Incarceration and Health: A Family Medicine Perspective (Position Paper)

Executive Summary

Regardless of where family physicians provide care, they have an interest in advocating for policies that improve the health of all people, particularly the most vulnerable. Incarcerated individuals have significantly higher rates of chronic health conditions, mental illness, and substance abuse than the general population, yet they also tend to receive limited care before, during, and after incarceration. Policies most likely to benefit this population include improving access to substance abuse and mental health treatment services, and reducing sentences for nonviolent and drug possession offenders. Interventions that could improve the health of incarcerated individuals include delivering improved health care services to jail and prison facilities and improving coordination of services following release. 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.

What Positive Actions Can Family Physicians Take?

  1. Learn about the unique needs of incarcerated or formerly incarcerated individuals and their families via continuing medical education and journal articles. Excellent resources include the American College of Correctional Physicians (http://societyofcorrectionalphysicians.org/(societyofcorrectionalphysicians.org)), the National Commission on Correctional Health Care (www.ncchc.org/(www.ncchc.org)), and the Center for Prisoner Health and Human Rights (www.prisonerhealth.org/(www.prisonerhealth.org)).
  2. Consider working in the prison system or volunteering to work with individuals in this population during or following their incarceration
  3. Advocate for prisoners, former prisoners, and their families to have adequate access to mental health and substance abuse treatment services
  4. Advocate to prevent unnecessary jail and prison stays by diverting eligible people from the justice system to substance abuse and/or mental health treatment
  5. Work with legislators on other policy issues related to prisoner health, such as eliminating racial disparities in sentencing, commuting sentences of nonviolent drug offenders, and facilitating health insurance enrollment processes after prisoner release

Defining the Problem

The United States has the highest incarceration rate in the world.1 In 2013, the corrections system in the United States had approximately 6.9 million people under its supervision, including people in prison or jail and people on probation or parole (i.e., community supervision).2 Since 1978, there has been a fivefold increase in the number of people in the U.S. prison population.3 While the increased incarceration rate attributed to a proportion of the decreased crime rate, the majority of the drop in crime was a result of other factors (e.g. economic growth, strategic policing, and community responses to crime). In addition, the increased incarceration rate has not resulted in a significantly safer or crime-free society.4

Two factors have been identified as the primary drivers of the increased incarceration rate. The first was an effort to “deinstitutionalize” mental health patients by moving them from inpatient facilities to outpatient care5 Much of the inpatient care was viewed as dehumanizing, and some experts theorized that new and better drugs would allow most mental health patients to be treated as outpatients. However, as inpatient populations dropped, additional funding was not allocated for outpatient treatment. As a result, large numbers of inpatients were released without adequate care, housing provisions, or social support.6 Many went untreated and became homeless and prone to being arrested for substance abuse, petty theft, and disruptive behavior. A 2009 study found that 14.5% of men in jail and 31% of women in jail suffered from serious mental illness.7 By comparison, the 2015 National Survey on Drug Use and Health found that 3% of men and 5% of women in the general population suffered from serious mental illness.8

A 2015 case study of the New York City jail system showed that among the most frequently incarcerated population, most were charged with misdemeanors such as trespassing, non-payment of transit fares, and low-level theft, and comparatively few were involved in assaults.9 In this frequently incarcerated population, 19% of prisoners had serious mental illness and 51.5% were homeless. The study suggested that providing adequate housing, health care, and social support to this group would be far less expensive than incarcerating them and would result in better outcomes.9

The second factor contributing to the incarceration rate has been the “war on drugs” that was instituted in the early 1970s. This campaign has resulted in harsh, lengthy sentences for possession of even small amounts of illegal drugs.10 Between 1985 and 2000, increased incarceration of drug offenders accounted for two-thirds of the increase in the federal prison population, and one-half of the increase in state prison populations.7 In addition, the lack of treatment and follow-up for drug use (continuity of care) and abuse during and after incarceration may be associated with increased recidivism11 and an increased rate of death due to overdose.12 Racial disparities in drug-related arrests and convictions are evident. For example, although there are only negligible differences in reported drug use between black and white populations, black individuals are more likely to be arrested for drug possession or use;7 in 1996, black inmates constituted 62% of drug offenders in the state prison population.13

For some inmates, incarceration may have a positive health impact in the short term by providing housing; making meals available; reducing access to drugs, alcohol, and cigarettes; and giving some access to health care.14 However, this protective effect is temporary because individuals lose these benefits once they are released. In fact, studies have documented a twelvefold increase in all-cause mortality in former inmates in the first two weeks following release.12

Health Issues During Incarceration

Inmates in correctional facilities have significantly higher rates of disease than the general population, and correctional facilities are often an ill-equipped provider of last resort for the medically underserved.1,15 This population tends to suffer in greater numbers from infectious disease, mental health problems, and substance use and addiction; their health can also be affected negatively by factors in their environment, such as violence or overcrowding.1

Infectious Disease
Infectious disease is more prevalent among incarcerated populations than in the general population.1 Compared to the general population, individuals living in correctional facilities are approximately three times more likely to have HIV or AIDS and are more likely to have hepatitis C and tuberculosis.16,17, 18 Rates of other sexually transmitted infections (STIs), such as chlamydia, gonorrhea, and syphilis, are also higher in inmates.19 In correctional facilities, STI rates are higher in women than men.19

Mental Health and Substance Abuse

It is estimated that greater than 65% of inmates meet the DSM-IV criteria for alcohol or other drug dependence or abuse; the percentage is even higher in female inmates.20 Unfortunately, only 11% of inmates who have a substance use disorder receive drug treatment while incarcerated.20 For this reason, inmates who have chronic addictions have a higher risk of going through withdrawal while in custody21 and then overdosing when they return to the community.22

Violence and Self-harm

Intentional and accidental injuries to prisoners, corrections officers, and correctional facility staff are common. In one survey, approximately 15% of state prisoners reported violence-related injuries.23 Suicide remains a leading cause of death, accounting for one-third of all deaths in jails between 2000 and 2009.24

Health Outcomes Across the Life Span

Approximately 6% to 10% of women entering jails are pregnant.25 One study found that 44% of pregnant women entering jail in Rhode Island had conceived within one year of release from a prior incarceration; of these women, 50% had conceived within 90 days of a prior release.25 Most of these women had not seen a physician on a regular basis prior to incarceration and suffered from various conditions secondary to malnutrition and substance abuse.26 Regular meals and access to health care can help improve birth outcomes; however, most state prisons fail to use best practices and established standards when caring for pregnant women.27 Among women who enter prison during the first trimester of pregnancy and deliver at term, the number of prison prenatal care visits appears to be positively associated with infant birth weight.28

Incarcerated youth have higher morbidity and mortality rates than the general adolescent population. Priority health care needs in this population include dental health, reproductive health, and mental health.29 Two-thirds of incarcerated boys and more than four-fifths of incarcerated girls meet criteria for at least one mental health disorder; disruptive disorders, substance abuse, anxiety disorders, and mood disorders (e.g., depression) are the most prevalent.30 Injuries and exposure to violence also contribute to the poor health seen in this population. Juvenile incarceration likely correlates with poor health and a lower social functioning status across an individual’s lifetime.29

From 1990 to 2009, the number of inmates older than 55 years of age increased over 300%.31 Older adults have higher rates of chronic conditions, including hypertension, diabetes, and heart disease. As the prison population ages, there will also be more people with cognitive impairment and physical disabilities that will make them vulnerable to injury and poorer health outcomes.31 Many prisons and jails are poorly equipped to meet the needs of elderly inmates who have chronic conditions and disabilities.32

Effects of Incarceration on Families
As the number of people incarcerated increases, more and more families have to deal with having someone from the household in jail or prison. For children, having an incarcerated parent may have negative health consequences. For example, paternal incarceration has been associated with increased drug use during the transition to adulthood for males and females in the United States.33 A 2012 meta-analysis that included children from birth to 18 years of age showed that children who had an incarcerated parent consistently had a higher rate of antisocial behavior.  Some subgroups of children also showed issues with poor school performance and mental health problems. 34 One study of unmarried parents in 20 U.S. cities found that men who had been incarcerated contributed nearly $1,300 less to their children per year than men who had never been incarcerated.35 This decrease can put a significant strain on families that are already struggling financially. Additional financial burdens for families include the traveling costs and lost wages associated with visiting loved ones incarcerated far from their communities.36

Privatization of Prison Services
In some states, prison services have been handed over to private companies, which also assume responsibility for health care services inside the correctional institution. Comparative effectiveness studies on health outcomes in private and state-run prisons are not available; however, published anecdotal reports have shown poor quality care at multiple private prisons across the country. These reports have shown an increase in inmate mortality37; gross deficiencies in care38, 39; and allegations of increased risk of pain, amputation, and disfigurement.40, 41 As a result, multiple court cases have been brought against private prisons.40, 41 Combined with concerns about safety and security,36 these issues led to a 2016 announcement by the federal government that it intended to phase out and stop using private prisons.42, 43

Immigration Detention Centers
U.S. Immigration and Customs Enforcement (ICE), under the auspices of the Department of Homeland Security, oversees the detention of immigrants in more than 200 county jails and for-profit prisons in the United States. An estimated 380,000 to 442,000 people are detained in the centers per year; they are primarily individuals taken into custody by ICE while their cases for deportation are being processed.44 Of these detainees, 10% are held in federal owned and directed facilities; 25% are held in facilities operated by county jails or other state or local government entities; and 65% are held in facilities operated by private, for-profit contractors.45 In recent years, several reports from watchdog groups, such as the American Civil Liberties Union (ACLU) and Human Rights Watch, have documented numerous cases of inadequate medical care—some of which led to death—at immigration detention centers.46-49

Health Issues After Incarceration

More than 650,000 individuals were released from prison in 2015.50 This transition, or reentry, may be a very stressful period for the former prisoners, their families, and communities at large. Individuals released from prison must navigate issues related to finding housing, employment, and access to health care, in addition to the challenges of reintegrating into their families and communities.

Studies have shown that former prisoners have higher rates of morbidity and mortality than the general population.12, 14, 51-53 As a population, prison inmates exhibit a high burden of chronic and noncommunicable diseases (e.g., hypertension, asthma), as well as communicable diseases (e.g., hepatitis, HIV, tuberculosis), mental health problems, and substance abuse disorders.17, 54 A representative sample of released prisoners noted that most had at least one physical health, mental health, or substance abuse problem, and approximately 40% of men and 60% of women in this population had multiple types of health conditions.55 Upon reentry into society, prompt and continuous management of these chronic conditions often falls by the wayside as former prisoners face challenges enrolling in health insurance coverage, finding a primary care physician, making health care appointments, and refilling prescriptions.55, 56 Barriers to care have been cited in studies that show the first few weeks after a prisoner’s release are a period of particularly high vulnerability in terms of morbidity and mortality.12, 51

Rates of hospitalization are higher in former inmates than in the general population, and one study found that approximately one in 12 former inmates is hospitalized for an acute condition within 90 days of release.51 Another study demonstrated a higher risk of death among inmates released from prison—particularly in the first two weeks—compared to the general population during the same period.12 Researchers noted that the adjusted relative risk of all-cause mortality within the first two weeks after release from prison was 12.7 times the risk of nonincarcerated individuals. The adjusted relative risk of death in former inmates was higher for women than men. Drug overdose, cardiovascular disease, homicide, and suicide were the leading causes of death.

Use of mental health and substance abuse treatment services falls significantly following an inmate’s release from prison.57 In addition, one survey noted that while two-thirds of men and three-quarters of women who had physical health conditions received treatment during their incarceration, those rates dropped dramatically within eight to 10 months after their release.55 The trend was similar for mental health treatment. For men, 60% were treated while in prison but only 50% were receiving treatment eight to 10 months after their release; in women, 60% were treated while incarcerated but only 40% were receiving treatment eight to 10 months after their release.55 Studies have also found delays in linkage to HIV treatment services after release from prison.58 Lack of insurance is one reason for the decrease in service utilization by former inmates in the first year after their release.52 Many former inmates rely on hospital emergency departments for episodic care for acute problems.14, 59 The absence of continuity of care leads to problems for former prisoners who have chronic conditions, particularly those who are HIV-positive.

Policy Implications
Former prisoners have significant health care needs and face multiple barriers to obtaining health insurance and access to care. These challenges affect not only the formerly incarcerated individuals, but also their families and communities, many of which are disadvantaged and experience health inequities born out of complex social determinants of health. Achieving the goals of improving the health of former prisoners, easing their transition back into the community, and preventing reincarceration will require interventions on multiple levels.14, 60 Successful interventions should encompass system-wide strategies at the community and policy levels, including the following:

  • Reentry processes that begin prior to release
  • Establishment of community-based collaborations61, 62
  • Integrated models of care, and linkages to housing, employment, substance misuse and abuse support, and mental health support56, 60·         

Successful reentry programs must also be culturally competent and appropriate, and must consider racial and ethnic disparities, as well as the needs, resources, and strengths of diverse groups and communities.60, 63 Models of chronic care and individual case management in the first few weeks after release from prison were shown to be effective in increasing the use of primary care and decreasing emergency department usage following release from prison.64, 65

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