Research Report

Behavioral Health Disabilities Reentry October 3, 2024

Implementing the Medicaid Reentry Waiver in California

Lore Joplin, Justice System Partners, Maureen McDonnell, TASC’s Center for Health & Justice, Kimberly Richards, Justice System Partners, Miriam Popper, Justice System Partners, Vikki Wachino, Health and Reentry Project, Margot Cronin-Furman, Health and Reentry Project, John Sawyer, Waxman Strategies, Silicia Lomax, Waxman Strategies, David Ryan, Health and Reentry Project

In January 2023, California became the first state in the nation to receive approval from the federal Centers for Medicare and Medicaid Services (CMS) for a Medicaid Section 1115 demonstration request to amend Medicaid’s inmate exclusion. People detained in jails and prisons have high rates of chronic and acute health needs, including physical, mental health, and substance disorders and reentry is a high-risk time. A key to addressing these reentry risks is addressing people’s health needs while they are incarcerated and building continuity of care from jail to community when they are released.

California’s waiver, called California’s Advancing and Innovating Medi-Cal (CalAIM), and the specific component focused on individuals who are transitioning out of the criminal justice system, the Justice Involved (JI) initiative, will for the first time provide a targeted set of Medicaid-covered services right before someone is released from prison or jail. These services aim to smooth reentry transitions from jail and prison to the community, establish better connections to community-based providers at release, and enhance access to necessary care and support. California’s approach is designed to reduce the high risk of post- release mortality, morbidity, and other adverse outcomes, including repeat contact with the criminal justice system, by bringing Medicaid financing and coverage standards to bear.

The work to implement California’s waiver and make these changes a reality is demanding, involving multiple partners at the state, county, and local level who have not previously worked together at this level of vital cross-system collaboration. Implementation of these changes is well underway, and county-level changes will roll out over the next two years, starting in October 2024. This paper highlights California’s implementation approach, focusing on the county-level impacts on jails, health care providers, and reentry processes. It also explores several implementation challenges and the steps the state and the counties have taken thus far to implement this change.

The John D. and Catherine T. MacArthur Foundation’s Safety and Justice Challenge Initiative provides funding for this project, including technical assistance conducted by Justice System Partners (JSP) and the Health and Reentry Project (HARP). As part of the project, JSP and HARP conducted interviews and group discussions with representatives from 11 California counties and the California Department of Health Care Services (DHCS) who offered insights into implementation challenges and promising approaches to maximize the benefits of these important changes.

Companion Paper: Using a Learning Collaborative to Facilitate Broad Systems Transformation

In this paper, we explore the process and impact of convening a cross-sector peer learning network to foster coordination and collaboration between criminal justice, health care, behavioral health and community parters in support of this new Medicaid and criminal justice initiative.

Read more on our blog.

Issue Brief

Behavioral Health Disabilities Frequent Jail Users Housing July 25, 2023

Recommendations To Reduce Frequent Jail Contact

Sarah L. Desmarais, Brandon Morrissey, Lisa Callahan, Samantha A. Zottola, Jen Elder, Kristin Lupfer, Elan C. Hope, & Richard A. Van Dorn

Although most jail admissions represent the only contact a person will have with the criminal legal system, there is a small group of people who experience more frequent jail contact and who represent a disproportionate number of both jail admissions and expenditures.1,2 People with frequent jail contact experience complex, interconnected social, economic, and behavioral health needs that may exacerbate (or be exacerbated by) their frequent jail contact. This group also experiences frequent contact with other services in the community, such as emergency rooms, homeless shelters, and treatment facilities. Strategies to implement services that meet complex needs and address structural barriers are critical to meaningfully and sustainably reduce system involvement among the population of people who experience frequent jail contact.

Effective change for people with frequent jail contact must proceed simultaneously on a systemic, policy level and on the individual services level. The population discussed in this policy brief typically has complicated behavioral and medical health needs, extensive criminal legal encounters, and significant social deficits such as poverty, isolation, and elevated risk of being unhoused. Many of their needs can be addressed with intensive, person-centered treatment in a coordinated continuum of care. The success of community-based solutions is supported by three foundational elements:

  1. A systemwide examination of structural barriers and opportunities,
  2. A focus on policies to effectively implement and support evidence-based interventions, and
  3. A re-envisioning of how the behavioral health and criminal legal systems can coordinate trauma-informed responses for people with frequent jail contact.

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1 Elsa Augustine and Evan White, High Utilizers of Multiple Systems in Sonoma County 1-31 (2020), https://www.capolicylab.org/wp-content/ uploads/2020/07/High-Utilizers-of-Multiple-Systems-in-Sonoma-County.pdf.

2 Ross MacDonald, Fatos Kaba, Zachary Rosner, Allison Vise, David Weiss, Mindy Brittner, Molly Skerker, Nathaniel Dickey, and Homer Venters, The Rikers Island Hot Spotters: Defining the Needs of the Most Frequently Incarcerated, 105 American Journal of Public Health 2262–2268 (2015), https://doi.org/10.2105/AJPH.2015.302785.

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Addressing Ableism In Criminal Justice Reform

By: Matt Davis

Community Engagement Disabilities Human Toll of Jail December 1, 2022

December 3 is International Day of Persons with Disabilities. So, we spoke to leaders working in the area involved with the MacArthur Foundation’s Safety and Justice Challenge (SJC) about what needs to change, and where there has been progress.

(From left to right: Chris Huff, Supreet Minhas, Candace Coleman and Jalyn Radzminski).

Chris Huff (he/him) is Diversion and Reentry Policy Analyst at Access Living—a center of service, advocacy, and social change for people with all kinds of disabilities, based in Chicago. In this role, Chris leads policy efforts centered on supporting people with disabilities impacted by the criminal justice system.

“I think we’re at an all-time high, right now, in terms of putting people with lived experience of disability and the justice system in the position to advocate for the changes that we need,” he said. “And I’m encouraged by that.”

The most discouraging part of his work is the lack of engagement and support from the law enforcement community to address the issue of working with people with disabilities. Oftentimes contact with law enforcement is a person’s first entry into the criminal justice system.

“To me, the root of these issues is that the system is not designed or intended to support people, but rather punish them,” he said. “Two thirds of survivors of crime say they prefer a system focused on rehabilitation than punishment, but we continue to run the system with that outdated mindset.”

When bringing up the idea of working to make the system more supportive of people with disabilities, Chris says he has been frustrated with responses that do not see that as part of the role of the criminal justice system.

“Even collecting data on people requires a level of clinical or social work-type training to be able to ask the questions in a proper way, to identify disabilities without being invasive or intrusive,” he said. “But to make that happen we need to have a sincere and aggressive interest in making it happen by law enforcement. And we’re not there yet.”

It matters to Chris to focus on more support and rehabilitation for people with disabilities in the criminal justice system because it is about unleashing more potential. Instead of focusing on people as potential risks, we should focus on their potential strengths, Chris said.

“To me this is really about helping America reach its full potential and living up to the high ideals we set forth at the creation of this country,” he said. “Without addressing the inequities created from the criminal justice system, there’s no way we can have a society where folks are fully free and have equal opportunity.”

Supreet Minhas (she/her) is a Senior Program Associate with Activating Change—a national nonprofit working to end victimization and incarceration of people with disabilities and Deaf people in the United States. Activating Change launched in 2022, but its work began in 2005 as a project of the Vera Institute of Justice. Activating Change launched as an independent nonprofit to increase the visibility of the justice issues people with disabilities and Deaf people face and to have a greater impact on ending those injustices. The organization is a Strategic Ally in the Safety and Justice Challenge.

“Criminal justice reform cannot take place equitably without accounting for the millions of people with disabilities ensnared in the system,” Supreet said. “Centering disability justice is essential to understanding and eliminating mass incarceration.”

Supreet helps organizations to understand how ableism and racism intersect. For example, 30-50% of people killed by police are people of color with disabilities. 40% of people in jail have at least one disability.

“The most vexing part of this work is continually being confronted with ableism and its pervasiveness in our society,” she said. “The Americans with Disabilities Act was passed 32 years ago but people with disabilities and Deaf people continue to be routinely denied access to accommodations like sign language interpretation.”

The criminal justice movement is decades behind in addressing ableism, especially in comparison to progress being made toward tackling sexism or racism, Supreet said. The omission of disability in the broader equity framework, has upheld and perpetuated structural barriers. People with disabilities are systematically excluded from having a part in crafting policies or making decisions—from being “at the table.” And there are myriad barriers for someone with a disability to even be at the table, from not being deemed worthy enough to warrant an invitation to the table itself being inaccessible. The impact of these challenges is borne out by the data on disability disparities, which shows that people with disabilities and Deaf people make up disproportionately high percentages of justice-involved individuals.

The “invisibilization” of people with disabilities has always been one of the most formidable challenges facing us, going all the way back to people with disabilities being excluded from ancient societies (e.g., leper colonies), then institutionalization in the modern era, and present-day mass incarceration. Most people do not want to talk or think about disability issues unless they are directly impacted—it’s a ‘problem’ for “others,” Supreet said.

“Even within the criminal justice reform field, the majority of organizations working to advance equity in the criminal legal system are not even considering disability justice in their approach, much less centering it,” Supreet said. “Disability is perceived as a complex, thorny issue best left to be worked on by disability-specific organizations in silos. However, until we all realize that justice and fairness for all cannot be achieved without intentionally considering people with disabilities and including them at policymaking tables, disability disparities will worsen, and we will have two separate, unequal tiers of justice.”

One of the biggest hurdles to improving outcomes for people with disabilities and Deaf people and achieving an equitable criminal legal system is that these two goals have been disconnected from one another, Supreet said. “The movements and organizations striving for these respective goals have been working in silos. This must change.”

Candace Coleman (she/her) is a Black disabled woman from the South Side of Chicago. As a Racial Justice Organizer at Access Living she works closely with disabled people affected by the justice system to organize around racial justice and disability. Candace’s most notable work involves organizing around mental and behavioral health emergency response. She played an integral in passing the Community Emergency Services and Supports Act in 2021—paving the way for Chicago’s 988 service. She continues to work diligently to implement non-police alternatives to emergency response in these situations.

Candace said a major area of her focus, right now, is the absence of accurate data about people with disabilities in the jail system.

“I’m encouraged by the work we’ve done over recent years to put people with lived experience at the center of decision-making, but if anything that has highlighted how little we did it in the past, and we’re really building the lane for people to participate,” she said. “Meanwhile, we’re doing that with very little data collection about people with disabilities who are in the system. If we don’t even have accurate numbers to reflect the scale of the issue, how can we move forward to help solve it?”

Recent focus on behavioral health and mental health issues has continued to marginalize other disabilities from the criminal justice reform conversation, Candace said.

“We’re not tracking people with cognitive disabilities, we’re not tracking people who are visually impaired, people who are Deaf, people who require physical accommodations and accessibility,” she said. “It’s just not been a priority to track such people. And without it being a priority, we can’t make progress.”

“We need to move towards supporting people as they come out of the system,” she said. “It means we need to identify people with disabilities who come into the system so that we can provide the programs and support they need when they come out of jail, or we fail.”

Jalyn Radziminski (they/she) is a Black and Japanese Disability activist from Indiana. Jalyn is the Communications Manager & Lived Experience Advocate at Bazelon Center for Mental Health Law and an Evening Student at Fordham School of Law. Jalyn builds coalitions to support the work of other peers with lived experiences of Jalyn also works on campaigns that promote community-based mental health supports.

“We’re trying to reduce the chances of people going through involuntary commitment and police response to a mental health crisis,” Jalyn said. “A lot of grassroots leaders and legal advocates are starting to understand that the mental health system and the criminal legal system are intertwined. I’m working to keep people out of both.”

“One of the major challenges of the new 988 numbers around the country, is how they can lead to these undesired outcomes. People may call these sort of hotlines in distress, and before they know it, the police might show up at their door. People are scared that if they say the wrong thing, then the police will come,” they said. “It’s surprisingly easy for people to fall into a loophole of a police encounter and then before long, there’s involuntary commitment or incarceration”

Despite community-based models operating successfully since at least the 1970s, the majority of mental health research cites involuntary psychiatric-based treatment and response methods. There are many barriers for people of color with disabilities to have their work funded and published. The data from community-based perspectives is often lacking and this feeds into the lack of published research on community-based models of mental health treatment, Jalyn said.

“I’m working to push academia to bring these alternative models into the research field,” they said. “One of my proudest moments is recently receiving a competitive research grant for a joint-research project between the Bazelon Center, Mental Health America, and the University of Pittsburgh to help study the disparities of that research while uplifting peer voices.” Projects like these are just the start of a larger push to better collect and analyze data on community-based models and compare their success rates to the mainstream involuntary, incarceral responses.

“Investment is a major challenge, too,” they said. “A lot of the time policymakers think simple reform will fix some of the issues but you’ve got to invest in peer-led models. Underinvestment can lead to short-staffing, and there’s a domino effect.”

Jalyn cited the Kiva Center’s Karaya Peer Respite as a great example of successful peer-led respite program with a mobile team. They also pointed to the Promise Resource Center in North Carolina. “These home-like models give people somewhere to go where they can get rest and reflection when they’re experiencing emotional distress,” Jalyn said. “They support people through crisis to find healing.”

“The more we uplift peer networks and lived-experience-led approaches, and the more we push back in our voices from the policy to on-the-ground level, we’ll start to have better ways of preventing these issues from happening over and over again,” they said. “It’s long overdue to move away from these models and on to something new.”

 

Research Report

Behavioral Health Disabilities Policing Racial and Ethnic Disparities May 26, 2022

Examining The Impacts Of Arrest Deflection Strategies On Jail Reduction Efforts

Shannon Magnuson, Cherrell Green, Amy Dezember, Brian Lovins—Justice System Partners

In 2015, the John D. and Catherine T. MacArthur Foundation launched the Safety and Justice Challenge (SJC), a multi-year initiative to reduce populations and racial disparities in American jails. To advance knowledge development grounded in a research agenda that explores, evaluates, and documents site-specific strategies to safely and effectively reduce jail populations and address racial and ethnic disparities, the Foundation engaged the Institute for State & Local Governance (ISLG) at the City University of New York (CUNY) to establish and oversee an SJC Research Consortium. Consortium members are nationally renowned research, policy, and academic organizations collaborating with SJC sites to build an evidence base focused on pretrial reform efforts.

Reducing jail populations and the collateral consequences of the legal system requires jurisdictions to critically examine the practices bringing these populations through the criminal legal system's front door. It requires implementing opportunities to reduce reliance on citation or arrest/booking, especially for populations with serious mental health disorders (SMHD) or substance use disorders (SUD), while also providing individuals the help and referrals they need to be well. Police-led deflection allows police officers discretion to replace arrest with outreach to community-based service providers. In an effort to learn more about how police-led deflection strategies operate, ISLG funded Justice System Partners to conduct mixed-methods studies of deflection strategies in two SJC sites.

Using administrative data from local crisis centers and interviews with police officers in Pima County, AZ and Charleston County, SC, this mixed methods study aimed to understand how deflection of individuals with SMHD/SUD operates in both sites.

Key takeaways include:

  • A parallel treatment revolving door to the legal system revolving door, which acknowledges the challenges of treatment initiation and engagement and provides individuals with SMHD/SUD with a "no wrong door" policy. This creates enhanced opportunities for treatment while eliminating collateral consequences of the legal system and jail for these vulnerable populations.
  • Deflection first, arrest rare as both policy and principle connects vulnerable individuals to the services they need. At the same time, it lessens opportunities for implicit bias and non-clinical judgements about readiness for change to impact the decision to deflect.

In summary, when police departments deflect as the primary response, they no longer make access to treatment conditional or contingent. In both Charleston and Pima counties, an individual can agree to treatment, receive a police transport to the local crisis center, and then at the door decide not to enter with no legal consequences, meaning that the individual is not arrested for refusing to initiate treatment. The findings suggest support for the implementation of deflection strategies, as well as a need for agencies to critically examine inconsistencies in policies that may result in disparate outcomes. Ultimately, the study finds that deflection strategies can be used to facilitate access to the treatment revolving door, rather than the justice system revolving door.

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Research Report

Behavioral Health Disabilities Diversion Frequent Jail Users May 13, 2021

Connection to Care in a Municipal Jail Setting

Jesse Jannetta and Travis Reginal, the Urban Institute

This brief examines the C2C pilot in Long Beach and its efforts to improve connections to behavioral health and social services for people who meet the definition of “high-frequency utilizers” (HFUs) of the jail, as defined by the City of Long Beach. It is one in a series of briefs supported by the Innovation Fund, an initiative sponsored by the MacArthur Foundation’s Safety and Justice Challenge. It situates the C2C pilot within Long Beach’s broader strategy to reduce jail incarceration among HFUs, outlines strengths and challenges in C2C’s implementation, and provides lessons for other localities seeking to better coordinate services for people who frequently cycle in and out of jail.