Special Feature: What Are the Public Health Implications of Prisoner Reentry in California?
Large numbers of ex-prisoners—many with significant medical, mental health, and substance abuse problems—are returning to cash-strapped California communities that are suffering with severely strained health care safety nets. At the same time, the implementation of California's 2011 Public Safety Realignment Plan is shifting the responsibility for low-level offenders from state to counties. Nationally, the Patient Protection and Affordable Care Act will increase access to health insurance via Medicaid for many low-income individuals. What does this changing policy landscape mean for public health, and how can the state, counties, and providers meet the reentry population's health care, mental health, and substance abuse needs?
What are the health care needs of individuals returning from prison?
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California inmate health care needs are high; they self-report a high burden of chronic diseases (such as asthma and hypertension) and infectious diseases (such as hepatitis and tuberculosis) — diseases that require continuous management for effective treatment. Their mental health and substance abuse needs are even higher; two-thirds report drug abuse or dependence problems, and 50 percent report recent mental health problems.
How are those needs being met in prison?
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Most inmates with physical health issues reported seeing a physician in prison, but the self-reported percentages are much lower for those with substance abuse and mental health problems: Only 22 and 50 percent, respectively.
What are the implications for communities dealing with the reentry population?
When it comes to health care needs, the likelihood of ex-prisoners receiving health care upon release is lessened by barriers to accessing care and obtaining health insurance. Thus, ex-prisoners returning to communities bring a host of unmet health needs and will depend on counties' abilities to meet those needs. Given the high prevalence of mental health and substance abuse problems in the prison population—and that most prisoners do not receive care for these problems there—ex-prisoners' need for services in communities is likely to be particularly high.
Which counties and communities are particularly affected by prisoner reentry?
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Individuals returning from prison tend to return to certain counties, communities, and neighborhoods. Geographic analysis using geocoded data showed that parolee concentrations are mostly in the Bay Area and in southern California. Los Angeles, Orange, San Bernardino, Riverside, and San Diego counties have the highest populations. Within counties, parolees cluster in urban areas, for example, near San Francisco, Oakland, the city of Los Angeles, and the city of San Diego.
What factors affect access to the health care safety net in communities?
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Access to resources varies by type of health care, geographic area, and race/ethnicity. In Los Angeles County, for example, a little over half of parolees reside in areas with the lowest levels of mental health clinic accessibility, and moreAfrican-American parolees (57%) have limited access than do Latino (49%) or white (47%) parolees. Results are similar for alcohol and drug treatment: 30-40 percent of parolees return to areas with low levels of accessibility to alcohol and drug treatment providers.
What are the implications of public safety realignment and federal health care reform for the reentry population?
The stakeholders involved in preparing for both policy measures overlap. For realignment, the California Department of Corrections must coordinate with counties to shift responsibility for low-level offenders; for health care reform, California's Department of Health and Human Services must coordinate with counties to prepare for full implementation and for expanding Medicaid.
What opportunities and challenges do the two policies have for addressing the reentry population's health care and reentry needs?
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Realignment focuses attention on the need to improve prerelease planning for the transition of care from correctional health to safety net providers. As a challenge, it dramatically changes how low-level offenders will obtain health care and social services, shifting their attention from state parole to county-level supervision.
Health care reform opens up the possibility for many ex-prisoners and others involved with the criminal justice system to become eligible for Medicaid. As a challenge, expanding Medicaid eligibility could lead to increased demand for county health care services that are already stretched thin.
What can California and the counties do to better prepare for the reentry population?
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The states and counties can develop better estimates of the percentage of the Medicaid expansion population that the reentry population represents. Because the Medicaid expansion population is expected to include individuals with multiple comorbidities and a high demand for mental health care and alcohol and drug treatment, investing in "health homes" and other integrated case management systems for this population will be important. Also, it will be important to develop strategies for enrolling in or reinstating Medicaid benefits for the reentry population.
Other Research on Prisoner Health Issues
Assessing Parolees' Health Care Needs and Potential Access to Health Care Services in California — 2009
California parolees' health care, mental health care, and drug- and alcohol-treatment needs, as well as where parolees go when they return to counties, place significant demands on counties' safety-net resources and on their ability meet those needs.
Understanding the Public Health Implications of Prisoner Reentry in California: Phase I Report — 2009
A variety of approaches to assessing the health care needs and geographic distribution of California parolees can help policymakers understand local communities' capacity to meet the needs of this population.
The Future of DIRECT Surveillance: Drug and Alcohol Use Information from REmote and Continuous Testing — 2008
The focus of this essay is on alcohol use among probationers and parolees, but is also explores use of electronic monitoring technologies in other settings, and for other drugs.
Does Parolee Drug Testing Influence Employment and Education Outcomes? Evidence from a Randomized Experiment with Noncompliance — 2008
Despite the ubiquity of drug testing in criminal justice settings, there is little experimental evidence suggesting that testing reduces drug use or engenders pro-social behavior. This paper estimates the effect of parolee drug testing on labor and education outcomes with data from a randomized experiment involving 1,958 young parolees.
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