The Affordable Care Act, Justice-Involved

Individuals, and Criminal Justice Reform

Kellen Russoniello – Staff Attorney, Health and Drug Policy

ACLU of San Diego and Imperial Counties Twitter: @krussonielloNovember 17, 2014

ACLU of San Diego and Imperial Counties

We fight for individual rights and fundamental freedoms for all through education, litigation, and policy advocacy

Focus areas:Criminal Justice and Drug Policy Reform Immigrants’ RightsVoting Rights

Overlap of ACA and Criminal Justice System

OverviewHealth Issues of Justice-Involved and Victims

Medi-Cal Eligibility/Coverage

Financial Incentives

Examples: San Diego & Imperial Counties

What Does ACA Mean for Criminal Justice Reform?DecriminalizationProposition 47

Challenges and Opportunities

Health Issues of Justice-Involved

Compared to the general population, the prevalence among justice-involved populations of: HIV infection is 8 to 9 times higher Hepatitis C is 9 to 10 times higher Tuberculosis is 4 times higher Serious mental illness is 3 times higher Substance use disorders is 4 times higher

12 times more likely to die w/in 2 weeks of prison release

80% of individuals in jail with chronic medical conditions have not received treatment in the community prior to arrest

Up to 90% of people released do not have health insurance

Health Issues of Crime Victims

Being a victim of crime increases risk of:Chronic health issuesSubstance use disordersTrauma/mental illness

Crime victims may have medical bills related to the physical injuries

Victims of violent crime are more likely to be low-income, and therefore less likely to be insured

Essential Health Benefits

Ambulatory patient services

Emergency services & hospitalization

Maternity & Newborn Care

Mental Health & Substance Use Disorder Services

Prescription Drugs

Rehabilitative & Habilitative services

Laboratory services

Preventive & Wellness Services

Chronic Disease Management

Pediatric Services, including dental & vision

Medicaid expansion and all health plans offered through health benefit exchanges must cover:

Preventive ServicesMost health plans must cover preventive services for

adults without cost-sharing, including:Alcohol misuse screening and counselingDepression screeningScreening for certain chronic conditionsVaccines

More preventive services available for women, including:Screening/brief counseling for domestic violenceScreening for breast/cervical cancerContraception

Medicaid Eligibility/Coverage

About 20% of newly eligible are justice-involvedGenerally, Medicaid does not pay for expenses when

person is an “inmate of a public institution”Exception: individuals admitted as inpatient in non-

correctional medical facility for > 24 hours (e.g. hospital)

Medicaid eligibility is not affected by incarceration status at federal level, can be suspendedBut most states terminate eligibility upon incarceration

Medicaid is available to those in community, even if under supervision (e.g. parole/probation) No disenfranchisement!

No open enrollment period – can enroll at any time

Financial IncentivesTraditional Medicaid match rate between 50%

and 74%

Rate for newly eligible pop is 100% through 2016, declining between 2017-2020 to 90% for 2020 and beyond

Incentive to enroll incarcerated people to pay for hospitalizations

Incentive for people with chronic conditions to receive care in the community

Health and Public SafetyMedicaid coverage at release associated with 16%

fewer subsequent detentions and more days in the community before next arrest for people with SMI

Substance use disorder treatment offered to low-income adults associated with significantly reduced risk of arrest (up to 33%)

Every dollar invested in substance use disorder treatment saves up to $12 in reduced crime, criminal justice, and healthcare costs

Medicaid expansion is a public safety issue – but be careful with this argument!

What’s Happening in San Diego County

About 90,000 jail bookings annually, about 62,000 of which are unique individuals

Average jail population is about 5,900 (majority pretrial)

Public Safety Realignment increased the number of people for whom local law enforcement is responsible

San Diego, cont. AB 720: State Legislation suspending Medicaid upon incarceration

(up to 1 year) and allowing jails to offer enrollment assistance

AB 82: $1.8 million for enrollment assistance over 2 years (private funding)

Four-tiered system County eligibility workers assist folks with immediate medical needs

(e.g. need to be hospitalized, HIV positive, and SMI) MOUs with community clinics to provide assistance with no funding AmeriChoice (United Healthcare) has hired 10 FTEs RFP for CBOs to provide assistance in final negotiations

Enrolling in 6 of 7 jails and two probation offices Over 350 applications received so far in jails Over 60 referrals by probation officers with 53% no show rate

San Diego, cont.Partnerships

Sheriff’s DepartmentProbation DepartmentDistrict Attorney (victims)Health and Human Services AgencyChief Administrative OfficeBoard of SupervisorsCommunity clinics

San Diego, cont.Healthy and Safe Communities Initiative

Community clinics, reentry service providers, and advocacy organizations

Pressure the county to make system run smoother Dedicated to reducing criminal justice response to health

issues

Accomplishments Change of process to ensure active case at release Medi-Cal managed care choice form included in app Brief education about accessing healthcare Materials at discharge of how/where to access services Voter registration

San Diego, cont.Next steps:

Ramp up to maximize reachEnsure people have benefit ID cards at releaseEnsure smooth transition to community care

Scheduling appointments prior to releaseRecord sharing while protecting privacy

Engage Medi-Cal managed care organizations Mobilize community to shift money from traditional

law enforcement to treatment and other necessary services

Imperial County10,000 releases from two county jails each year

MOU with CBO for enrollment at Day Reporting Center

Moving to enrollment at booking

Challenges:Treatment capacityTransportationEmployment opportunity

ACA & Criminal Justice Reform

ACA establishes a framework to build health-oriented responses to substance use and mental health issues

Federal funds can help expand access to community health services

Alternatives to arrest, prosecution, and incarceration more possible and sustainable

Incentive to treat individuals outside of correctional setting

Impetus for reform of sentencing law and practice

Proposition 47Approved by 58.5% of CA voters on Nov. 4th, 2014; Took

effect Nov. 5th!

Reduces simple drug possession and petty theft from felonies to misdemeanors

Applies retroactively

Reinvests savings into mental health/substance use disorder treatment, K-12 education, and victims’ services (estimated $1 billion in next 5 years alone)

Advocacy is just beginning Funding to be decided via grant processes Ensure law enforcement is cooperating with spirit of law

ACA can help ensure folks have coverage for treatment

Decriminalization ACA lays framework capable of addressing substance use

disorders as a public health issue

Expanded coverage and access to treatment reduces need to rely on criminal justice approaches to substance use

APHA Policy Number 201312 (2013) – Defining and Implementing a Public Health Response to Drug Use and Misuse “[E]liminating criminal penalties for personal drug use and

possession is an essential feature of a public health response to drugs and drug misuse, and APHA calls on state and federal governments to remove such criminal penalties.”

APHA “[e]ncourages state governments to leverage resources potentially available through the Affordable Care Act toward effective community-based drug treatment, harm reduction, and physical and mental health services”

Portugal Portugal decriminalized personal possession of drugs in 2001

People are no longer arrested; instead cited and asked to appear in front of civil commission

Commission determines whether to apply sanctions or recommend treatment

Simultaneous expansion of prevention/treatment funding

Results Decrease in HIV cases among injection drug users by 71% Drug-related deaths decreased 28% Youth and injection drug use rate decreased People seeking treatment substantially increased Reductions in prison overcrowding

Challenges Treatment Capacity

Ensuring timely access to the right level of care IMD exclusion and alternatives to residential treatment

Moving health decisions out of criminal justice system Ensure non-health professionals are not making health

decisions (moving away from drug court models)

Investment in other resources Housing – Inclusion as a Medicaid benefit? Transportation IDs

Health disparities in the community

Health education/navigation (cultural competency)

OpportunitiesForm/strengthen relationships with both agencies

and community partnersProposition 47 implementationSteer criminal justice funding towards treatment

and other necessary servicesPolitics on criminal justice are changing;

consensus buildingUsing ACA to bolster harm reduction treatment

modalitiesExpansion of covered benefits (e.g., health homes,

housing)

ConclusionsThe ACA is a tool to improve the health of

justice-involved individuals and crime victims

Partnerships with new allies are possible

Medicaid expansion is a public safety issue

ACA and expansion of treatment is a path towards ending criminalization of drug and mental health-related offenses

Your help is needed to maximize the potential in ACA for improving community health and safety

ResourcesACLU - ACA: A Primer for Advocates

ACLU & DPA – Healthcare Not Handcuffs: Putting the ACA to Work for Criminal Justice and Drug Policy Reform

CSJ – Health Coverage Enrollment of California’s Local Criminal Justice Populations

CSG – Implications of the ACA on People Involved in the Criminal Justice System

Community Oriented Correctional Health Services

Russoniello – The Devil (and Drugs) in the Details: Portugal’s Focus on Public Health as a Model for Decriminalization of Drugs in Mexico

Contact

Kellen RussonielloStaff Attorney, Health and Drug Policy

krussoniello@aclusandiego.org

619-398-4489

Twitter: @krussoniello