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Kansas Medicaid Expansion Could Reduce Jail Populations

Local jails struggling to provide adequate mental health treatment to inmates could benefit from the expansion.

Crawford County, Kan., Sheriff Danny Smith
Crawford County, Kan., Sheriff Danny Smith, seen during a Nov. 2, 2023, interview with Kansas Reflector, talks about mental health needs at his jail. (Sherman Smith/Kansas Reflector)
Crawford County, Kan., Sheriff Danny Smith stretches his arms wide to demonstrate the scope of the state’s struggle to provide mental health care to inmates.

“The main thing, and I imagine every sheriff would say the same thing, is there’s nowhere to take them, or there’s nowhere to take them that’s going to be how you need it now,” Smith said.

His county jail has capacity for about 100 inmates, and he estimates a large majority of them have some sort of mental health problem. Advocates for Medicaid expansion say expanding access to medical care would save jails like his medical costs, cut down on the number of mentally unwell people in jail and reduce recidivism rates.

As things stand, counties in Kansas shoulder in-facility health care and treatment expenses for inmates, a cost that’s become more burdensome because of the severe shortage of room in psychiatric facilities across the state.

The Crawford County Jail and 95 others like it in the state are operated by local governments. They’re responsible for holding inmates waiting for their court date or trial, as well as those serving sentences. In some situations, although not in Crawford County, people who haven’t been accused or convicted of a crime but who are deemed a danger to themselves or others are also processed by prosecutors and sent to the county jail until a hospital bed is ready.

State mental health hospitals — Larned in western Kansas and Osawatomie in eastern Kansas — have been overwhelmed with demand. Though the state has increased mental health beds in the past four years by about 32 percent — with 954 mental health beds now available in the state according to March data — need far outpaces resources.

In the Sedgwick County Jail, which holds more than 1,500 inmates at times, an estimated one-third of the population has some sort of mental illness. Sedgwick County Sheriff Jeff Easter repeatedly has testified before the Legislature about the struggle of figuring out where to house them.

The jail has a mental health pod with capacity for about 55 people. But that’s nowhere near enough, he said.

Looking at July data for inmates waiting to receive care, Easter said the shortest wait time for an inmate to get into Larned for evaluation was 90 days, and the longest was 340 days — nearly a year. One person had to have a deputy watching him 24 hours a day to make sure he was not harming himself.

“We have other inmates that are not as bad as he is, but that we spent an inordinate amount of resources on,” Easter said in a Reflector interview.

Lawmakers approved new reimbursement for county jails during the 2023 legislative session to help offset the expenses that stack up as people wait for health care. The legislation provides $100 per day to counties to help cover those awaiting examination, evaluation or treatment for competency.

Sharon Brett, legal director for the American Civil Liberties Union of Kansas, said the reimbursement lowered costs for counties but had not led to shorter waits or better care.

“In general, jails are not meant to be hospitals,” Brett said. “They are not meant to be places where individuals go to receive comprehensive medical and mental health care services. And we shouldn’t be relying on that as such. It is putting a Band-Aid over a bullet hole, essentially.”
Sharon Brett of the ACLU of Kansas
Sharon Brett of the ACLU of Kansas says the mental health treatment system needs to be fixed. (Thad Allton for Kansas Reflector)
In 2022, the ACLU of Kansas filed a lawsuit against the state over delays in mental health evaluations at Larned. People who face criminal charges have had to wait behind bars for as long as 13 months before getting a pretrial competency evaluation, according to the lawsuit, and in some cases, they spend more time incarcerated while waiting for an evaluation than they would if they had been convicted. The legal case is ongoing.

“They’re essentially warehousing people in local jails where they do not receive adequate treatment,” Brett said.

Brett said Medicaid expansion would provide alternatives.

“If we have more comprehensive, accessible, affordable options here in the community, then individuals are less likely to get to a place where they are untreated in their mental illness so much that they commit a crime and then have to go into the jails and the carceral system more broadly in order to receive mental health care,” Brett said. “These are all in a single continuum of expanding services.”

Smith said he and his staff have implemented measures on their own, such as partnering with community health organizations and bringing in an addiction treatment navigator, but more outside help would be welcomed.

Smith said practices have changed over his almost three-decade-long career.

“When I first started, somebody that had diminished mental capacity, we didn’t bring them to jail,” Smith said. “That didn’t happen when I first started. And then it just seemed like that was the trend that slowly happened because a hospital closes here and there.”

Smith described a holiday weekend a few years ago when the department encountered a woman with suicidal tendencies. His staff members called the state’s suicide hotline, but they could not get her help until Tuesday. So he had a deputy drive the woman over the border to Missouri where she could get immediate treatment.

“It’s just one of those things,” Smith said. “And that’s the difficult thing for everybody, when it comes to mental health, there is no streamlined solution or streamlined therapy. It’s a case-by-case thing that you have to deal with. It is very challenging, and it’s very exhausting for the deputies that are out there, the law enforcement out there, but they’re going to get through it.”

Medicaid Studies

To qualify for the state-run Medicaid program, called KanCare, a person must be either under 19 or over 64, pregnant, or mentally or physically disabled. People responsible for children under 19 and people who have someone disabled in their family also are eligible.

Besides these requirements, the individual must be below a certain income level. An adult with a dependent child at home would qualify for KanCare if they made below 38 percent of the federal poverty level, around $7,493.60 per year.

With expansion, the same adult could make up to $27,214, or any income below 138 percent of the FPL, and still qualify for KanCare, even without meeting other requirements such as caring for a child. An estimated 148,000 more people would be covered through expansion.

Under expansion, the federal government pays 90 percent of Medicaid services and states pay the rest. Kansas is one of 10 states that haven’t adopted the plan, mainly because of Republican opposition in the Legislature. Without expansion, the federal government only covers 61 percent of Medicaid costs.

Democratic Gov. Laura Kelly has touted the multiple benefits of Medicaid expansion in an attempt to get the reform passed in the upcoming legislative session.

“Under the current system, individuals experiencing crisis or struggle with substance abuse frequently end up in our emergency rooms or our jails,” Kelly said during an October Medicaid expansion promotion tour in Pittsburg. “This creates enormous challenges and puts a huge strain on emergency departments, our courts and our law enforcement. That's not to mention the undue burden on people who have mental illness and who would otherwise benefit from treatment or other interventions now. These people just need help.”

Cynthia Snyder, a research analyst for the Kansas Health Institute, co-authored the report “Medicaid Expansion’s Impact on the Kansas Behavioral Health System and Users of Behavioral Health Services.”

Her research showed people who go to county and city jails are likely to have a substance use disorder or mental health condition and lack health insurance. She pointed to a 2017 study from the U.S. Bureau of Justice Statistics that found that 64 percent of jail inmates met the criteria for serious psychological distress or had previously been told by a mental health provider that they had a mental health disorder

“Lack of access to community behavioral health providers is often cited by researchers as a potential cause of higher rates of substance use disorders and mental health conditions among justice-involved populations,” the report said.

Among other findings, the report showed out of the 108,800 adults expected to newly enroll in Medicaid if the health care is expanded, an estimated 24,154 Kansans are likely to use behavioral health services.

“Medicaid expansion, it's been associated with fewer arrests and reduced rates of re-arrest and a reduction in risk, which could potentially lead to reduced incarceration in the criminal justice system,” Snyder said in an interview with Kansas Reflector.

Benefits of expansion, such as increased access to care, reduced medical debt and treatment for mental health and substance use disorders, and cut down on crime rates and arrests, according to Snyder’s report.

“If we can get them all signed up before they walk out those doors, the rate of recidivism would go down significantly,” the governor said in an Reflector interview.
Susie Roling, associate director of Journey to New Life
Susie Roling, associate director of Journey to New Life, says Medicaid expansion would help cut down on recidivism. (Rachel Mipro/Kansas Reflector)

State Correctional Facilities

When Erin Fraser left the Topeka women’s prison for the last time in 2009 with five teeth missing and about to go through withdrawal, she wished Kansas had better mental health and medical service programs.

Dealing with a long history of drug addiction that started when she was a teenager, Fraser said she had been in and out of Kansas county jails and prisons for years.

She described the mental health treatment inside the facility as borderline non-existent. But exiting the system also came with a lot of worries, especially as she experienced withdrawal symptoms.

“It's like these little brain zaps. It's hard to describe my experience, but it's a very uncomfortable feeling,” Fraser said.

Kansas correctional facilities are mandated to provide medication while people are under their care, but once they leave many no longer have access to the medication and go through cold-turkey withdrawal while also struggling to rebuild a life on the outside.

“Medicaid expansion would definitely help re-entry,” said Susie Roling, associate director for Journey to New Life, a Kansas City, Missouri, recovery program for people leaving women’s prisons.

“Re-entry is a community problem, and it can be a community success,” Roling said. “It makes sense for the safety of all of our communities for people coming out of prison to have their needs met. It keeps us all safer.”

Since the state also terminates Medicaid coverage for people in jail — a policy many have called inhumane — people exiting the system are left without medical care until they can re-enroll.
Kansans demonstrate in support of Medicaid expansion during a March 15, 2023, rally at the Statehouse in Topeka.
Kansans demonstrate in support of Medicaid expansion during a March 15, 2023, rally at the Statehouse in Topeka. (Sherman Smith/Kansas Reflector)
David Thompson, spokesman for the Kansas Department of Corrections, said Medicaid expansion was likely to reduce recidivism rates and improve quality of life for many incarcerated people.

The Kansas Department of Corrections contracts with Centurion to provide daily health care needs for inmates. If Kansas were to expand Medicaid, there would be an estimated $3.6 million in annual prison savings for Kansas taxpayers, Thompson said.

Thompson said 82 KDOC inmates qualified for Medicaid in fiscal year 2023. Another 370 inmates, or about 9 percent of the 3,851 who were released during that same period, also qualified for Medicaid under the current guidelines. Under Medicaid expansion, 80 percent of the inmates released would have been eligible for health care coverage.

“Many more residents would then have access to the mental and physical health care they need to get and hold down a job and take care of their families,” Thompson said. “This could reduce recidivism.”

Fraser described the current system as extremely restrictive. With the help of friends, she was able to rebuild her life, earning bachelor’s and master’s degrees in social work.

Now the executive director of Benilde Hall, a Kansas City, Missouri, community-based organization that provides transitional housing and substance use disorder treatment services, Fraser is one of many advocating for better health care in the Missouri and Kansas correctional systems.

“Being able to utilize that benefit is kind of like, ‘Here's your prize, but you can't use it. Here's your resource, but you can't use it right now.’ You can't use it the way you wanted,” Fraser said. “Not only are you having a dehumanizing experience, but you're also having to deal with mental health issues and medical issues because you're not receiving the care.”

This story is part of “The Holdouts,” a reporting collaborative focused on the 10 states that have yet to expand Medicaid, which the Affordable Care Act authorized in 2010. The collaborative is a project of Public Health Watch. This article was first published by the Kansas Reflector. Read the original article.
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