Two major sea changes under way in California's health care system could have effects beyond the health care system itself.
The Affordable Care Act, in addition to bringing significant changes to California's state prison system, could contribute to increased public safety and a reduction in crime statewide, according to some experts and stakeholders.
The realignment of state and county responsibilities for government health programs also could have similar effects, according to some others.
We asked experts to explain:
- Can realignment of county and state health care responsibilities help improve public safety and reduce crime either in the short term or long term? How?
- Does the Affordable Care Act offer opportunities to make changes that could contribute to increased public safety and/or a reduction in crime in California? How?
We got responses from:
How Health Coverage Can Reduce Jail Overcrowding
Director, Californians for Safety and Justice
Could the Patient Protection and Affordable Care Act be a crime-fighting tool?
Possibly, based on three reasons -- one well-known, one somewhat known, the other barely heard of at all.
1. October 2011's "public safety realignment" law shifted responsibility of tens of thousands of people convicted of non-violent, non-serious, non-sex offenses from state prisons to counties. Many of these individuals are now in county jails.
2. Mental health problems and drug addiction are major drivers of crime. A 2009 survey by the National Sheriffs Association revealed that one in six people in jail had forms of mental illness. An official overseeing L.A. County's Adult Day Reporting Center estimates that 50% to 75% of its probationers have mental health problems. Meanwhile, 58% of California prisoners display symptoms of drug dependency.
Law enforcement alone can't solve these health problems. Until these problems are solved, these individuals will likely continue cycling in and out of jail, at great taxpayer expense. To stop the cycle, these individuals need access to drug rehabilitation, treatment and health care. Yet nine out of 10 people in jails have no insurance to pay for it, according to Community Oriented Correctional Health Services.
3. The good news -- but little known -- is that rule changes with and leading up to ACA could help counties save money and reduce the recidivism that strains jail populations.
California used a Medicaid waiver to establish the Low Income Health Program (LIHP) to provide health services to qualified low-income Californians in participating counties before the ACA expands Medi-Cal in 2014. Such counties may receive partial federal reimbursement for covering residents that would otherwise require county funds.
Reports from states offering similarly expanded coverage to low-income adults indicate that this population tends to have higher rates of mental illness and substance abuse -- clearly overlapping with jail populations.
LIHP may help counties narrow the treatment gap -- and its cost -- for such behavioral disorders. For example, counties often pay 100% of inpatient hospital costs when people in jail receive services outside the jail. LIHP allows counties to shift some of this expense to LIHP's "Medi-Cal Inmate Eligibility Program."
Counties may be able to access additional state funds by aligning LIHP enrollment efforts with county initiatives under AB 109. If counties use a portion of these funds for purposes that satisfy LIHP's federal reimbursement criteria, they could possibly double every dollar from the state.
By increasing the likelihood that people in the criminal justice system receive treatment for behavioral health disorders before or upon release, we're more likely to stop cycles of crime.
This improves public safety and saves counties money.
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ACA Can Improve Health of Crime Victims
Founder, CEO, Center for Youth Wellness
Crime, like health, can go in cycles. Certain factors (poverty, lack of education, etc.) start ripple effects that create and then worsen problems. But we also can reverse cycles in health and crime.
More importantly, the two are not separate. Another post in this forum, from Lenore Anderson of Californians for Safety and Justice, explains how counties can provide care to people in jail who need mental health or substance abuse services to stop cycles of crime.
Stopping those crimes doesn't just prevent victimization of individuals but actually has a direct correlation to health outcomes in entire communities fraught with violence, drug abuse and mental illness.
First, it's important to recognize how experiencing violence negatively affects the health of those exposed to it. Take for example, San Francisco's Bayview Hunters Point neighborhood, which has high rates of poverty and violence.
Last year, as part of my work at the California Pacific Medical Center Bayview Child Health Center, I joined Stanford psychiatrist Victor Carrion to conduct a study that analyzed the records of 701 children treated at the health clinic. Of those, two out of three had experienced some level of adversity (exposure to violence, substance abuse, etc.). Those experiencing higher levels were twice as likely to be overweight or obese, and 30 times as likely to show learning and behavior problems as those who had not.
These findings confirm previous studies on the impact of early adversity on brain development and the body. When facing a threatening or scary situation, the body releases stress hormones like adrenaline and cortisol that quicken the heart rate and increase blood pressure. Stress responses also decrease activity in parts of the brain responsible for impulse control and judgment, while stimulating inflammation by the immune system. Children repeatedly exposed to household or community stressors can experience long-term learning and health problems.
The 1998 Adverse Childhood Experiences Study of 17,000 adults found that those exposed to four or more adverse experiences in childhood had increased risk of adult diseases like heart disease, hepatitis and cancer.
Too often people living in communities exposed to violence cannot access care because they can't afford insurance. Enter the ACA.
In addition to expanding coverage, the ACA also increases reimbursements for case management, preventive services and the creation of a primary care "home." All this translates into more individualized attention for people who need to break cycles of drug abuse and mental health struggles.
Ultimately, this new focus on individuals and a continuum of care benefits entire communities, since each life that is improved builds a healthier cycle of behavior and well-being that can reverse negative trends in our neediest neighborhoods.
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Realignment Brings Potential for Improvement
Executive director, National Alliance on Mental Illness California
Our community-based mental health systems are currently overwhelmed. As times get harder and tax revenues decrease, the need for mental health services increases.
The realignment of 2011 sends the responsibility for all behavioral health and several other services to the counties where many would argue it truly belongs. However, counties still do not have the authority to raise taxes for these services, and so the state is sending specific dollars to pay for them. In addition, AB 109, enacted in 2011, transfers responsibility for low-level offenders from the state prison system to the county jail and probation system, increasing the number of people a county must serve. The funding that comes with that responsibility can allow counties to provide necessary treatment to individuals in this population with serious mental illnesses. Inadequate funding would result in relapse potential among all people requiring ongoing mental health services if a county has to spread its resources thin. It also could lead to more recidivism, more unnecessary costs, and more blaming the individuals -- that is, stigma.
Thoughtful use of the AB 109 funding and other parts of public safety realignment can reduce recidivism and help continue reducing the number of individuals incarcerated in the state system. However, it is up to each county to assess its need for mental health services, drug and alcohol treatment, and jobs and housing programs as well as enhanced police, probation and jail services. Most county departments view this as an opportunity, although they realize that planning at the local level must be careful and that realignment funds from the state must be reliable to realize the potential benefits.
Short-term improvements to public safety result from each county's ability to tailor funding to meet the needs of its citizens. For example, there can be some immediate diversions from incarceration to treatment. The long-term impact depends on a continuing process of needs assessment, appropriation of funds and evaluations of outcomes that should help each county increase public safety and well-being. The statewide evaluation of outcomes that is being developed will further assist counties by helping them learn from each other about effective programs.
With the passing of AB 109, there is an opportunity for the criminal justice system to partner with the mental health system to improve the quality of care of those living with a mental illness. It also creates the potential to reduce the number of people entering the criminal justice system.
Many communities around the state have implemented specific programs that teach first responders effective techniques to de-escalate encounters in the field with people in psychiatric distress. Crisis intervention team programs have reduced incidents of violence between persons with serious mental illness and local law enforcement officers. We hope that with the passing of AB 109, these types of programs will be funded to help reduce crime and increase public safety.
Health care reform and the Mental Health Services Act enhance the beneficial opportunities of this realignment. Both emphasize seeing individuals as whole people and the systems that help them as working better when coordinated. The MHSA has already funded full service partnerships for people with mental illness transitioning out of incarceration. Health care reform is encouraging service integration.
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