PEDIATRICS Vol. 121 No. 2 February 2008, pp. e397-e398 (doi:10.1542/peds.2007-0780)
COMMENTARY |
Role of Pediatricians as Advocates for Incarcerated Youth
a Department of Pediatrics, University of California, San Francisco, California
b Department of Pediatrics, Stanford University School of Medicine, Stanford, California
Abbreviations: AAP, American Academy of Pediatrics • SB, Senate bill • HB, House bill
In the United States an estimated 88000 youth are released from juvenile detention facilities each year.1 Youth exiting the juvenile detention system suffer from high rates of health risk behaviors and a disproportionate share of adolescent morbidity and mortality.2–5 These youth often lack access to the health care system, and their incarceration is their only contact with a physician outside of any emergency setting.6–8 The time of their release provides a critical opportunity for connecting these youth with the medical system to establish a medical home. During their reemergence into the community, these youth need as much support as possible, and physicians can play an important role.
In 2001, the American Academy of Pediatrics (AAP) issued a policy statement stating that children and adolescents confined to correction care facilities should have special attention focused on, among other things, the establishment of a medical home before release.7 The AAP's "medical home" concept is an ideal model of health care delivered or directed by a physician who provides preventive, acute, and chronic care that is accessible, continuous, comprehensive, compassionate, and coordinated with specialized services such as mental health provided by community agencies.9 One big obstacle for youth exiting detention to establishing medical homes is their insurance status. Uninsured individuals are less likely to have a usual source of care.10 Not only are incarcerated youth less likely to be enrolled in federally sponsored health insurance programs before incarceration, in most states those who were enrolled previously have their insurance terminated at the time of their incarceration, because the state is required to assume their health coverage while they are incarcerated.11
Gupta et al11 outlined the policy issues and barriers to care for these youth in a 2005 Pediatrics commentary. They cited federal legislation including code of federal regulations statute 416.21112 and statute 1905(A) of the Social Security Act,13 which exclude federal financial participation in "care or services for any individual who is an inmate of a public institution" unless the individual is in a medical institution. As a result, most states terminate a youth's Medicaid benefits on incarceration.14 As Gupta et al pointed out, states have an option to suspend rather than terminate such youths' public health insurance program benefits. Many states terminate coverage for fear of potential billing duplication, because they are responsible for providing necessary services. An alternative option is to apply presumptive eligibility in enrolling these youth into programs at release. However, states are wary of adopting this policy for fear of the state paying health care costs for individuals who are later found to be ineligible for public health insurance.
As states continued to struggle with this complex situation, we identified a policy change that we believe could address the challenge. We wrote a piece of legislation that requires the county of jurisdiction to assess the eligibility and enroll youth for public health insurance before their release back into the community. After identifying a state assembly member and senator interested in sponsoring this legislation, we worked with their staff to devise the proper wording that would accomplish our aims. As clinicians, we built a broad coalition including pediatricians, psychologists, juvenile court judges, parole officers, social workers, and lawyers to work toward the bill's passage. We attribute the success of this legislation not just to the power of our testimony as clinicians in front of legislative committees but also to our success in bringing together the endorsements of medical groups such as the AAP and the California Medical Association, legal advocates for youth such as Youth Law and the Youth Law Center, and various other parties involved in the welfare of these youth. We conducted several letter-writing campaigns on behalf of pediatricians and so mobilized the voices of the primary medical providers of these youth. By using pediatricians as the advocacy voice of this disenfranchised pediatric population, we were able to create systemic change in the realm of their health policy. The legislation, Senate bill (SB)1469, passed both the California Senate and Assembly and was recently signed into law by Governor Schwarzenegger. Through this legislation, the first impediment to creating medical homes for these youth has been removed.
Although SB1469 targets health insurance coverage for youth who are exiting detention, other states have taken steps to provide mental health services for youth in the juvenile justice system. In Colorado, the state enacted SB06-005, which requires health insurance providers to cover the cost of mental health services, which have been ordered by either the criminal or juvenile justice court. In Rhode Island, the state enacted House bill (HB)7120, which requires that all insurance policies or contracts cover children's intensive services. Such services include, but are not limited to, juvenile justice and local police services, assessments and evaluations, therapy, and intervention services pertaining to mental health or substance abuse problems. In Massachusetts, the state enacted HB4756, which intends to create an alternative to detention by making behavioral health services more accessible. HB4756 ensures that children who lack private insurance and have been recommended by the court to obtain behavioral health services as an alternative to incarceration shall be enrolled in the state's public health insurance program.
Although we are hopeful that SB1469 will help facilitate detained youths' access to health insurance on release, we also realize that legislation has no weight unless it has both a system by which to ensure its implementation and a tool by which to evaluate its efficacy. As a result, once SB1469 was enacted into law, we began implementing the steps necessary to facilitate counties' participation in the enrollment process. In partnership with a legal advocacy organization, Youth Law, we are implementing county-specific training sessions throughout the state on how to assess eligibility and enroll detained youth into public health insurance programs. In addition, we have devised a questionnaire that will be sent to all of the county juvenile halls in California. This short questionnaire asks the juvenile halls to record the number of youth who were routinely evaluated for public health insurance eligibility on exiting their juvenile hall before and after the enactment of SB1469, the number of those who were found eligible, and the number of those who were subsequently enrolled. We will then analyze these numbers on an annual basis to evaluate the efficacy of our legislation. We have built supportive relationships with medical directors at several of the major county juvenile detention centers, which will be important to the success of our monitoring program.
Much remains to be done, because youth entering the juvenile detention system face substantially higher rates of both mental and physical health disorders and are traditionally of the lowest socioeconomic backgrounds.2–5 By taking this first step to connect these youth to a medical home, their physical and mental health diagnoses will continue to be addressed after their incarceration. There then emerges the opportunity to connect these youth to appropriate community agencies, thus creating assets for these isolated youth who stand at an important crossroad. It is these connections that may allow a child to exit his or her life of crime.
Through the success of this bill, we have seen a unique role that pediatricians can play in advocating for youth: we can create and help pass legislation that facilitates our profession's opportunity to connect with and support a group of youth and their families whom most of society has abandoned. If we do not advocate for these children, who will?
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FOOTNOTES |
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Accepted Jun 19, 2007.
Address correspondence to Mana Golzari, MD, 505 Parnassus Ave, M 691, San Francisco, CA 94143. E-mail: mana.golzari{at}gmail.com
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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