See the video: http://vimeo.com/30743539

There we go. I work at a company called TASC.  We are Treatment Alternatives for Safe Communities.  We are a statewide organization in Illinois, and for the last 30 years, we’ve been providing direct services and doing policy advocacy and policy development and research to help advance this tremendous opportunity to provide behavioral health interventions for people who are involved with the criminal justice system.

So, annually, we serve about 20,000 people who are involved in the justice system, mostly, today, people who are on probation and people who are on parole, and we have designed and managed a number of many kinds of projects that that connect the criminal justice system and community-based care.  We participate extensively on state and national planning on health care reform with this particular interest in mind.

So, our goals today in this webinar are, trying to advance this slide here.  There we go.  The goals of the webinar are:  To provide an overview of the current challenges in providing substance abuse and mental health services for justice-involved populations, which is essentially to provide the background, to understanding how the Affordable Care Act can, then, change this situation.  Then, further, how can we use evidence-based practices and services expansion to actually move the whole field forward and move our efforts to reduce recidivism and build community recovery dramatically forward.

There are certainly planning steps that we would recommend will be happening now.  We’ll talk about that towards the end of the presentation, and we’ll look a little bit at the financial and practical implications for the criminal justice system, specifically, of taking on these challenges.

So, first of all, what is the Affordable Care Act?  This a law known as Health Care Reform passed on March of 2010 and signed in March of 2010.  It’s hard to believe that’s almost a year and a half ago, but it is.  The goals, broadly, of the legislation are to extend access to underserved populations, to improve health outcomes, and to maximize efficiency of public health expenditures.  The Affordable Care Act, itself, is 2700 pages long.  I don’t know anybody who’s actually read all pages although I’m sure there are people who have, and there’s quite a bit of federal guidance.  Then, when you multiply that by every state in acting their own required processes, there’s quite a bit of administrative rule on this.

So, what we’re going to focus on for the Affordable Care Act is the one particular aspect that creates this big opportunity in the criminal justice system and the community substance abuse, mental health system, and that is the expansion of access to care for low income populations regardless of disability.  This expansion shifts us from planning on a program level to planning on a system level and creating enduring linkages between the criminal justice system and the community behavioral health system for purposes of good re-entry, good diversion programs, and reducing, ultimately, the number of people whose ongoing untreated mental health and substance abuse by bringing them into contact with the criminal justice system.

So, where are we in implementation?  The federal and state governments are currently in the planning processes and early implementation phases.  There were a number of requirements that took effect a year ago in September that, for example, the limitations on, the conditions of coverage to young adults up to the age of 26 being covered on their parent’s health insurance.  So, those are already in process.  There’s a number of things the state has to get done by 2013 in preparation for the expansion of coverage in 2014.  Those include building things like health insurance exchanges, setting up expedited enrollment procedures.

The federal government is in the process of determining what’s called the essential benefit plan, which will be the minimum services that have to be included in any expansion plan, whether it’s a Medicaid expansion plan or it’s a subsidized insurance plan that will be sold on the exchange.  The Medicaid expansion and the expansion of subsidized insurance actually takes effect January 1st of 2014.  So, that is the target that we’re working towards in our state and many other states are working towards.  A lot of things have to come together at that point.

I do want to acknowledge the general error of uncertainty and concern that’s been generated by how we will pay for this and where this is going to go.  That got particularly intense this summer during the discussion.  We had to address the debt ceiling and what would be required, and I would expect that conversation to intensify, given that we’re heading into a national election next year.

I think what’s important to remember is that we actually have the slot on the books that it does currently point us in the direction of doing these things, and states are moving forward to do implementation.  Many states are moving forward in implementation, and for us, as people who have been working on this for many years, this is the best shot that our clients and people like them in other states and other communities have at getting their untreated health conditions actually treated.

So, our position is we need to continue to explore what could happen and to figure out how to broaden this conversation so that even if the Affordable Care Act doesn’t proceed as we all hope it will that we’ll have gained some ground in this conversation.  So, I offer that to you as a framing and acknowledgment that the political reality of the current situation, but we’re still very optimistic about this.  The rest of those presentation will be about why:  Why aren’t we optimistic?  Why aren’t we thinking this will make a difference?

So, a little bit of background, a little bit of epidemiology and numbers of people that we’re talking about.  First of all, this won’t be a surprise to anybody on this phone call, substance use disorders are nearly universal in the criminal justice system.  We know because of 30 years of research conducted by the Department of Justice, the National Institute of Justice, the National Institute of Drug Abuse, and many, many prominent national researchers that the criminal justice population include people who are both addicted to drugs and alcohol and people who abuse and misuse drugs and alcohol.  It may be in combination with a co-occurring mental health disorder.  It may be in combination with lots of other medical issues, but we know this is the consistently documented reality.

The National Institute on Justice’s research on jail inmates, they do quarterly testing in a number of cities around the country.  They consistently find that over 70% of jail inmates test positive for some illegal drug, and when you add alcohol into that mix, it goes up to nearly 100%.  So, this is a test within 3 days of arrest, and the prevalence is very, very high.  So, then, the next question we want to ask is what is the level of intensity and severity of those issues?  Are we talking mostly about people with risk use? Are we talking about people with ongoing problem use, or are we talking about people whose lives are like when the wheels come off the cart where their lives are run on their dependence on alcohol or illegal drugs or both?

The research on that shows that about 48% of prison inmates and about 44% of local jail inmates meet criteria for substance dependence, and that’s seven time greater than the general population.  So, we’re definitely looking at an area of concentrated, untreated addiction.  We are also looking at an area of untreated, risky use and abuse that has never been there.  So, both of these things can be addressed through healthcare reform.  Through the expansion of services, that’s possible through health care reforms in 2014.

Most of the remaining groups, the dependent group demonstrated significant substance abuse that has various consequences, obviously, including the legal consequences of their being in jail or in prison at the time.  When you think of how we manage this problem right now, we manage it by incarcerating people and putting them in community supervision, which can be expensive, especially the [10:08] Report and the public safety portfolio.  So, about 90% of the criminal justice dollars, corrections are actually spent on incarcerating people, and 10% is spent on all community supervision and other management population efforts that go on.  So, that’s really the big ticket item, and we have the opportunity to shift that a bit here.

Other chronic conditions in addition to substance abuse are very much more widespread than in the general population.  There are much higher rates of serious mental illness.  There was a very good study that was done by 1046 and other folks in the last couple of years that show the cross site analysis of jail populations consistently demonstrated serious and persistent mental illness.  So, schizophrenia, bipolar disorder, major depression, those are the ones that they looked at at over 15% of men, and about 30% of women who were in jail demonstrated that level of serious mental illness.  It’s also pretty high in the parole population, and it’s less high among the probation population.  So, that’s why I have over 10% on this slide.

There are higher rates of chronic medical conditions, including, we definitely see these in our patients, diabetes, heart disease, asthma, cancer, and HIV among the most prevalent ones.  There are also that only about 10% of these folks have insurance, whether that is Medicaid already through mental health or physical disability.  You have access to the All Kids Program. They call it something slightly different in other states, but it’s the subsidized Medicaid program for youth under 19.  Occasionally, folks have work and have private insurance, but because folks don’t have access to consistent health care, all their chronic conditions including their behavioral health conditions get treated episodically and get undertreated, essentially.  S

So, we see the effect of that in the behavioral health side with repeated cycling through problematic conditions, repeated arrests, but we also see the impact of that with chronic medical conditions.  So, undertreated diabetes and heart disease have much worse complications.  People are affected by those complications sooner, and they may die significantly younger as a result.  So, it’s a very large population group with a very high rate of untreated disease.

When we look at what this looks like in Illinois, this next slide is just a snapshot of the jails in Illinois.  In 2008, there were almost 367,000 jail booking.  We weren’t able to get an unduplicated number for those jail bookings, but if you just assume that, on average, everyone has two jail admissions, knowing that a lot of people have a lot more and some people have fewer.  I think it’s a conservative amount, about 180,000 in Illinois, and fewer of those jail admissions report to using drugs regularly.  So, two-thirds of the 180,000 would be about 120,000 unique people or 240,000 admissions.

So, about 14.5% have psychiatric disorders.  That’s 53,000 admissions, and of those, most have a co-occurring substance abuse as well.  With very highly variable lengths of stay and not a lot of organized re-entry services in jail, which are organized for people to come in and out of largely, it’s very difficult to coordinate care around case processing.  There’s not a lot of post-release care and a very high likelihood that people will return to jail if their behavioral health needs, in particular, are not addressed.

We also took a look at what are the numbers in probation across the four states at the area.  In Illinois, there were about 144,000 people in probation in 2009.  Indiana was a few less, 130,000.  Michigan, quite a few more at 175,000.  In Ohio, quite a few more at 260,000.  There are a number of very good, quite organized projects to link people on probation into substance use and mental health treatment programs.  They tend to be called like special probation supervision, specialty courts like drug courts and mental health courts, and certainly individual officers make a lot of referrals.

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