The necessity of a national decarceration strategy

National concern continues to center on the profound and persistent problem of excessive incarceration in city and county jails, and the enmeshment of persons with mental and substance use conditions in the jails. Tonight, these jails will house about 730,000 persons, at least three quarters of whom will have behavioral health conditions.                                                
This is not a new problem, but rather a very persistent and intractable one. I have written about this problem on an earlier occasion. I also have written about ways to address this problem.

Good progress is being made to confront this problem in some locales, such as San Diego and San Antonio. And some progress is being made by national organizations and foundations, like NACo/NACBHDD and the MacArthur Foundation. All of this was very evident in a national meeting, held in San Antonio on January 29-31, organized by the Institute for Behavioral Health Improvement.

This progress is exceptionally important, and it is equally important to share these solutions from city to city and county to county. However, until we actually develop a coordinated national strategy, these gains will remain local and national progress will remain elusive.

National strategy

So, what can be done to begin framing and building support for a national solution? Two things seem to be foundational. We must develop a strategic national plan, and we must set sequential goals for decarceration.

Our national plan must be strategic. Coordinated action will be required at the federal, state, and county levels. At a minimum, federal coordination must include all relevant programs in HHS, HUD, and DOJ. This coordination can be achieved through an external management board housed in the White House Domestic Policy Council. This board would be charged specifically with developing the national strategic plan and overseeing its implementation. The plan must address effective coordination of health, housing, and social support programs, as well as targeting these services toward the behavioral health and ID/DD populations most at risk of incarceration. The board also would be charged with developing and implementing strategies to achieve coordination of relevant state, county, and city programs.

Virtually all persons with behavioral health or ID/DD conditions at high risk of incarceration also are eligible for participation in state Medicaid Programs. Thus, it will be essential to insure that the board include provisions in the plan for enrolling in Medicaid all persons in these populations who are not currently enrolled. This strategy also must assure that all potential sites of service, including community health, behavioral health, and ID/DD service providers, diversion centers, and jails themselves qualify for Medicaid-reimbursable care. For jails, this will require a waiver of current federal regulations, which now prohibit federal Medicaid reimbursement for services provided there.

The national strategic plan also must set reasonable goals, and the management board must put in place both accountability and measurement tools to assure that these goals are met. A reasonable set of goals would be the following: reduce the behavioral health and ID/DD population currently in city and county jails by 20% by 2020; 40% by 2022; 60% by 2024; and 80% by 2026—a full 10 years from now. A reduction of 80% would be deemed full success for the strategy. City and county jails always will include some persons with  behavioral health conditions who are culpable for felonies and misdemeanors. The difference from now would be that they would receive appropriate services while incarcerated, which actually could accelerate their release.

Decarceration of persons with mental health, substance use, and ID/DD conditions must be a top priority for all of us going forward. The current situation not only is very inhumane and demeaning, it also reflects severe service system failure in both communities and jails. We can and must do better, not only in exemplary counties, but also nationally.