Individuals involved in the criminal justice system often have complex health needs—rates of mental illness, substance abuse, and other health conditions are as much as seven times higher for justice-involved individuals than the general population. Behavioral health issues in particular are prevalent among the justice-involved population. Estimates are that approximately 56 percent of individuals in state prisons and 64 percent of individuals incarcerated in jails have a mental illness. Further, the majority of incarcerated individuals with mental health issues also have a co-occurring substance use disorder. Connecting justice-involved individuals with behavioral health issues to appropriate treatment services either as an alternative to incarceration or upon release is crucial for meeting their needs as well as potentially contributing to lower recidivism rates and government costs.
Effectively addressing the behavioral health issues of individuals involved in the criminal justice system requires coordination and a shared accountability approach among a diverse group of stakeholders and officials at both the state and local level. One widely-recognized tool that can help states and communities is the Sequential Intercept Model, which identifies different points within the criminal justice system to link justice-involved individuals with behavioral health disorders to services rather than incarceration when appropriate. The model’s five intercept points and associated action steps begin with initial local law enforcement interaction and include court hearings and community reentry services. For example, to help increase access to treatment services upon returning to the community and promote successful reentry, some states that expanded Medicaid through the ACA have implemented efforts to enroll justice-involved individuals in coverage prior to their release from incarceration.
But even in states that have not implemented the ACA’s Medicaid expansion, there are initiatives focusing on the behavioral health needs of the justice-involved population that aim to prevent individuals from cycling in and out of incarceration. In Utah, state officials in 2014 directed the Utah Commission on Criminal and Juvenile Justice (CCJJ) to conduct a comprehensive review of the state’s correctional system. The CCJJ found that the state’s prison population was increasing at a rate of more than six times the national average and had grown by 18 percent over the past ten years. Further analysis identified some of the underlying reasons for this increase—eight of the top ten criminal offenses resulting in imprisonment were for non-violent crimes, and 62 percent of individuals who were sent immediately to prison from court in 2013 had been convicted of non-violent offenses. Also, two-thirds of prison readmissions were due to individuals not meeting probation or parole requirements. In response to the findings state officials developed new policy goals, such as focusing prisons primarily on individuals who have committed serious and violent crimes and improving and expanding reentry and treatment services for mental health and substance use disorders. Specifically, the state revised drug court eligibility to be based on risk and need, and passed legislation to revise sentencing guidelines for minor drug offenses and establish treatment standards for individuals required by the judicial system to participate in behavioral health services. The state legislature also provided $4.5 million in new funding for mental health and substance use disorder treatment services.
The state identified positive results soon after implementing these changes—in 2016 the prison population had declined by 21 percent and there was a significant reduction in the number of individuals incarcerated in prisons due to non-violent, low-level crimes. However there are still a few challenges the state is working to address, such as the need to reduce stigma associated with substance use disorders and to continue to strengthen partnerships between behavioral health and criminal justice entities. There are also some limitations in terms of being able to expand the capacity of behavioral health services significantly due to workforce shortages in rural areas and higher costs associated with implementing evidence-based treatment protocols.
Utah’s experiences were discussed at a roundtable hosted by Optum at NASHP’s 2016 Annual Conference. Optum also facilitated an event in June 2016 called the Spark Initiative that brought together behavioral health stakeholders and county officials to identify better ways to respond to the needs of individuals with mental health issues and/or substance use disorders and to help them avoid incarceration. The event focused on building consensus around healthcare and law enforcement strategies at each stage of individuals’ potential interactions with the criminal justice system, and follow up activities are ongoing. These efforts align with the goals of the national Stepping Up Initiative, led by the Council of State Governments, the National Association of Counties, and the American Psychiatric Association Foundation, which focuses on reducing the number of mentally ill individuals in jails. More than 300 counties and many state and national associations have passed resolutions in support of the initiative, and local officials are in the process of developing action plans. Regardless of changes that may occur to health coverage and delivery at a national level with the transition to a new administration, collaborations among a wide range of healthcare, law enforcement and other stakeholders at both the state and local level will continue to be essential to better address the behavioral health needs of the justice-involved population and improve outcomes for both individuals and communities.
 National Institute of Corrections, Federal Register 76, no. 129 (2011): 39438-39443.
 Doris J. James and Lauren E. Glaze, “Mental Health Problems of Prison and Jail Inmates,” Bureau of Justice Statistics, September 2006.