Just released from prison? Good luck finding a primary care physician.

A young man with schizophrenia, opioid use disorder (OUD) and chronic hepatitis C infection completed a 5-year prison sentence and was discharged back into the community. While he was incarcerated, he received antipsychotic medications and periodic laboratory monitoring of his liver disease; medication-assisted treatment for OUD was unavailable. At the time of his release, he was given a 30-day supply of pills and told to follow up with a primary care physician. The next few weeks will be a critical time for this patient's health, according to an article on care of incarcerated patients in the November 15th issue of American Family Physician:

Most inmates are discharged from correctional facilities without a supply of medications or referrals to primary care, mental health services, or substance abuse treatment. Lack of care coordination directly affects the health of former inmates. In the two weeks following release, former inmates are 129 times more likely to die of a drug overdose and 12 times more likely to die of any cause than members of the general public.

Former inmates face two significant obstacles to accessing primary care: affording care, and the reluctance of some clinicians to accept formerly incarcerated patients. Before 2014, an estimated 80 percent of incarcerated persons lacked health insurance or the financial resources to pay for basic health care. Even after the expansion of Medicaid to single and childless adults earning up to 138% of the federal poverty level in 36 states and the District of Columbia, many patients continue to slip through the cracks. A 2016 Kaiser Health News article recounted the case of Ernest, a man with severe mental illness who served prison time in Indiana for killing his 2 year-old daughter during a psychotic delusion. Even though Indiana had expanded Medicaid by the time of Ernest's release and set up a system to enroll all eligible prisoners, records show that he was forced to enroll in the program on his own, wasting valuable time and delaying his transition of care:

Ernest’s letters to Medicaid and a clinic before he got out didn’t help. He had to start the application process from scratch after he got home, making increasingly frantic calls and scrambling to find his birth certificate and other paperwork as his supply of lithium and perphenazine, an antipsychotic, dwindled. “Somebody who’s committed a violent felony because of a mental illness is getting out of prison, and we don’t have anything set up yet?” he said.

Having health insurance does not necessarily mean that a patient will be able to access care, as illustrated in a recent Canadian study published in the Annals of Family Medicine. Researchers posing as prospective patients telephoned all family physicians listed as accepting new patients in British Columbia. The only difference between the patient roles was that one set mentioned that he or she had been released from prison a few months before. Among the 250 family physicians who answered the phone and were still providing primary care, control patients were twice as likely to be offered an appointment compared to persons recently released from prison (absolute risk difference = 41.8%).

In 2017, I co-authored a position paper on Incarceration and Health for the American Academy of Family Physicians that suggested "family physicians can promote the health of individuals during the transition from correctional facilities to the community by supporting reentry processes that begin prior to release; collaborations between prison and community health services; integrated models of care; and linkages to housing, employment, and mental health support." To that, I would add that we should not discriminate against patients with a history of incarceration.

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This post first appeared on the AFP Community Blog. Via responses on Twitter, I was pleased to learn that some family physicians prioritize appointments for these vulnerable patients.