Among the more than 20 million Americans who gained health care coverage under the Affordable Care Act (ACA) are thousands of former prison and jail inmates in California. In some communities before the ACA, about 90% of people entering jail were uninsured. Most were not eligible for Medi-Cal and relied on emergency departments and underfunded county programs for health care. Because ACA coverage expansion included low-income childless adults, most of this population is now eligible for coverage upon "reentry," providing them with comprehensive services including primary care, mental health, and substance use disorder treatment.
This coverage has led to the creation of new programs specifically targeting the needs of people returning to the community from jails and prisons. Solano County, which stretches from the San Francisco Bay almost to Sacramento, is deeply affected by incarceration, with more than 1,500 people paroled from state prisons in 2011 alone. In Solano's largest city, Vallejo, La Clínica North Vallejo has a new program to help formerly incarcerated people transition back to the community. The clinic is partnering with Partnership HealthPlan of California, a Medi-Cal managed care plan, and is following a "transition clinic" model pioneered in San Francisco. La Clínica North Vallejo provides a medical home and support for recently released people who have chronic medical conditions.
Help from People Who've Been There
The central piece of the transition clinic model is the employment of community health workers (CHWs) who themselves have histories of incarceration. These CHWs meet recently released people at parole meetings, the probation office, substance use disorder treatment programs, and shelters. They offer help with clinic appointments, groceries, a gift card for a local grocery store, and transportation vouchers, along with comprehensive assessments of health and social service needs. The CHWs act as advocates, health system navigators, and case managers. Their understanding of the jail and prison systems, along with their CHW training, makes them particularly effective.
Consider 45-year-old parolee Norman C. (not his real name). While at a mandatory parole meeting shortly after he was released from prison, Norman met a CHW from the La Clínica Vallejo Transition Clinic. He told her that he was done with the drugs and the violence that landed him in prison for 20 years. He said he was sure he was going to live the rest of his life as a free man, but he wasn't sure how to put his life back together.
Norman had no idea how to go about finding a job in a world of cell phones and the Internet. He didn't know how to afford the healthy food he needed to keep his diabetes under control or what to do about a hernia that caused him pain whenever he tried to lift anything heavier than a coffee cup. The CHW immediately set him up with an appointment at the clinic. Norman has completed treatment at La Clínica for chronic hepatitis C and recently had his hernia repaired. He has kept his commitment to himself to stay away from drugs and alcohol and is now employed at a local food packaging facility.
Reducing the Burden on the Health Care System
In addition to the success of transition clinics in connecting people to care, they can benefit the broader health care system by keeping patients out of emergency rooms and hospitals. A randomized controlled trial conducted at the Southeast Health Center, a transitions clinic in San Francisco, demonstrated a 14% reduction in emergency department use over 12 months, an average cost savings of $912 per patient. And early data show potential for reducing recidivism. Studies from Florida and Washington have found that Medicaid enrollment is associated with lower rates of reincarceration for people with mental illness, and a Connecticut study found that people on probation who completed the state's 12-month reentry health program, with linkage to behavioral health and primary care services, were significantly less likely to reoffend within that year (23% vs. 41%). The Transitions Clinic Network, a group of 14 clinics in six states and Puerto Rico (including four in California), is working to study and spread the model further. CHCF is supporting the group's implementation work.
In California, the Whole Person Care (WPC) Pilot program — a $3 billion, five-year program that is part of the Medi-Cal 2020 waiver — offers an avenue to spread efforts like those of La Clínica and the network. WPC is designed to coordinate health, behavioral health, and social services to improve health outcomes for Medi-Cal beneficiaries who are high utilizers of the health care system. Eighteen counties currently participate in the WPC program, and several are using their pilots to focus on the reentry population. For example, Los Angeles County's plan calls for jail-based screening, comprehensive assessments, a warm handoff to a community reentry team, and the use of community health workers.
While these developments are promising, they are being initiated in an era of political and policy uncertainty. Changes to the ACA that diminish Medicaid funding or roll back the expansion of behavioral health benefits would threaten the groundbreaking work of La Clínica and other transitions clinics. These programs are showing success in helping people live productive lives in their communities and avoid costly returns to jail or prison. Pulling the plug on them would be a policy mistake — and a human tragedy.