1. Jail Medicaid Policy Analyses Final Report to the Pinellas Data Collaborative A Collaborative effort by The Policy Services & Research Data Center at the Florida Mental Health Institute, Paul Stiles, Diane Haynes, Joe Morrissey, Hank Steadman, Kathy Dalton, & Alison Cuellar Funded by The MacArthur Foundation Network on Mental Health Policy Research November 4, 2003

2. Two of the Network’s Goals To improve access to quality mental health services To provide research and practice to guide evidence-based policy

3. Our Study Objectives Examine barriers to accessing services experienced by seriously mentally ill (SMI) people in the criminal justice system Ensure that policies generated to reduce barriers are evidence- based

4. Estimated SMI Under Correctional Supervision in a Given Day PrisonsJailsCommunity Supervision Number Of SMI Persons 93,00044,000320,000

5. Current Policy Issues ~ 1 Growing interest by Federal agencies (DOJ/CHMS) in diversion & reintegration of mentally ill persons released from prisons and jails Many jurisdictions are looking to Medicaid as a way of financing community services for these people

6. Current Policy Issues ~ 2 Lot of confusion and inconsistent policies at Federal/state/local levels about disenrolling jail detainees from Medicaid, whether it’s required and whether it actually happens Although research shows that Medicaid recipients have much higher access and use of general health services than the uninsured, there are no studies of this issue for SMI persons released from jail

7. Policy Research Question Does Medicaid enrollment improve access and receipt of community- based services for SMI persons released from jail?

8. Three Hypotheses Higher percentage receiving services Shorter lag times to first service More days of service and higher rates of service receipt Medicaid enrolled vs. not-enrolled within 90 days of jail release will have:

9. Study Design & Findings

10. Study Sites Pinellas County (Florida): Main focus of current MacPolicy project; joint effort with FMHI-USF King County (Washington): Leveraged earlier MacPolicy/current NIMH study to address same questions Selected because of the availability of multi-agency administrative data:

11. Table 1. Year 2000 County Profiles IndicatorPinellas CountyKing County Total Population921,4821,737,034 % White87.375.7 % Black9.15.4 % Asian2.110.8 % Hispanic/Latino4.75.5 Md. Income$37,111$53,157 Avg. Jail Census2,5042,953 Total Jail Bookings44,39560,992 Incarceration Rate4,8183,511

12. Pinellas Data Collaborative Permitted by statute: Chapter 163, Part VI, F.S.: Collaborative Client Information Systems. Purpose: To establish an information system between state, local and private agencies to address various mental health planning and/or substance abuse planning. Objective: to examine issues relating to how mental illness and substance abuse impacts the county in areas such as medical care funding, emergency medical transportation and the criminal justice system.

13. Available Databases for Pinellas Criminal Justice Florida Department of Law Enforcement Baker Act (Civil Confinements) EMS Agency for Health Care Administration Department of Health CMS (Medicare) Integrated Data Systems (DCF) Social Services Juvenile Welfare Board Department of Juvenile Justice Child Welfare

14. King County Databases King County Jail King County outpatient mental health services Medicaid enrollments State hospital services Community general hospital psych inpatient (CHARS) State Dept HSS substance abuse services (TARGET)

15. Sample Identification Pinellas County: linked Medicaid claims (MediPass) with SMI identifiers to jail incarceration file for 2-yr. study interval King County: linked county MH file with SMI identifers, Medicaid enrollment file, and jail incarceration for 2-yr. study interval

16. Case-Control Design Cases: Persons w SMI released from jail with Medicaid enrollment Pinellas: Jul98-Dec00 King: Jan97-Dec98 Controls: Persons w SMI released from jail without Medicaid enrollment Sampling strategy controls for Medicaid eligibility—everyone was on Medicaid at some point during study interval

17. Sample Size & Medicaid Status by County SamplePinellas Med Pinellas NonMed Pinellas Total King Med King NonMed King Total Arrests2,2156632,8783,1222,1185,240 Total Persons1,0233731,2101,6521,1892,209

18. Demographic and Diagnosis Profiles of Jail Releases with SMI, Pinellas County (1998-00) and King County (1997-98)

19. Service Access/Use Measures 1.Percent received any community- based service within 90-days 2. Days to first service 3. Days of service received within 90-days 4. Rate of service use within 90-days— adjusted for #days in community

20. Services Data Base Pinellas County: used Medicaid claims and State block grant administrative data system ( IDSDW) King County: Medicaid claims not available; used county mental health and state substance abuse administrative data

21. Overview of Findings 1. Two of 3 hypotheses confirmed—Medicaid cases with SMI have higher access and more timely services following jail release but, once there, they receive a similar intensity of services 2. Medicaid advantage is not uniform across counties: Access: Pinellas 5:1 vs. King 1.25:1 (but non-M have 5:1 greater access in King) Lag-time: Shorter by 10-13 days in King County Intensity: Same for Medicaid/non-Medicaid in each county, but King County is twice as intense as Pinellas County

22. Average Service Use Indicators for Jail Releases with SMI by Medicaid Status, Pinellas and King Counties a/ Based on duplicated sample of jail releases, not distinct persons. b/ Each average is adjusted for age, gender, race, diagnosis, length of incarceration, whether violent offense, and prior substance abuse treatment. Numbers in parentheses are sample sizes. *** p<.001, ** p<.01, *p<.05

23. Implications 1.Medicaid is important for SMI persons leaving jail 2.But insurance is not the total answer in promoting continuity of care (40- 47% on Medicaid never accessed services in 90-days post release) 3.There was a stronger safety net in King County during late 1990s for the uninsured

24. Implications-cont’d 4.Economic conditions post-9/11 have eroded this safety net in King County and new CMS Medicaid rules (Jun ’03), if implemented fully, will do away with any service safety net for the uninsured throughout the US 5.Bottom Line: Big obstacles remain for persons with SMI in jail re: access to high quality, evidence-based services—these obstacles will intensify in next few years

25. Some Further Analyses 1.Lengths of detention for SMI persons 2. Why few SMI persons are disenrolled from Medicaid? 3. Factors that predict service use post- release among Medicaid enrolled 4. Charges for SMI persons—what’s the mix of minor & serious offenses?

26. Next Steps Examine the impact of Mental Health and/or Substance abuse Treatment in reducing jail recidivism