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Obamacare impacts recidivism

Thursday, February 06, 2014
BloombergBusinessweek
by Mark Niquette

Being arrested in Chicago for, say, drug possession or assault gets you sent to the Cook County Jail to be fingerprinted, photographed and X-rayed. You’ll also get help applying for health insurance.

At least six states and counties from Maryland to Oregon’s Multnomah are getting inmates coverage under Obamacare and its expansion of Medicaid, the federal and state health-care program for the poor. The fledgling movement would shift to the federal government some of the more than $6.5 billion in annual state costs for treating prisoners. Proponents say it also will make recidivism rarer, because inmates released with coverage are more likely to get treatment for mental illness, substance abuse and other conditions that can lead them to crime.

“When someone gets discharged from the jail and they don’t have insurance and they don’t have a plan, we can pretty much set our watch to when we’re going see them again,” said Ben Breit, a spokesman for the Cook County Sheriff’s Office.

The still-small programs could reach a vast population: At the end of 2012, almost 7 million people in the U.S. were on parole, probation, in prison or locked up in jail, according to the federal Bureau of Justice Statistics. About 13 million people are booked into county jails each year, according to the Washington-based National Association of Counties.

Obamacare replaced a hodgepodge of state requirements that typically excluded childless adults from Medicaid. The 2010 law opened it to anyone making less than 138 percent of the federal poverty level, about $16,000 for an individual. In the 25 states that expanded the program under the Affordable Care Act, eligibility extends to many of the people most apt to be in jail or prison, said Fred Osher, director of health services and systems policy for the New York-based Council of State Governments Justice Center.

Governments generally must provide prisoners health care. Medicaid can’t be used, except when inmates are hospitalized off site 24 hours or longer. That lets a state or county pass on costs for such things as heart surgery or a stay in a psychiatric facility.

Medicaid expansion also enables more prisoners to have coverage when they are released. States that don’t expand it can help inmates get subsidized coverage in the insurance exchanges created under the law when they’re released.

Counties in about half the states are responsible for some level of indigent care at hospitals, so getting inmates enrolled can reduce costs, said Paul Beddoe, deputy legislative director for the National Association of Counties.

Cook County has been operating a pilot project to enroll prisoners in Medicaid since April under a federal waiver, while states including Connecticut, Illinois and Maryland and counties such as Multnomah, which includes Portland, have helped hundreds of prisoners apply for coverage under the Affordable Care Act since it took effect Jan. 1. California, Ohio, San Francisco and other jurisdictions are starting programs or considering them.

About 90 percent of inmates are uninsured, and many have never had treatment for their illness, Osher said. They have disproportionate rates of communicable and chronic diseases and behavioral disorders, he said. About 488,000 people in U.S. prisons and jails suffer from a mental illness, according to the National Alliance on Mental Illness in Arlington, Virginia.

Getting them covered is just one way that state and local governments are using the health-care overhaul to save money. With U.S. cities facing rising benefit expenses and billions of dollars in unfunded liabilities, municipalities including Detroit and Chicago are planning to move retirees off city rolls and into federal insurance exchanges.

While analysts couldn’t estimate what states and counties could save by getting inmates covered, state and local spending on corrections in 2011 was $73.2 billion, according to the U.S. Census Bureau. Prison health-care expenses in 44 states studied by the Philadelphia-based Pew Charitable Trusts increased to $6.5 billion in 2008 from $4.3 billion in 2001, and grew 90 percent or more in 11 states, according to an October report.

“A lot of states will come to this, because state corrections budgets are huge and county jail budgets are huge,”said Maureen McDonnell of Treatment Alternatives for Safe Communities, a Chicago nonprofit that helped establish inmate enrollment programs in Illinois.

The Ohio Department of Rehabilitation and Correction, which plans to start enrolling inmates during the next two months, expects that it will save $18 million a year on hospitalization alone, said Stu Hudson, managing director of health care and fiscal operations. Ex-prisoners who have insurance will be more likely to get treatment that would help them avoid committing crimes that got them locked up in the first place, Hudson said.

“They’re provided good continuum of care from incarceration through their release into the community and onward,” Hudson said by phone.

Illinois is seeking to get Medicaid coverage for prisoners who must be hospitalized, and for all when their release is imminent, said Tom Shaer, a spokesman for the Corrections Department. He said the state has enrolled about 125 parolees or inmates since Jan. 1.

Cook County, which includes Chicago and has the largest single-site jail complex in the U.S., has started about 13,000 insurance applications since April, said Marlena Jentz of the sheriff’s public-policy office. More than 2,000 prisoners have obtained coverage after their release, she said.

When people are booked into the jail, they get photographed and fingerprinted, turn over their personal property, go through a full-body scan and head to a classification area. There, they are assigned a cell, and a worker from Treatment Alternatives for Safe Communities helps them complete an application for Medicaid.

In Multnomah County, the jail has completed Medicaid applications for about 800 inmates during the past three weeks using seven eligibility specialists, said Nancy Griffith, director of corrections health.

The county is targeting inmates who have the highest costs for treatment, including those with a mental illness or chronic conditions, as well as those with frequent arrests, Griffith said.

“The hope is that this benefits the whole county,”Griffith said in a telephone interview.

Former U.S. Senator Kent Conrad, a Democrat from North Dakota who was on the Senate Finance Committee when the Affordable Care Act passed, said he doesn’t recall discussions about the law’s being used to cover inmates.

Conrad said that while he agrees that it’s better to have as many people as possible insured -- including prisoners --he’s bothered by federal taxpayers picking up the tab for inmate hospital stays. “It starts to look a little like a scheme by the states and local jurisdictions to avoid responsibilities that are really theirs,” Conrad said in a telephone interview.

Still, it would be “foolish” not to adopt the strategy, said San Francisco Sheriff Ross Mirkarimi. He estimates it would save $2,500 a year per inmate and reduce repeat incarcerations about 20 percent. “This is the most unsympathetic population there is,”Mirkarimi said in a telephone interview. “But the evidence and the jury is in: This is the way to enhance public safety and reduce recidivism.”



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