Target Population and Relevance to Re-Entry

As earlier policy statements in this Report make clear, even if individuals receive high-quality health care during their incarceration, when they leave a correctional facility, they face the challenge of maintaining continuity of care in the community. (See Policy Statement 20, Continuity of Care, and Policy Statement 27, Maintaining Continuity of Care, for more on how individuals can work with institutional staff and other providers to continue treatment upon release.) Indeed, a person's access to quality health care is one of the major determinants of his or her health status, along with physical and social environment, behavior and individual biology. ^[1]   But the majority of individuals released from prison and jail find themselves in the predicament of many other poor Americans: seeking adequate care from a health care system that often provides only limited, fragmented, unaffordable services.

Just over sixty percent of working Americans receive commercial health insurance through their employers, paying part of the premiums out of their wages and paying for other health care expenses out-of-pocket. ^[2]   Most people released from prison or jail, however, will not be employed in positions with richly funded health benefits. Indeed, the great majority of releasees will have very low incomes, if they are employed at all. ^[3]   Many re-entering individuals will thus join the ranks of more than 44 million uninsured Americans, a number that has been increasing by more than one million per year for more than a decade. ^[4]   Some health care experts estimate that that number will continue to grow, reaching between 51.2 to 53.7 million by 2006. ^[5]  

Key Issues

The key problems in the US health care system boil down to issues related to access, costs, and quality. As detailed below, health care is too expensive, and too many people, especially poor people, lack access to it (or, more generally, the insurance coverage which could pay for it). For those who do not have coverage, serious health troubles are virtually inevitable. Further, the treatment which is available is often substandard. For many, especially those without insurance, a gap remains between the care that should be provided with that which is actually delivered.

Spending on health care is one of, if not the most, challenging problems facing the health care system. Overall, the United States spends much more on health care than any other nation. On a per capita basis, health care costs in the United States are more than twice the median level for the 30 industrialized nations in the Organization for Economic Cooperation and Development (OECD). ^[6]   In 2002, health spending accounted for nearly 14.9 percent of the country's economy. ^[7]   According to the Department of Health and Human Services, health care spending in the US shot up 9.3 percent in 2002, the largest increase in 11 years, to a total of $1.55 trillion, representing an average of $5,440 for each person. ^[8]   Projections by the Centers for Medicare and Medicaid Services indicate that the health share of the economy will continue to grow and could reach 18.4 percent in 2013. ^[9]  

Although the United States spends more per capita on health and health care than any other country-and there have been signs of the overall improvement in the health of our population-the health of some segments of the population has lagged behind. ^[10]   In general, health care access in low-income communities is limited. ^[11]   People living in poverty and near poverty remain at high risk for poor health outcomes and in need of greater access to health care. ^[12]   Among adults with a health problem, physician visits are correlated with family income, irrespective of race, ethnicity, or sex. ^[13]   Poor women, for example, are nearly three times more likely to have gone without a physician visit in the past year than are high-income women. ^[14]  

In general, people who obtain regular medical care can afford to do so because they have health insurance. Without health insurance, people either do not seek timely care or are not able to find it. Indeed, the uninsured poor are more than three times as likely as the insured poor to have no health care visits in a year. ^[15]   Compared to those who have insurance, the uninsured are less likely to do the following:

• Get cancer screening tests, delaying diagnosis and leading to premature death;

• Receive care recommended for chronic diseases, like timely eye exams (to prevent blindness) and foot exams (to prevent the need for amputations) in persons with diabetes;

• Obtain regular access to medications to manage conditions such as hypertension or HIV/AIDS infection; and

• Receive diagnostic and treatment services after a traumatic injury or a heart attack, resulting in an increased risk of death even when in the hospital. ^[16]  

In sum, Americans without regular health care are more likely than those with health insurance to receive too little medical care and to receive it too late; to be sicker and to die sooner; and to receive poorer care when they are in the hospital, even for acute situations like a motor vehicle crash. ^[17]   The Institute of Medicine estimates that 18,000 Americans die prematurely each year due to the effects of lack of health insurance coverage. ^[18]  

Failure to provide affordable preventive and ongoing treatment not only worsens health outcomes, but also puts an additional financial strain on the nation's economy, as early intervention and regular care are cost-effective in terms of both treatment and productivity. ^[19]   The uninsured are up to four times more likely than the insured to experience an expensive, avoidable hospitalization or to require emergency care. ^[20]   In fact, the cost of an emergency hospital visit is three to four times more expensive than a cost of a regular office visit. ^[21]   The Institute of Medicine estimates that the diminished health and shorter life spans of Americans under age 65 who lack health insurance translates into costs ranging from $65 billion to $130 billion, even before taking into account the additional positive effects on health and longevity after age 65 for individuals who had continuous health coverage. ^[22]  

Even for those with insurance, many people do not receive care which is consistent with the key evidence-based practices and optimal standards of care. According to the National Committee for Quality Assurance (NCQA), an independent, not-for-profit organization whose mission is to improve quality of care, over 57,000 Americans die needlessly each year because they do not receive appropriate health care. ^[23]   The majority-almost 50,000-die because known conditions are not adequately monitored and controlled; others die or are at increased risk of death because they have not received the right preventive or follow-up care. These are individuals who die not because of some mistake in medical judgment or because they did not have access to care. Rather, a lack of agreed upon standards, incentives for excellence, performance measurements, reporting of outcomes, and collaboration among health care organizations are issues which contribute to a sizeable gap between low-quality and high-quality care.

System Organization and Funding

For elderly Americans and some non-elderly poor or disabled people, the federal government provides health coverage. Medicare, a form of federal health insurance, pays a large part of the medical bills (but not prescription drugs) incurred by Americans who are 65 and older and those who are disabled, regardless of age. Medicare is administered by the federal government and financed by a portion of the Social Security tax, premiums paid by recipients, and federal funds.

Medicaid, the nation's largest social-welfare program, also provides health care coverage for poor people. ^[24]   Medicaid helps cover some low-income Americans, but applicants must meet stringent income and asset eligibility standards. Typically, unless they are aged, blind or severely disabled, even the poorest individuals are generally ineligible if they do not have dependent children. ^[25]  

In addition to Medicaid and Medicare, the federal government provides direct, personal health care services to particular populations through agencies such as the Veteran's Health Administration, the Indian Health Service (for American Indians and Native Alaskans in 35 states), and the Department of Defense (for individuals serving in the armed forces). A host of other federal agencies, ranging from the Food and Drug Administration to the National Institutes of Health, are also involved in health and health care related issues such as regulation, licensing, research, occupational health, public health, and prevention. But for non-elderly, low-income adults who are not veterans, there are very limited opportunities for health coverage through federally-funded entitlement programs.

The Department of Health and Human Services (HHS), the principal federal agency administrating health care programs and funding, also has several administrative branches which provide funding related to the provision of health care in low-income communities. The Bureau of Primary Health Care, for instance, funds select community health centers in low-income communities and obligates these health centers to provide unreimbursed care to low-income, uninsured people. ^[26]   These health centers are located throughout the nation in urban and rural areas. The Bureau of Primary Health Care also coordinates programs designed specifically for migrants, homeless people, and residents of public housing. The Health Resources and Services Administration (HRSA), also part of HHS, funds grantees to coordinate care in some communities for uninsured, low-income people through the Community Access Program and the Rural Health Grant Programs. These are just a sampling of the existing federal health initiatives, but even collectively, these programs do not provide comprehensive care for the millions of uninsured Americans.

At the state level, the provision of health care is often dominated by the administration of Medicaid. Although the federal government funds the program in part, much of the funding is matched by the states. Moreover, in contrast to Medicare, the states administer the eligibility and funding for Medicaid. States also provide support for health care services through their own departments of health. To the extent that state agencies (or, in some cases, their county-based counterparts) provide funding for such programs, there is tremendous variation in their eligibility requirements, scope, and services.

Direct services at the local level are often provided by a fragmented mix of private and public individuals and entities, including both for-profit and nonprofit organizations. By law, hospital emergency departments are not allowed to turn away patients with life-threatening emergencies. ^[27]   However, because of fiscal realities, hospitals do not supply unreimbursed care easily. Some of these local service providers receive government funding to support their work through fee-for-service payments (such as government insurance programs). When low-income people have Medicaid or other coverage, for example, they may be seen in private medical offices, either individually or through their practitioners' enrollment in Medicaid managed care programs. Other local health care entities receive government funding more directly, through contracts or grants, including the HHS grant initiatives detailed above.

Public health agencies are another major component of the nation's health care system, one which comprises federal, state, and local elements. Rather than providing individual treatment and personal care, public health departments generally focus on education, research, and outreach activities targeted toward promoting good health and preventing and controlling the spread of disease. For public health, just as for personal health care, federal and state funding supports local providers.

The primary actor in the public health field is the Centers for Disease Control and Prevention (CDC), another HHS agency. Among other programs, the CDC has national centers that fund state and local health departments to prevent transmission of communicable diseases such as tuberculosis, HIV/AIDS (and other sexually transmitted diseases), and viral hepatitis. ^[28]   Through CDC and state categorical funding, state and local health departments provide care and follow-up for patients with contagious tuberculosis; latent tuberculosis infection; and sexually transmitted diseases such as syphilis, gonorrhea, and chlamydia. (See sidebar, "Coordinating Funding Streams for Comprehensive Service Delivery" in Policy Statement 4, Funding a Re-Entry Initiative, for more on categorical funding generally.) Some public health authorities also provide maternal and child care for the poor, although these programs have been largely eliminated by cutbacks in funding.