The United States imprisons more of its people than any other nation – currently one out of every 31 Americans. Lots of prisoners naturally leads to a steady flow of people leaving prison. Each year more than 700,000 U.S. prisoners are released to their communities. These men and women often have little education and poor prospects for finding jobs or establishing stable homes – and to make things worse, their health often deteriorates right after they leave prison.

About four out of every five newly released people suffer from chronic medical, psychiatric or substance abuse problems – but only about one in five visits a physician outside of hospital emergency departments during the first year after release. Imprisoned patients are often released without adequate follow-up instructions, medications, or access to health insurance coverage. Many let problems fester until they end up in hospital emergency rooms – inflating costs in U.S. health care and forcing taxpayers or insured Americans to foot bills the ex-prisoners cannot pay. An obvious solution is to ensure continuous good health care for people leaving prison.

Health Care in the Prison System

Jails and prisons are grim – but they do ensure food, clothing, and basic medical care. Ironically, in an era when many Americans have had no health insurance or steady access to good care, prisoners are an exception. Often, newly arrived prisoners gain access to basic health care for the first time – and get new treatment for chronic health problems such diabetes, depression, or hepatitis C. While behind bars, prisoners see providers who diagnose and treat these conditions, ensure that medications are regularly dispensed, and provide specialty care when needed. Imprisonment can improve health outcomes – if the gains can be sustained.Ironically, in an era when many Americans have had no health insurance or steady access to good care, prisoners are an exception.

Risks upon Release

However, many jails and prisons do not have a well-coordinated system in place to ensure that released individuals continue to receive health care on the outside. This failure is especially likely when ex-prisoners go to communities far away – for example, if they leave Dannemora Prison in remote upstate New York to return to a poor Brooklyn neighborhood. Close to two-thirds of released prisoners may not have the daily medications that they were taking in prison, and even those given a minimal supply may have no ready way to get their medications refilled. Most states cut off enrollments in Medicaid when poor people are sent to prison, making it hard for them to get physician appointments upon release. With medications and care cut off, ex-prisoners may return to abusing dangerous substances or experience sudden mental breakdowns – at the same time they have difficulty finding jobs, homes, or regular meals.With medications and care cut off, ex-prisoners may return to abusing dangerous substances or experience sudden mental breakdowns – at the same time they have difficulty finding jobs, homes, or regular meals.

• Former prisoners with drug convictions are often legally barred from getting Food Stamps or temporary welfare assistance – which can leave them doing risky things to survive.
• Many ex-prisoners move in with family or friends, but not all have this option and ex-prisoners are often barred from public housing. High rates of homelessness follow.
• Research has shown that in the first two weeks after release, former prisoners are twelve times more likely to die than other people. Ex-prisoners are also much more likely to go to hospital emergency rooms – just to get simple basics like renewed prescriptions.

Solutions to Help Ex-Prisoners Get Continuous Care

Two pieces of the health care puzzle must fall into place to ensure steady care for ex-prisoners – access to health insurance and immediate links to primary health care providers.

• The new national health reform law – the Affordable Care Act or “ObamaCare” – calls for states to expand their Medicaid systems to cover all poor adults. To the degree that states carry out this expansion, between one-third and three-fifths of newly released prisoners will become eligible for basic health insurance coverage. That will help, but may not be a full solution, because ex-prisoners might still find themselves turning to hospital emergency rooms, given long waits for primary care. Costs could shoot up, especially in cities and states without strong primary care safety-net systems.
• The best models of transitional care must also include ways to get ex-prisoners quickly into new primary care arrangements – and community-based clinic programs specifically devoted to helping returning prisoners are a promising solution.

A Promising Model: The Transitions Clinic

Eleven community health centers in the Transitions Clinic Network spread across the United States and Puerto Rico provide medical homes for returning prisoners. Each clinic has health care providers who are experienced at working with recently-released prisoners, and each has community health workers who have themselves experienced incarceration. Aiming not only to provide appropriate continuing care, but also to help ex-prisoners fit into the community and avoid going back to prison, clinic workers help people manage diseases, accompany them to medical appointments, and provide referrals to housing, employment, and educational resources. Patients can be seen within two weeks of their release date. A recent study showed that, compared to ex-prisoners referred to expedited primary care, Transitions Clinic patients had a 51% lower annual rate of visits to emergency departments. Almost half of the patients in the study visited their clinic more than twice in a one year period, showing that recently-released prisoners will use primary care services if they are made readily available.

The success of the Transitions Clinic model suggests that further interventions must focus on giving ex-prisoners access to basic health care at the earliest possible date after they walk out of the prison gates. Doing so can keep troubled people from committing new offenses – and it can reduce the grievous costs that interruption of care imposes on the larger community as well as on the ex-prisoners themselves.