The Affordable Care Act (ACA) has created a new opportunity for California to reach and enroll a medically vulnerable population-the jail population-in health insurance coverage. While inmates receive health care services from county jail systems while incarcerated, few have coverage after they are released from custody. Expansion of the state’s Medicaid program (Medi-Cal) under the ACA has extended insurance eligibility to much of the currently uninsured jail population. As a complement to the ACA, California recently signed into law Assembly Bill 720 (AB 720), which facilitates the use of jails as sites of health insurance enrollment. Increasing enrollment levels for the jail population holds the potential to reduce corrections costs, as well as improve public health and safety.
The Jail Population Is High Need and Hard to Reach
The jail population has high health needs but faces substantial barriers to accessing health care. Available data suggests that rates of infectious diseases (such as tuberculosis and hepatitis) and chronic conditions (such as hypertension and asthma) are higher among incarcerated individuals compared to the general population.1 Inmates also have higher rates of mental health and substance use issues-in fact, national statistics suggest that local jail inmates are more likely to have mental health problems than even state and federal prisoners are.2 These challenges are exacerbated by the low rate of health insurance coverage among incarcerated individuals-who are disproportionately young adults, male, and low income.3
Prior to the ACA, few among California’s jail population were eligible for public health insurance. This population also has limited access to employer- or school-based health insurance and, as a result, they are hard to reach through traditional enrollment mechanisms. The Medi-Cal expansion under the ACA has extended eligibility for public health insurance to all adults with incomes up to 138 percent of the federal poverty line, creating the opportunity to expand coverage for many among the uninsured jail population. California’s passage of AB 720 compliments the ACA by facilitating the use of jail systems to connect inmates to coverage before they are released from custody.
In this report, we take advantage of the Jail Profile Survey (JPS) to assess the recent level of health care provision in county jail systems, as well as trends in care over the past decade. We then discuss how the ACA coverage expansion, along with California’s recently passed AB 720, provides local corrections systems with new tools to reduce costs, lower recidivism, and improve public health.
Jails Are Important Health Care Providers
Because of the disproportionately high health needs of jail inmates and their relatively low access to health services outside of custody, jail systems are important providers of health care in California. In 2012, there were nearly 2.3 million health care visits provided to California’s county jail inmates (Table 1).4 The vast majority of these visits were “sickcalls,” whereby inmates requesting medical attention are treated by onsite jail medical staff.5 Depending on the medical need, a sickcall may result in a scheduled medical appointment with a physician or mid-level practitioner. Of the more than half a million scheduled medical appointments in 2012, nearly 95 percent occurred within the jail facility.6 There were also nearly 80,000 dental visits provided by local jails in 2012.
In 2012, county jails provided almost 200,000 medical visits each month, an average visit rate of nearly 2.4 medical visits per inmate. As a point of comparison, in 2012 the state’s network of more than 1,000 free and community clinics provided an estimated 1.17 million visits from males age 20 to 34, which translates into a visit rate of 0.73 visits per uninsured male age 20 to 34.7
Jail inmates also have significant mental health needs. In 2012, the statewide monthly average of active mental health cases open was nearly 13,000, or about 20 percent of ADP among reporting jurisdictions (Table 2).8 About 8,300 jail inmates received psychiatric medication, and another 2,800 were assigned to mental health beds.9
Table 1. Jails provided nearly 2.3 million health care visits in 2012
Table 2. sizable shares of jail inmates have mental health needs
When it comes to health care provision and, in particular, visit rates, it is important to acknowledge the flow of inmates through county jail systems. The number of inmates counted on any given day-the only metric we have-does not give us the total number of people entering the jail system who could require medical attention. County jail inmates have relatively short stays; in 2012 the average county jail stay in California was about 21 days, but the majority of jail stays were even shorter. This underscores the high level of inmate turnover in the course of a year.10 The Bureau of Justice Statistics estimates that the number of people admitted to local jail systems nationwide was about 16 times higher than the average daily population.11 This would suggest that about 1.25 million people were admitted to California jails during 2012 and would yield visit rates comparable to those presented in Table 1.12
The average number of monthly onsite medical appointments in county jails has increased over the past decade. But when we account for changes in the size of the jail population, it seems that jails, on average, have been providing a fairly constant level of health care (Figure 1).
Figure 1. jail health care visit rates have held steady over the past decade
Recent changes-notably California’s 2011 public safety realignment-have affected the size and composition of jail populations. In addition to increasing the population pressure, realignment has increased the sentenced and felony shares of California’s jail population13 and lengthened the amount of time an individual can serve in county jail. These changes may affect the underlying health status and needs of the jail population, and it will be important to monitor future trends in jail health care provision.
The ACA Expands Eligibility for the Jail Population
California’s implementation of ACA, including the Medicaid expansion, has extended eligibility and enhanced access to health insurance for the jail population. Nationally, an estimated 35 percent of those newly eligible for Medicaid are individuals who have been involved with the criminal justice system, largely due to relatively low incomes and low insurance rates.14 Prior to the ACA, the few who were enrolled often lost coverage when they entered the corrections system. To better facilitate the enrollment of jail inmates in public health insurance, the state recently enacted AB 720. The legislation removes enrollment barriers by:
- Authorizing counties to designate an entity to assist inmates in applying for health insurance coverage;
- Authorizing this designated entity to act on behalf of inmates to apply for Medi-Cal coverage for inpatient hospital services;
- Changing state law to suspend, rather than terminate, Medi-Cal coverage while in county jails, allowing inmates to retain or initiate coverage while in custody; and
- Clarifying that county welfare departments are not precluded from processing applications for the Medi-Cal program because a person is an inmate in a county jail.
While AB 720 does not require the enrollment of jail inmates, there are several reasons counties may see this legislation as an opportunity to reduce corrections costs, lower recidivism rates, and advance public health goals.
Opportunities for Counties to Reduce Costs and Improve Health and Safety
Given the jail population’s substantial health needs, it is not surprising that inmate health care is an important driver of corrections costs. According to national estimates, 9 to 30 percent of the total cost of incarceration is attributable to health care expenditures.15 Although we have limited information about health care costs in jails, the Legislative Analyst’s Office (LAO) reports that more than a quarter of the average cost of prison incarceration per inmate in California is attributable to health care expenditures,16 and that inmate health care costs are an important driver of recent increases in corrections costs.17 In the context of corrections realignment, counties may find that enrolling this population in public insurance programs can help them reduce costs, improve recidivism outcomes, and improve public health.
Jail systems can realize direct savings by shifting acute inpatient hospitalization costs to the federal government for inmates enrolled in Medi-Cal. The federal “inmate exception” rule does not allow counties to claim reimbursement through Medi-Cal for most health services provided within the jail system,18 but Medi-Cal does cover the cost of inpatient hospital care for inmates who remain offsite for more than 24 hours. In addition, given the degree to which jail inmates cycle in and out of custody, their access to health care outside of the jail system could allow for preventative intervention and management of chronic conditions that indirectly reduce the cost of in-custody care.
Counties may derive public health benefits from enrolling the jail population in health insurance coverage.
Health insurance enrollment could also help reduce the likelihood that individuals will cycle back into the corrections system. Evidence suggests that well-targeted substance abuse treatment can substantially reduce recidivism. A recent cost-benefit analysis of substance abuse treatment in 13 California counties found that the intervention substantially reduced recidivism, as well as corrections and health care costs.19 Similar research conducted in Washington demonstrated that treatment for chemically dependent individuals reduced recidivism.20 Under the ACA, individuals enrolled in Medi-Cal can receive coverage for substance abuse and mental health services.21 Additional funding for these reentry services would stretch local expenditures further and could lead to greater reductions in recidivism.
Finally, counties may derive public health benefits from enrolling the jail population in health insurance coverage. Given the particularly high rates of infectious disease among those cycling between jails and the community, diagnosis and treatment are key components in maintaining their health and the health of their families and communities.
The potential for savings will depend on the relationship between corrections and health systems and the degree of health service provision in the jail system in each county. Many counties are still coping with the burden of realignment; they may lack resources for enrollment efforts. County constituencies may also have differing perspectives on whether health care enrollment for the jail population should be a priority. As a result of these differences in incentives, capacities, and priorities, we anticipate substantial variation in county efforts to utilize jails as sites of health insurance enrollment.
The ACA and AB 720 offer opportunities for California’s local jail systems-which have been important health care providers-to become sites of health insurance enrollment for high-need populations. Health services are an important driver of corrections costs statewide, and there is now an opportunity for local systems to cover a share of the direct costs of health care and reentry services with federal funds. In addition, the provision of post-release health care-including mental health and substance abuse services-could reduce recidivism and improve public health and safety.