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

    Executive Summary

    Family physicians have an interest in advancing policies that improve the health of all people, with a special focus on the most vulnerable members of our communities. Incarcerated individuals and those detained in immigration facilities are disproportionately affected by chronic health conditions, mental illness, and substance abuse. However, they tend to receive inadequate health care before, during, and after incarceration or detention, further exacerbating their disadvantage.

    The American Academy of Family Physicians (AAFP) supports policies that mitigate health disparities, such as improved access to substance use disorder treatment, reproductive health care, and mental health services. Furthermore, as incarceration and detention are themselves detrimental to health, the AAFP supports reducing sentences for nonviolent and drug possession offenders and ending detention for those seeking legal asylum in the United States.

    The AAFP supports efforts to address issues surrounding the current bail system and to reduce negative health outcomes of individuals in correctional facilities awaiting trial. Interventions that could improve the health of incarcerated individuals include delivering improved health care services in correctional and detention facilities and improving coordination of services following release.

    Family physicians can promote the health of individuals who are incarcerated by working or volunteering in correctional or detention facilities; aiding them during the transition to their communities by supporting collaborations between prison or detention facilities and community health services; promoting integrated models of care; and supporting more linkages to housing, employment, and mental health support.

    Positive Actions Family Physicians Can Take

    • Learn about the unique needs of incarcerated or formerly incarcerated individuals and their families. Resources include the American College of Correctional Physicians (http://societyofcorrectionalphysicians.org/), the National Commission on Correctional Health Care (www.ncchc.org/), and the Center for Prisoner Health and Human Rights (www.prisonerhealth.org/).
    • Work in the prison health system or volunteer to work with individuals in this population during or following their incarceration.
    • Advocate on behalf of individuals who are incarcerated or who have been incarcerated and their families to have adequate access to all helathcare and preventive services (e.g., immunizations, PrEP, mental health services, and evidence-based substance use treatment, including medication-assisted treatment for opioid use disorders.)
    • Advocate to prevent unnecessary incarceration by diverting eligible people from the justice system to substance abuse and/or mental health treatment.
    • Oppose detention of those seeking asylum and against separation of parents and children in immigration detention centers, and promote policies for humane treatment of families detained as a result of seeking safe haven in the U.S.
    • Partner with legislators on other policy issues related to prisoner health, such as eliminating racial disparities in the bail system, sentencing, commuting sentences of nonviolent drug offenders, and facilitating health insurance enrollment processes after release.
    • Be aware of tools and resources for addressing health disparities and apply them as appropriate in their practices and communities.

    Defining the Problem

    The U.S. has the highest incarceration rate in the world.1 In 2016, the corrections system in the U.S. had approximately 6.6 million people under its supervision, including people in prison or jail and people on probation or parole.2 From 1978 to 2016, there has been a nearly fivefold increase in the number of people under the jurisdiction of state or federal correctional authorities in the U.S.3 While the increased incarceration rate has contributed to a proportion of the decreased crime rate, the majority of the drop in crime is a result of other factors. One analysis suggests that 25% of the decline in violent crime in the 1990s was due to increased incarceration. It suggested that the remaining 75% was due to other factors, such as economic growth, changes in drug markets, strategic policing, and community responses to crime.4 Moreover, increased incarceration has not resulted in a significantly safer or crime-free society.4

    Two factors contributed to the increased incarceration rate. The first was court cases that “deinstitutionalized” mental health patients by ruling that they be moved from inpatient facilities to outpatient care.5 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 and 31% of women in jail suffered from serious mental illness.7 By comparison, the National Survey on Drug Use and Health reported that 3-4% of adults in the general population suffered from serious mental illness from 2008 to 2014.8

    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 Among 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 health outcomes.9

    The second factor contributing to the incarceration rate has been the war on drugs that was instituted in the early 1980s. This campaign has resulted in harsh, lengthy sentences for possession of even small amounts of illegal drugs.10 From 1980 to 2016, the number of individuals incarcerated for drug offenses increased from nearly 41,000 to more than 450,000—more than a tenfold increase.10 In addition, the lack of treatment and follow-up for drug use and abuse during and after incarceration is likely associated with increased recidivism,11 as well as 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.13 In 2015, the percentage of non-Hispanic black or African-American individuals in federal prison for drug offenses was almost twice the percentage of whites.14

    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.15 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 the first two weeks after individuals were released from prison when compared to all other populations.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 for the medically underserved.1,16 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 AIDS17 and are more likely to have hepatitis C18 and tuberculosis.16 However, access to screening and evidence-based treatment for HIV is not consistently available in many prisons.17, 18 Rates of other sexually transmitted infections (STIs), such as chlamydia, gonorrhea, and syphilis, are also higher in individuals who are incarcerated.22 In correctional facilities, STI rates are higher in women than men.22 Additionally, individuals who are incarcerated or held in detention centers may not receive necessary immunizations, which may lead to outbreaks of infectious diseases like influenza.  

    Mental Health and Substance Abuse
    It is estimated that greater than 65% of individuals who are incarcerated meet the Diagnostic and Statistical Manual (DSM)-IV criteria for alcohol or other drug dependence or abuse.20 Unfortunately, only 11% of individuals who have a substance use disorder receive drug treatment while incarcerated.20 For this reason, individuals 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

    Since 2000, the rate of deaths from drug overdoses in the U.S. has increased 137%, including a 200% increase involving opioids. Opioids, primarily prescription pain relievers and heroin, account for the majority of drug overdoses in the U.S.26 While these deaths were initially related to prescription opioids, beginning in 2016, illicit forms of opioids (e.g. heroin and fentanyl) became the main source of deaths due to overdoses.27 With an increase in illicit drug use, there may be an increase in the number of individuals incarcerated with opioid use disorders. Evidence-based treatment of substance use disorders improve health outcomes and reduce the spread of infectious diseases. Additionally, treatment of substance use disorders of inmates has been shown to reduce mortality28, 29 and recidivism.30

    Violence and Self-harm
    Intentional and accidental injuries to individuals who are incarcerated, corrections officers, and correctional facility staff are common. In one survey, more than 32% people in state correctional facilities reported being injured since their admission.31 Suicide has been the leading cause of death in local jails every year from 2000 to 2014, accounting for nearly one-third of all deaths in local jails during that period.32

    Health Outcomes Across the Life Span
    At any point, between 6 and 10% of women who are incarcerated are pregnant.25 One study found that 43% of pregnant women entering jail in Rhode Island had conceived within one year of release from a prior incarceration. Among those women, 50% had conceived within 90 days of a prior release.25 Providing contraceptive services to these women during incarceration increases the likelihood they will initiate birth control compared to providing those services only in their communities.35However, most state prison health providers fail to use best practices and established standards when caring for pregnant women.36 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.37

    Compared to the general adolescent population, incarcerated youth have higher morbidity and mortality rates. Priority health care needs in this population include dental health, reproductive health, and mental health.38 Two-thirds of boys and more than four-fifths of girls who are incarcerated meet the criteria for at least one mental health disorder. The most prevalent include disruptive disorders, substance abuse, anxiety disorders, and mood disorders (e.g., depression).39 Injuries and exposure to violence also contribute to increased prevalence of mental health disorders seen in this population. Juvenile incarceration likely correlates with poor health and a lower social functioning status across an individual’s lifetime.38

    From 1990 to 2009, the number of inmates older than 55 years of age more than tripled.31 This increase has economic consequences. Older adults have higher rates of chronic conditions, including hypertension, diabetes, and heart disease. As they age, there will be more people in the prison population with cognitive impairment and physical disabilities that will make them vulnerable to injury and poorer health outcomes.31Mostly due to health care costs, this translates to older people in prison being the most expensive group. Many prisons and jails are poorly equipped to meet the needs of elderly inmates who have chronic medical conditions and disabilities.32

    Effects of Incarceration on Families
    As the number of people who are incarcerated in the U.S. increases, so do the households who have family members in jail or prison. For children, having an incarcerated parent may have negative health and social consequences. Parental incarceration has been associated with increased drug use during late adolescence for males and females in the U.S..33 A 2012 meta-analysis showed that children who had an incarcerated parent consistently had higher rates of antisocial behavior.  Some subgroups of children also showed issues with poor school performance and mental health problems.34 Another study found that men who had been incarcerated contributed nearly $1,300 less to their children per year than men who had never been incarcerated.44 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.45

    The impact of incarceration can begin prior to sentencing as people living in poverty are often incarcerated while pending trial due to their inability to pay the cash bond, regardless of their potential threat to society, severity of their alleged crime. In 2014, more than 60% of people who were incarcerated were awaiting trial.46 African-American defendants are disproportionately affected by the cash bail system as they often receive higher bail amounts than white defendants who are accused of similar crimes.47, 48 Pre-trial incarceration can last weeks, and sometimes months to years placing individuals at risk of losing necessities like housing, employment or custody of their children while awaiting trial. Many families cannot afford to post bail and subsequently lose income, implementing barriers to meeting basic needs, including housing and food.

    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 mortality49; gross deficiencies in care50, 51; and allegations of increased risk of serious harm, preventable injury, amputation, disfigurement, and death due to conditions at correctional facilities.52, 53 As a result, multiple court cases have been brought against private prisons.52, 53

    Immigration Detention Centers
    U.S. Immigration and Customs Enforcement (ICE), under the direction of the U.S. Department of Homeland Security, oversees the detention of immigrants in more than 200 county jails and for-profit prisons in the U.S. An average of more than 350,000 people immigrating to the U.S. are detained in the centers per year. They are primarily individuals taken into custody by ICE while their cases for deportation are being processed.54 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 at immigration detention centers.46-49

    The detention of immigrants has negative physical and mental health implications for adults and children alike. Detention has been associated with anxiety, depression, post-traumatic stress disorder (PTSD), self-harming behavior, sleep disturbances, and social withdrawal.59 In many instances, detained individuals have already experienced traumatic events in the country of origin from which they sought a safe haven. The AAFP opposes the separation of family units, and in particular the separation of minor children from parents/guardians in immigration facilities.60 In instances where separation cannot be avoided, family members should have the ability to communicate frequently and receive updates on the status of legal proceedings.  

    Women, especially pregnant women, held in immigration detention facilities have poor access to medical care. Advocates also point to major concerns of sexual assault and physical violence to  women in ICE custody.57 Immigration detention facilities must adhere to women’s health standards including prenatal care, preventive services and contraception, and should be held to that standard in a transparent and public facing manner, as do other federally-funded public health facilities such as community health centers and health departments. Additionally, all individuals held in immigration facilities should be provided immunizations to protect them from influenza and other communicable diseases.  

    Health Issues After Incarceration

    More than 650,000 individuals were released from prison in 2015.61 This transition, or reentry to society, may be a very stressful period for the individuals, their families, and communities. Individuals released from prison must find housing, employment, and access to health care, in addition to reintegrating themselves with their families and communities.

    Studies have shown that individuals who have been incarcerated have higher rates of morbidity12, 14, 51-53 and mortality than the general population.17, 54 As a population, people in prison exhibit a high burden of chronic and noncommunicable diseases (e.g., hypertension, diabetes, and asthma),65 as well as communicable diseases (e.g., hepatitis, HIV, tuberculosis),18, 65 mental health problems, and substance abuse disorders.65 A representative sample of individuals released from correctional facilities noted that most had at least one physical health, mental health, or substance abuse problem, and nearly 40% of men and more than 60% of women in this population had multiple health conditions.66 Upon reentry into society, prompt and continuous management of these conditions often falls by the wayside as individuals who have been incarcerated face challenges enrolling in health insurance coverage, finding a primary care physician, making health care appointments, and refilling prescriptions.66, 67 Barriers to health care  contribute to an individual’s particularly high vulnerability to morbidity and mortality the first few weeks after release.12, 64

    Rates of hospitalization are higher in individuals who have been incarcerated than in the general population. One study reported that approximately 1 in 12 individuals is hospitalized for an acute condition within 90 days of release from correctional facilities.64 Another study demonstrated a higher risk of death among individuals 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 was higher for women than men. Drug overdose, cardiovascular disease, homicide, and suicide were the leading causes of death.

    The use of mental health and substance abuse treatment services decreases significantly following release from prison.68 Additionally, one survey noted that  for men and women  who received treatment for physical health conditions during their incarceration, treatment rates dropped dramatically within 8-10 months after their release.66 The trend was similar for mental health treatment. For men, more than 60% were treated for mental health issues while in prison but only 53% received treatment 8-10 months after their release. For women, 57% were treated for mental health issues while incarcerated, but only 42% received treatment 8-10 months after their release.66 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 individuals in the first year after their release from correctional facilities.62 Many of these individuals rely on hospital emergency departments for episodic care for acute problems.14, 59 The absence of continuity of care after incarceration leads to increased morbidity for patients who have chronic conditions, particularly those who are HIV-positive.71

    Policy Implications

    The AAFP supports policies that mitigate health disparities, such as improved access to substance abuse treatment, reproductive health care, preventive healthcare, and mental health services. Furthermore, as incarceration and detention are themselves detrimental to health, the AAFP supports reducing sentences for nonviolent and drug possession offenders and ending detention for those seeking legal asylum in the U.S. Due to increased incarceration time for many individuals, the AAFP calls for a review and changes to the cash bail system, as it increases the risk of both short- and long-term negative health outcomes, exacerbates socioeconomic disparities, and is racially biased.

    The AAFP advocates for individuals who are incarcerated or detained to have access to comprehensive medical services including mental health care and reproductive health care. Reproductive health services should include evidence-based prenatal care, preventive services, as well as, contraception during incarceration and at the time of release. Universal access to menstrual hygiene products for menstruating women and transgender males should be available at no cost. Other services and items should be made readily available, such as medication and counseling to treat and prevent sexually transmitted infections and should include integration of routine HIV prevention strategies including Pre-Exposure Prophylaxis (PrEP) medication, condoms, education, and frequent screening for HIV and other sexually transmitted infections. Access to evidence-based treatments for substance use disorders should be provided by correctional health facilities. Facilities should publicly report quality and safety performance on key metrics such as those that are consistent with the Unified Data System maintained by the Health Resources and Services Administration (HRSA) as a condition of federal funding.

    The health and well-being of children of immigrant parents should be protected. Children should not be placed in settings that do not meet basic standards for their physical and mental health.  Children should not be separated from a parent or primary care giver who is detained in an immigration facility, as this separation poses great risks in terms of emotional trauma, safety, and diminished overall well-being. Federal policy should mandate access to medical services for all individuals, particularly pregnant women and children, who are in detention centers. Private prisons and immigration detention centers should report quality and safety performance on key metrics such as those that are consistent with the Unified Data System maintained by the Health Resources and Services Administration (HRSA) as a condition of federal funding.

    Individuals who have been incarcerated 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 future 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, comprehensive primary care,                substance use support, and mental health support56, 60

    Successful reentry programs must be culturally competent and 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 The AAFP supports the funding and implementation of these models and other evidence-based programs to assit those who have recently been incarcerated.


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