November 16, 2011
With the health care safety net in California under stress from the state's continuing financial crisis, jurisdictions across the state face unprecedented challenges caring for the health and social service needs of people released from state prisons, according to a new RAND Corporation study.
But federal health care reform may provide an opportunity to help shore up some needed services, the report suggests.
Budget cuts have trimmed many state-level programs that typically serve parolees, leaving county health services and other traditional safety net providers as a key resource for people released from prison, according to the study. These county-level services providers also have been stretched thin by budget cuts.
The cuts coincide with major changes to California's criminal justice system. Under the Public Safety Realignment Plan, the state is transferring jurisdiction for low-level offenders to counties. Some of those offenders will serve their sentences in county jails, while others will be released and supervised by county probation instead of by state parole.
Researchers say federal health care reform, which will provide support to extend health coverage to many low-income people through Medicaid, may provide an opportunity to shore up some services, and will help provide access to needed services to people after they are released from prison.
"Counties across California face a significant challenge responding to this seismic shift in corrections policy," said Lois Davis, the study's lead author and a senior policy researcher at RAND, a nonprofit research organization. "While state and local services are stretched thin, there are ways to put into place service delivery strategies for this population and seize the opportunities presented by both public safety realignment and health care reform."
This multi-year project was supported by The California Endowment to examine the health care needs of prisoners reentering California communities and the challenges communities face in meeting those needs.
This report examines the health care needs of newly released prisoners, identifies communities most affected by prisoner reentry and assesses the capacity of the health care safety net. It also discusses the opportunities and challenges public safety realignment and health care reform present to meet the needs of the prison reentry population.
Researchers provide detailed information about four regions with significant parolee populations—Alameda, Los Angeles, San Diego and Kern counties. They also conducted focus groups with former prisoners and their family members, and interviewed key service providers and community groups to better understand how health affects prisoner reentry and to identify options for addressing barriers to care.
Among the report's key findings:
- Prisoner reentry varies in its impact, with 11 counties in the San Francisco Bay Area and in Southern California having high rates of return from prison. Parolees tend to cluster in certain communities and neighborhoods, which has implications for how to target reentry and health care resources at the local level for this population.
- African-American and Latino parolees, in particular, tend to return to disadvantaged neighborhoods and communities that are defined by high poverty and low educational attainment. This suggests that reentry will be particularly challenging for these groups.
- People released from prison have high need for health care, particularly mental health care and alcohol and drug treatment. For example, nearly two-thirds of prisoners reported symptoms that met the diagnostic criteria for drug abuse or dependence.
- Budget cuts at the state level, including a 40 percent reduction in funding for in-prison rehabilitative programs, suggest that prisoners will return to local communities with more unmet needs and so must rely even more on counties' health care safety net and social services than in the past.
- Community health care providers find this population to be resource-intensive to treat given their complex set of health care and social service needs. Lack of health insurance and finances serve as major barriers for providers and case managers in linking individuals to needed services. Another barrier is a lack of medical records, which forces providers to treat individuals without information about their past health status and care.
Researchers say the strategies presented in the report should aid state and local officials' planning for how they can respond to the challenges posed by prisoner release. It outlines an array of recommendations for state and county officials, as well as for health care providers.
One key strategy is to use the upcoming expansion of the Medi-Cal program to help improve access to health care services to more of those leaving prison. The federal Affordable Care Act will extend Medi-Cal eligibility to more adults with low incomes, making it possible for the program to help pay for the care needed by the reentry population, according to researchers.
"Health care reform will provide new opportunities to improve access to health care services for this population and to create services that will help to better manage their care," Davis said. "Investing in treatment for this population may help offset criminal justice costs later. Moreover, expanding access to primary care may help avoid expensive care such as emergency room visits and preventable hospitalizations for this population."
Other suggestions include improving prerelease planning for prisoners with medical or mental health conditions and involving counties more in the discharge planning process, developing Medi-Cal enrollment strategies, and training service providers in cultural competence.
In addition, researchers suggest that the state might consider funding an effort to assess the effects of the Public Safety Realignment Plan. Such an effort would help policymakers to better understand the overall crime rates, which offenders fare better or worse under realignment, and which service delivery and management models result in better outcomes for this population.
"The state and the counties need to work together to collect consistent information about the consequences of this new policy," Davis said. "Without this type of coordinated effort, it will be difficult to make the case for additional resources or modifications to the program."
The report, "Understanding the Public Health Implications of Prisoner Reentry in California: State-of-the-State Report," is available at www.rand.org. Other authors of the study are Malcolm Williams, Kathryn Pitkin Derose, Paul Steinberg, Nancy Nicosia, Adrian Overton, Lisa Miyashiro, Susan Turner, Terry Fain and Eugene Williams.
The work was done within the Health Promotion and Disease Prevention Program of RAND Health and the Safety and Justice Program of RAND Infrastructure, Safety, and Environment.
The California Endowment, a private, statewide health foundation, was established in 1996 to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of all Californians. The Endowment challenges the conventional wisdom that medical settings and individual choices are solely responsible for people's health. The Endowment believes that health happens in neighborhoods, schools, and with prevention. For more information, visit The Endowment's website at www.calendow.org.