17a launched our “Just Health” initiative in 2019, focused on achieving more equitable outcomes in community health and county corrections.
Just Health works to reorient county court and corrections activities and spend toward healthcare and other community supports. We do this through better information sharing and coordinated action.
Understanding county jail stays
Across the country, jail officials and other community leaders are often quick to point out the abundance and futility of short jail stays, particularly for community members with clear problems that the criminal justice system was never meant to fix—the latest oft-cited example of this problem is the fact that roughly two thirds of the population in county jails have a substance use disorder. Jail time should not be a common prescription for the sick and vulnerable in a civilized society.
Today, local jail systems are acting—ineffectively—as stewards of last resort for community health and wellness. Placing county corrections in such a role reinforces and worsens inequities; it also wastes valuable opportunities to promote the sort of wellness and support actually required for justice in many cases. As part of fixing the many serious problems with the corrections system in America today, the county jail must be redesigned to better integrate with community healthcare delivery.
Unlike prison stays, most county jail stays are short: for example, in one large county, stays are an average of 7 days for misdemeanor charges and 14 days for felony charges. Short stays are disruptive, costly and generally unhelpful to resolving the underlying issues that may have led to legal system involvement in the first place. A short stay is very effective at little more than shaking any existing stability in daily work and family life, disrupting access to important community and health services, and introducing additional stress, trauma and cost.
Mediciad in the county jail population
When they are not incarcerated, most people booked into county jails are Medicaid beneficiaries if they live in states with Medicaid expansion. In both expansion and non-expansion states, many more of the individuals in jail are likely eligible for Medicaid but just not enrolled. Our team refers to the population that is enrolled in Medicaid and is booked into the county jail at least once a ‘multisystem member’. Outside of jail, healthcare for the vast majority of multisystem members is led by Medicaid Managed Care Organizations (MCOs).
Where Jail-Health overlaps matter
Missed opportunities for information sharing and coordinated action between the criminal justice system and healthcare delivery system begin well before incarceration. In a standard pretrial process today, determinations about candidacy for diversion are made with incomplete information about whether someone meets the eligibility criteria. At best, attorneys and pretrial workers rely on clients to self-report health conditions that are relevant to eligibility for diversion; as a result, many people are not recommended for diversion even though they are eligible—leading to unnecessary, disruptive jail time and missed opportunities for treatment. MCOs hold data that could be used for more informed eligibility determinations and more diversions to treatment; MCOs also have an existing incentive to support diversion to treatment, given that many conditions lead to more costly healthcare utilization when left untreated and also given that short jail stays may worsen health outcomes and costly forms of utilization (e.g., high ED admission rates after county jail discharge, mainly to access medications).
The problem does not end with pre-trial; once someone is booked into a county jail, the jail assumes responsibility for their healthcare. Healthcare delivery inside and outside of the jail is not integrated. Jails pay for and directly contract with health providers for services delivered while people are incarcerated—and generally do not have access to general health records beyond some limited pharmacy data. As a result, jail health providers operate with limited knowledge of member health status and have little opportunity or incentive to intervene on non-acute health issues given the typical length of a county jail stay; instead, they typically work with jails to simply mitigate risk of health emergencies during incarceration. When multisystem members are booked into jail, the treatment they will receive while incarcerated is determined based on self-reporting, a cursory scan of prescription databases and a short evaluation to determine acute or emergency needs. No detailed health assessment is administered at intake and no detailed health records are available to the jail health provider. This means that treatment in jail is often inadequate. Instead, short stays are harmful to members who have conditions where continuity of care is important. MCOs hold data that would improve continuity of care for these members during incarceration, and have an incentive to ensure continuity of care (e.g., for bipolar disorder, costly Hepatitis C treatment, pregnancy).
Meanwhile, MCOs are not able to identify members who are being incarcerated for short stays; without access to real-time booking data, MCOs are unable to invest in resources for multisystem members to establish continuity of care for chronic conditions, re-engage them in treatment at re-entry, and link them to new, more intensive services that incarceration has helped indicate might be needed. Bookings for short stay-charges could serve as an important indicator of underlying health access and utilization challenges, if properly shared with the community provider organizations that serve multisystem members.
There is also some potential for better integrated health and booking data to be used to improve the role of short jail stays in linking multisystem members to services that improve their wellbeing through better health outcomes and lower recidivism; a booking in the county jail can serve as an additional potential opportunity for service providers to find and reach hard-to-engage populations for services offered far outside the jail. In pilot work we are currently leading with an MCO in one county jail, care management staff are excited about the simple ability to use a short jail stay as an opportunity to meet with a member they have been unable to reach.
Across the courts and corrections continuum, officials, administrators and service providers operate with an incomplete picture of multisystem members. Despite the potential for better cross-system decision-making, investments in efforts to better use combined criminal justice and health data are limited. Basic criminal justice and health data remains disconnected even when policies require integration for simple program administration purposes –though all states have regulations in place to ensure that Medicaid enrollment is not active during incarceration, fewer than half even have the basic electronic and automated systems to operationalize those regulations.
A valuable, whole-person view of multisystem members is lacking across the board:
- Courts lack information about diagnoses and treatment history, which can be useful to facilitate diversion to community services in lieu of short stays for certain charges and for members with specific conditions.
- County corrections systems, including jail administrators and jail health providers, lack basic information about the health status of people incarcerated in order to provide proper care during incarceration; they also lack information about population health trends among multisystem members, which is important for planning and preparedness.
- MCOs and community health providers operate without knowing who is (or has been) incarcerated, leaving them unable to support needs at re-entry; further, they unable to incorporate incarceration patterns into a whole-person view of the members needs for specific forms of treatment and other community supports
- All state and community leaders lack a holistic understanding of the health status and incarceration patterns of the short stay population – impeding the development of new insights about potential high value interventions that might be used to improve outcomes for multisystem members, particularly through more support via Medicaid managed care networks and dollars.
What comes next
Better use of combined criminal justice and health information is the first step in reducing the number of short stays and improving the impact of the short stays that continue to occur. Today, even basic information about health status is not shared with courts or corrections agencies, though it is relevant to many of their decisions and services. Similarly, basic information about criminal justice involvement is not shared with health providers well positioned to use that information to inform care delivery decisions as well as pathways through the courts and corrections system.