What Are the Public Health Implications of Prisoner Reentry in California?

The landscape for assessing the public health implications of prisoner reentry in California has changed dramatically over the past few years. First, California (and the nation as a whole) is in the midst of a deep and persistent recession, which has significantly weakened the health care safety net that ex-prisoners rely on. Second, California's new 2011 Public Safety Realignment Plan — which shifts responsibility for low-level offenders away from the state and on to counties — will have a number of implications for thinking about meeting the health care and rehabilitative needs of the reentry population. Finally, implementation of the federal Patient Protection and Affordable Care Act (ACA) will expand Medicaid eligibility and, thus, will help in removing a key barrier to access to care for the reentry population.

This puts California at an important crossroads: The state faces numerous challenges, but the recent changes in policy also present important opportunities to improve California's ability to meet the needs of individuals returning from state prison. In this context, then, it is critical to better understand the public health issues associated with returning ex-prisoners, to help communities and providers in the communities to which ex-prisoners return better meet the reentry and health care needs of this population.

This study helps inform planning for these policy changes by producing a "state-of-the-state" report — a synthesis of findings from a multiyear effort — that examines the specific health care needs of California's reentry population, the public health challenges of reentry in California, and the policy options for improving access to health care safety-net resources for this population within the context of significant policy changes.

What Are Inmates' Health Care Needs?

Based on an analysis of self-reported data from California inmates in the Bureau of Justice Statistics (BJS) Survey of Inmates in State and Federal Correctional Facilities, we found that California inmate health care needs are high. In particular, inmates self-report a high burden of chronic diseases, such as asthma and hypertension, and infectious diseases, such as hepatitis and tuberculosis — conditions that require regular health care for effective management. Among those who reported a current medical issue, most reported seeing a physician since admission to prison; but their likelihood of 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.

Our analysis shows that self-reported mental health and drug treatment needs are especially high. About two-thirds of California inmates reported having a drug abuse or dependence problem. Yet among those reporting drug abuse or dependence, only 22 percent reported receiving treatment since admission to prison. More than half of California inmates reported a recent mental health problem, with about half of those reporting receiving treatment in prison. Given the high prevalence of these problems in the prison population — and that most prisoners do not receive care for these problems in prison — ex-prisoners' need for services in communities is likely to be particularly high.

What Challenges Do Providers Face in Meeting These Needs?

To determine how such treatment needs place demands on or affect communities where inmates return, we reviewed the relevant literature about ex-prisoners' access to insurance and how the safety net is organized to meet ex-prisoners' needs. In parallel, we conducted exploratory interviews with a group of health care providers in clinics, community health centers, drug treatment programs, and multiservice centers in Alameda, Los Angeles, and San Diego counties. Although our sample of providers does not cover the full range of provider perspectives, the themes and stories we heard are consistent with what the literature says and with what we heard in focus groups with ex-prisoners and family members of prisoners in the same three counties.

The interviews revealed that providers face a host of significant issues in treating this population:

• The reentry population has substantial treatment needs and is resource-intensive to treat. As reflected in the survey analysis and focus groups we conducted with ex-prisoners, providers note that this population has substantial mental health and substance abuse treatment needs, as well as significant health problems — needs exacerbated by neglect or reduced access to care. Also, this population has such non–health care needs as transportation, employment, housing, and family reunification. Given this complex set of needs and the prevalence of untreated health conditions, ex-prisoners tend to be more resource-intensive for providers to treat.
• Discharge planning is limited, raising concerns about continuity of care. Lack of medical records was seen as problematic, because providers must treat individuals without information about their past health status and care. 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. This was also true for those with chronic health and mental health conditions. Providers also noted delays in seeking care upon release, leaving ex-prisoners at risk of running out of medications and self-medicating as a result.
• A number of factors limit access to care. Lack of health insurance or funding is a major barrier to accessing care, limiting the treatment options that providers and case managers have in referring individuals to services. For example, case managers can refer ex-prisoners to mental health counseling or drug treatment clinics that provide services on a sliding fee scale, but even this may be too expensive for these individuals without health insurance, who simply lack the ability to pay anything.
• Also, individuals often have difficulties navigating the health care system, and the different silos in the health care and social services systems can complicate the referral process for those with a complex set of needs. Having patient navigators who are culturally competent and understand the experience of incarceration was seen as essential in helping the formerly incarcerated to link to services.
• Budget cuts have impacted providers. Providers reported on having to eliminate programs, such as HIV or dental programs, or to cut back on services, such as mental health programs. For example, a provider from a community assessment center noted the need to reassess whether to focus only on conducting assessments or to continue to also provide other services, such as drug treatment and mental health care. For one provider, state-level cuts in community-based treatment programs meant eliminating its sober living facility. Importantly, budget cuts also affected alcohol and drug treatment program models, including decreasing the length of stay in residential treatment programs.

What Counties and Communities Are Particularly Affected by Reentry?

To understand which counties and communities individuals return to upon release, we conducted a geographic analysis using geocoded data for parolees released in 2005–2006 from California state prisons and a cluster analysis to examine the geographic distribution of parolees and identify concentrations of parolees across and within counties.

Figure 1 shows the clustering of parolees within California. The yellow circles identify clusters of parolees statewide; the black dots represent the count of parolees. The blue shading shows the concentration of parolees statewide, with darker shades of blue indicating those areas with higher parolee rates of return and lighter shades indicating those with lower rates of return. We found that certain counties have higher rates of return, and parolees tend to cluster in certain communities and neighborhoods within counties, which has implications for effectively targeting reentry and health care resources for this population. Eleven counties had the highest parolee rates, concentrated around the Bay Area and in the southern part of the state. By far the highest rates of parolee returns were in southern California, especially, Los Angeles, Orange, San Bernardino, Riverside, and San Diego counties. Looking within counties on the map, we find that most of the clusters are in urban areas, for example, near San Francisco, Oakland, the city of Los Angeles, and the city of San Diego.

Figure 1 Distribution of Parolees Across California

SOURCE: CDCR parolee data, 2005–2006.

Within the state, we focused on four counties that received one-third of the total parolees: Alameda, Kern, Los Angeles, and San Diego. For each county, we analyzed the distribution of parolees who returned to the individual counties. For example, almost 45 percent of the returning parolee population within Alameda County is concentrated in five distinct clusters of parolees primarily around Oakland and the northern section of the county. Kern County has four distinct clusters of parolees — two around the urban area of Bakersfield and two in the northern and northeastern sections of the county; these clusters accounted for almost 58 percent of parolees within Kern County. Eight clusters account for nearly half the parolee population within San Diego County, with the largest clusters near Downtown San Diego and Southeast San Diego. Finally, there are 23 distinct clusters of parolees covering a large geographic area but accounting for only 35 percent of the total number of parolees within Los Angeles County. This dispersion suggests that providing services to the reentry population requires a targeted approach in different county supervisorial districts and across urban and rural areas.

Analysis also shows that in California, African-American and Latino parolees, in particular, tend to return to disadvantaged neighborhoods and communities, defined by high poverty rates, high unemployment rates, and low educational attainment. Further, our analysis of the geographic distribution of safety-net resources, as discussed below, highlights that health care resources in these communities tend to be scarce.

What Is the Capacity of the Health Care Safety Net to Meet Ex-Prisoners' Needs, and How Does It Vary?

To assess the capacity of the health care safety net in the four counties, we assumed that most individuals returning from prison would become part of the medically indigent and uninsured population. Using facility data to characterize the respective health care, mental health, and substance abuse treatment safety nets in the four counties, we found that parolees' access to safety-net resources varies by facility type, by geographic area (across counties and within county), and by race/ethnicity. As policymakers consider how to ensure access to services for the reentry population in California, they will need to take into account this variation in counties' safety nets.

For example, in Los Angeles County (as shown in Figure 2), some county supervisorial districts with high concentrations of parolees (the darker shades of blue) tend to have fewer hospital and primary care clinic resources. For instance, in District 2, which covers South Los Angeles and has relatively high concentrations of parolees, there is only one medically indigent service provider (MISP) hospital. There are also relatively sparse clinic resources, both MISP clinics and other primary care clinics, in this district. In all the counties, community clinics appear to play an important role in filling gaps in primary care coverage vis-à-vis the reentry population.

Figure 2 Gap Between Parolee Concentrations and Health Care Resources: Example of Southern Los Angeles County

As for accessibility to health care resources, we developed measures of potential access based on capacity, demand, and distance. Capacity was measured using full-time equivalents for facilities, when available; underlying demand for services was measured as the percentage of households below the federal poverty level (FPL), given that parolees are not the only populations seeking care from these facilities; and distance was measured in terms of a ten-minute travel time to facilities, assuming this population would be less mobile and more reliant on public transportation.

Table 1 shows an example of hospital accessibility for Los Angeles County. Overall, more than half the parolees reside in areas with the two lowest levels of accessibility to hospitals (shaded rows); there is also variation by parolees' race/ethnicity. For example, more African-American parolees live in areas with lower accessibility than Latino or white parolees. By way of comparison, Alameda County had a similar pattern, but in Kern and San Diego counties, more Latino parolees resided in areas with lower accessibility to hospitals than white and African-American parolees (not shown).

In terms of accessibility to mental health care resources across the four counties, a larger share of parolees in Alameda and Los Angeles counties returned to areas with lower levels of accessibility to mental health resources than parolees in Kern or San Diego counties. In terms of accessibility to alcohol and drug treatment providers, we see a similar pattern. About 40 percent of parolees in Alameda and Los Angeles counties resided in areas with low levels of accessibility to alcohol and drug treatment providers, compared with about a third of parolees in Kern and San Diego counties.

Although separate networks exist that provide mental health care and drug and alcohol treatment services to the parolee population, both networks have very limited capacity, suggesting that most of the reentry population must rely instead on counties' safety-net resources.

Our analysis of the health care safety net was conducted in 2009, just prior to the deep cuts made in rehabilitative programming for prisoners and in health care safety-net services in California. As of late 2011, the safety net has been stretched even thinner by budget cuts. For example, the California Department of Corrections and Rehabilitation (CDCR) has reduced funding for rehabilitative services by 40 percent, including cuts made to in-prison substance abuse programs and community-based alcohol and drug treatment programs for ex-prisoners. Although treatment providers contracted under California's Substance Abuse and Crime Prevention Act (also known as Proposition 36) appear to be a viable source of care for the reentry population, local counties are no longer funding these providers. Beginning in October 2011, Proposition 36 became instead a fee-based, participant-self-pay counseling program.

What Can California Do to Better Prepare for Public Safety Realignment and Health Care Reform?

Along with the ongoing financial crisis, California's new Public Safety Realignment Plan and federal health care reform are affecting how the state and counties deal with the public health needs of returning prisoners. In 2005, California's prison medical system was put under a court-appointed federal receiver charged with bringing the level of medical care in California prisons up to a standard that no longer violates the U.S. Constitution. On May 23, 2011, the U.S. Supreme Court held that medical and mental health care for inmates still fell below a constitutional standard of care and that the only way to meet these constitutional requirements was to further reduce the size of the prison population. Public safety realignment will help close the revolving door of low-level offenders cycling in and out of prison and will help reduce the size of the prison population, returning more ex-prisoners to their communities.

As for health care reform, the ACA's expansion of Medicaid eligibility to include all non-Medicare-eligible citizens and legal residents under age 65 with incomes up to 133 percent of the FPL will allow many ex-prisoners and other individuals involved in the criminal justice (CJ) system to become eligible for health insurance under Medi-Cal (California's Medicaid program). Also, Medicaid will be expanded to more fully cover drug treatment, prevention services, and wellness programs — services particularly important for the reentry population — and create opportunities to put in place key elements of health care delivery systems (e.g., health homes, case management, patient navigators) needed to effectively manage ex-prisoners' care. Combined, these changes create a critical opportunity for California to improve access to care for the reentry population.

Importantly, public safety realignment and health care reform have a similar set of stakeholders involved in planning for these policy changes. More specifically, as part of realignment, CDRC and the counties must coordinate on transitioning responsibility for low-level offenders, while for health care reform, California's Department of Health and Human Services must coordinate with the counties on developing service delivery strategies, for example, for Medicaid expansion. This means that both policies will require the state and counties to assess capacity and build or enhance existing integrated service delivery systems, which requires a similar set of stakeholders. Coordination is key; otherwise, California may end up with 58 separate, county-level implementation experiments.

The two policies also present opportunities and challenges for dealing with the reentry population. For example, realignment provides the opportunity to reduce the size of the state's prison population and the state's high parole revocation rates and focuses attention on the need to improve prerelease planning, build better mechanisms to transition care from correctional health to safety-net providers, and create or enhance existing local partnerships among probation, law enforcement, county agencies, and community- and faith-based organizations to better serve the needs of ex-prisoners returning to communities. Realignment will also enable low-level offenders to serve their time closer to home, thus giving them better access to family members, employers, and community organizations, which can possibly aid them with the reentry process.

But realignment will also present challenges; specifically, the traditional mechanisms for linking ex-prisoners to health care and social services (e.g., parole officers) will change dramatically for individuals placed on county-level post-release community supervision and for low-level offenders who will serve their time in county jail. Also, for low-level offenders who serve their sentence within county jail systems, a key concern is that many of these systems have little or limited rehabilitative programming. Finally, counties are concerned about their capacity to meet increased demand for mental health and drug treatment — a number of low-level offenders to be housed and monitored at the county level are expected to include individuals convicted of drug-related offenses, some proportion of whom will require treatment programs.

Similarly, the ACA will expand Medicaid, opening up the possibility for many ex-prisoners and other individuals involved with the CJ system to become eligible for Medicaid (Medi-Cal in California) and to have drug treatment services, prevention services, and wellness programs more fully covered. But there are also some challenges. For example, expansion of Medicaid eligibility could lead to increased demand for health care safety-net services that are already stretched thin, thus possibly affecting access to care if provider capacity at the county level is not increased. Also, although treatment for substance abuse problems will be more fully covered, there could be substantial cost-sharing or other utilization limits that may make it difficult for some of the reentry/CJ population to afford this care.

In that light, the study offers a series of recommendations (Table 2), which can be acted on at both the state and county levels and are based on a combination of our review of the literature and analyses of the inmate survey, parolee data, data on the health care safety net in four counties, provider interviews, and focus group discussions with formerly incarcerated men and family members.

Concluding Thoughts

We began our study with the premise that much of the reentry population eventually will become part of the uninsured and medically indigent populations in counties. This is even more the case today. Specifically, when we completed our initial analysis of the capacity of the health care safety net to meet the needs of the reentry population, we concluded that the safety net was sparse in some services and that ex-prisoners' potential access to health care services varied by county, type of service, and race/ethnicity. Given the ongoing financial crisis, the capacity of the health care safety net has shrunk substantially over time because of state and county budget cuts, while the demand for services has increased because of growth in the number of uninsured or underinsured persons. Also, within the state prison system, rehabilitative services, including substance abuse programming, have been substantially reduced. This means that the reentry population will have greater unmet needs and will have to be even more self-determined than previously, because transition points and linkages to care will become even more difficult to navigate.

While public safety realignment and federal health care reform pose some substantial challenges, they also offer unprecedented opportunities to address the needs of the reentry population by improving rehabilitative services at the local level and by improving access to health care for the reentry population (and other components of the CJ population) through Medi-Cal and other coverage expansions. Implementing both policies in ways that help serve the needs of the reentry population will require the state and counties to closely coordinate to leverage these opportunities and meet these challenges.

Both realignment and federal health reform come with funding streams to help support putting needed services into place. Realignment legislation includes initial funding for counties to implement the plan, while federal grants are available to help support states' planning of health care reform, including expanding Medicaid and developing the workforce to provide services.

Investments in planning for health care reform should be leveraged for the reentry population, for example, to develop health homes or case management systems. Doing so makes sense, because investing in treatment for this population now can help offset recidivism and other CJ costs later; moreover, expanding access to primary care and to health homes can help avoid expensive and resource-intensive care for this population.

Topics

• California
• Health Care Access
• Health Care Services Capacity
• Prisoner Reentry
• Social Services and Welfare