Health Care Reform: One train not to miss

Just when many states and communities were beginning to figure out how to improve access to health and behavioral health services for justice involved persons with mental illness, the health care landscape is changing.

With the support of federal initiatives such as the Bureau of Justice Assistance’s (BJA) Justice and Mental Health Collaboration Grants, BJA’s Second Chance Act and Substance Abuse Mental Health Services Administration’s (SAMHSA) jail diversion initiatives there have been great strides in development of diversion and reentry models and identification of best practices to engage justice involved persons in behavioral health services.

Many communities and states have developed collaborative task forces to address criminal justice and behavioral health issues.  A small number of states have passed Medicaid suspension legislation which insure that Medicaid will be available to access needed health and behavioral health services when inmates are released from jail or prison.

The Patient Protection and Affordable Care Act (ACA) has stimulated the development of health homes and increased utilization of managed care providers in provision of services to Medicaid recipients. Regardless of the Supreme Court’s decision on the constitutionality of ACA and its mandated insurance coverage requirement, health delivery is changing.

Few communities are including criminal justice stakeholders in their planning activities and I’m worried that as in the past the justice involved person with behavioral health disorders will be invisible to both state and local health care reform planners. Health care insurance exchanges, payment methodologies and services will be set up without the considering the needs and special circumstances of the justice involved consumers.

Health Care Reform and the ACA hold great promise for justice involved persons. In ACA for example,

Medicaid eligibility is expanded to include people earning up to 133% of the federal poverty level. Eligible individuals are defined as anyone not convicted of a crime. Should this definition remain intact, then individuals held in jail pending conviction (pre-trial detainees) (with income below 133% of the poverty level ) would be eligible for Medicaid.  This provision removes many barriers to care for person being released from jail.  First, it expands the population that will be covered under Medicaid. Second, it removes the barrier of disruption of Medicaid coverage during incarceration.

These initiatives can also impose hazards to access to care for justice involved persons if criminal justice stakeholders are not involved in health care planning.

Some of the issues that need to be addressed to insure inclusion of justice involved populations are:

  • How will jail screening need to change to promptly identify both persons with Medicaid coverage and those without?
  • Will jails have the capacity to promptly enroll persons in Medicaid?
  • What will be the relationship of community health care providers to jail health care providers? Will there be seamless information exchange? Will providers be able to “reach-in” to the jail to provide transition services?
  • How will jail releases get enrolled in health care exchanges? Will providers be able to provide prompt services upon release or will there be delays in enrollment and service access?
  • Will outcome measures include justice outcomes to measure how successful providers are at reducing criminal justice involvement?
  • Will jails be included in existing health care reform initiatives and initiatives? The Center for Medicaid Services (CMS), Substance Abuse Mental Health Services Administration (SAMHSA), and Health and Human Services (HHS) have provided states and communities with grants to develop models to improve health and behavioral health integration, reduce health care costs and improve services access. How many of the communities receiving these grants have included criminal justice stakeholders?
  • How will providers interact with diversion programs and probation and parole?

Action Steps:

  • Health care reform planners can reach out to criminal justice stakeholders and invite them to planning discussions
  • Criminal justice stakeholders can provide data on behavioral health and health needs of their population to the local and state health care planners to insure adequate resources are available to address health care reform changes and ACA changes
  • Health care planners can include jail health care personnel in Electronic Medical Records initiatives. Having a continuous medical record from community to jail could dramatically improve quality and continuity of care for the jail population.
  • Workforce training can include a “working with the justice involved consumer” component. (See SPECTRM) Training issues may include: the culture of incarceration, understanding the criminal justice system and understanding risk/needs assessment
  • Health care reform initiatives include provisions for peer specialist positions. However, to insure inclusion of peer specialists who have been justice involved, hiring practices and Human Resource policies must be reviewed to insure that justice involved peers are not unfairly excluded from employment.

To learn more visit these resources:

Criminal justice, Diversion, Legislation