Continued clinical care for ex-convicts

People newly released from prison confront serious health risks the moment they step off the bus. Many lack identifying documents and have only a few dollars in their pockets. Many don’t know how to find health insurance or medical care. And many quickly wind up in emergency departments with overdoses or exacerbations of chronic diseases that were being treated in prison. These are problems that Assistant Professor of Medicine Emily Wang, M.D., M.A.S., is trying to resolve.

While an internal medicine resident at the University of California–San Francisco, Wang decided to talk to current and former prisoners about these barriers. In 2006, she co-founded a San Francisco clinic based on what she learned. The Transitions Clinic Network (TCN) is designed to connect ex-prisoners with medical and social services as soon as they leave prison. Eight years after its founding, the TCN has grown to serve 13 locations around the country, including at Yale-New Haven Hospital’s Primary Care Center.

TCN has drawn substantial national media attention, in part because of its help enrolling returnees under the Affordable Care Act (ACA)—or “Obamacare”—may strengthen insurance rolls as well as reduce recidivism. Wang and colleagues at the TCN meet regularly with President Obama’s Federal Interagency Reentry Council to discuss policy barriers to returnee health, such as Medicaid termination for people incarcerated longer than a year.

Funded by a Career Development Award from the National Heart, Lung, and Blood Institute, Wang also studies health outcomes in returned prisoners. In September 2013 she reported in JAMA Internal Medicine that about one in 12 are hospitalized within three months of release.

The structure of the TCN is based on advice from current and former prisoners, who suggested to Wang that effective medical care for returnees needs four key elements: early access to primary care; workers with a history of incarceration to guide returnees to medical and social services; providers with correctional health experience or training; and strong connections to community organizations like housing, employment, and legal aid. Returnees have also alerted Wang to discrimination in the health care setting.

“A big problem in many of the interventions that are designed for this population is that often they haven’t solicited the opinion of former prisoners,” Wang says. “You end up with interventions that either aren’t palatable or aren’t feasible.”

By contrast, the TCN is succeeding. When Wang and her colleagues compared returnees receiving all four elements of the TCN’s care to returnees receiving just an early primary-care visit, they found that only one-quarter of TCN patients visited the emergency department in a year compared with 40 percent of non-TCN patients. The results appeared in the American Journal of Public Health in September 2012.

Though medical care for prisoners is mandated under the Eighth Amendment of the U.S. Constitution, that care often abruptly ends when imprisonment does. The clinic makes it possible to access prison health records and resume care. In 2012 the TCN received a Health Care Innovation Award from the Center for Medicare and Medicaid Innovation. The program has been mentioned in The Atlantic, Newsweek, and CNN.com.

Some of the attention has centered around the TCN’s connections to Medicaid and the ACA. Poor health care in the form of untreated mental health problems and addiction lead many people to offend in the first place. So getting ex-prisoners enrolled in Medicaid—and making sure they receive treatment tailored to their needs, as the TCN does—might mean fewer of them return to prison.

“Obamacare is key to reducing recidivism,” Wang says. She adds, however, that the reverse is also true. Over one-fifth of people eligible for Medicaid under the ACA expansion are incarcerated, on probation, or on parole. Many are young and healthy, making them attractive to insurance companies looking to dilute their risk pools. Far from being burdensome, then, these individuals may strengthen the health care system—much as their involvement has made the TCN more effective.

“In order for the Affordable Care Act to work,” Wang says, “you have to get former prisoners involved.”