Colleague Interview A Conversation with Tyler Winkelman, MD, MSc

Tyler Winkelman, MD, MSc is an internist, pediatrician, and health services researcher at Hennepin Healthcare in Minneapolis, MN, an Assistant Professor in the Departments of Internal Medicine and Pediatrics at the University of Minnesota, and a staff physician at the Hennepin County jail. He is the co-director of the Health, Homelessness, and Criminal Justice Lab at Hennepin Healthcare Research Institute. Dr. Winkelman completed his medical school and internal medicine/pediatrics residency training at the University of Minnesota Medical School. He obtained a master’s degree in health and healthcare research at the University of Michigan through the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Winkelman studies issues at the intersection of criminal justice and health, with particular interest in Medicaid, substance use disorders, and healthcare utilization. He works closely with Hennepin County on cross-sector data projects that integrate criminal justice, health care, housing, and social service data to inform county policy and programs. These projects inform public policy across multiple departments and serve as a model for evidence-based policy across the state and country.

What is the scale and scope of the criminal justice system in the United States?

On any given day, approximately two million people are in jail or prison in the United States. Because of the high turnover in jails, where people are either pre-trial or serving sentences of less than one year, there are approximately 10 million people who spend time in jail every year. In addition, there are approximately four million people on any given day who are on supervision in the community —typically probation or parole. The criminal justice system in the United States has grown exponentially in the last several decades and this growth is uniquely American. There is no other country in the world with a criminal justice system that has grown as quickly or as large. In Minnesota, we have among the lowest incarceration rates but one of the highest rates of community supervision in the United States.

What racial disparities exist in the criminal justice system?

Black, Indigenous, and people of color are disproportionately impacted by the criminal justice system. Black individuals are six times more likely to be incarcerated than white individuals. These disparities are so large that one in three Black men will spend time in prison during their lifetime. Racial disparities in Minnesota are among the largest in the United States. For example, Native Americans represent just over 1% of Minnesotans but account for 22% of women in prison. Black Minnesotans represent 6.8% of Minnesotans but represent up to 46% of men in some prisons across Minnesota. These disparities not only impact the individual, but also have negative consequences for their children, their families, and their communities.

How and by whom are people in jails and prisons screened for healthcare needs?

Screening and assessment protocols vary substantially from jail to jail and prison system to prison system. In general, individuals entering jail or prison should be screened for acute and chronic conditions, including physical health, mental health, and substance use conditions. Medications prescribed in the community should be continued and systems should be set up to triage particular health concerns to the appropriate provider.

What percentage of people in jails and prisons have mental health issues?

Mental health issues are very common among people in jails and prisons, with up to 80% of individuals reporting some history of a mental illness. Serious mental illnesses, like schizophrenia, are up to 10 times more common among people in jails and prison compared with the general population.

How are PTSD and TBI screened for and managed in jails and prisons?

Post-traumatic stress disorder and traumatic brain injuries are extremely common conditions. Mental health providers at jails and prisons often prescribe medications for symptoms related to PTSD. Access to counseling approaches, like cognitive behavioral therapy, is typically very limited, though more common in prisons than in jails. Treatment for traumatic brain injuries in jails and prisons is often very limited.

What legal obligations do jails and prisons have to provide health care?

Jails and prisons are one of few places in the United States where health care is constitutionally mandated. Jails and prisons must provide “services at a level reasonably commensurate with modern medical science and of a quality acceptable within prudent professional standards.”

Who dispenses meds? Including controlled substances?

At the Hennepin County Jail, where I have clinic, medications are dispensed by a team of nurses who staff the jail 24 hours per day. There is a doctor on call 24 hours a day who can help triage urgent issues when there is not a doctor onsite.

How is health care in jails and prisons paid for?

Federal law prohibits the use of federal healthcare programs like Medicaid and Medicare to pay for health care in jails and prisons. This means county governments are responsible for financing all health care in jails and state governments are responsible for paying for all health care in prisons. Medicaid is a critical tool for financing health care for up to 80% of people with recent incarceration. Despite the importance of Medicaid, it is either suspended or terminated when someone is incarcerated. This means that an individual’s health insurance may be turned off when they are incarcerated and would need to be re-enrolled upon release, a process that can create delays in care. Further, because Medicaid cannot be used in jails and prisons, healthcare budgets may be threatened during economic downtowns if counties and/ or states take in less revenue. What are some of the barriers to health after release from jail or prison?

People are at high risk of death and medical complications in the weeks following release from jail or prison. Mortality rates after release are up to 10 times higher compared to the general population. This is primarily due to risk of overdose death, but also because of complications of cardiovascular disease and other physical health conditions. Therefore, coordinated care upon release is critical to ensure continuity of care, particularly for people with opioid use disorder. However, there are a number of barriers to continuity of care after release: 1) medical records can be difficult to transfer to a primary care provider; 2) access in the community can be limited, particularly for opioid use disorder treatment; 3) medication is not always provided at release; 4) the timing of discharges can be unpredictable; and 5) Medicaid does not cover care coordination for people in jails and prisons. These are a few important barriers, though many others exist.

Discuss the availability of health care after release from jail or prison.

Once an individual is released from jail or prison, they are able to re-enroll in Medicaid or other public health insurance programs. However, there is typically limited assistance in re-enrolling in these health insurance programs upon release. Many individuals who access the healthcare system are stigmatized because of their criminal justice involvement. Individuals recently released may have difficulty finding primary care appointments within a timeframe needed to refill meds or address chronic health conditions. Thus, rates of emergency department and hospital use are high for people with recent criminal justice involvement. Many people with substance use disorders who are released from jail enter a treatment facility. Often care is continued while in treatment, but the transition out of the treatment center can also be complicated by poor coordination and there is a high risk of death after treatment completion. At Hennepin Healthcare we are developing a Transitions Clinic that is staffed by a multi-disciplinary team to meet the diverse health needs of people leaving jail. A primary goal of the Transitions Clinic is to help people with opioid use disorder stay engaged with treatment after release.

How has the Affordable Care Act affected health insurance for people involved in the criminal justice system?

Our research team has shown that the Affordable Care Act dramatically improved health insurance for people involved in the criminal justice system who are not currently incarcerated. In addition, the ACA increased access to medications for opioid use

Colleague Interview (Continued from page 7)

disorder for people involved in the criminal justice system who were admitted to treatment centers. However, other work our team has done has shown that the ACA did not have a substantial impact on access to mental health care for people with criminal justice involvement and other work has shown a relatively modest impact, overall, on access to substance use treatment. Overall, our research suggests that Medicaid expansion through the ACA is an important tool for expanding access to needed medical care for people with criminal justice involvement, but is not sufficient to reduce the large disparities that persist between people with and without criminal justice involvement.

Why do we often hear about substance use in the setting of criminal justice involvement?

Most people in jails or prisons have a substance use disorder related to opioids, methamphetamine, cocaine, or alcohol. The overlap between substance use disorders and incarceration is high for several reasons, including the so called “war on drugs.” Because the approach to substance use disorders in the United States has often relied on the criminalization of substance use, rather than treatment, people with substance use disorders are at high risk of incarceration. My research team has shown that over half of people with an opioid use disorder and more than 70% of people who use heroin will spend time in the criminal justice system. This means that if we want to address the opioid crisis, we have to ensure policies in jails and prisons increase access to needed treatment. In addition to opioid use, there are a number of other types of substance use that are increasing. Methamphetamine use is increasingly common and is associated with increasing levels of mortality across the United States. Often methamphetamine use occurs alongside opioid use, which should not preclude individuals from treatment of their opioid use disorder. While there are well established and effective medications available for the treatment of opioid use disorder, there is less information available for the treatment of methamphetamine use disorder. However, recently released data have shown promising results for medications that may help people reduce their methamphetamine use.