Health matters to the justice-involved population. Compared to the general population, inmates are seven times more likely to have chronic health conditions, infectious diseases, sexually transmitted infections, addictive behaviors, and medical and mental health co-morbidity. (1) Health matters to the criminal justice system because health-related factors are important and substantial predictors for recidivism. (2) Since becoming law in March (2010), the Patient Protection and Affordable Care Act (PPACA) has been touted as a major "game changer" for the justice-involved population. (3) One of the requirements of the PPACA is that states provide targeted outreach to underserved, vulnerable, hard-to-reach populations. Individuals in jails and prisons fit those criteria.4
Since 70 to 90 percent of inmates released from jails and prisons have no health insurance, they are frequent users of high-cost local emergency medical services. (5) Lack of health insurance coverage and lack of continuity of health care in the community upon release are associated with increased rates of recidivism, high health care costs, poor health outcomes and a 12-fold increase in the risk of death in the first two weeks after release. (6) With Medicaid expansion occurring in over (30) states, uninsured and underinsured justice-involved individuals are eligible for much needed medical services, especially treatment for substance abuse and mental health disorders. Many Medicaid-expansion states are realizing the advantage of enrolling eligible inmates in health insurance coverage. (7) Because of the complexity and multifaceted nature of the criminal justice system from state to state; enrolling the justice-involved population in health care coverage requires a variety of approaches. (8)
Project Design and Methods
The period of confinement in jail provides an excellent opportunity to engage, educate and promote enrollment in health insurance coverage. The project was designed to build and expand upon a prior successful project with inmates to improve health literacy, self-care management and health care decisionmaking. (9) All of the community partners and three members of the research team from the previous project were involved in the current project.
No matter how effective a health-based instructional curriculum is during incarceration, major barriers and impediments to health care coverage exist for inmates reentering communities.
The overall goal of the current project was to engage, educate and prepare inmates to enroll in health insurance coverage upon release from the local detention center. The specific objectives were as follows:
--To increase inmates' knowledge and understanding of the health reform law, mandatory benefits and consumer protections.
--To improve inmates' level of health insurance literacy.
--To educate and prepare inmates for making informed choices for health insurance coverage.
This project was designed, developed and implemented as a community-based collaborative effort working with inmates housed at the local detention center. The following institutions, organizations and partners participated in the project:
--Gallatin County Detention Center.
--Gallatin County Mental Health Center.
--Gallatin County Reentry Task Force.
--Montana State University Extension Service, College of Nursing, Library, and Department of Sociology and Anthropology.
--Bozeman Public Library.
--National Network of Libraries of Medicine, Pacific Northwest Region, National Library of Medicine.
Workshop Sessions and Modules
The program was designed to provide small groups of participants five sessions (one per day), each about two hours in length, which were scheduled to run Monday through Friday for a maximum total of 10 hours. The workshop sessions were carefully scheduled around daily meals, regular lockdowns, and other programs and classes to avoid interruptions. The program design involved the following threefold intervention:
--Delivery of four instructor-led teaching/learning modules comprised of PowerPoint presentations with videos (see Table 1).
--Scheduled time for independent study/review.
--Distribution of nine health information and health insurance information handouts (see Table 2).
Two university student interns involved with the project served as instructors. Instructor-led sessions involving the presentation of teaching/ learning modules were held Mondays, Wednesdays and Fridays in program rooms separate from the cell pods. Independent study/review workshops were held Tuesdays and Thursdays in the computer lab of the detention center. The four teaching/learning modules were loaded on the hard drives of the desktop computers in the computer lab. During the two independent study/review sessions on Tuesdays and Thursdays, at least one student intern was available at all times to provide oversight and to answer questions. All five sessions were designed to be interactive, allowing ample time for questions and answers.
Target Population/Recruitment/Participant Description
The target population was adult inmates housed in the detention center for more than seven to 10 days. A minimum of a 10-day length of stay was required to allow time for introduction of the project, recruitment and completion of 10 hours of workshop sessions. During the tenure of this project, the average length of stay in the detention center was 12 days and the average daily population was 170.
The recruitment approach involved announcing the project to correctional officers...