Charles W Mathias
Only two days after booking into the new Marion County jail, a person who was incarcerated died by suicide. This state-of-the-art facility has technology for tracking movement of inmates, tablets for making medical requests and building design elements that omit sharp corners in the housing area.
This design is what the future of incarceration can be. But, federal law bars resources for health service in these facilities. Smart buildings can reduce risks of harm to inmates and staff. It is clinical care that’s needed to address the root causes of these deaths.
Not just in Marion County, jails across the country are struggling to meet the rising demand for medical and behavioral health care. This shortfall is the direct result of the Medicaid Inmate Exclusion Policy, which denies patients access to their federal health care benefits while incarcerated and shifts the financial burden for their care onto the county. To fix this looming crisis in jail health care, we need a federal solution.
When this policy was created in 1965, most incarcerated people were serving time in prison after conviction. Now, about two-thirds of inmates are in pretrial detention, held in county jail between arrest and their day in court. They are innocent until proven guilty, except when it comes to accessing their Medicaid health coverage.
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Pretrial detention is a high-risk period — 76% of Indiana jail deaths occur before conviction, according to an IndyStar investigation.
“Inmates are dying in county jails from suicide, from lack of medical care, lack of mental health care and withdrawal symptoms and it’s happening at an alarming rate” said Stephen Wagner in the investigation, a Carmel attorney who has represented the families of more than 30 people who died in Indiana jails.
Jailers are blamed when a person dies in custody, but these outcomes reflect decisions at all levels of government. A key driver is lack of funds for operating jails as the new asylums they have become. Four out of five Indiana jail inmates struggling with mental illness and/or substance abuse.
Without Medicaid billing, jails are unable to meet their requirements for inmate care. Under the Medicaid Inmate Exclusion Policy, counties and the state cover 100% of the jail health care cost. But, if they could bill Medicaid for beneficiary care, 72.5% of costs are born by the federal budget. This federal to local cost shift is bankrupting local jails. The national organizations representing sheriffs and counties are lobbying to seek federal relief from this policy.
In 2019, Congress considered legislation allowing Medicaid billing for pretrial jail-based health care. But there was difficulty estimating program costs and jails’ ability to adopt this new approach to care came into question. In the end, the bill did not pass.
Now, there is a new opportunity to start fixing the jail health care crisis. Congress is considering a narrower solution to fund demonstration projects for jail health care under the Medicaid program. The Due Process Continuity of Care Act would fund planning for developing the jail health care workforce, collaborative learning to promote quality and a reporting mechanism to ensure program quality. These supports are needed to successfully build Medicaid health care inside jails.
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Some may balk at increasing spending on health care for those who are incarcerated. But when mental illness is left untreated an even higher price tag is incurred. Of those who are incarcerated, 95% return to the community, and coming home sicker than before their incarceration perpetuates the cycle of recidivism and re-arrest.
Eliminating this policy is also not a form of Medicaid expansion. Only inmates who are already Medicaid beneficiaries would receive this health care coverage. If it wasn’t for their detention, they could access their health care benefit.
Marion County has made a major investment in next generation jail infrastructure. To deliver on the promise of promoting community safety by improving the health of inmates, the jail needs sustained funding for clinical services. The ability to bill Medicaid is the solution for solving the clinical care gap inside the new Marion County jail and jails across the US.
Charles W. Mathias is a health policy research expert on mental illness among people in the criminal justice system.