Letter

In Reply: We welcome Dr. Parker's letter, which allows us another opportunity to stress that prisons and jails are different institutions, with different populations of offenders who have different mental health needs. As a result, in policy discussions we have to avoid lumping jails and prisons together because there is no one-size-fits-all correctional program. Rather, mental health interventions must be tailored to each setting.

We agree that Medicaid restoration is a crucial step in prison reentry programs similar to those in Indiana, because all inmates will have lost benefits and having benefits at release will likely increase service use in the community. But Medicaid restoration is often not an issue in jails because of the much shorter stays in jails. The key for anyone considering a Medicaid benefits restoration program for a local jail is to first determine the average length of stay of detainees with mental illness. Stays of several weeks or less are unlikely to have any effect on detainee Medicaid status; stays of several months or more begin to mimic those in prisons and are much more likely to lead to benefit termination under current Medicaid policies. Therefore, a restoration program makes sense in the latter case but not in the former. Long jail stays result primarily from delays in criminal court processing; thus focusing on court-based interventions could have large effects in these situations.

In reply to another of Dr. Parker's comments about cost savings in the Indiana corrections budget, we note that cost savings for one system (state corrections) often lead to cost shifting and cost increases for other systems (federal, county, and municipal governments). In effect, the system that benefits from a new program is not the one that ends up paying for it. This has been an insidious problem in mental health programming in the United States for many years. Real progress in community reintegration of persons with mental illness from prisons and jails will require us to take a broad societal view to determine ways of overcoming these asymmetries. We agree that new partnerships are needed to identify common ground, mutual benefits, and necessary contributions for joint action across these agency silos.