The Affordable Care Act and Improving Health Access and Outcomes for Justice-Involved Populations
Cynthia Golembeski (Fortune Staff)
Robert Fullilove (Fortune Advisory Board Member)
The Patient Protection and Affordable Care Act (ACA) may be one of the most significant health care reform measures in the past four decades. The ACA is well suited to improve upon health care access and quality, as well as to reduce the stigma associated with certain health conditions, particularly those linked to substance use and mental health challenges. This expansion of coverage and care will increase access to coordinated, patient-centered, community-based health care resources, particularly for those that have been marginalized and neglected by the previous health care system. Additionally, many advocates and researchers have noted, with some optimism, the possible transformative effects the ACA might usher in for justice-involved individuals.
Three decades of mass incarceration in the United States coincide with a significant lack of support for community mental health treatment, deinstitutionalization, as well as the rise of punitive approaches to substance use and mental health challenges. The emphasis on punishment, rather than treatment, care, and support, has disproportionately impacted low-income communities of color. The withering social safety net combined with incarceration’s role in uprooting social, family, and community networks has had devastating effects on both individual and population-level health. Additionally, involvement with the criminal justice system has been identified as contributing to health disparities. Compelling evidence suggests that the conditions of incarceration lead to poor health outcomes because of, for example, poor nutrition and diet, an elevated risk of sexual assault or other violence, and the mental health repercussions of both crowding and prolonged isolation.
Rates of chronic illness, infectious illness, mental illness, and substance use disorders in the criminal justice system are far higher than those found among the general population. Inadequate treatment options and discontinuity of care exacerbate such disparities and further compromise a high-need, medically underserved population. Significantly, for instance, there are three times as many seriously mentally ill persons in jails and prisons than in hospitals. Such high rates of illness among those in prisons, jails and under community supervision reflect the reality that the majority of justice-involved individuals come from and return to under-resourced communities with limited access to prevention, screening and treatment services. Criminal justice involvement increases the risk of poor health outcomes, with direct or indirect effects on health and health care for individuals, families, and the communities that bear both individual and collective burdens. Understanding and addressing the health of justice-involved individuals is one component of a comprehensive strategy to reduce health disparities and improve upon community health.
Health care coverage:
Among the ways the ACA improves access to health care coverage are: Coverage for people with pre-existing conditions; expanded Medicaid coverage; more affordable coverage; and lower prescription drug costs for Medicare recipients.
The ACA’s expansion of Medicaid to include those under age 65, also incorporates those without children, who have incomes up to 133% of the poverty level. Notably, this newly eligible population includes a considerable subset of those who are also justice-involved. Ultimately, decreasing financial barriers through expanding Medicaid and subsidizing insurance exchanges will increase health care coverage for those being released from correctional facilities. One estimate suggests that up to 35% of the newly Medicaid eligible population will be comprised of justice involved individuals. Enrolling people while they are still incarcerated will facilitate enhanced access to care and continuity of services between correctional institutions and the community.
Expanding the provision of universal health care coverage that does not exclude or impose undue cost burdens based on previously existing conditions, will serve the justice involved population well, given the higher rates of co-occurring physical and mental health conditions. Several studies have documented the importance of health care access for those on parole and its positive impact on recidivism and reintegration. Moreover, regular medical care may decrease some of the high-risk behaviors that are associated with rearrests and reincarceration.
Quality of coverage:
The ACA seeks to ensure quality coverage through preventive services that emphasize early intervention; comprehensive coverage; and coordinated care for those with chronic conditions.
As part of ensuring comprehensive coverage, the ACA builds on the Mental Health Parity and Addiction Equity Act of 2008 in extending mental health and substance use disorder coverage as essential benefits. Along with comparable coverage for physical and mental health benefits, designated funds will be disbursed through the ACA in order to assist community health clinics in bolstering their mental health services. Indeed, framing access to mental health services as an essential benefit may also prevent over-reliance on the criminal justice system to address addiction and mental health challenges. According to the National Association of State Mental Heath Program Directors Research Institute, the number of mentally ill prisoners that the Cook County, New York and Los Angeles jails handle daily is equivalent to 28% of all beds in the nation’s 213 state psychiatric hospitals.
Under the ACA, all women will receive enhanced benefits and will not have to pay more for services than their male counterparts. Preventive health care specific to women, such as mammograms, pap smears and pelvic exams for cervical cancer, and contraceptives will now be available at no charge. According to a 2012 report from the National Women’s Law Center, 36 states previously allowed insurers to charge women between 20% and 40% more than they charged men of the same age. Out of pocket expenses for maternity care will also be greatly reduced, as all insurance plans will be mandated to cover such services. Justice-involved women and female partners of justice-involved individuals stand to especially benefit from ACA related changes guided by gender parity and cost equity.
In terms of medical care for prisoners, Medicaid only covers hospital stays longer than 24 hours, which may improve the quality of care for pregnant women who are incarcerated. Pregnant women who are incarcerated constitute a vulnerable health population because of their increased risk of complicated and preterm deliveries as well as greater need for sexual and reproductive health services. Cost reduction at the local and state level through expanding Medicaid coverage for extended hospital stays is a positive development, which may also stem health compromising actions on the part of correctional staff seeking to lower costs associated with childbirth-related care. Correctional facilities often delay furlough until the point at which they think the woman is immediately ready to deliver, which may incur unnecessary harm, including emotional stress, to both the mother and child. Pregnant women or new mothers being released will also benefit from the opportunity to secure improved health care coverage and continuity of care for themselves and their child prior to release.
Another crucial aspect of improving quality of coverage is ensuring coordinated care continuity for those with chronic conditions, which the patient-centered medical home model and Accountable Care Organizations (ACO) typically provide. In 2011, the New York State Department of Health introduced the health homes program as a service model for providing comprehensive case management of high-needs patients, which should ultimately result in improved care and lower costs. The provider network coordinates patient-centered service delivery efforts, including behavioral health, primary and acute care. In New York City, warm linkages to care are in place for those recently released from the jail system where approximately 40% of patients cope with substance use disorders and 35% with mental health challenges. The Department of Health and Mental Hygiene, in partnership with local social services, dedicates significant resources into medication eligibility screening and pre-enrollment services for those who are incarcerated and living with mental illness, which account for approximately 30,000 annual admissions.
It is widely cited that upwards of 80% of those leaving prison or jail do so without any health insurance and ultimately face significant barriers to care during a critical time period. Immediately following release, women and men may seek to address basic needs and reestablish housing, financial security and social relationships, which can be particularly stressful. Often, the process of accessing and securing health care, which may include mental health and substance use treatment, may not be the highest priority. However, engagement with caring and competent health professionals may prove crucial for the significant number of recently released persons who are at high risk of death due to overdose or suicide during the period immediately following release. In fact, a study found the risks of drug-related death and homicide in formerly incarcerated persons were two times higher than those of NYC residents who had not been incarcerated in NYC jails during 2001-05. Overwhelmingly, coordination among correctional health care, community-based health care, and agencies that assist with various needs and services associated with reentry, is crucial to ensuring more positive health outcomes for justice-involved individuals and communities.
Capacity-building of the healthcare delivery system as part of ACA related reforms may include: Expansion of community health centers; delivering culturally competent care; increasing the health care workforce for underserved communities, and improved health information technology.
Enactment of several key ACA reforms may significantly enhance the health care system’s overall quality and efficiency and may additionally strengthen both its workforce and infrastructure. Such noteworthy ACA provisions include increasing support and subsidies for research and tracking on key health measures, local public health, prevention, and community development efforts, public education campaigns, and community needs assessments. In addition, the ACA includes an explicit requirement to track, report on, and evaluate progress toward reducing racial disparities in health outcomes. Such measures are of particular importance for practitioners, advocates, and researchers who have uniformly noted a lack of equity of care in the provision of health and social care services to justice-involved individuals, particularly at the community-level.
The ACA explicitly supports cultural competence training programs, which meaningfully encompass the dynamics of race, ethnicity, gender, sexuality, class and other factors, in improving understanding and care on the part of health care providers and institutions. Cultural competency and sensitive care provision can lead to improved health outcomes for individuals and communities. In the case of justice-involved individuals, sensitivity toward and knowledge of the risk factors and challenges associated with involvement with the criminal justice system, may increase continued engagement in care.
Facilitating health care service, which routinely includes assuring caring relationships with providers, will be key to managing various health challenges and encouraging health-enhancing behaviors for those who access these services. Such assurances are particularly relevant immediately after release when certain social conditions and individual behaviors may place one at high risk for injury, substance abuse, or contracting infectious diseases, including HIV. Cultural competence bolsters the development of more responsive and informed interventions and practices, whether in regards to the many factors that reflect social and cultural aspects of ethnicity/race, gender/sexuality, or those that are associated with justice involvement. The ACA’s expansion of coverage and support for cultural competency training programs may ease health care burdens and mitigate the many barriers that justice involved individuals face within correctional institutions and the community.
Increasing cultural competency coincides with education, research, policy, advocacy, and practice that seek to implement alternatives to the criminal justice system, which in all too many instances serves as the de facto treatment for substance use, mental illness, and other social concerns. The ACA also has the capacity to increase disease prevention and health promotion efforts that do not only emphasize changing individual behavior, but rather seek to change the social and structural realities that reinforce health inequality. Cultural competency incorporates understanding how structural and social dynamics increase health burdens and poor health outcomes.
One study, analyzing data from a cross-sectional survey of 172 men recently released from a state prison, revealed that 42% self-reported a history of criminal record discrimination by healthcare workers, which adversely impacted healthcare utilization. Transitions clinics, which are designed to specifically meet the needs of patients with justice involvement, maximize peer-based support and patient navigation. Relatedly, the City College of San Francisco offers community health worker training that includes special certification in caring for the post-prison population.
Health information technology improvements as part of ACA-related reform efforts include financial reimbursements for implementing electronic health records (EHR), which could support smoother transition of care from correctional facilities to the community. The use of EHR by correctional and community health care providers could help ensure that treatments are consistent across health care settings.Moreover, researchers and practitioners have noted how the EHR is a technological innovation that may increase efficiency, accuracy, continuity of care, information sharing, the reduction of medical error, and the identification of people appropriate for specialized services, including diversion programs. In New York, Medicaid is suspended rather than terminated if one is incarcerated, and EHR can expedite the re-enrollment process upon release. Moreover, a recent study describes how implementing EHR across 12 New York City jails enabled better surveillance of vulnerable populations and ultimately, enhanced the reporting and analysis of patterns of abuse, neglect, and other patient concerns related to human rights.
Health care should be a basic human right, but it can also be a tool for social justice. The ACA presents new possibilities in improving the health, wellness and safety of individuals and communities as well as in strengthening community health systems via health promotion, disease prevention, early detection, and universal access to care. Comprehensive health insurance reforms expand coverage, increase insurance companies’ accountability, decrease costs, expand options, and improve health care quality for all. For far too long, crucial health needs have gone neglected in under-resourced communities, which also experience disproportionate rates of involvement with the criminal justice system. Moreover, addressing illness and poverty, which often underlie certain behaviors that are criminalized, pathologized, or stigmatized, through punitive means does not correspond with first doing no harm.
Ultimately, public health and clinical professionals, whether engaged in research, data collection, education, advocacy, policy, or direct services, play a crucial role in improving individual and population health outcomes. Proactively intervening and focusing prevention efforts as far upstream as possible may more effectively decrease burdens further downstream, while building on community values, strengths and assets. Sharing responsibility for the public’s health through respect for justice and for inclusiveness entails collaboratively promoting the health, wellness and safety of individuals and communities. Hopefully, the ACA will assist in promoting true health equity through creating and bolstering conditions that enhance health and alleviate suffering.
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