Legalization: The Necessary Path Forward

Legalization: The Necessary Path Forward

Josh Pagano, D.O.

How do Joe Biden and Cory Booker differ on their policy stances on marijuana decriminalization and legalization? Which is the better policy?

Legalization of marijuana has become a major issue in the Democratic primary, inspiring the now-viral moment in which Cory Booker quipped at Joe Biden, “I thought you might have been high” when Biden announced he did not support the legalization of marijuana.

The criminalization of mental illness and addictive disorders is the major stressor affecting many stigmatized patients. Incarcerated people with substance use disorders are disproportionately poor and African American. As if suffering from addictive disorders were not difficult enough, the ramifications of resulting arrests are also debilitating. The immediate effects include job loss and homelessness, and the intermediate effects include all of the psychological consequences of incarceration — the trauma of physical violence, the fear for one’s safety, and the pressure to join gangs. Individuals leave prison having missed large portions of their family lives, with resulting damage to meaningful relationships. All of these effects compound with the long-term consequence of a criminal record that significantly limits the ability to acquire jobs or housing, and ultimately increases the risk of future violence and recidivism.

Of all illicit drugs, the one resulting in the most arrests is marijuana. Democratic candidates, Joe Biden and Cory Booker, propose different policies regarding how to address the legal status of marijuana. 

Joe Biden supports the decriminalization of the personal use of small amounts of marijuana, claiming that “The punishment should fit the crime, but I think legalization is a mistake.” Instead, he would prefer to reclassify marijuana from a Schedule I Controlled Substance (where it currently resides with Heroin and LSD) to a Schedule II Controlled Substance (listed alongside Dilaudid®, Percocet®, and Fentanyl). However, the unlawful possession of a Schedule II Controlled Substance is a misdemeanor or a felony depending on local state laws, implying that such a re-classification would likely not affect the rates of marijuana-related arrests. It is unclear how Biden will square this with his stance that marijuana should be decriminalized. 

As a point of comparison, alcohol was not always legal. The prohibition of alcohol between 1920 and 1933 initially reduced alcohol use and alcohol-related harm, but these benefits diminished over time as a black market developed to meet consumer demands. A review of arrest records indicates that prohibition had an immediate effect but no long-term impact on public intoxication. Moreover, Harvard University historian, Lisa McGirr, points out that prohibition had unduly adverse effects on African Americans, immigrants, and those with lower socioeconomic status. Law enforcement disproportionately policed these communities. Much like the war on drugs.  

Conversely, it was the legalization and regulation of alcohol, not its decriminalization, that helped America prosper. After the repeal of prohibition, the U.S. reduced criminal violence costs and accumulated billions from tax dollars, which were often earmarked for education, healthcare, addiction treatment, and prevention programs. What’s more, taxes reduce alcohol consumption, as they would similarly limit marijuana use. 

Cory Booker seeks to legalize marijuana and remove it from the Controlled Substances Act entirely. Booker has said, “It’s not enough to simply decriminalize marijuana. We must also repair the damage caused by reinvesting in those communities that have been most harmed by the War on Drugs. And we must expunge the records of those who have served their time. The end we seek is not just legalization, it’s justice.”

While those opposed to legalization argue that it would lead to increases in cannabis-related medical harms (e.g. pulmonary disease and psychosis), mere decriminalization also carries its own costs. Cannabis smokers will still primarily acquire their marijuana from unregulated and often violent drug cartels. Neighborhoods will still live in fear. Young people will still join gangs. Communities of color will still be over-represented in drug arrests. Only legalization will directly address these factors.

Upon legalization, preemptive policies can be implemented to mitigate the anticipated increase in marijuana use. With proper taxes, age restrictions, and prevention programs, society can reap the benefits of lower crime rates and less undue incarceration. To be sure, there is a cost to every solution, including legalization. However, decriminalizing marijuana will not decriminalize mental illness, and ignoring the societal cost of mass incarceration is more than we can continue to bear.  

Unfortunately, the issues of marijuana legalization and criminal justice reform were excluded from the Democratic Debates in December. As we approach the first primary votes, we can only hope that the American people will notice these omissions and take the initiative to continue this conversation. In Senator Booker’s absence, it will be up to the remaining candidates to pick up the torch and light the way toward reforming our criminal justice system.

Joshua Pagano, D.O. is a member of Physicians for Criminal Justice Reform. He is a forensic psychiatrist who specializes in competence to stand trial evaluations and the treatment of severe mental illness.

A New Partnership for PfCJR

PfCJR Partners With A New Criminal Justice Taskforce From ACOEM

In 2016, the United States held 2.2 million people in prisons and jails, and about 870,000 of these inmates performed some type of work, whether supporting the functioning of the prison, for prison industries, or under contract for private corporations.

 

They work jobs with well characterized occupational hazards – agriculture, manufacturing, fire fighting, chemical production, and many others – yet our standard occupational health surveillance systems (eg OSHA and NIOSH) explicitly ignore work-related injuries, illnesses, or fatalities in this “institutionalized” population.

 

Furthermore, there are precisely zero articles in our medical and public health literature addressing the occupational health of prisoners, and prison inmates are almost completely excluded from every major labor and employment protection in the US.



 Finally, inmates are exposed to all the unique hazards of the prison environment – psychosocial stressors, physical and social isolation, poor institutional oversight, and vulnerability to exploitation, powerfully suggesting that these workers suffer higher rates of injury and illness compared to counterparts in the free market.

 

Herein lies the opportunity – physicians have precisely the training and authority to guide research and address hazards in prisoners’ workplaces. That research must document current injury and illness rates and advocate workplace controls equivalent to those in the free labor market. We must also characterize unique hazards faced by inmates, informed by social epidemiological and qualitative methods, while recognizing the larger environmental forces shaping their overall safety. 

 

The following article is the first to ever recognize the position inmates hold as the most marginalized of occupational populations, written by a member of the Incarcerated Workers Occupational Health Task Force, under the American College of Occupational and Environmental Medicine (ACOEM). OEM physicians are certified by the American Board of Preventive Medicine and specially trained to attend to the health of workers through epidemiological investigation, direct medical care, prevention of occupational injuries and illnesses, and protection from environmental hazards.

 

This task force will be applying precisely these skills to address the workplace health of incarcerated workers. In the coming years we will confirm a literature review, scope and plan a research strategy, identify stakeholders, and publish the initial results from our investigations, but a challenge of this magnitude will require broader expertise.

 

The Task Force is seeking partners from all other medical specialties to help. Virchow reminds us that “It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation,” but together we can build this research from the ground up, propose policy, and to lend the powerful, trusted, and moral voices of physicians to a critical and growing conversation about criminal justice reform. 

 

Andre Montoya-Barthelemy MD MPH

    Incarcerated Workers Occupational Health Task Force

    American College of Occupational and Environmental Medicine

    agmb1214@gmail.com

 

Andre Montoya-Barthelemy is a physician of Occupational and Environmental Medicine (OEM) in Minneapolis, Minnesota. He is a recent graduate of the HealthPartners OEM residency where he completed his thesis on the labor rights of incarcerated workers, and now serving as clinical faculty, assistant residency director, and consultant medical director for Xcel Energy and General Mills. He intends to continue searching for ways for physicians to combine their unique skills and voice to address topics of human rights.

The right to healthcare: A false promise of health in America’s prisons

Last month’s coverage of the conditions at Riker’s Island have people across the country appalled. Dr. Vernier, former physician at Riker’s Island, shared many of his experiences with patients at the prison with NPR, describing the horrific case of Carlos Mercado, who died within 15 hours of arriving at the prison due to complications of his diabetes. He had been denied insulin during the intake process.

Prisoners are the only people in the country with a constitutional right to healthcare, under the 1976 Supreme Court Estelle v. Gamble decision, which held that withholding healthcare from prisoners constituted “cruel and unusual punishment,” prohibited by the Eighth Amendment. But isn’t the case of Carlos Mercado grounds for “cruel and unusual punishment?” The right to healthcare seems to be a false promise at Riker’s, especially when we consider the facility’s history.

Riker’s is notorious for cruelty and inhumane treatment of prisoners. Earlier in de Blasio’s appointment as city mayor, a 2014 report from U.S. attorney Preet Bharara detailed graphic human rights abuses and use of violence against adolescent males placed at Riker’s Island. One such account from 2012 reads:

“…Inmate F, a mentally impaired inmate, was repeatedly punched in the face by an officer who has been involved in well over 20 other RNDC use of force incidents. Although the officer admitted that he delivered multiple blows to the inmate’s face, the Department concluded that the force used was appropriate based on the officer’s contention that he was acting in self-defense… There is no video of the incident…

…Inmate F reported that the officer challenged him to a one-on-one fight… According to DOC records, the officer was involved in a total of 24 use of force incidents… from 2007 through early 2013, including eight incidents in 2012 alone. He also has been subject to repeated disciplinary actions.”

Unfortunately, these human rights violations persist not just at Riker’s, but as an inherent part of the nation’s correctional system. Earlier this year, approximately 1,600 prisoners at the Metropolitan Detention Center in Brooklyn were left with sporadic heating and no lighting over the course of multiple days. Families were left completely in the dark about the fact that their loved ones were suffering in the facility. No generators were powered on to restore lights and heating as detainees pounded on the windows in retaliation to being left to freeze.

There are physical health consequences of being unable to read your medication labels in the dark. However, more latent are the mental health repercussions when prisoners realize they are not just trapped, but that there is nobody to even allow them their basic rights or human dignity. The right to healthcare applies to mental as well as physical health. We need to take a close look at outcomes to truly assess whether the right to healthcare is upheld in prisons or not.

The capacity for cities like New York to harm people through incarceration is vast, and there is a poor track record of tangible benefit coming from imprisonment for those detained nationwide. In 2016, the Avid Prison Project described that solitary confinement routinely exacerbates symptoms for those with mental illness. Moreover, inmates with psychiatric needs are put on waiting lists for hospital treatment much too often, even when hundreds of beds are available. It seems that the right to healthcare is a promise to take two leaps back for every small step forward.

Broken policies that keep the mentally-ill from receiving care in prisons can change. We can start by re-routing those with mental health needs from prisons to programs focused on healing and reintegration for the 42% of inmates at Riker’s Island who suffer from mental illness. Instead of reverting to punishment-based criminal justice, we can transform the lives of those in prison and reduce incarceration rates by expanding proven alternatives to incarceration.

In particular, we should expand New York’s assertive community treatment (ACT) programs for those with mental illness. Programs like Manhattan ACT bring holistic treatment and therapy to those with mental illness who face incarceration due to a felony arrest directly to them in their communities. Manhattan ACT itself has seen a 36% decrease in psychiatric hospitalizations among program participants in Northern Manhattan. In addition to their mental health benefits, ACT programs have also reduced recidivism rates. Nathaniel ACT’s graduates since 2014 have had no violent arrests within one year of graduation and its graduates since 2013 had no new felony convictions within two years. ACT programs turn lives around and are one just solution to the crisis of housing the mentally-ill in federal and state prisons.

The right to healthcare is one of prisoners’ civil rights, protected under the Eighth Amendment to the Constitution. However, if prisoners are delayed necessary treatment and placed in conditions that worsen their health problems, then this right is far from being upheld seriously. With 45% of federal prisoners having mental health or behavioral problems, we need to expand evidence-based alternatives to incarceration like ACT programs and work with our communities instead of against them.

Syed Kaleem is a medical student at Drexel University College of Medicine. He is a fellow of Physicians for Criminal Justice Reform. @ZaneKaleem on Twitter

Waffle House: America’s Best Place To Eat, Not Engage Police

by Drs. Otega Edukuye, Christopher Hoffman, Kevin Simon, and Christopher Smith on behalf of Physicians for Criminal Justice Reform, Inc.

If you have lived in the South, you know Waffle House for its 24-hour table service and meals like the All-Star breakfast served with a waffle, bacon, eggs, toast, and hash browns – scattered, smothered and chunked for under ten bucks. If you lived in this country last year, you also know Waffle House as the place where 22-year-old Anthony Walls and 25-year-old Chikesia Clemons were manhandled by police. Then, tensions were so high that Bernice King, daughter of Martin Luther King, Jr., called for a boycott of Waffle House. [1] While the media coverage has dwindled, we will revisit these situations so that passion for change and resolve does not die when the incidents are no longer headlines.

We empathize with Ms. Clemons and Mr. Anthony and recognize that her experience at Waffle House is representative of a larger dilemma. As Black male physicians, these incidents are a grim reminder that our medical degrees will have little influence on our path to address health disparities as long as the criminal justice system ensnares and oppresses those of the darker skin tone.  As more videos of police exerting excessive force on people of color continue to surface, it is evident that a paradigm shift in law enforcement is necessary.

Many argue that the constant influx of police brutality videos overestimate its occurrences, but the evidence and available literature suggest otherwise. It is estimated that law enforcement officers use measures of force against Black people a staggering 3.6 times higher than when dealing with White people. [2] These differences persist even when controlling for variables such as alleged offense committed and type of force utilized. The study “Deaths of People with Mental Illness during Interactions with Law Enforcement” found that “African American race and presence of mental illness were strongly associated with fatalities.”

Our concern is that while there is compelling data to support that over-use of force against citizens of color is indeed a real issue, there is resistance among law enforcement agencies to adopt tactics that will universally decrease excessive use of force, namely, de-escalation training.

In these videos, we noticed that police rarely attempt to reduce the suspect’s tensions. As fourth-year psychiatry residents, we have been skillfully trained in human behavior and treatment of patients with mental health concerns. We realize that approaching agitated people with demands and hostility rarely, if ever, improve a situation. Each of us has successfully de-escalated many of our agitated patients by simply talking with them; no physical contact or medications. Although conditions for a police officer in a community differ from those we face as doctors on the psychiatry wards, there is ample evidence that increased training in de-escalation could have merit for professionals working to save lives and keep the peace across disciplines.

According to reporter Albert Samaha, “excessive force complaints against the Dallas Police Department dropped by 64% between 2009 and 2014. The number of arrests and officer-involved shootings also declined in recent years.” [3] The changes Dallas Police Chief David Brown implemented emphasized de-escalation. Brown stated, “Rather than running into a situation, take your time approaching a suspect, talk over a strategy with your partner. Have just one officer talking with a suspect — rather than multiple people shouting — try to build a rapport with the suspect.”[4] To us, calm discussion with an agitated individual seems the obvious first step. We perceive this unfathomable opportunity a loss in the fact that nearly 70% of states do not require de-escalation training for police. [5]

With all the videos, data, and protests by those marginalized by the majority, police still maintain permission to overstep justice in their attempt to restore order and make an arrest. The United States was founded nearly 250 years ago, and yet, people of color continue to find themselves treated as second-class citizens. As Black men and physicians backed by Physicians for Criminal Justice Reform, we are advocating for concerted collaborative change within the policing community. While Waffle House employees should receive better training, the positive impact on disenfranchised communities and people of color will be greatest if police training across the U.S. included de-escalation training. As psychiatrists in training, we know that as protracted trauma and mistrust persist, the psychological effects worsen and become intractable. Until we see genuine changes in the way law enforcement engages our communities, tensions between police and Black people will not improve.

 

REFERENCES

  1. Baer, Drake. “The Dallas Police Force Is Evidence That ‘De-Escalation’ Policing Works.” The Cut, 8 July 2016, www.thecut.com/2016/07/deescalation-policing-works.html.
  2. Cognac , Chris. “Ready, Set, Engage! Ideas and Options for Community Engagement and Partnership Building.” COPS, June 2015, cops.usdoj.gov/html/dispatch/06-2015/community_engagement_and_partnership_building.asp.Samaha, Albert. “Dallas Officer-Involved Shootings Have Rapidly Declined In Recent Years.” BuzzFeed, BuzzFeed, 8 July 2016, www.buzzfeed.com/albertsamaha/dallas-police-numbers?utm_term=.ead1DP0L8.
  3. Samaha, Albert. “Dallas Officer-Involved Shootings Have Rapidly Declined In Recent Years.” BuzzFeed, BuzzFeed, 8 July 2016, www.buzzfeed.com/albertsamaha/dallas-police-numbers?utm_term=.ead1DP0L8.
  4. Gilbert, Curtis. “Most States Neglect Ordering Police to Learn De-Escalation Tactics to Avoid Shootings.” What It Takes | APM Reports, 5 May 2017, www.apmreports.org/story/2017/05/05/police-de-escalation-training.
  5. King, Bernice. “Family, Let’s Stay out of @WaffleHouse until the Corporate Office Legitimately and Seriously Commits to 1) Discussion on Racism, 2) Employee Training, and 3) Other Plans to Change; and until They Start to Implement Changes. Https://T.co/NJWFOBKN7i.” Twitter, Twitter, 10 May 2018, twitter.com/BerniceKing/status/994564295374655488.

Alton Sterling, Philando Castile and Dallas Police Killings: PfCJR Call to Action. Open Conference Call Monday, July 11, 2016 at 9:00PM EST

PfCJR OPEN CONFERENCE CALL MONDAY, JULY 11, 2016 AT 9:00PM EST

  In the last four days, this country has watched a devastating series of tragedies unfold.  We watched police shoot Alton Sterling at point blank range while pinned to the ground.  We watched Philando Castile die after being shot four times by a police officer in front of his fiancée and daughter.  We watched Dallas police officers massacred even as they seeked to protect citizens at a peaceful protest.   All of these have served to underscore the urgency of acting NOW to begin combatting the forces that are driving these events. pfcjr call invite Physicians for Criminal Justice Reform invites you to join us on an open conference call this Monday, July 11, 2016 at 9:00pm EST.  You do not need to be a physician to join either the call or the organization.  We recognize that we need the unified voices of all allies if we are to effect meaningful, lasting change.  Click the graphic above for more details about the call.  If you haven’t already, please join us at www.pfcjreform.org/join so we can keep you informed of updates.   Please spread the message far and wide.  We need as many voices as possible.

Legislation – S.2123 – Sentencing Reform and Corrections Act of 2015

S.2123 – Sentencing Reform and Corrections Act of 2015
People of color comprise more than 60 percent of the population behind bars despite making up only approximately 39.9 percent of the U.S. population. Policymakers act to end mass incarceration and overcriminalization—particularly with regard to how they affect poor communities and communities of color—by creating an equitable and balanced justice system that removes unnecessary barriers to opportunity for people with criminal records. Congress is now moving to address some of these issues. The Sentencing Reform and Corrections Act of 2015, also known as the Sentencing Reform Act. The bipartisan Sentencing Reform Act includes several key recommendations proposed by the Center for American Progress, including improving the accuracy of criminal history records and sealing or expunging juvenile records under certain circumstances. The bill takes a number of steps to end the unnecessarily harsh penalties and outcomes that characterized the now-discredited policies of the tough-on-crime era. These measures include:

  • Expanding the existing safety valve and giving judges additional discretion to relieve significant numbers of people from unnecessarily harsh mandatory minimum sentences
  • Making the Fair Sentencing Act of 2010 retroactive, thereby making the reductions in the sentencing disparities between crack and powder cocaine—disparities that have a disproportionate racial impact—available for thousands of current federal prisoners
  • Providing sentence reductions and early releases for prisoners who successfully complete rehabilitation programs
  • Limiting the use of solitary confinement for juveniles in federal custody
  • Providing for the sealing or expungement of juvenile criminal records under certain circumstances, which would help create opportunities for young people to overcome or avoid many of the barriers that confront those with criminal records, including barriers to employment, housing, and education
  • Requiring the attorney general to develop a process for individuals who are undergoing employment criminal background checks to challenge the accuracy of their federal criminal records, which would help to address the well-documented problem of errant criminal records databases

Legislation – S.993/H.R.1854 – Comprehensive Justice and Mental Health Act of 2015 – passed Senate

S.993/H.R.1854 – Comprehensive Justice and Mental Health Act of 2015 – passed Senate, currently Referred to the Subcommittee on Crime, Terrorism, Homeland Security, and Investigations (House). Introduced by Senator Al Franken (D-MN) and Representative Doug Collins (R-GA) – primarily reauthorizes and improves the Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA) of 2004. The legislation would also:

  • Continue support for mental health courts and crisis intervention teams;
  • Expand services to veterans that include treatment court programs, peer to peer services, appropriate services to veterans who have been incarcerated, and training programs for criminal justice, law enforcement and corrections personnel to identify and respond to incidents involving veterans with a mental health condition;
  • Make grants to provide broader training during police academies and orientation that teach law enforcement personnel how to identify and respond to incidents involving persons with mental health disorders;
  • Would create programs that offer federal first responders and tactical units comprehensive training in procedures to identify and respond appropriately to incidents involving mentally ill individuals;
  • Increases focus on prison and jail-based programs;
  • Gives local officials greater control over program participation eligibility; and
  • Requires annual audits of all grant recipients to prevent waste, fraud, and abuse of funds by grantees.

The legislation extends the Mentally Ill Offender Treatment and Crime Reduction Act , including support for mental health courts and crisis intervention teams; supports efforts to identify people with mental health conditions at each point in the criminal justice system and direct them to appropriate mental health services; specifically directs assistance to veterans with mental health conditions in the justice system; and increases focus on corrections-based programs and supports additional training for law enforcement officials. APA endorses S.993.

Legislation – HR 2646, the Helping Families in Mental Health Crisis Act of 2015, House Energy and Commerce Health Subcommittee passed

HR 2646, the Helping Families in Mental Health Crisis Act of 2015, House Energy and Commerce Health Subcommittee passed.

Positives of legislation:

  • Screening and early intervention;
  • Community-based systems of care;
  • Enhancing the behavioral health workforce;
  • Innovation to develop new evidence-based programs;
  • Integration of health and behavioral health care;
  • Enforcement of parity in coverage between health and behavioral health services;
  • Incentives for Assisted Outpatient Treatment (AOT) rather than mandates;
  • Elevation of behavioral health in the federal government, including increased coordination of services; and
  • Suicide prevention based on the Garrett Lee Smith Act Reauthorization.

 

Additions needed

  • Provisions that best support the development of a properly-credentialed peer workforce that can work competitively in clinical settings;
  • Preservation of Protection and Advocacy organizations’ flexibility to promote recovery and non-discrimination for individuals with serious mental illness, not only to prevent abuse and neglect;
  • Funding for community mental health programs with money taken from the jail and prison system, not from other health services; and
  • Assurance that individuals with serious mental illness will be able to voluntarily access to the services associated with AOT, and that community-based services will be adequately funded.

American Psychiatric Association (APA), Mental Health America (MHA) endorse HR 2646.

Medicaid Expansion Shifts Focus to Improve Re-Entry and Community Transitions

Medicaid Expansion Shifts Focus to Improve Re-Entry and Community Transitions – Erick Allen Eiting

Mass incarceration has had a significant impact on urban America. Los Angeles County and New York City represent the largest municipalities in the country, and they also have some of the highest incarceration rates. Both New York and Los Angeles have taken recent steps to improve the health and healthcare provided to their inmates. Rikers Island in New York had previously contracted out its correctional healthcare to a private company. Last spring, Mayor Bill de Blasio shifted this care to Health and Hospital, the network of public hospitals and clinics in New York City. Similarly, the Los Angeles County Board of Supervisors voted to move correctional care to its Department of Health Services, a similar healthcare network that provides public medical care.

Several provisions in the Affordable Care Act (ACA), often referred to as Obamacare, were major drivers in these decisions. The Medicaid expansion under the ACA includes several provisions that make it easier for inmates to qualify for insurance while they are incarcerated. This has shifted the focus of many providers to improving the re-entry process to society for released inmates, reducing recidivism and addressing the social determinants of healthcare for these patients. All eyes will be on these two large, urban areas to see the impact of this expansion. Medicaid coverage is only the first step. Inmates will need appropriate community transitions and treatment options to ensure access to housing, substance abuse treatment and mental health care to have a significant impact on mass incarceration. PfCJR salutes these two cities for their progressive, patient-focused approach to this issue.

Expedited Medicaid Access Increases Use of Mental Health Services, Unfortunately Did Not Reduce Recidivism for Those Recently Released from Prison

Expedited Medicaid Access Increases Use of Mental Health Services, Unfortunately Did Not Reduce Recidivism for Those Recently Released from Prison – Kristin Huntoon

Providing expedited access to Medicaid to people with serious mental illness as they are released from prison increases their use of mental health and general medical services, but does not reduce criminal recidivism, according to new research published online today in Psychiatric Services in Advance.

People with serious mental illness depend on public-sector mental health services and are covered primarily by Medicaid. Most states suspend or terminate Medicaid for prison inmates. At any given point, an estimated 250,000 people with severe mental illness are in prisons, and more than a million others are on probation or parole in the U.S. Many have difficulty accessing mental health services and other services when they leave these institutions. Lack of health insurance can be a particular barrier to access.

The study used data from Washington state to look at whether enrolling people with severe mental illness in Medicaid before their release from prison increased their use of community mental health services and reduced rearrest and reincarceration rates. State and local programs that expedite Medicaid enrollment for people being released from jails and prisons have become more common in recent years as part of efforts to reduce soaring criminal justice costs.