OAKLAND -- It's been two months since Rodrigo Salido left the maximum security wing at the Santa Rita Jail, and two months without pills for his bipolar disorder.

The medication, Risperdal, prescribed by a jailhouse psychiatrist, had quelled Salido's angry moods. "It helped me be more relaxed," he said. "Not as much on the edge and feeling like everybody is out to get me."

When he got out of jail, Salido, who served two years for burglary, assault and gang involvement, had no health insurance and few options for refilling his medication. He was like many inmates who leave county jails and state prisons with mental health problems and chronic physical ailments. Because they typically are not custodial parents, ex-offenders have had long been ineligible for Medicaid, a public health insurance program aimed at kids, mothers and the disabled.

But with the advent of the federal health care law, California is now one of 26 states that opened up Medicaid (called Medi-Cal in California) to single and childless adults. The change in eligibility criteria will extend Medicaid coverage to vast numbers of ex-offenders whose incomes are up to 138 percent of the federal poverty level.

"Historically, 10 or 11 percent of folks in detention have been eligible for Medicaid," said Alex Briscoe, Alameda County's health director. "That number is well over 90 percent as of January."


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Indeed, of those newly eligible under the Medicaid expansion, 1 out of 3 nationally will be former inmates or detainees, experts predict. A handful of states have predicted how much they might save in health care costs under broader Medicaid rules: For example, Oregon health officials estimate the state's general fund will be spared $79 million in the first six years, largely from services used by current and former inmates.

Alameda County health officials estimate 18,000 offenders in its two jails will qualify for Medi-Cal.

Men and women involved in the criminal justice system are more likely to be sicker than the general population, with higher rates of diabetes, hypertension, depression, mood disorders and alcohol and drug addiction. Many have spent years -- perhaps their entire adult lives -- without health insurance and have medical conditions that must be stabilized when they're incarcerated.

"They come to us in bad shape, and we get them as good as possible," said Richard Lucia, the undersheriff for Alameda County.

At Santa Rita Jail in Dublin, one of the largest detention facilities in the United States, the pharmacy dispenses some 350,000 prescription drugs each month and spends $28 million each year on medical and mental health services. But because recidivism rates are so high in Alameda County -- 2 out of 3 inmates re-offend -- the jails' medical clinics often end up restabilizing the same inmates.

"They leave and they get in bad shape again," Lucia said. "And they come back to us, and we fix them up again."

The churning of sick offenders costs the county when inmates are in custody -- but it also strains public hospital budgets when they're released. "When they do need care, they come to our emergency department. They cost us between $600 and $800 a visit," Briscoe said. "The cost drivers on our system are intense."

The Medi-Cal expansion, county officials in California say, offers a rare opportunity to connect men and women with criminal records to ongoing medical and mental health services on the outside, reducing costly interruptions in treatment.

While it remains against federal law to use Medi-Cal to pay for day-to-day medical care for inmates, the program, funded by federal and state dollars, will cover hospital stays longer than 24 hours. Those longer hospital visits often involve costly and complicated surgeries, and Alameda County estimates that expanded Medi-Cal coverage could save it $3 million to $5 million a year in off-site hospital care.

"That would shift the cost, essentially, from the county to the state or to the federal government," Lucia, the undersheriff.

Over the last few months, a constellation of Alameda County agencies, including the sheriff's office, public health and social services, have been feverishly working to create new protocols that will automatically enroll all eligible inmates into Medi-Cal. Other enrollment efforts are underway in Contra Costa, San Francisco, Solano and Lassen counties.

The bureaucratic and technical challenges are immense: Archaic information technology platforms must be retooled to share data with other county systems; arrested individuals often give false information about their marriage status, number of children, home address and income, foiling Medi-Cal eligibility background checks; and labor union rules permit only certain county workers to approve Medi-Cal applications.

Overcoming those obstacles is a priority, county officials said, not only because of the potential cost savings, but also because the Medi-Cal expansion offers a solid chance at reducing the county's dismal recidivism rate. Several studies have shown that ex-inmates who have access to health care when they leave jail, especially mental health and substance abuse counseling, are less likely to re-offend.

A Medi-Cal card is no panacea for troubled lives. "You can't treat away the problems that face poor communities," Briscoe said. "It's about a good job. It's about a sense of belonging. It's about a place to sleep, but health care can be a tool for social justice if it's delivered effectively and creatively, and that's why the Medicaid expansion is such a great opportunity for us."

As for Rodrigo Salido, whose neck is tattooed with the name of an ex-girlfriend, his top priority remains providing for the three children who have been out of his custody.

He has a job in construction and plans on staying out of jail. "I'm on three strikes," Salido said. "I can't go back."

One pressing problem he likely won't have to worry about anymore, though, is health insurance. A health clinic in Oakland, Healthy Oakland, helped Salido apply for Medi-Cal last month, and a nurse practitioner wrote him a prescription for more Risperdal and a new asthma inhaler.

Once the state approves his application, he'll be able to keep both medications filled at no cost.

Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.