I began my public health career on a Yale postdoc. One of my formative experiences there was to accompany colleagues on the Community Health Care Van, a needle exchange-based mobile clinic for street drug users.
Tagging along with the staff, I helped some patients complete basic paperwork. A weathered middle-aged guy stepped on. When I asked what brought him there, he pulled back his shirt to reveal a chalky-white oozing crater in his shoulder. That festering infection was my rude introduction to the life realities of injection drug users.
Most of these women and men suffered greatly with addiction and a variety of complex illnesses. Most were uninsured, yet still consumed enormous health system resources as they cycled through correctional facilities, became emergency department frequent-fliers, and required heavy use of other safety-net services.
The CHCV reduced patients’ emergency department use by about twenty percent. We could have done more if we could have provided reliable primary care, appropriate drug treatment, and other services requiring insurance coverage.
This won’t matter politically, but the Affordable Care Act will quietly improve public health by expanding coverage for hundreds of thousands of ex-prisoners and others under the control of the criminal justice system. Most of these men and women are on parole or probation. A nice Health Affairs paper by Alison Evans Cuellar and Jehanzeb Cheema runs the numbers. Roughly half of the 700,000 people released every year from correctional institutions will gain coverage or improved care under health reform.
More here, in my latest column for healthinsurance.org.
Harold, good story. I was appointed by Sec Sebelius to serve on a negotiated rulemaking committee created by the ACA to redo the Health Professional Shortage Area and Medically Underserved Area methodologies. One of the huge stumbles we ran into was whether or not local jails could be designated to get federal resources (to care for people in pre-trial detention, who had not been convicted, but who lost Medicaid once charged and incarcerated). We spent much time only to be told by OMB that we were limited in what could be done in this area. It is a tremendous example of human suffering/poor access, made all the worse that people are essentially being punished without being convicted. I should write about that committee…..33 cumulative days in a room with no windows!
An extraordinary as well as shameful situation. Isn’t providing medical care to prisoners a basic duty of the criminal justice system, and access to such care by prisoners a human right? If you lock somebody up, you are responsible for them.
Medical care for all prisoners is certainly covered in some detail by the UN Standard Minimum Rules for the Treatment of Prisoners, Articles 22 to 25. The moral status of the Rules as consensual international standards is higher than their legal force, as they have not so far been incorporated in a covenant. Bleg: what part did US representatives play in the drafting of the Rules? what statements if any have been made by high-level US representatives on the reception and application of the Rules in the US?
@James Wimberley
I think it is the case that the one group with a constitutional right to medical care is prisoners, secured by US courts I believe (this was discussed on the commission; I need to dig up the reference to court cases), it is just that the system to provide this care is not so good, esp for mental health. States spend less per capita on prisoners than in Medicaid, and that is the fiscal logic of ending Medicaid eligibility.
I’m relieved that it’s only a partial, not a total disaster.