Offenders and the Affordable Care Act-The Urban Institute
DC Public Safety Radio
Radio show at http://media.csosa.gov/podcast/audio/2014/07/offenders-affordable-care-act-urban-institute/
LEONARD SIPES: From the nation’s capital this is DC Public Safety. I’m your host Leonard Sipes. Ladies and gentlemen, today’s topic, Offenders and the Affordable Care Act, something of real importance to those of us in the criminal justice system and throughout the country. It’s a real pleasure to have Kamala Mallik-Kane; she is a research associate, Justice Policy Center for the Urban Institute, www.urban.org, www.urban.org. Kamala Mallik-Kane, welcome to DC Public Safety.
KAMALA MALLIK-KANE: Hi, Len. I’m glad to be here.
LEONARD SIPES: Hi. This is exciting, because we have a new study that Urban is going to come out with next week talking about the Affordable Care Act and offenders, how many enroll, and what happens. Tell me about that.
KAMALA MALLIK-KANE: Sure. This is a study that is funded by the National Institute of Corrections, and we are very excited to be doing this work, because it gives us an important preview of what might be happening under the ACA as states are expanding their access to Medicaid. In our study we look at two states that were early adopters of Medicaid expansion. We’re looking at what these states did before 2014, so that we can have some insights about what may happen as Medicaid expansion moves forward post-ACA.
LEONARD SIPES: Now, those of us in the criminal justice system, this is the Holy Grail, and I’ve seen that term “Holy Grail” used in a wide variety of articles. We have said for decades, those of us throughout the criminal justice system throughout the United States, that people in the criminal justice system, offenders, people on supervision, are not getting mental health treatment, they’re not getting substance abuse treatment. I’ve seen surveys that put it at 10% or less within some state correctional systems. People on the outside, again, are not getting substance abuse treatment; they’re not getting mental health treatment. We all see the potential of the Affordable Care Act as being something that’s going to revolutionize the way that we deliver services. Is there a snowball’s chance in Hades of that actually happening?
KAMALA MALLIK-KANE: I’m optimistic. I think there’s a good chance of that happening. I think it’ll take a while, but I think that this is definitely a step in the right direction. We know that so many people in the criminal justice system suffer from substance abuse problems, mental illness, and various chronic physical conditions, and we know that before the ACA, in most places, that they would be released from prison without health insurance. So what would happen is somebody comes into prison or jail, they get a certain level of treatment while they’re in prison or jail, they get stabilized and they manage these conditions, then they get released without health insurance. And so within a couple of months they are no longer receiving treatment for these conditions and they can spiral out of control.
LEONARD SIPES: When I was with the Maryland Department of Public Safety for 14 years the staff there explained to me that mental health treatment was designed to do nothing more than stabilize their experience while in prison or while in jail, it had little to do with stabilizing that experience in the community. So that’s what you’re talking about in terms of in many cases getting access to mental health treatment in prisons or in jails. It’s not designed for them to transfer to the community and for some sort of services to follow. It’s purely to help them maintain their sanity in the correctional facility.
KAMALA MALLIK-KANE: Right. My understanding is that many prison and jail systems provide people with a small supply of what they like to call walking meds, and sometimes may set people up with a prescription to get a refill at a community-based pharmacy, but we all know if you don’t show up at a pharmacy with insurance this going to cost you an outrageous amount of money.
LEONARD SIPES: Yes.
KAMALA MALLIK-KANE: And so having insurance is a key step for people to be able to get those medications in an affordable way.
LEONARD SIPES: Now, there is I think a dollar amount stipulation, that they have to earn less than a certain amount every year to be eligible for the Affordable Healthcare Act.
KAMALA MALLIK-KANE: Right. With the ACA that is 138% of the poverty level and to qualify for the subsidies for the ACA exchanges I think you can be up to 400% of poverty. And programs in the States vary with respect to what their income thresholds are, because Medicaid is a combined federal state program, and so the states have some discretion too in setting those limits.
LEONARD SIPES: I’ve seen figures like 16,000 dollars, 18,000 dollars, less than that, and I would imagine it does vary from state to state, because, as you said, it’s a combined federal-state program.
KAMALA MALLIK-KANE: Right. That sounds about right to me. And certainly in the pre-ACA time period that we studied the thresholds for the two states that we looked at, Oregon and Connecticut, were quite different.
LEONARD SIPES: Again, and it’ll be the last time I’ll beat this point to death, is that we see, those of us in the criminal justice system are so excited about Urban, the fact that you’re coming out with this report next week. I’d really urge everybody to go to the website at the Urban Institute, www.urban.org, www.urban.org, because this whole idea is, again, we in the system understand that they need treatment, we in the system understand that oftentimes the experience throughout the United States is that they’re not getting treatment. We believe that if they got treatment they would do a lot better, recidivate less, cost taxpayers fewer dollars, cost victims of crime – there would be fewer victims of crime. We see this as a huge win for people in the criminal justice system and our ability to control cost.
KAMALA MALLIK-KANE: Right. I think there’s a lot of research out there showing things like substance abuse treatment with aftercare being effective at engaging people in treatment after release and keeping their reoffending rates lower and similar things with mental health treatment. I think that what we tend to see in the justice system are pretty small-scale programs that are effective but serve a pretty small slice of the total population coming out. But we know there’s such a lot of unmet need. And that’s what makes the potential under the ACA very exciting is that insurance can be extended to a huge swath of individuals who are returning. As long as they meet the program eligibility requirements this is something that doesn’t affect 1% or 2% of people coming out but the majority.
LEONARD SIPES: Okay. So we know that the, I would say the majority of people caught up in the criminal justice system have substance abuse history, certainly. I’ve seen self-reporting studies that say 55% self-report mental health issues in the past. I’ve seen studies that say; suggest that 16%, up to 16% of people have diagnosable histories of mental health problems. But physical health problems, if you throw all that in, I think we’re talking about certainly the majority and probably more than that of people caught up in the criminal justice system.
KAMALA MALLIK-KANE: At Urban we did a study called Returning Home several years back that interviewed people as they were leaving prison and then followed up with them in the community at several times over the course of a year. And when we did interview them in prison we found that when you looked across the spectrum of the types of issues that someone could have it was eight in ten men had at least one chronic physical or mental or substance abuse condition, it was like nine in ten women. So it’s really a huge swath of the population. Of course the severity of these conditions can vary, but in some of the, in some other data that I’ve seen I’ve seen numbers I think around something like 60% having conditions that require active treatment or management.
LEONARD SIPES: Okay. So they leave prison, they’re typically uninsured, and their health deteriorates, right?
KAMALA MALLIK-KANE: Right.
LEONARD SIPES: Okay. And so the bottom line in all of this is, we in the criminal justice system care, but I’m not quite sure the average person out there sees this as that big of an issue, but it really is to them, is it not, in terms of holding down costs of correctional care, holding down re-victimizations?
KAMALA MALLIK-KANE: Sure. I think that the most obvious connection that you can make for an average layperson who’s looking at this is to think about substance abuse and relapse. When someone is clean they are not stealing or victimizing people or doing other harmful things just for the purpose of being able to obtain more drugs. When somebody has relapsed they slide into those behaviors again. I’m not saying that everybody who’s addicted does these things, but it’s a common enough pattern that substance abuse is one of these key drivers of this revolving door phenomenon that we see in the justice system.
LEONARD SIPES: So we all agree that this could have a huge impact. I said I would not bring that topic back up again. What can be done on the part of the criminal justice system? I mean what we have to then, and I’ve seen in some articles where jails and prisons are actually creating staff to help the men enroll, that they’re being very proactive in terms of getting as many people enrolled as possible, but this involves a lot of effort on the part of the criminal justice system in terms of discharge and release planning, treatment referrals, care coordination, so this, the criminal justice system should take an active role in terms of enrolling as many people as possible.
KAMALA MALLIK-KANE: Yeah. I agree with that. And I think that states and localities are doing a number of these various things. They’re engaged in some level of release planning. They make treatment referrals for individuals. I think some of this is triaged so that you’re putting more resources into the people that have greater needs. But Medicaid enrollment is something that is being implemented into release planning curricula or programming in criminal justice systems around the country.
LEONARD SIPES: Okay. The report that’s coming out next week – is this, do we have specific findings in terms of how many enroll and what happens? Or what is the purpose of the study? It is it describing what it is that you’re doing or will it have impact findings?
KAMALA MALLIK-KANE: Sure. So our study has two broad goals. One of them is to understand more about the enrollment process, how do you get inmates connected to Medicaid, what are some of the challenges that systems and individuals face, and what are the rates of enrollment when people have the opportunity to apply for Medicaid. So that’s the first part of our study. The second part of our study is a little further down the road. We’re looking at impacts post-release with regard to when people get enrolled in Medicaid, do they utilize Medicaid health services, and are there impacts post-release, one to two years later on employment and recidivism.
LEONARD SIPES: You and I were talking before we hit the record button is that I remember a national researcher, I’m sorry, a national reporter reporting for a national publication was trying to do an article that he was calling ObamaCare and Offenders or ObamaCare and Inmates, and he said he found a general reluctance on the part of those of us in the criminal justice system to talk about this, because we don’t know what the impact will be, we don’t have a clear understanding as to whether or not this will have a huge impact. What he was heard on an off the record basis from so many people was that just because you have health insurance doesn’t mean you act on it, doesn’t mean that you go out and get the mental healthcare that you need, doesn’t mean that you go out and get the substance abuse care you need. You may use it to fund your physical infirmaries, but not necessarily mental health or substance abuse. So we really don’t know what the impact is and we won’t know until your research is completed, correct?
KAMALA MALLIK-KANE: That’s right. I think that’s a very valid point, just because you have insurance doesn’t mean that overnight you change the way that you seek services or get care or take care of yourself. But having insurance I think is a necessary first step to being able to use preventative health services, to be able to use mental health treatment services and substance abuse treatment that’s out in the community.
LEONARD SIPES: And this study that you all are doing is in Oregon in terms of the prison stage and a jail study in Connecticut.
KAMALA MALLIK-KANE: That’s right.
LEONARD SIPES: And how – was it difficult to get them involved in this?
KAMALA MALLIK-KANE: Well, in Oregon what we did was we looked historically at an effort that the Department of Corrections had implemented. In Oregon before the ACA Oregon had a very interesting Medicaid program for what’s called childless adults. Have you heard that phrase or should I talk through that?
LEONARD SIPES: That’s fine.
KAMALA MALLIK-KANE: Okay. Just that historically Medicaid had been a program for children and parents and people with disabilities and people with some specific eligibility criteria in addition to being low income. And before the ACA Oregon had expanded its Medicaid program to be more broadly a low income adults program, but because of limited funds in the state what they did was to have a lottery process so that it would be fair who they could provide this to. And so they had been doing this lottery process from about 2008, and we looked at what was going on in the prisons in 2010 and 2011 with respect to signing up for this lottery process, and then if people were selected at random to apply for Medicaid, how many of them did apply given that opportunity.
LEONARD SIPES: We’re more than halfway through the program. What we’re talking about today, ladies and gentlemen, is offenders and the Affordable Care Act. At our microphones is Kamala Mallik-Kane; she is a research associate with the Justice Policy Center at the Urban Institute, www.urban.org, www.urban.org, coming out with a new study report next week talking about what they plan on looking at in terms of how many enroll in the Affordable Care Act and what happens afterwards, correct?
KAMALA MALLIK-KANE: That’s right.
LEONARD SIPES: And that’s exciting, because we in the system are really, really looking forward to these findings. Okay. Some of the challenges of getting and keeping inmates enrolled in Medicaid, now, again, you’re talking jail, you’re talking prison, you’re not talking about necessarily community supervision, but some of the releases could be on community supervision at the same time, right?
KAMALA MALLIK-KANE: That’s right.
LEONARD SIPES: Okay. Tell me about that.
KAMALA MALLIK-KANE: About community supervision in particular or –?
LEONARD SIPES: Well, federal, the federal and state Medicaid rules. You’re not allowed to use Medicaid while incarcerated, a few states let you stay covered but suspend your benefits, so some of this gets technical in terms of the challenges of getting and keeping inmates enrolled in Medicaid.
KAMALA MALLIK-KANE: That’s right. The timing really matters, timing it appropriately with release so that – the Medicaid rules don’t permit people to be, to receive Medicaid benefits while they’re incarcerated. And this is an old provision in the Medicaid program and one that’s really intended to guard against Medicaid billings that are inappropriate.
LEONARD SIPES: Right.
KAMALA MALLIK-KANE: But what happens when –
LEONARD SIPES: So they get double billing because they’re already getting healthcare within the prison setting.
KAMALA MALLIK-KANE: Right. And I think as a way of sort of ensuring that there’s not a community provider that’s billing for somebody –
LEONARD SIPES: Right.
KAMALA MALLIK-KANE: That’s not out in the community.
LEONARD SIPES: Right.
KAMALA MALLIK-KANE: But I think the difficulty for people who are frequently in and out of the justice system is that the information technology systems that are out there aren’t particularly good at keeping track of when people are in and out of jail. And so this is an issue that a lot of states are grappling with. I believe that there’s funding through the ACA for Medicaid systems to upgrade their information technology systems for a whole lot of reasons. But places that are attuned to this issue of correctional populations and their need for Medicaid and the challenges of timing things correctly so that the Medicaid system is aware of when people are being released from prison so that they can have benefits when they’re in the community is –
LEONARD SIPES: Okay. But this is specifically – we’re not talking about necessarily medical care within a correctional facility. We’re talking about giving them access to Medicaid so they can get treatment in the community.
KAMALA MALLIK-KANE: Right. Because in general inmates receive healthcare from the correctional system when they’re in, and so Medicaid is not – the purpose of the Medicaid is to have continuity of care from the prison or jail setting to the community so that –
LEONARD SIPES: Okay.
KAMALA MALLIK-KANE: They can continue that care when they’re in the community.
LEONARD SIPES: Well, that’s an important distinction. But what if they don’t get like say mental health treatment or substance abuse treatment while in prison, because the studies I’ve seen put that figure pretty low, at around 10% or lower, for most state systems. So what if you’re getting a, what if you’re getting mental health treatment or substance abuse treatment in prison, would Medicaid still provide funding for those particular programs while in prison?
KAMALA MALLIK-KANE: For mental or for substance abuse treatment in prison?
LEONARD SIPES: Uh huh.
KAMALA MALLIK-KANE: No. I don’t believe Medicaid funds that.
LEONARD SIPES: Okay. All right, so we’re talking about getting them enrolled and when they get out to the community and seeing what happens, and your study is looking specifically at one jail and one prison.
KAMALA MALLIK-KANE: We’re looking at prisons in Oregon and we’re looking at some jail facilities in Connecticut.
LEONARD SIPES: Okay. The level of interest, so we find folks in the criminal justice system are really interested in this, what about the offenders themselves?
KAMALA MALLIK-KANE: Right. In Oregon what we saw was that given the opportunity – so, again, let me just go back to what I was saying about –
LEONARD SIPES: Sure.
KAMALA MALLIK-KANE: The way you had to apply before the ACA in Oregon was you had to two stage process. The first stage was that you put your name what they called a reservation list, and so about half of the inmates who were leaving Oregon prisons at the time of our study put their names on that reservation list. Then the state did a random drawing and then based on who they invited at that point then people got mailed a Medicaid application and then they had 45 days to fill out the application, turn in their documentation, and then get it reviewed by the Medicaid agency. What we found that was very interesting in Oregon was that about 4 in 10 of the inmates that got invited turned in their application and this was identical to the level of participation in the general population in Oregon.
LEONARD SIPES: So 4 in 10, and that was indicative of the population across the board that was eligible, not necessarily for people caught up in the criminal justice system.
KAMALA MALLIK-KANE: Right.
LEONARD SIPES: And, okay, findings on Medicaid impacts. So you’re working on this data and you’re collecting this data. Are you aware of anybody else out there in terms of your literature review who has looked at this issue previously?
KAMALA MALLIK-KANE: We’ve seen smaller studies from a couple of years back –
LEONARD SIPES: Okay.
KAMALA MALLIK-KANE: Looking at specific subpopulations. So I know that there are studies of people who are seriously mentally ill and their rates of Medicaid enrolment and how that impacts arrest, for example.
LEONARD SIPES: Do we have any findings?
KAMALA MALLIK-KANE: I believe that they found a lower rate of rearrest among the people that were enrolled, but I don’t remember too, too clearly to talk about it more than that.
LEONARD SIPES: Okay. But in essence, as long as they meet guidelines, as long as they meet the state Medicaid guidelines they’re eligible, as long as they’re under a certain – I know the percentage of gross poverty, whatever – it’s even confusing to me. If they make, what I’ve seen commonly thrown out in newspaper throughout the country, if they make less than 16, 18,000 dollars, it depends upon it at state level, they’re eligible. And so there’s no question about eligibility. You’ve just got to be under that threshold.
KAMALA MALLIK-KANE: Right. And when we looked at the applicants in Oregon we found that when people got their applications into the Medicaid agency that about 8 in 10 of them qualified, and that was higher than in the general population, because there was more poverty –
LEONARD SIPES: Right.
KAMALA MALLIK-KANE: Among the people who were leaving prison.
LEONARD SIPES: So 8 in 10 are eligible. And so that gives us hope that those of us in the criminal justice system can find sources of funding for substance abuse treatment and mental health treatment.
KAMALA MALLIK-KANE: Right. This gives people a ticket to be able to –
LEONARD SIPES: Right.
KAMALA MALLIK-KANE: Access those services in the community.
LEONARD SIPES: So what is the sense between yourself or your peers at Urban in terms of what the impact could be down the road? I mean you’re talking to people, again, specifically in Connecticut and Oregon, but you’re probably talking to other people throughout the country. You were quoted in a rather extensive article, ObamaCare for Ex-Inmates: Is Health Insurance an Antidote to Crime?, and I think that was from the Christian Science Monitor, a very powerful article talking about how people around the country feel about the Affordable Care Act and what its potential could be. So what are your perceptions from talking to people?
KAMALA MALLIK-KANE: I think there’s a sense of a lot of potential and a lot of work ahead of us. I think, yeah, I like to think of having the insurance card as being sort of a ticket that you need to enter, but you need to do a whole lot of other things in order to make the change happen. I think some of the challenges are getting people to use healthcare differently, and I think that involves education.
LEONARD SIPES: Right.
KAMALA MALLIK-KANE: One of the things in our Connecticut study was as they were doing enrollment there was an eligibility worker who talked with individuals about what kinds of services they could go out and get in the community. But another thing that we saw as we observed these recruitment sessions in Connecticut was that there was some confusion about the program, there was confusion about whether people had Medicaid or not. We had people in our sessions that we felt we had screened and thought them to be needing Medicaid who said, “No, no, I already have it. I don’t need to stay here and I don’t need to apply for this.” So I think people knowing what their status is and knowing how their perception affects what they do out in the community, that’s an important thing for us to figure out.
LEONARD SIPES: So there’s an educational process on the part of the system. This is not going to be an easy process for those of us in the criminal justice system. It’s going to take a lot of work to explain what the rules are, to figure out if they are eligible, to sign them up, to, and, again, try to encourage them to participate if they have funding. So it’s a multi-step process between correctional facilities and community correction facilities and parole and probation agencies, so this is going to involve a lot of work.
KAMALA MALLIK-KANE: And I would add that also community based health organizations have to be a partner in these conversations, because I think some of the disconnect that we may see are that there are treatment providers that have been serving the criminal justice population that have not been previously Medicaid providers and they may need to do things about the way they run their organizations in order to be qualified Medicaid providers so that the insurance can actually be used to pay for services in those facilities.
LEONARD SIPES: I didn’t even think about that. So not only must the criminal justice system gear up in terms of implementing this, the providers need to gear up to implement it.
KAMALA MALLIK-KANE: Right. There was a story in the New York Times recently about an old Medicaid rule about just which types of residential substance abuse treatment facilities they could reimburse or not. And so I think there needs to be that exchange between the provider network that’s out there and the Medicaid structure to figure out whether these are going to be reimbursable services.
LEONARD SIPES: Why is that a question though? I thought it would be pretty much straightforward.
KAMALA MALLIK-KANE: I would’ve thought that too. But I think that these kinds of details, you have a population that’s been receiving typically non-Medicaid services –
LEONARD SIPES: Right.
KAMALA MALLIK-KANE: That are now coming into the Medicaid world, and so I think these details haven’t yet been worked out.
LEONARD SIPES: And we need to remind the audience that only half the states are involved in the Affordable Care Act provision, so half the people in the country listening to this are going to say, “Well, yes, this applies to me.” but half it doesn’t apply to the offenders within their states.
KAMALA MALLIK-KANE: Right.
LEONARD SIPES: And so what’s the final analysis? In the final minutes of the program, I mean we in the criminal justice system do have to gear up, correct? We probably have to add staff; we probably have to add training. A significant burden falls on us to be sure that people who are eligible enroll. But that’s going to require a lot of effort and probably staffing and training on our part.
KAMALA MALLIK-KANE: Right, and a certain amount of coordination with the Medicaid agency. A lot of what we observed in our Connecticut Study and a lot of what was possible in the Connecticut Study was the result of a year’s long collaboration between the Department of Corrections and their Department of Social Services to establish procedures and workarounds that would let the correctional population enroll.
LEONARD SIPES: Okay. And that’s the other part of it is that we need to need to reach out to all the providers out there, because some who may be eligible to be providers may not want to take upon an offender based population. So we need to do a lot of work on our part to convince people who are the providers to get involved in this and to be sure that they are attuned to our needs and the needs of the people coming out.
KAMALA MALLIK-KANE: Yeah, absolutely.
LEONARD SIPES: And what else? What is the general sense to the public that they need to understand? You’re talking to aides to mayors, aides to governors through this program. What do they need to understand?
KAMALA MALLIK-KANE: Sure. I think that this is a great opportunity, because I think for years we have all known that substance abuse and mental illness are problems that have been feeding this revolving door cycle that we’ve had in our justice system, and you’ve had people coming in with problems, the problems don’t get resolved, and then they get released without any resources to deal with them. So I think that this is a great opportunity to begin addressing those problems that can slow down this revolving door of recidivism.
LEONARD SIPES: I couldn’t agree with you more. Our guest today has been Kamala Mallik-Kane; she is a research associate, Justice Policy Center, the Urban Institute, www.urban.org, www.urban.org. Ladies and gentlemen, this is DC Public Safety. We appreciate your comments, we even appreciate your criticisms, and we want everybody to have themselves a very pleasant day.
