ACTION NEEDED:

Urge your members of Congress to support counties’ efforts to improve health services for justice-involved individuals and reduce the number of people with mental illness in jails.
Specifically, urge your representatives on health-authorizing committees to support legislation that would allow individuals in custody to continue receiving Medicaid and other federal health benefits until they are convicted, sentenced and incarcerated; require states to suspend instead of terminate Medicaid for individuals in jails; and allow for comprehensive behavioral health services and the recruitment of health professionals in county jails.

BACKGROUND:

Counties nationwide invest more than $173 billion annually in community health systems and justice and public safety services, including the entire cost of medical care for all arrested and detained individuals. Counties are required by federal law to provide adequate health care for nearly 11 million individuals who pass through more than 3,000 local jails each year with an average length of stay of 25 days. This population has a higher prevalence of chronic health conditions (e.g. cervical cancer, hepatitis, arthritis, asthma and hypertension) than the general population. Serious mental illnesses are three to four times more prevalent among inmates than the general population. Approximately 44 percent of jail inmates have a diagnosed mental illness, and almost two-thirds have co-occurring substance use disorders. Medicaid is the single largest source of funding for behavioral health services in the U.S., and the number of inmates who are eligible for health coverage has increased as more states have accepted Medicaid expansion.

Six out of ten individuals detained in jails at any given time are pre-trial and presumed innocent until proven guilty. Nevertheless, Section 1905(a)(A) of the Social Security Act prohibits federal Medicaid matching funds from being used to pay for their medical care, even if they are eligible and enrolled. This results in counties covering the full cost of health care services that are unnecessarily disconnected.

More than 95 percent of inmates eventually return to the community, bringing their health conditions with them. In many states, federal benefits are completely terminated instead of being suspended. It can take months for former inmates to reenroll and for benefits to be restored upon reentry into the community, creating a break in access to needed medical, mental health and addiction treatments. Ultimately, this lack of continuity increases the risk of recidivism, reincarceration and even mortality for individuals post-release, each of which can harm communities and increase costs for county health and justice systems.

In a key victory for counties, the FY 2023 omnibus appropriations bill included a provision to remove the limitations the use of federal funds for eligible juveniles being detained pending disposition of charges. Upon this provision’s enactment in FY 2024, states will have the option to continue Medicaid coverage for juveniles in pre-trial status. The bill also granted states the option of juveniles to access federal health benefits 30 days prior to release, starting in FY 2024.

Key Talking Points

• Increasing flexibility in Medicaid is crucial to helping counties fulfill their safety net obligations to justice-involved individuals and improve health outcomes. Extending health benefit coverage to those in pre-trial custody would enable counties to better coordinate systems of care and treat previously undiagnosed individuals with higher incidences of chronic disease, mental illness and substance use disorder.

• Improving health services to justice-involved individuals decreases both short-term costs to local taxpayers and long-term costs to the federal government. When required jail health care is provided for and reimbursed, pressure on local taxpayers is reduced. In addition, increasing access to primary care and behavioral health and substance use disorder treatment for justice-involved individuals has been shown to reduce “downstream” health care, disability and criminal justice costs.

• Coordination between counties’ mental health and criminal justice systems improves public safety. By treating these populations, jails can help break the cycle of recidivism caused or exacerbated by untreated mental illness, substance use and other co-occurring disorders. County law enforcement can also allocate more resources to keeping communities safe.