One of the first people I met at Yale was Dr. Frederick Altice, who provided care to HIV-infected prisoners and drug users at the community health-care van, a needle-exchange-based health service targeting street drug users.
One of my first times out, a woman came to the van to get some care. She was a sex worker, and she injected drugs. She was very grimy, probably homeless. Within the close quarters of that van, many of the other people waiting gave her a little extra room. Rick called her over. He pulled out an apple and split it with his penknife. He handed her one piece, and said, “Why don’t you share this with me?” As they ate together, he conducted a beautiful clinical interview.
Rick has been doing this kind of work for more than 25 years now. Much of his work involves patients who are incarcerated, who are on probation or parole or who are in other ways subject to the supervision and tender ministrations of the criminal justice system. I caught up with him over Skype. Below is a edited transcript of our conversation.
Harold Pollack: Tell me a little bit about the patients that you take care of in these settings.
Rick Altice: The minute a patient is incarcerated, he or she is removed from the Medicaid rolls. When that happens, it often takes a long time to get them reestablished [after their release]. So their care is often completely disrupted at a moment of maximum vulnerability. Whatever health-care gains they’ve made during incarceration -- let's say getting them back onto antiretroviral therapy or treating their diabetes, managing their psychiatric illnesses -- that often goes out the window when they’re released because there is no after-care plan. Even if they wanted to get care afterwards, they really can’t, because it requires them re-enrolling in Medicaid just to get their prescription medications, let alone to make an appointment with their clinician.
HP: What do they actually have to do re-enroll in Medicaid?
RA: It’s highly variable from state to state. Just as a start, they need some sort of identification to prove who they are. If they’ve been incarcerated, their belongings are usually locked up. They are often estranged from their families. They don’t have access even to an identification card. They have to start at the very beginning to get their identities back. The process is often costly for them. Even just a small identity card may cost $10.
There’s a lot of paperwork. They have to get a clinician to verify they’ve got a disability or a health problem. They will have to demonstrate they’ve had no income. And there are some perverse situations and definitions. According to HUD, even if you are homeless upon community release, you are not considered homeless until you’ve been out in the community for at least six months without a house or an apartment. If you’re incarcerated, you’re considered to be safely housed.
HP: Many readers might say: "There’s a long list of people in America who are needy. We have poor single moms. We have people with disabilities. We have all sorts of people we want to help. When we think about people who have committed crimes, why should we offer them health coverage when there are so many other things we might do to help others who seem more worthy of our assistance?"
Rick: You could think about it a couple of different ways. The first is rooted in the philosophical idea that everybody should have health insurance. I believe that’s a human right. It really shouldn’t matter whether you’re incarcerated or not. But let's say you don't believe that.
The people who’ve been in the criminal justice system have increased prevalence and severity for many treatable and preventable diseases like HIV, viral hepatitis, mental illness, substance hypertension, etc. If they have these costly-to-treat diseases, inadequate care is either going to cost more from preventable emergency department use or hospitalization or through re-incarceration, because if diseases like alcoholism or other substance-use disorders remain ineffectively treated, they have a markedly increased likelihood of coming back.
If you think about it, we’ve established a very inefficient way to provide care: putting people back in prison. When people are released from prison and they are desperate, they are going to find it challenging to obtain employment and to engage various forms of needed care. They do desperate things, and typically they go back and do the same desperate thing that got them in trouble in the first place. Then we can provide medical care when they come back to prison, where they have a constitutional right to health care. They have three square meals and a place to live. But it’s a very inefficient use of our dollars.
HP: Before we go on, we should remind people of the practical differences between jail and prison. What’s different about the challenge of providing care for people who leave jail compared to when they leave prison? What’s different about the challenges inside these facilities, as well?
Rick: The largest number of people who interface with the criminal justice system flow through jails, typically staying for a relatively short time. Some are un-sentenced, and they’re not even found to be guilty. People aren’t generally sent to prisons unless they are sentenced to a year or two or even longer, with the details depending upon jurisdiction. In prison, you’re able to work with people and to do much more planning and organization around transitional care.
Unfortunately, many years ago when our jail system was developed, jails were seen as a place for young people who were unruly, under the age of 25, and who had almost no health issues. Over the last 40 or 50 years, that has changed dramatically. People who have medically or psychiatrically treatable conditions tend to come in for relatively short times, resulting in marked disruptions in care and function.
One of the most basic challenges is to simply identify people’s underlying medical and psychiatric diagnoses, to identify what sorts of medications need to be administered or continued. It can take a long time to verify these matters because we don’t have a unified health-care system. When you have incredibly high turnover and low staffing, it’s very difficult to communicate and make those connections across different systems. Quite honestly, correctional staff are often consumed by emergencies, suicides, experiencing drug or alcohol intoxication and withdrawal, people who are dying, etc. -- as opposed to identifying chronic conditions or re-engaging people in care.
Once people are stabilized, you’re able to assess them, to look over things a little bit more carefully and to engage them. When people arrive at the jail, they are often in various states of intoxication, experiencing withdrawal symptoms or various forms of untreated or undertreated mental illness. Being able to gather a relevant medical history is also challenging under those circumstances. When people expect that they’re going to be there for a very short time, they have less reason to be candid. There are issues around disclosure, concerns about being identified especially with stigmatizing problems such as substance use disorders, mental illness, HIV, viral hepatitis.
HP: Most experts believe that the Affordable Care Act’s Medicaid expansion will eventually include almost every state. We have a whole system of safety-net providers that cares for men and women who pass through the criminal justice system. Over time, that system will become much more connected to Medicaid. Almost everyone coming out of jail or prison will be Medicaid-eligible. It seems to me this is an opportunity around the country to make these safety-net systems work better. Any suggestions about what states might do differently?
Rick: To be effective, primary care must be continuous, coordinated and comprehensive. That’s virtually the definition. Entry into a prison or jail disrupts all of the major components of primary care. The Affordable Care Act does not really address this challenge. We should really seize on the opportunities presented by the criminal justice setting to insure people who aren’t on Medicaid or don’t have private insurance. We need systems that are poised to provide more continuous care.
Take a person who is incarcerated for some time and who is not using Medicaid services. It’s not costing anybody anything during that time period if they are being provided with prison-based health care. So, the idea of cutting that person off from Medicaid is really not an intelligent notion. This issue is important, because an individual’s greatest period of vulnerability -- their greatest period of need for health services, emergency care, hospitalization, and the greatest risk of death — occurs very soon after release from prison, within the first two weeks. There’s no real reason and no extra cost to society to keep that person on Medicaid while they’re incarcerated. It really should be continuous.
HP: Many of the people we’re talking about have been continuously under the administration of parole and probation systems. Some of them are out on bond. Whatever the story is, we know most of these people. What can we do either from a medical or a public-health point of view within parole and probation to improve people’s health?
Rick: We need to better align public health and public safety. Public safety is certainly a big part of what probation and parole are charged to protect. They’re using community-based approaches to keep the public safe without having to spend a lot of money on incarceration. This public-safety network of probation and parole offers new opportunities to engage people into health care when they have underlying substance use or psychiatric disorders. One way of keeping them from breaking the law, engaging in public disorder or having other problems, is to really ensure they have adequate insurance and that they are engaged in effective treatment services.
Now in some places, the rules of parole and probation are inconsistent with clinical recommendations. For example, if you have an underlying substance-use disorder such as heroin dependence, you can be deemed to be in violation by probation or parole officers and sent back to prison or jail if you happen to be prescribed methadone or buprenophine, even when this is prescribed by your doctor within a substance-abuse treatment setting. There’s a concerning disconnect between how we think about public safety and public health.
HP: I should mention the word “alcohol,” as well.
Rick: I just will point out there are some very effective treatments for alcohol-use disorders. Some of them are behavioral, and support is woefully inadequate for them. Probably the most effective treatment is a medication that can either be taken once a day, like Naltrexone, or if you have trouble remembering to take your pills, you have incredibly high adherence with the once-a-month injection of Naltrexone. It’s these depot injections that we’ve been very successful using as contraception and that are effective one to three months after an injection. Why are we not using these strategies for those involved in criminal justice settings?
We’re almost at that technological point for treating alcohol. Yet these treatments are dramatically underutilized in the criminal justice system.