People who are incarcerated have complex health needs. To make matters more complicated, prisons and jails have seen some of the worst COVID-19 outbreaks in the U.S.
But what happens when they leave prison or jail and need to receive health care on the outside?
Many states that have expanded Medicaid are also trying to ensure that people leaving jail or prison are able to enroll in health coverage upon release.
On the latest episode of The Dose podcast, learn how these and other health care and criminal justice reform efforts work together. Our guests include Vikki Wachino, who heads a nonprofit that connects jails with community health care providers, and Rebekah Gee, who oversaw Medicaid expansion as Secretary of the Louisiana Department of Health.
Illustration by Rose Wong
SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. Today’s episode is about how people who are involved with the criminal justice system receive health care and what happens when they leave jail or prison. This was complicated to begin with, but COVID-19 has added new challenges. Outbreaks in jails and prisons have been particularly severe. My guests today are Vikki Wachino, who heads Community Oriented Correctional Health Services, a nonprofit that connects jails with community health care providers, and Rebekah Gee, who oversaw Medicaid expansion when she was Secretary of the Louisiana Department of Health.
Vikki, Rebekah, welcome to the show.
VIKKI WACHINO: Thank you, it’s great to be here.
REBEKAH GEE: Thanks for having me.
SHANOOR SEERVAI: All right. So to get started, Vikki, could you describe the problem for me a little bit? Who is the incarcerated population in the U.S.?
VIKKI WACHINO: There are about 2.3 million people who are incarcerated in the United States. And if you take a step back, the U.S. has the highest incarceration rates of any nation. The people who we incarcerate are disproportionately poor, they have low incomes, and there are significant racial disparities in incarceration. People who are Black, Hispanic, or Native American are more likely to be incarcerated than white people are.
SHANOOR SEERVAI: So before we keep going, I think we should get one detail out of the way. It’s sort of come up. What’s the difference between a jail and a prison, because people are incarcerated in different ways?
VIKKI WACHINO: Prisons serve people who have been sentenced and people who’ve committed felonies. In general, people who are in prison serve long sentences and prisons are run by states and the federal government. Jails play a very different role. Jails serve people who have not yet been sentenced, as well as some people who are serving shorter stays of less than a year, as well as some people who’ve committed misdemeanors. And jails are generally run by local governments.
SHANOOR SEERVAI: And what are the kinds of health conditions that people who are in jail and prison have?
VIKKI WACHINO: People who are incarcerated have very complex health care needs, much more complex than the rest of the general population. They experience chronic conditions like asthma and hypertension and diabetes at very high rates. And of course, all of those are risk factors for COVID-19. In addition, people who are experiencing mental health issues or substance use disorder are incarcerated at very high rates. About two-thirds of people in jails have drug dependence. And so what’s happened over time is that jails and prisons have come to play a role as mental health and addiction treatment providers. And frequently they are filling in the gaps nationally, in our national response to behavioral health crises.
SHANOOR SEERVAI: And so instead of there being a place for people with substance use or behavioral health conditions where they get treatment, they’re actually in jail. But what kind of health care do they get when they’re incarcerated?
VIKKI WACHINO: Well, one thing that’s important to understand is that the health care system for people who are incarcerated is completely removed and very different from the health care system, that the rest of us experience as people who aren’t incarcerated. We talked a little bit earlier about the footprint of roles that the federal, state, and local government play. So jails and prisons are administered very differently by different types of levels of government and the funding levels that are reached significantly, which leads to variations in access, significant variation in quality standards, and sometimes deficiencies in basic infrastructure for health care. So we can’t assume that the health care that’s being provided looks like the health care that those of us in the community receive.
REBEKAH GEE: I wanted to add to what Vikki said, that when individuals are incarcerated, normally they’re only getting treatment when they’re symptomatic. So the kinds of things that happen for those of us who are on the outside, like screenings for cancer, well visits, making sure diabetes is under really good control, typically don’t happen because the resources aren’t there to do really good preventive care.
SHANOOR SEERVAI: And you’re saying symptomatic immediately makes me think of COVID. And one of the biggest struggles that we’ve had is that a lot of transmission is from people who are asymptomatic. So what’s been going on with the spread of COVID asymptomatically or otherwise in jails and prisons?
VIKKI WACHINO: Sure. The conditions in prisons and jails create an environment where it’s very difficult to control the spread of COVID. People who are incarcerated live in very close quarters, in very close physical proximity to each other. There is frequently overcrowding of prisons and jails, which makes it even more challenging to create distance. Sometimes basic measures of infection control, like soap and hand sanitizer, aren’t present. There’s a linkage as well between the health of the community and what’s going on in the jails that I think is frequently not well understood. Which is that people think of prisons and jails as being completely walled off from society, but really people come and go. The jail population in particular has experienced short stays, so maybe they are only for a day or two. And of course the correctional staff goes back to their families at the end of each day, and back to their communities.
SHANOOR SEERVAI: As you’re both pointing out, it’s not possible to keep a COVID-19 outbreak completely isolated in a prison or a jail. And I wonder if we have examples from previous outbreaks of infectious diseases, where we saw the disease spreading at a higher rate among the incarcerated population than in the general population.
VIKKI WACHINO: Sure. The dynamic around COVID-19 and prisons and jails is not new. We’ve seen high rates of hepatitis C, high rates of HIV, high rates of tuberculosis in prisons and jails. And those are all significant public health threats. The difference now is the scale of COVID-19 and how rapidly it’s spreading.
SHANOOR SEERVAI: And when we think about the transitional nature of this population, as you’ve both made the point, people are going in and out of jails and prisons. So what happens if someone’s getting treated for a health condition while they’re incarcerated? What happens at the time of release?
VIKKI WACHINO: Well, too often, when people are released, they are released without connections to the community health care system and left to navigate their way to a provider on their own. And let’s be clear that the time of release is an incredibly vulnerable time in an individual’s life. They’re trying to rejoin their community and they need health care. They typically need housing and they need basic supports. And what’s innovative about Louisiana’s program is that it’s starting to build those connections. But what we see when there aren’t connections to people, when people aren’t supported at release with health coverage, is we tend to see very high rates of mortality across a range of conditions. But the mortality is particularly evident with respect to overdose deaths.
People in their few weeks before release are at extremely high risk of death from overdose, at a rate that’s been estimated to exceed that of the general population by a factor of more than a hundred. So in other words, people are more than a hundred times more likely to die of an opioid overdose death in the few weeks postrelease than is the general population. So we’re really failing to make connections for people to health care services when they’re being released. And that’s where Louisiana really stepped in to try to create a Medicaid reentry program that makes connections for people as they are transitioning back to the community.
REBEKAH GEE: So the Medicaid expansion in Louisiana allowed us to create a prerelease program that connected individuals who were incarcerated to Medicaid and a health plan and primary care and a case manager prior to release. And then within seven to 10 days postrelease, Medicaid benefits remain active. And so because of this effort, which has benefited over 7,000 individuals leaving our criminal justice system, we’ve been able to find a lot of individuals who needed special help.
One of them was a client who had served more than 35 years at Angola, who had been told that his hepatitis C was cured. But in fact, that wasn’t true. And when he was tested, when he came out of jail, it was found that he had hepatitis C. And because of our program, that was the first in the nation effort to have a subscription model for hepatitis C medications for everyone. Not only those who are incarcerated, but those in Medicaid. He was able to be diagnosed with hepatitis C and receive treatment and be cured of his hepatitis C. And what he said is that he feels amazing for the first time in 20 years.
So this new program allowed him to come home, be healthier during that transition, and be prepared to receive medical care and all of it in a seamless way. Such a difference from what would have happened before, where all that was offered to most individuals leaving was a bus pass and a “good luck.”
SHANOOR SEERVAI: So before Medicaid expansion, when you were leaving prison or jail, you did not have access to health care. Is that correct?
REBEKAH GEE: The only health care you would have access to would be, if you could get a job, which is very challenging right out of jail. Or if you had such a severe disability that you would qualify for Medicaid, but that was very difficult prior to expansion, or if you went to an emergency room.
SHANOOR SEERVAI: Right. And so health care is available now because in the states that have expanded Medicaid and in states like Louisiana, there are innovative programs that help people who are transitioning back into normal life to also be enrolled in a health plan. And then there are supports like a care coordinator to make sure that they’re not just enrolled in a health plan, they actually do see a provider. Is that right?
REBEKAH GEE: That’s right.
VIKKI WACHINO: Just to inject some national perspective to that. And what is notable about Louisiana’s work is that when they expanded Medicaid three years ago, they really saw the potential of Medicaid expansion supporting the need for criminal justice reform in the state. And they made that linkage by creating the prerelease program that Rebekah described, which is connecting people to health care services as they exit incarceration.
SHANOOR SEERVAI: Vikki, are there other states with prerelease programs or perhaps other programs to help during this transition period?
VIKKI WACHINO: Sure. Over the past few years, and particularly since the implementation of Medicaid expansion, we’ve seen a lot of progress in a number of places across the country. We’ve seen prerelease enrollment programs like Louisiana’s, we’ve seen states develop health homes, which are an integrated set of services that serve people with multiple chronic conditions, and that it plays a very big role in connecting people to behavioral health services. And we’ve also seen more states use peer supports, which are people who have lived experience, who are trained to help other people navigate the health care system.
So we’ve seen a lot of promising practices, but there’s a lot more that needs to be done. These programs right now are the exception rather than the role. It is still generally the case that when people are released, they’re released without supports. So what we need to move towards is more approaches like Louisiana’s that actually support people at release.
SHANOOR SEERVAI: And can you spell out what are the benefits of making sure that somebody coming out off the criminal justice system has health care?
VIKKI WACHINO: There are benefits both to the health care system and to the criminal justice system, as well as to the communities in which people live. So right now, if people are released without supports, they’re more likely to go to the emergency room, more likely to use other hospital services. And that’s very inefficient. It’s an inefficient to poor use of health care resources. We know that when people are supported at reentry, their arrest rates go down and it can contribute to reduced recidivism.
And then, of course, when people are incarcerated and returned to their communities without supports, that has an impact, not just on them, but on their families and on their communities. Jails in particular tend to be located in low-income, disenfranchised communities. So there’s a ripple effect from people leaving incarceration without health care supports.
SHANOOR SEERVAI: So you’ve described a situation in which people before the Affordable Care Act passed would come out of jail or prison and they just wouldn’t have health care. So they’d be uninsured. And in some states that have expanded Medicaid, states like Louisiana, where there’s a big effort to create programs for people who are reentering society and make sure that they have access to health care, in this case, Medicaid. At least we don’t have people coming out being uninsured, but I imagine that this transition is still difficult and complicated.
VIKKI WACHINO: It is. It is complicated. So the good news is that many more people, as they’re leaving incarceration, have access to Medicaid coverage because of Medicaid expansion. And of course we have states like Louisiana that have really tried to strengthen connections to health care services at release. But we still have a missing piece of the puzzle, which is that Medicaid can’t cover services while people are incarcerated. And this is holding back efforts to ensure continuity of treatment, continuity of substance use treatment for opioid addiction, continuity of care for people with diabetes. And so even in states that are furthest along, we still have a gap in coverage.
SHANOOR SEERVAI: I feel like a situation in which there’s a gap in somebody’s health care is not the most efficient way to make sure that a disease, especially a chronic condition or substance use disorder, something that needs constant treatment. This probably isn’t the most efficient way of treating it.
VIKKI WACHINO: That’s right. That’s right. When there are gaps in coverage, services turn off and on. And there’s much less incentive and ability to manage someone’s health care needs, whether that’s a chronic condition like asthma or an acute mental health condition. And this is one reason why we see costs ripple through the health and the criminal justice systems. We spend an enormous amount as a country and states spend an enormous amount on both their health care and their criminal justice systems.
Yet, by failing to make the connections for health care people when they’re incarcerated, we’re seeing more people go to the emergency room after release, more people receiving hospital care. And then a number of people cycling back into the criminal justice system. So there’s a lot of potential to address inefficiency for people and for governments.
SHANOOR SEERVAI: The other thing I guess that governments are thinking about now is racial equity, especially in light of the protests around the killing of George Floyd earlier this year. So I wanted to ask about prerelease and other programs and racial disparities. How do these programs help on issues like health equity?
REBEKAH GEE: Well, I define health equity is every individual being able to achieve his or her optimum health. And Black individuals are disproportionately more incarcerated, 67 percent of people in jail are Black in Louisiana, and only about 30 percent of our population is Black. And so addressing the needs of prisoners is very important to achieving health equity. And also, as Vikki mentioned, a lot of individuals are in jail because they had conditions that were untreated, mental health and substance use disorder.
And so having access to treatment is important and it allows individuals a better chance of staying in their communities, of being successful in reentry, and of having lives that are successful going forward. Part of achieving health equity is not forgetting about anyone. Every human being matters and those who are in jail or prison also matter. Our work in Louisiana on hepatitis C, ensuring that we treat it, we’re able to treat everyone in jail with hepatitis C, is an important also a health equity initiative that we don’t neglect the needs of Americans just because they’re incarcerated.
VIKKI WACHINO: Black people are five times as likely to be in prison or jail as white people are. And so as we’re in this moment in our nation’s history and really coming to this point of racial reckoning, I think it’s important that we think about policing, following George Floyd. But we also think about the broader criminal justice system and the role that it is playing in Black, Hispanic, American Indian communities across the country. And I think part of achieving racial equity means rethinking the way that we are approaching incarceration and the health needs of people who’ve experienced incarceration.
SHANOOR SEERVAI: And of course, bringing it back to this pandemic that we’re dealing with as a nation. We’re also seeing disproportionate rates of COVID-19 cases and deaths in communities of color. And addressing this, and ultimately emerging from this pandemic, requires addressing racial disparities as well.
VIKKI WACHINO: That’s right. And I think that’s why it’s important that we not consider jails and prisons as a separate silo, removed from the rest of the health system. They’re not. What happens in prisons and jails affects the health of everyone and it particularly has a big impact on racial equity. And if we’re going to close the gaps in racial disparities systemwide, if we’re going to close the gaps in racial disparities in COVID-19, we need to make a commitment to the health of this population that’s different from the commitment that we’ve made in the past.
SHANOOR SEERVAI: All right. Well, thank you both so much for joining me today.
REBEKAH GEE: Thank you.
VIKKI WACHINO: Thank you.
SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show along with Joshua Tallman for the Commonwealth Fund. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, Oona Palumbo for mixing and editing, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.