NATALIE ORTIZ, PH.D.
NACo WHY COUNTIES MATTER SERIES • ISSUE 3 • SEPTEMBER 2015
Protecting public safety and ensuring the health and well-being of residents are essential functions of county governments. County governments own and operate a majority of all jails in the U.S. and spend $70 billion annually on the criminal justice system. Counties balance the pursuit of justice with the strategic management of the jail population and prudent county spending on the corrections system, including for the healthcare of the jail population.
The jail population has complex healthcare needs. Better management of the inmates with mental illnesses and chronic medical conditions may assist counties with reducing the number of people in jail that require medical and mental health treatment. This approach may also reduce costs and better provide for the healthcare needs of this population. An analysis of U.S. Department of Justice Bureau of Justice Statistics (BJS) data on the jail population and the results of a 2015 NACo survey of county jails finds:
A LARGE SHARE OF THE JAIL POPULATION HAS A MENTAL ILLNESS OR MEDICAL CONDITION.
County jails have large jail populations with serious healthcare needs, including mental illnesses and medical conditions (See Key Terms). According to BJS, 40 percent of inmates have a chronic medical condition (See Figure 1).1 High blood pressure/hypertension is the most frequent medical condition in the jail population. Female jail inmates are more likely than male inmates to have a chronic medical condition and these conditions are more common among the persons in jail over 35 years.2 One-third of individuals who enter jail with a chronic medical condition were receiving medical treatment in the month prior to their admission to jail.3 A significant share of jail inmates with a chronic medical condition take prescription medication while in jail.4
MENTAL ILLNESS IS A COMMON OCCURRENCE WITHIN THE JAIL POPULATION, AND IT IS OFTEN COUPLED WITH SUBSTANCE ABUSE.
BJS reports that 64 percent of the jail population has a mental illness.5 According to a 2009 study, 15 percent of male jail inmates and 31 percent of female jail inmates have a serious mental illness, which includes depressive disorders, bipolar disorders, schizophrenia, delusional disorders and psychotic disorders.6 Co-occurring substance abuse is common among individuals with a mental illness. BJS data indicate that more than half of jail inmates with a mental illness used drugs or alcohol at the time of their crime.7
TOP FIVE CHRONIC MEDICAL CONDITIONS AMONG JAIL INMATES, PERCENT OF JAIL INMATES WITH A CHRONIC MEDICAL CONDITION, 2011–2012
Source: Bureau of Justice Statistics, Medical Problems of State and Federal Prisoners and Jail Inmates, 2011–12, (February 2015).
Notes: Chronic conditions include high blood pressure/hypertension, asthma, arthritis, heart related problems and diabetes/high blood sugar in addition to kidney-related problems, stroke-related problems, cancer and cirrhosis of the liver. Medical conditions among jail inmates are categorized by the status of symptoms and the need for treatment. “Ever had” includes jail inmates diagnosed and told by a health professional at least one point in their lifetime that they had the medical condition. “Currently has” includes jail inmates told they currently have the medical condition by a health professional. Inmates who ever had a chronic medical condition may be at risk for the return of symptoms or additional health problems, while currently having a condition identifies those who have present healthcare needs.
BEHAVIORAL HEALTH is the mental and emotional circumstances and the choices and actions that affect well-being, including substance use and abuse, psychological distress and mental illness.8
CHRONIC MEDICAL CONDITION is a long-term physical health problem that can be controlled but not cured.9
MENTAL ILLNESS is defined using the 2006 BJS definition of mental health problems, including having symptoms consistent with a mental illness based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) and/or receiving professional mental health treatment within the previous 12-months of confinement. The 2006 BJS study estimated the percent of the jail population with a mental health problem.10
SERIOUS MENTAL ILLNESS is defined using the 2009 Steadman and others definition of serious mental illness, including the presence of one or more of the following diagnoses: major depressive disorder; depressive disorder not otherwise specified; bipolar disorder I, II and not otherwise specified; schizophrenia spectrum disorder; schizoaffective disorder; schizophreniform disorder; brief psychotic disorder; delusional disorder and psychotic disorder not otherwise specified. Steadman and others estimated these diagnoses in the jail population.11
SUBSTANCE/DRUG ABUSE is an addiction to an illegal or legal drug or medication that involves compulsive drug seeking behavior, risky drug use, increased tolerance to the amount consumed, social withdrawal, disregard for the consequences of using drugs and withdrawal symptoms.12
ADDRESSING THE MENTAL AND MEDICAL HEALTH NEEDS OF THE JAIL POPULATION IS A MAJOR CHALLENGE CONFRONTING COUNTY JAILS.
Many of the challenges confronting county jails relate to addressing the mental health and medical needs of the jail population. A 2015 NACo survey of county jails found that addressing the mental health needs of inmates is the most common concern for county jails. Nearly three-quarters of respondent county jails prioritize ways to reduce the number of people with mental illnesses in jail and almost half face challenges in coordinating mental health treatment for inmates.
Inmate healthcare, medication and hospital stays are significant cost drivers for counties. Inmate healthcare expenses represent between nine and 30 percent of jail costs, with many counties covering costs through funds outside of the jail budget.13 County jails have a constitutional responsibility to provide inmates with adequate healthcare.14
Medicaid and other forms of private or public insurance could help, but county jails cannot bill insurance providers or Medicaid for any health services provided in a jail facility. Medicaid’s inpatient exclusion allows for Medicaid reimbursement if an inmate is admitted as a patient to a hospital or medical facility for more than 24 hours. Most respondent jails (68 percent) to the 2015 NACo survey identify as part of the booking process whether individuals have health insurance, including private or government subsidized coverage. Recent research showed that most people who are in jail do not have insurance.15 More than one-quarter of respondent county jails to the NACo survey screen for Medicaid eligibility.
Medicaid enrollment helps beyond the jail, as it may also improve health outcomes for individuals released from jail by streamlining access to care in the community. County jails in states that expanded Medicaid are more likely to screen for eligibility and also provide assistance in Medicaid enrollment than county jails in states that did not expand Medicaid (See Figure 2). To learn more about the role of county jails in Medicaid enrollment, see the King County, Wash. and Cook County, Ill. case studies accompanying this report.
MEDICAID ELIGIBILITY SCREENING AND ENROLLMENT IN COUNTY JAILS, MARCH–APRIL 2015
Source: NACo survey, March–April 2015.
Notes: As of March–April 2015, 30 states, including the District of Columbia, expanded Medicaid coverage under the Affordable Care Act, making health coverage available to individuals and families with incomes below 133 percent of the federal poverty level. The NACo survey of county jails asked if the booking process includes screening for Medicaid eligibility and if the jail provides Medicaid enrollment assistance to the pretrial population. Alaska, Connecticut, Hawaii and Rhode Island do not have county operated jails.
A SMALL NUMBER OF COUNTY JAILS SUPERVISE JAIL INMATES OUTSIDE OF CONFINEMENT IN MENTAL HEALTH OR MEDICAL TREATMENT PROGRAMS.
County jails provide treatment to inmates within the jail as well outside the jail. Inmates with behavioral health or medical problems can receive treatment outside of confinement through community supervision programs run by county jails, but this is a limited occurrence.
Twenty-two (22) percent of respondent county jails indicated having a community based supervision program that provided behavioral health treatment outside of the jail, including for mental health, alcohol and/or drug use. Another 18 percent of county jails provide medical treatment, including for chronic medical conditions, outside of confinement through community based supervision programs.
County jails with community based treatment programs are more likely to have both types available than only one. For example, among medium-sized counties, 19 percent of county jails have both treatment programs while seven percent have only a medical treatment or behavioral health treatment program available (See Figure 3). Most behavioral health and medical treatment programs are available to both pretrial and convicted jail populations. The majority programs, including both behavioral health and medical treatment, determine eligibility for participation by using a diverse set of criteria, including criminal history, the results of a health screening or assessment as well as the recommendation of a health professional.
BEHAVIORAL HEALTH AND MEDICAL TREATMENT PROGRAMS OF COUNTY JAILS, BY COUNTY POPULATION SIZE, MARCH–APRIL 2015
Source: NACo survey, March–April 2015.
Notes: Small counties have populations less than 50,000 residents. Medium-sized counties have populations between 50,000 and 500,000 residents. Large counties have more than 500,000 residents. Population size is based on 2014 population data from the U.S. Census Bureau’s Population Estimates Program. Alaska, Connecticut, Hawaii and Rhode Island do not have county operated jails.
Counties have a significant responsibility to provide healthcare to those in jail with mental illnesses and medical conditions. Without proper attention and care, medical conditions may worsen, putting individual and public health at a greater risk. Tackling behavioral health needs may reduce homelessness, unemployment and victimization among the jail population and prevent their cycling through the criminal justice system. For many county jails, connecting the jail population that has a medical condition or mental illness to the type of treatment they need is a pressing issue. To learn more about collaborative approaches and partnerships between health services and justice agencies, Montgomery County, Md. case study.
Collaboration between the county justice system, county health system and other community based organizations is essential to the success of treatment programs and for meeting the immediate and long term health needs of those with behavioral health or medical conditions who come into contact with the county jail. Counties strive to effectively provide the criminal justice population with greater access to healthcare and treatment. The delivery of care and service to this population can lead to greater individual well-being, reduce recidivism and improve public health.16
COMPANION COUNTY CASE STUDIES
- Bureau of Justice Statistics, “Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012,” (February 2015), available at
- Bureau of Justice Statistics, “Mental Health Problems of Prison and Jail Inmates,” (December 2006), available at http://www.bjs.gov
- Henry J. Steadman and others, “Prevalence of Serious Mental Illness among Jail Inmates,” Psychiatric Services 60 (6) (2009):761–765.
- Bureau of Justice Statistics, “Mental Health Problems of Prison and Jail Inmates.”
- Substance Abuse and Mental Health Services Administration, “Leading Change: A Plan for SAMSHA’s Roles and Actions 2011-2014,” (Department of Health and Human Services, 2011), available at http://store.samhsa.gov
- The University of Michigan Center for Managing Chronic Disease, “What is Chronic Disease?” (2011), available from http://cmcd.sph.umich.edu
- Bureau of Justice Statistics, “Mental Health Problems of Prison and Jail Inmates.”
- Steadman and others, “Prevalence of Serious Mental Illness among Jail Inmates.”
- National Institute on Drug Abuse, “The Science of Drug Abuse and Addiction: The Basics,” (National Institute of Health, 2014), available at http://www.drugabuse.gov
- Phil Schaenman and others, “Opportunities for Cost Savings in Corrections without Sacrificing Service Quality: Inmate Health Care,” (Washington, DC: Urban Institute, February 2013), available at http://www.urban.org/research/publication
/opportunities-cost-savings-corrections-without-sacrificing-service-quality; Christian Henrichson, Joshua Rinaldi and Ruth Delaney, “The Price of Jails: Measuring the Taxpayer Cost of Local Incarceration,” (New York: Vera Institute, May 2015), available at http://www.vera.org/sites/default/ files/resources/downloads/ price-of-jails.pdf
- Estelle v. Gamble, 429 U.S. 97 (1976).
- Stephen A. Somers and others, “Medicaid Expansion: Considerations for States Regarding Newly Eligible Jail-Involved Individuals,” Health
Affairs 33 (3)(2014): 455–456.
- Nicholas Freudenberg, “Jails, Prisons, and the Health of Urban Populations: A Review of the Impact of the Correctional System on Community Health,” Journal of Urban Health 78 (2) (2001): 214–235; Marsha Regenstein and Jade Christie-Maples, “Medicaid Coverage for Individuals in Jail Pending Disposition: Opportunities for Improved Health and Health Care at Lower Costs,” (Washington, DC: The George Washington University School of Public Health and Health Services, 2012), available at http://hsrc.himmelfarb.gwu.edu/cgi
/viewcontent.cgi?; Danielle Wallace and Andrew V. Papachristos, “Recidivism and the Availability of Health Care Organizations,” Justice Quarterly 31 (3) (2014): 588–608; Emily A. Wang and others, “Discharge Planning and Continuity of Health Care: Findings from the San Francisco County Jail,” American Journal of Public Health 98 (12) (2008); 2182–2184. article=1000&context=sphhs_policy_facpubs
The author would like to thank the representatives of the county jails who responded to the 2015 NACo survey. I would also like to thank the American Jail Association, especially Robert Kasabian, for their assistance with distributing the survey and reviewing an earlier draft.
Within the National Association of Counties, the author extends gratitude to Matt Chase, Deborah Cox, Maeghan Gilmore, Emilia Istrate and Brian Namey for their thoughtful and helpful comments on an earlier draft. I also wish to thank Public Affairs for providing graphic design and producing the website of this report.
ABOUT THE AUTHOR
DR. NATALIE ORTIZ
SENIOR RESEARCH ANALYST
Dr. Natalie Ortiz joined the Research Department as a Sr. Research Analyst focused on justice-related issues. She graduated with a PhD in Criminology and Criminal Justice from Arizona State University.