the affordable care act, justice-involved individuals, and criminal justice reform kellen...
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The Affordable Care Act, Justice-Involved
Individuals, and Criminal Justice Reform
Kellen Russoniello – Staff Attorney, Health and Drug Policy
ACLU of San Diego and Imperial Counties Twitter: @krussonielloNovember 17, 2014
ACLU of San Diego and Imperial Counties
We fight for individual rights and fundamental freedoms for all through education, litigation, and policy advocacy
Focus areas:Criminal Justice and Drug Policy Reform Immigrants’ RightsVoting Rights
Overlap of ACA and Criminal Justice System
OverviewHealth Issues of Justice-Involved and Victims
Medi-Cal Eligibility/Coverage
Financial Incentives
Examples: San Diego & Imperial Counties
What Does ACA Mean for Criminal Justice Reform?DecriminalizationProposition 47
Challenges and Opportunities
Health Issues of Justice-Involved
Compared to the general population, the prevalence among justice-involved populations of: HIV infection is 8 to 9 times higher Hepatitis C is 9 to 10 times higher Tuberculosis is 4 times higher Serious mental illness is 3 times higher Substance use disorders is 4 times higher
12 times more likely to die w/in 2 weeks of prison release
80% of individuals in jail with chronic medical conditions have not received treatment in the community prior to arrest
Up to 90% of people released do not have health insurance
Health Issues of Crime Victims
Being a victim of crime increases risk of:Chronic health issuesSubstance use disordersTrauma/mental illness
Crime victims may have medical bills related to the physical injuries
Victims of violent crime are more likely to be low-income, and therefore less likely to be insured
Essential Health Benefits
Ambulatory patient services
Emergency services & hospitalization
Maternity & Newborn Care
Mental Health & Substance Use Disorder Services
Prescription Drugs
Rehabilitative & Habilitative services
Laboratory services
Preventive & Wellness Services
Chronic Disease Management
Pediatric Services, including dental & vision
Medicaid expansion and all health plans offered through health benefit exchanges must cover:
Preventive ServicesMost health plans must cover preventive services for
adults without cost-sharing, including:Alcohol misuse screening and counselingDepression screeningScreening for certain chronic conditionsVaccines
More preventive services available for women, including:Screening/brief counseling for domestic violenceScreening for breast/cervical cancerContraception
Medicaid Eligibility/Coverage
About 20% of newly eligible are justice-involvedGenerally, Medicaid does not pay for expenses when
person is an “inmate of a public institution”Exception: individuals admitted as inpatient in non-
correctional medical facility for > 24 hours (e.g. hospital)
Medicaid eligibility is not affected by incarceration status at federal level, can be suspendedBut most states terminate eligibility upon incarceration
Medicaid is available to those in community, even if under supervision (e.g. parole/probation) No disenfranchisement!
No open enrollment period – can enroll at any time
Financial IncentivesTraditional Medicaid match rate between 50%
and 74%
Rate for newly eligible pop is 100% through 2016, declining between 2017-2020 to 90% for 2020 and beyond
Incentive to enroll incarcerated people to pay for hospitalizations
Incentive for people with chronic conditions to receive care in the community
Health and Public SafetyMedicaid coverage at release associated with 16%
fewer subsequent detentions and more days in the community before next arrest for people with SMI
Substance use disorder treatment offered to low-income adults associated with significantly reduced risk of arrest (up to 33%)
Every dollar invested in substance use disorder treatment saves up to $12 in reduced crime, criminal justice, and healthcare costs
Medicaid expansion is a public safety issue – but be careful with this argument!
What’s Happening in San Diego County
About 90,000 jail bookings annually, about 62,000 of which are unique individuals
Average jail population is about 5,900 (majority pretrial)
Public Safety Realignment increased the number of people for whom local law enforcement is responsible
San Diego, cont. AB 720: State Legislation suspending Medicaid upon incarceration
(up to 1 year) and allowing jails to offer enrollment assistance
AB 82: $1.8 million for enrollment assistance over 2 years (private funding)
Four-tiered system County eligibility workers assist folks with immediate medical needs
(e.g. need to be hospitalized, HIV positive, and SMI) MOUs with community clinics to provide assistance with no funding AmeriChoice (United Healthcare) has hired 10 FTEs RFP for CBOs to provide assistance in final negotiations
Enrolling in 6 of 7 jails and two probation offices Over 350 applications received so far in jails Over 60 referrals by probation officers with 53% no show rate
San Diego, cont.Partnerships
Sheriff’s DepartmentProbation DepartmentDistrict Attorney (victims)Health and Human Services AgencyChief Administrative OfficeBoard of SupervisorsCommunity clinics
San Diego, cont.Healthy and Safe Communities Initiative
Community clinics, reentry service providers, and advocacy organizations
Pressure the county to make system run smoother Dedicated to reducing criminal justice response to health
issues
Accomplishments Change of process to ensure active case at release Medi-Cal managed care choice form included in app Brief education about accessing healthcare Materials at discharge of how/where to access services Voter registration
San Diego, cont.Next steps:
Ramp up to maximize reachEnsure people have benefit ID cards at releaseEnsure smooth transition to community care
Scheduling appointments prior to releaseRecord sharing while protecting privacy
Engage Medi-Cal managed care organizations Mobilize community to shift money from traditional
law enforcement to treatment and other necessary services
Imperial County10,000 releases from two county jails each year
MOU with CBO for enrollment at Day Reporting Center
Moving to enrollment at booking
Challenges:Treatment capacityTransportationEmployment opportunity
ACA & Criminal Justice Reform
ACA establishes a framework to build health-oriented responses to substance use and mental health issues
Federal funds can help expand access to community health services
Alternatives to arrest, prosecution, and incarceration more possible and sustainable
Incentive to treat individuals outside of correctional setting
Impetus for reform of sentencing law and practice
Proposition 47Approved by 58.5% of CA voters on Nov. 4th, 2014; Took
effect Nov. 5th!
Reduces simple drug possession and petty theft from felonies to misdemeanors
Applies retroactively
Reinvests savings into mental health/substance use disorder treatment, K-12 education, and victims’ services (estimated $1 billion in next 5 years alone)
Advocacy is just beginning Funding to be decided via grant processes Ensure law enforcement is cooperating with spirit of law
ACA can help ensure folks have coverage for treatment
Decriminalization ACA lays framework capable of addressing substance use
disorders as a public health issue
Expanded coverage and access to treatment reduces need to rely on criminal justice approaches to substance use
APHA Policy Number 201312 (2013) – Defining and Implementing a Public Health Response to Drug Use and Misuse “[E]liminating criminal penalties for personal drug use and
possession is an essential feature of a public health response to drugs and drug misuse, and APHA calls on state and federal governments to remove such criminal penalties.”
APHA “[e]ncourages state governments to leverage resources potentially available through the Affordable Care Act toward effective community-based drug treatment, harm reduction, and physical and mental health services”
Portugal Portugal decriminalized personal possession of drugs in 2001
People are no longer arrested; instead cited and asked to appear in front of civil commission
Commission determines whether to apply sanctions or recommend treatment
Simultaneous expansion of prevention/treatment funding
Results Decrease in HIV cases among injection drug users by 71% Drug-related deaths decreased 28% Youth and injection drug use rate decreased People seeking treatment substantially increased Reductions in prison overcrowding
Challenges Treatment Capacity
Ensuring timely access to the right level of care IMD exclusion and alternatives to residential treatment
Moving health decisions out of criminal justice system Ensure non-health professionals are not making health
decisions (moving away from drug court models)
Investment in other resources Housing – Inclusion as a Medicaid benefit? Transportation IDs
Health disparities in the community
Health education/navigation (cultural competency)
OpportunitiesForm/strengthen relationships with both agencies
and community partnersProposition 47 implementationSteer criminal justice funding towards treatment
and other necessary servicesPolitics on criminal justice are changing;
consensus buildingUsing ACA to bolster harm reduction treatment
modalitiesExpansion of covered benefits (e.g., health homes,
housing)
ConclusionsThe ACA is a tool to improve the health of
justice-involved individuals and crime victims
Partnerships with new allies are possible
Medicaid expansion is a public safety issue
ACA and expansion of treatment is a path towards ending criminalization of drug and mental health-related offenses
Your help is needed to maximize the potential in ACA for improving community health and safety
ResourcesACLU - ACA: A Primer for Advocates
ACLU & DPA – Healthcare Not Handcuffs: Putting the ACA to Work for Criminal Justice and Drug Policy Reform
CSJ – Health Coverage Enrollment of California’s Local Criminal Justice Populations
CSG – Implications of the ACA on People Involved in the Criminal Justice System
Community Oriented Correctional Health Services
Russoniello – The Devil (and Drugs) in the Details: Portugal’s Focus on Public Health as a Model for Decriminalization of Drugs in Mexico
Contact
Kellen RussonielloStaff Attorney, Health and Drug Policy
619-398-4489
Twitter: @krussoniello