State and local governments bear a large share of the health care costs for justice-involved individuals, not only as providers of jail-based health care, but also through funding of uncompensated care by safety net providers such as state and county hospitals and community health centers. The ACA’s Medicaid expansion and enhanced federal funding have the potential to address health care needs and coverage of jail populations before and after incarceration while also providing significant cost savings for state and local governments. Therefore, state and local government officials are beginning to consider new strategies to increase jail populations’ enrollment in health coverage.
Hampden County (population 467,319) has a long track record of successfully enrolling inmates in health coverage at its correctional center in Ludlow. Administered by the Hampden County Sheriff’s Department, the Hampden County Correctional Center (HCCC) serves the Springfield-Holyoke metropolitan area, supervising approximately 1,500 offenders including pre-trial detainees and people sentenced for two and a half years or less at minimum to medium security.
Since 1992, the county has taken a proactive approach to help jail inmates and former inmates access comprehensive medical care, behavioral health and social services, and the financial support they need to improve their life circumstances and ultimately become productive members of their communities. Facilitating timely enrollment in Medicaid is an important component of this strategy.
The following sections summarize the key elements of Hampden County’s approach to supporting inmate access to health coverage and health services.
Commitment to Address Inmates’ Complex Needs
Like most justice-involved populations, HCCC inmates have complex behavioral health and social service needs:
- Forty to 50 percent of men and 60-70 percent of women entering HCCC have serious mental illnesses including major depression, schizophrenia, and mood disorders. Personality disorders for which there are no effective medications and for which the state does not provide treatment in community-based health facilities account for an estimated 20 percent of serious mental illnesses among inmates.
- Nearly all HCCC inmates (85–90 percent) have substance abuse problems.
- Virtually all inmates (85–90 percent) are uninsured.
HCCC spent approximately $7 million on inmates’ medical care in FY 2013 and has a strong commitment to address the full range of inmates’ needs to improve their lives. HCCC officials believe it is their job to send incarcerated people back into the community in better shape than when they first entered the correction system.
Support from the Top
Hampden County Sheriff Michael Ashe has been the driving force behind HCCC’s approach to promoting successful community re-entry and continuity of care for jail populations.19 Ashe, who was trained as a social worker and has been sheriff for 38 years, recognizes that without effective intervention to help inmates make positive life changes, the chances for recidivism are high. To help inmates improve their life circumstances and avoid reincarceration, HCCC’s correctional case managers connect them with GED classes, medical care, behavioral health and substance abuse services, job training and placement, transportation, housing, and any other support services they need. Jail-based correctional case managers coordinate with social work staff for the county’s after-incarceration support program to ensure that inmates continue to receive the assistance they need post-release. HCCC leaders view medical care and, by extension, health coverage as essential elements of the comprehensive support inmates need to turn their lives around.
Case Management Staff Dedicated to Medicaid Enrollment
Ensuring that jail inmates have health coverage upon release always has been a key component of HCCC’s discharge planning program. HCCC tracks the release dates of all inmates and initiates the Medicaid enrollment process 30 days prior to discharge. At each facility, a MassHealth case coordinator works one-on-one with inmates to complete the 29-page Medicaid application. The case manager faxes completed applications to the Massachusetts Medicaid office and monitors their status throughout the enrollment process. Completed applications generally are approved within three to five days.
A Public Health Model for Correctional Health Care
Based on success in addressing the HIV/AIDS epidemic in the early 1990s, leaders from HCCC and county health services worked together to develop a public health model for correctional health care. Under the model, physicians serving community health centers in neighborhoods with high proportions of incarcerated residents also provide care in HCCC’s facilities. Therefore, inmates who had been receiving care in community health centers prior to incarceration can see the same physicians while in jail and following release. HCCC’s health and social service providers work together to ensure that inmates and former inmates receive comprehensive, high-quality medical, behavioral health, dental, and vision care.
Partnering with community health center-based physicians has been critical to improving the health of justice-involved populations. Community health center doctors take a proactive approach to prevention and treatment of the many chronic diseases that are prevalent among jail populations, and they are committed to ensuring continuity of care for their patients following release.
The timing of an inmate’s release from jail can be difficult to predict. A person may enter the jail at 3 p.m. and be released on bail at 4 p.m. or a week later. Sometimes individuals are sentenced and then paroled unexpectedly. Regardless of how long an individual is in HCCC’s custody, he or she is entitled to receive After-Incarceration Support Services (AISS), coordinated at a facility in nearby Springfield, Massachusetts. Jail-based correctional case managers connect inmates to AISS case managers for post-release follow-up. Case managers reach out to people following their release, and, if necessary, bring them into the AISS facility for assistance. Inmates who were unable to complete the Medicaid enrollment process before discharge are enrolled as soon as possible upon re-entering the community.
Maximizing Available Medicaid Coverage
Because it provides comprehensive coverage with minimal cost sharing, Medicaid has been the primary source of health coverage for the HCCC population. Massachusetts is among a subset of states that take advantage of federal law allowing states to bill Medicaid for the care of inmates who are admitted to hospitals, nursing facilities, juvenile psychiatric facilities, or intermediate care facilities that are not part of the local correctional system. As a result of this practice, Hampden County saved approximately $387,000 in FY 2013. Additionally, under a new policy enacted as part of the state’s FY 2015 budget, Massachusetts counties can suspend rather than terminate Medicaid benefits when individuals are admitted to jail. Therefore, inmates who had Medicaid coverage before incarceration can re-enroll immediately upon release rather than go through the process of re-applying. Although this policy is allowed under federal Medicaid law, the vast majority of states have not adopted it.
Effective Information Sharing
Ongoing information sharing among correctional facilities, jail-based health facilities, and communitybased health care providers is an important element of HCCC’s strategy to promote continuity of inmates’ medical care, behavioral health services, and health coverage. Two successful information components are:
- Electronic health records to promote continuity of care by enabling the sharing of inmates’ health information—with patient consent—between jailand community-based health care providers.
- A virtual electronic gateway to expedite Medicaid enrollment. The system transmitted eligibility information in real time to the state Medicaid office, which often approved completed applications on the same day, saving HCCC approximately $410,000 in FY 2012 and $276,000 in FY 2013. The gateway was suspended in 2014 because of technology problems associated with rollout of the Affordable Care Act in the state, and HCCC returned to a paper-and-fax system for Medicaid enrollment. HCCC staff expects the gateway system will be re-activated once the technical issues are resolved.
A Spirit of Inter-Agency Cooperation
Ongoing cooperation among corrections departments, the state Medicaid agency, and local community center staff has been critical to the county’s success in empowering inmates to re-enter their communities successfully. This cooperation provides not only better opportunities for inmates, but also significant cost savings for communities.
HCCC has experienced decreases in both reincarceration rates and its total inmate population which officials attribute, in part, to its comprehensive efforts to help inmates and former inmates gain access to the resources and support they need to improve their life circumstances. Reincarceration rates for HCCC inmates are among the lowest in the country. According to the most recent data available, one year after being released in 2011, 14.3 percent of inmates were incarcerated for a new crime; and three years following release, the reincarceration rate was 31.7 percent. Ten years ago, the one-year reincarceration rate for HCCC inmates was 20.2 percent, and the three-year rate was 43.6 percent. By comparison, the most recent national data on the U.S. jail population indicate that in 2002, 41 percent of jail inmates had a current or prior violent offense, and 46 percent were nonviolent recidivists.
From FY 2008 to FY 2014, the number of inmates in HCCC corrections facilities declined by approximately 29 percent, from 2,085 to 1,477. This decline was associated with a 7.5 percent reduction in the total jail budget-from $72.2 million in FY 2008 to $66.8 million in FY 2013—and a 27.4 percent reduction in the total medical budget—from $9.58 million in FY 2008 to $6.97 million in FY 2013.
Nationwide, the total number of jail inmates fell by 6.9 percent, from 785,533 in 2008 to 731,208 in 2013.
- Taking a proactive approach to help inmates and former inmates gain access to comprehensive medical care, behavioral health and social services, and financial support contributes to improved life circumstances, lower reincarceration rates, and a decrease in the number of inmates.
- The availability of new federal funds under the Affordable Care Act (ACA) provides an opportunity for state and local governments to realize significant cost savings for justice-involved individuals who are admitted to hospitals, nursing facilities, juvenile psychiatric facilities, or intermediate care facilities that are not part of the local correctional system.
- Helping inmates complete the Medicaid enrollment process before discharge ensures that they will have health coverage after release which is important to sustaining progress on lifestyle changes initiated while incarcerated.
- Ongoing cooperation among corrections departments, the state Medicaid office, and local community center staff has contributed to this county’s success in empowering inmates to re-enter their communities successfully