County Examples

Addressing Mental Illness and Medical Conditions in County Jails: King County, Wash.


King County started preparing in 2013 for the implementation of health insurance coverage changes under the Patient Protection and Affordable Care Act (ACA), including a major push by Public Health to coordinate a community-based network (45 agencies) of in-person enrollment assisters at places frequented by the public such as libraries and shopping malls.

The county has a strategic plan to incorporate equity and social justice in all departments to address racial and health disparities, and in response to this the County also trained a Jail Health Services (JHS) project manager and release planners to be in-person enrollment assisters within the King County jail. Enrolling individuals in the jail was important to King County leaders because an estimated 90 percent of people who come into the jail are eligible for expanded Medicaid in the state, and people of color have some of the highest health disparities and incarceration rates in King County.


The JHS project manager spent a great deal of time reaching out to the criminal justice community—from police to defender agencies, prosecuting attorneys, courts, and the many other entities involved along the way—to ensure that all stakeholders understood how expanded Medicaid eligibility would provide opportunities and open doors for the justice-involved population. Providing outreach services at the jail and other locations like the court house and Court Resource Center allows staff to work one-on-one with clients and enroll them into services. This customer service model supports the most vulnerable members of the community.

For individuals receiving release planning services, the enrollment process takes place 30 days prior to release from jail. This ensures health care enrollment as well as the coordination into service upon release. “We ruled out having a booth at the actual release point—they just want to leave. They have a multitude of things to do—finding shelter, food, etc.— upon release, so it is not an opportune time for enrollment,” says Bette Pine, the JHS Director. “Similarly, we didn’t think booking was the best time because people are dealing with a number of issues at that point. We also struggled with enrolling the general population; since approximately 50 percent of the people in our jail are released within the first 72 hours, this doesn’t leave us time to complete the enrollment process.” 

Given the success of the community-based network of in-person enrollment assisters in enrolling the general population, and the creation of outreach locations that targeted residents involved in the criminal justice system (such as the Court Resource Center, King County Drug Court and the Department of Social and Health Services), JHS ultimately decided to put enrollment in the hands of its release planners to focus on high-needs individuals, including those with mental illnesses, acute or chronic health conditions, substance use disorders, pregnant women, HIV patients and others who may be particularly vulnerable upon release from jail. The planners work with individuals to enroll them into Medicaid, if eligible, and help set up benefits, make medical appointments, coordinate mental health and substance abuse treatment and arrange other social services.


Meaningful collaboration has been key to the success of the county’s enrollment effort, including in the adult jails. “Specialty courts trained up on this, as did defenders,” says Pine. “Service providers, police, prosecuting attorneys, every agency in the county, they all understand the importance and have been actively involved. Our County Executive is very committed to assisting this population, and getting them enrolled is a key step. The all-around support from the county and the community agencies and leaders has been critical, and we place a lot of emphasis on and are very proud of the relationships we’ve built here.”

King County has also successfully adapted its system to mesh with Washington State law that only allows for an individual’s Medicaid eligibility to be suspended for 30 days while in jail. After 30 days, eligibility must be terminated. JHS and state health officials understand the challenges with terminating Medicaid benefits, and in the meantime the County is “working with what we have,” Pine says. Because more than 80 percent of those in King County jail are released within 30 days, release planners enroll as many individuals as possible. If a person does hit the 30-day mark, planners get a reminder through the electronic health records system and then dis-enroll when necessary. “Because so many of them are gone within 30 days, it’s worth it to enroll the majority and have to dis-enroll a few,” Pine says.

With about 200,000 people enrolled in coverage since the ACA was passed and the uninsured rate estimated to be cut in half, King County is creating a culture of coverage. JHS also tracks enrollment of those newly booked in to the jail by taking a snapshot of one 24-hour period every month, and has found that it has increased from approximately 11 percent in 2013 to approximately 43 percent in July of 2015.



King County leaders reached out to other counties that had begun enrolling jailed individuals into health insurance coverage, and found it very helpful to take advantage of lessons already learned, Pine says. Although King County heard from other counties that enrolled individuals early in their stay, King County considered the strengths and weaknesses of its own system and ultimately decided it could best be of service to individuals by complementing the enrollment process with re-entry services.


JHS recognizes not only the importance of enrolling the uninsured Medicaid-eligible individuals into health care but also the complexities of accessing care in the community. To ensure the best patient outcomes and connection to needed mental health, substance use and medical services, those with the most complex needs are identified for enrollment and receive coordination directly into services upon release.


“We certainly faced barriers like issues with technology and funding, as everyone does,” Pine says. “But the state, county, community service agencies and criminal justice system were all engaged in trying to make this work. When your interests are aligned, you’ll find a way to make things work.” 

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