As California Releases Prisoners, It Must Confront the Public Health Consequences
The confluence of three events has dramatically broadened the public health implications of prisoner reentry into California communities. First, the state is in the midst of a deep and persistent recession, which has severely strained the resources available for the health care safety net upon which ex-prisoners rely. Second, the state is implementing its 2011 public safety realignment plan, which shifts responsibility for low-level offenders from the state to counties; this will aid the state’s efforts to abide by a U.S. Supreme Court order to reduce the prison population. Third, federal health care reform will expand Medicaid eligibility and coverage for some important services, removing a key access-to-care barrier for the prisoner reentry population.
These events argue for assessing the health needs of California’s reentry population, the related public health challenges, and the policy options for improving access to safety net services. In a study sponsored by The California Endowment, a research team at RAND conducted such an assessment and concluded the following:
- The health care needs of California prisoners are high, but their mental health and drug treatment needs are even higher.
- Certain California counties and communities are particularly affected by reentry.
- Ex-prisoners’ access to California’s health care safety net varies across counties, within counties, and by race and ethnicity.
- Public safety realignment and federal health care reform present challenges and opportunities for improving access to services for this population, all requiring the state and counties to coordinate their efforts.
Numerous Unmet Needs Reported
With respect to physical health conditions, California state prisoners reported a high burden of chronic diseases, such as asthma and hypertension, and infectious diseases, such as hepatitis and tuberculosis. Ex-prisoners face a number of barriers to accessing health care, including lack of health insurance. As a result, ex-prisoners returning to communities will largely have to rely on counties’ health care safety nets for the uninsured to meet their health needs.
Self-reported mental health and drug treatment needs are especially high. More than half of California inmates reported a recent mental health problem, but only about half of those reported having received treatment in prison. Nearly 60 percent of California inmates reported having a drug abuse or dependence problem. Given the high prevalence of these reported conditions, the need for county mental health services may be particularly high.
When we interviewed health care providers who deal with the reentry population, their observations confirmed that this population has substantial mental health and drug treatment needs and other health problems — needs exacerbated by neglect or reduced access to care. Providers also noted a range of social services needs — such as transportation, employment, housing, and family reunification — that make treating ex-prisoners for such health conditions even more resource-intensive. For example, if an individual has a wound that requires periodic cleaning and dressing, would there be a hygienic place to do it?
Inadequate discharge planning for prisoners can be another major barrier to continuity of care. Upon release, many ex-prisoners lack medical records to give health care providers; thus, providers have little information about their medical history. For individuals with infectious diseases, such as HIV/AIDS or hepatitis, providers felt it was critical to know what kind of care and education a patient had received while incarcerated. Ex-prisoners without health insurance have limited treatment options. Difficulties navigating the health care and social services systems complicate referrals. Discharge planning needs to take such factors into account.
Budget cuts present further barriers to care. Providers report that they have had to eliminate or curtail HIV, dental, mental health, or alcohol and drug treatment programs. Because of state-level cuts in funding for community-based treatment programs, one provider we interviewed had to close a sober living facility.
Parolees Are Concentrated in 11 Counties, Mostly in the South
SOURCE: California Department of Corrections and Rehabilitation parolee data, 2005–2006.
Ex-Prisoners Concentrated Primarily in 11 Counties
To understand where ex-prisoners go upon release and which counties and communities are especially affected by reentry, we used parolee data to examine their geographic distribution following release, illustrated here in the map of California. The map shows that certain counties are particularly affected by reentry. Tiny dots represent each of the nearly 140,000 parolees released in 2005 and 2006, with major clusters shown as yellow ellipses. Darker shades of blue indicate counties with higher numbers of returnees per 1,000 residents; lighter shades indicate lower numbers of returnees. As shown, parolees tend to cluster in certain communities and neighborhoods, with implications for targeting resources.
Eleven counties, concentrated around the Bay Area and in the southern part of the state, had the highest rates of return. By far the highest rates were in Southern California, especially Los Angeles, Orange, Riverside, San Bernardino, and San Diego counties. Also, African-American and Latino parolees tended to return to disadvantaged neighborhoods and communities, defined by high poverty rates, high unemployment rates, and low educational attainment.
We focused on four counties — Alameda, Kern, Los Angeles, and San Diego — that received a third of the state’s total parolees. In Alameda County, almost 45 percent of the returning population was concentrated in five clusters, primarily around Oakland and the northern section of the county. Four clusters within Kern County accounted for almost 58 percent of its parolees, while in San Diego County there were eight clusters accounting for nearly half the parolee population, with the largest in downtown and Southeast San Diego. Unlike the other counties, Los Angeles County had 23 clusters covering a large geographic area but accounting for only 35 percent of the total number of returnees.
Unequal Access to Care
We also wanted to know where ex-prisoners were located relative to communities’ health care safety nets: the hospitals, clinics, and mental health and substance abuse treatment providers that would serve the reentry population. So we overlaid such facilities on our county-level maps and found that the capacity of the health care safety net varies within counties. Many ex-prisoners in the three large urban counties — Alameda, Los Angeles, and San Diego — returned to areas with lower levels of accessibility to safety net facilities than found elsewhere in those counties.
In Los Angeles County, for example, some county supervisorial districts with high concentrations of ex-prisoners tended to have fewer hospital and primary care clinics than did other districts. In District 2, which covers South Los Angeles and has a relatively high concentration of ex-prisoners, there are relatively few clinics. And there is only one hospital affiliated with the Medically Indigent Services Program, which is the county-provided program of last resort for those who are not eligible for Medicare, Medicaid (Medi-Cal in California), or private health insurance and who meet socioeconomic eligibility standards.
To understand how much access ex-prisoners had to these facilities, we created accessibility measures for each facility based on its capacity, demand, and travel distance. In Los Angeles County, more than half of parolees (53 percent) returned to areas with lower levels of accessibility to hospitals. More African-American parolees (60 percent) lived in areas with lower accessibility than did Latino or white parolees (51 percent and 47 percent, respectively). Alameda County had a similar pattern, but in Kern and San Diego counties, more Latino parolees lived in areas with lower accessibility to hospitals than did white and African-American parolees.
Realignment and Reform
California’s public safety realignment plan and the U.S. federal health care reform represent important opportunities to improve services to the reentry population, and the stakeholders involved in preparing for both policy measures overlap. For realignment, the California Department of Corrections and Rehabilitation must coordinate with counties to shift responsibility for low-level offenders; for health care reform, California’s Department of Health Care Services must coordinate with counties to prepare for full implementation and for expanding Medicaid.
Both policy measures present opportunities and challenges for addressing ex-prisoners’ health care and reentry needs. As an opportunity, 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, realignment dramatically changes how low-level offenders will obtain health care and social services, shifting attention from state parole to county-level supervision.
As an opportunity, health care reform opens up the possibility for many ex-prisoners and others in the criminal justice system to become eligible for Medicaid and to have drug treatment services, prevention services, and wellness programs covered more fully. As a challenge, expanding Medicaid eligibility could lead to increased demand for health care safety net services that are already stretched thin.
There are many steps the state and counties can take. They 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” (teams of providers) and other integrated case management systems for this population will be an important way to manage their complex care needs.
Expanding prerelease planning to more fully include those with chronic medical, mental health, and substance abuse problems makes sense, as does having the state assess options, such as electronic medical records, for easing the transition of care to community health care systems. Also important will be developing strategies to enroll the reentry population in Medicaid or reinstate their Medicaid benefits and to improve the needed expertise and capacity of treatment providers, especially in localities with higher numbers of ex-prisoners, so providers can better meet the expected increase in demand for services.
Both public safety realignment and federal health reform come with funding streams. Some of this money could leverage existing investments in planning for health care reform for the reentry population. For example, some funds could be used to develop “health homes” or other case management systems. Investing in treatment for this population now may help offset criminal justice costs later on, and expanding access to primary care and integrated care may help avoid more expensive and intensive care down the road.