällgren J, Westman J, Osby U, Alinaghizadeh H, et al. Excess mortality, causes of death, and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland, and Sweden. PLoS One. 2013;8(1): e55176. Mukku VK, Benson TG, Alam F, Richie WD, Bailey RK. Overview of substance use disorders and incarceration of African American males. Front Psychiatry. 2012;3:98.
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