Obamacare in Jail: How San Francisco Policy Helps Inmates

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A new law permits San Francisco Sheriff Department staff to enroll people into health plans. (Thomas Hawk/Flickr)
A new law permits San Francisco Sheriff Department staff to enroll people into health plans. (Thomas Hawk/Flickr)

The San Francisco Sheriff's Department is implementing a new city law allowing its staff to enroll inmates into health insurance under the Affordable Care Act. Sheriff Ross Mirkarimi believes that making sure people have health coverage when they're released will help prevent them from committing another crime and coming back.

“I believe that will go a long way to helping us improve public safety by using a public health strategy,” he said.

He estimates this will help save taxpayers millions of dollars.

One inmate – Sophia – recently requested help signing up for health insurance. Sophia, who asked that her last name not be used, was caught driving a stolen car in January and sentenced to three months in the county jail. She says that was because she stopped getting treatment for her substance abuse and mental health problems when her health insurance expired.

“It stopped in December. And I didn’t get it reinstated. So I didn’t address any of my issues and I guess that’s why I found myself in a car, driving around,” she said.


She thought she might not do that again if she could get back on a health plan. She asked the jail if they could help her find one. Tanya Mara, the director of the health division of jail reentry services, came to walk her through the process of applying for health insurance.

“Prior to your arrest, did you have an income?" Mara asked Sophia. "Does your income change from month to month? What do you expect your income to be for 2014?”

Mara quickly identified a program for Sophia.

“You would likely qualify for Medi-Cal,” she says. “With the Affordable Care Act, you can now qualify for Medi-Cal based on income.” Medi-Cal is California's version of Medicaid, health insurance for people who are low income.

Obamacare has changed two key things for the formerly incarcerated. First, it expanded Medicaid to include childless adults. That means most prisoners will now qualify for the free government health coverage when they get out. Second, all plans must now cover treatment for mental health and substance use disorders –- problems that affect more than half the people in prison or jail, according to a report by the U.S. Department of Justice.

"Captive Audience" for Enrollment

Pretty soon, health insurance sign-ups like Sophia’s will happen for all inmates at the San Francisco county jail -- whether they request it or not. And they’ll happen right when most new arrivals get booked into custody.

“You have a captive audience,” Sheriff Mirkarimi said. He wants to make sure the 30,000 prisoners who come through the jail system every year are covered on the day they’re released.

The sheriff was behind the new city law. It authorizes his staff to enroll people into health care plans under the Affordable Care Act, 24 hours a day, 7 days a week. Other counties and states are exploring similar efforts for people exiting jail or prison.

But Mirkarimi acknowledges that getting coverage is just one small step. Just because someone has a newly minted Medi-Cal card doesn't mean they'll know how to use it.

“No, they’re going to have to demonstrate the wherewithal and resourcefulness to use that Medi-Cal card,” he said. “We, and our staff, help them get ready. But ultimately, it’s on them.”

That’s not how Wanda Fain sees it. She was just released from state prison after 21 years behind bars. Everything is new to her. Getting on and off escalators is weird. Mobile phones are a new concept. She says she needs a friend just to help her ride the bus.

“They tell me what bus we on, they tell me what stops to get off,” she said, “what specific things to look for so I won’t miss a stop.”

Don’t even get her started on housing.

“Us parolees, we can’t leave San Francisco. But at the same token, we can’t afford to stay in San Francisco,” she said. “Cause it’s, what ,$4,000 for a one bedroom? Who coming out of prison got that money?”

Navigating the health care system is even more confusing. Fain has seizures, lymphoma, and bipolar disorder. In prison, the guards regulated all of her care for her. She wasn't allowed to eat a meal until she took her meds. But on the outside, it's up to her to find the right doctor, the right pharmacy –- and to figure out which four buses she needs to take to get there.

“It's little things like that that people think are so easy," she said, shaking her head. “They are so overwhelming.”

If Sheriff Mirkarimi's plan is going to work, people getting out of jail are going to need help on the other side.

Clinic Helps Former Prisoners Navigate Health Care System

Most inmates leaving jail or prison are like Fain and have several chronic conditions. And most are so focused on other things that they rarely get medical help until things are so bad that they end up in the Emergency Room.

“These are really some of the sickest patients we see in our system,” said Shira Shavit, a family doctor in San Francisco. “They have high rates of hospitalization, very high rates of using the emergency room, and also very high rates of death.”

Dr. Shavit is trying to shift those trends. She’s the director of The Transitions Clinic, a specialized program designed for former prisoners, where doctors, psychiatrists, and social workers all consult together on the same patients. But its key staff are community health workers who have all spent time behind bars, too; people like Juanita Alvarado who help patients with all the tasks that would otherwise get in the way of caring for their health -- applying for housing, social security, finding a job, printing out paperwork or bus maps.

“Basically holding their hands in the first few weeks after they’re out,” Alvarado said.

She keeps the bookshelf behind her desk stocked with soup, breakfast bars, peanut butter, and tuna fish. A lot of their patients are denied food stamps because of drug convictions and have trouble finding affordable groceries.

“So I hook them up with a little bag,” Alvarado said.

The one-stop-shop approach works. Transition program patients show up for their appointments at higher rates than other patients, and, Dr. Shavit says ER use among their patients has dropped by 50 percent.

That caught the attention of the federal government, which foots a lot of those ER bills with taxpayer dollars. It gave the clinic a special $6.8 million innovation grant created under the Affordable Care Act to expand the concept beyond San Francisco. The team is using the money to help 11 clinics in six states and Puerto Rico hire and train former prisoners to staff similar programs. Federal health officials believe this will ultimately save $8 million.

The even broader goal – for both Mirkarimi’s plan and the Transitions Clinic – is that health care will help keep people from going back to jail or prison. Recidivism rates have dipped in recent years, but they are still high – 61 percent of people who leave a California prison return within three years. For people on parole or probation in San Francisco, the rate is even higher.

Wanda Fain feels like she’s just skirting those statistics. She lives a short walk away from the Transitions Clinic and comes often to get help with a range of tasks and health issues.


“If I didn't have Juanita Alvarado, or Dr. Shavit, or any of them, I’d be in – I don’t know where I’d be,” she said. “Probably on my way back.”