The Effects of Insurance Status and Medical Need on Community-Based Health Care Access Among Jail Detainees with Serious Mental Illnesses

Background & Purpose. In comparison to the general population, individuals with serious mental illnesses (SMI) are at increased risk for developing co-occurring chronic medical conditions and for experiencing barriers to accessing medical care. Evidence also suggests individuals with SMI involved with the criminal justice system (CJS) are at even greater risk for experiencing poor health outcomes. Despite the need for medical services among the CJS-involved SMI population, research exploring the factors that impact patterns of community-based medical service use is limited. To address this gap, this study explored how access to and use of medical care prior to detention was impacted by insurance status and level of medical need among jail detainees with SMI.

Methods. Adult male (N = 305) and female (N = 154) detainees in residential psychiatric treatment within the Cook County Jail in Chicago were randomly selected and administered the WMH-CIDI to obtain data for the main independent (insurance status and level of medical need) and dependent variables (having a regular place for care, number of visits for routine care, number of visits for emergency care) as well as socio-demographic and psychodiagnostic covariates such as race/ethnicity, age, education, homelessness, and DSM-IV-TR Axis I psychiatric diagnoses including substance abuse. A binary logistic regression assessed the associations of the predictor set with having a regular care provider. Zero-inflated negative binomial (ZINB) and negative binomial regressions tested for associations  with utilization rates of non-emergency and emergency care visits respectively. All models estimated robust standard errors with weighting and stratification to control for survey design effects.

Results. After adjusting for socio-demographic and psychodiagnostic factors, insured participants (AOR=0.83, p< .05) with at least a moderate need for medical care (AOR=2.79, p < .05) had higher odds of having a regular health care provider or clinic. Medical insurance was also associated with a higher rate of routine care (IRR=2.75, p < .01) but a lower rate of emergency care visits (IRR=0.46, p < .05). Both insurance status and need for medical care were strongly associated as inflation factors in the ZINB model of routine medical visits. Those who were insured and those with a high need for medical care had extremely low odds (AOR<.001, p < .001) of having no past-year medical visits.

Conclusion & Implications.  Insurance status and increased medical need increase access to as well as the rate of health care use. While these results suggest the Affordable Care Act (ACA) provides an important opportunity to expand access to care for the CJS population with SMI, they also point to the importance of the establishment of medical homes that provide coordinated medical and mental health care for individuals with co-occurring medical and behavioral health conditions. This is especially true for the small but medically complex group of individuals with a high level of medical need and multiple co-occurring behavioral health disorders. In this rapidly emerging context, social workers will have a substantial role providing health care navigation for those in the CJS with SMI who obtain insurance under the ACA.