(Chicago) – April 2016 marks the third anniversary of Cook County’s groundbreaking jail-based Medicaid application project, through which people detained at the jail have received assistance in applying for health coverage. Some 15,000 detainees have gained Medicaid coverage since 2013, making Cook County’s initiative the nation’s largest and most ambitious projects of its kind to date.
Most of the 11 million admissions to local jails in the U.S. each year—646,000 are detained at any given time—represent people who have untreated medical and behavioral health issues, perpetuating cycles of arrest and incarceration. With health coverage, they have the means to access care in the community, which is far less expensive than corrections-based care and emergency rooms—the predominant healthcare options for uninsured people prior to Medicaid expansion.
What’s happening in Cook County is occurring in many counties and jurisdictions across the country, as local governments seek to reduce the cost burdens of corrections and emergency care, and ultimately improve public safety and public health.
Since Medicaid expansion came about as a result of the Affordable Care Act, TASC (Treatment Alternatives for Safe Communities) has been working with partners in Cook County and across the U.S. to bring aspects of this national public policy from concept to local implementation and results.
Early Adopters: Cook County and Medicaid Expansion
Before Medicaid expansion, nine out of 10 people entering jails lacked health insurance. At the same time, justice-involved populations have high rates of substance use disorders, mental health conditions, and chronic medical conditions requiring treatment during detention and immediately after release. For decades, large and small counties have struggled to meet these needs with very limited resources. The expansion of coverage to low-income adults provides new and welcome means to address this perennial challenge.
Cook County has been a national leader in implementing processes for Medicaid application assistance at the jail, having obtained a waiver in 2012 for early expansion of Medicaid. Transformation has come about through coordinated planning and collaboration between the Cook County Health and Hospitals System, the Cook County Sheriff’s Office, and TASC, aided by significant public and private support from the Cook County Justice Advisory Council, The Chicago Community Trust, the Michael Reese Health Trust, and the Polk Bros. Foundation.
A National Sea Change
Building on the Cook County experience, the Center for Health and Justice at TASC works with counties and states to leverage available federal health care funding in order to create linkages to care, divert people from the justice system, and improve individual and community health. To these ends, and in partnership with the National Association of Counties, TASC provides national consulting, which also is supported by the Open Society Foundations and the Public Welfare Foundation.
Working in more than a dozen states, TASC has observed the following trends with regard to Medicaid expansion for justice populations:
- The proportion of people entering large county jails with Medicaid coverage has increased from 10% to 40-60% since 2014;
- Most jails in large urban counties are assisting some of their detainees in applying for coverage;
- Jails vary as to where applications are taken. It is relatively rare to take applications at jail intake (as in Cook County). It is increasingly common for medical providers to assist with applications and for applications to be taken at release;
- Jails in rural communities are less likely to have application processes in place, though there are notable examples of small and rural community jails taking Medicaid applications routinely; and
- States such as New Mexico and Indiana have passed legislation that enables or requires state and county corrections to facilitate applications. These states are leading the way in building statewide infrastructure and processes that institutionalize access to coverage and care for people under justice supervision.
As coverage becomes more common, counties and states can build reentry systems and expand diversion from jail to services in the community. Elements of success in building these processes include:
- Understanding the impact of coverage on people’s use of treatment for substance use disorders and psychiatric conditions after release and on subsequent arrests;
- Building comprehensive systems that provide seamless bridges to care upon release from jail;
- Expanding substance abuse and mental health capacity in the community to support safe reentry; and
- Building jail diversion projects that take full advantage of these new health care services.
Ultimately, these systems changes are intended to bring about not only cost savings and the more efficient use of public resources, but a healthier society as well, where quality treatment and other health services are accessible in the community. “For decades now, jails have been inundated with people who have severe substance use and mental health conditions,” said TASC President Pam Rodriguez. “Medicaid expansion offers the means to change that. Together with our partners in the public and private sectors, we are leveraging an unprecedented opportunity to shrink the oversized justice system.”