Health and Incarceration - A Workshop Summary, Smith, 2013

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Health and Incarceration - A Workshop Summary, Smith, 2013

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Health and Incarceration: A Workshop Summary

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Amy Smith, Rapporteur; Committee on Causes and Consequences of High
Rates of Incarceration; Committee on Law and Justice; Division on
Behavioral and Social Sciences and Education; National Research
Council; Board on the Health of Select Populations; Institute of Medicine

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Health and Incarceration: A Workshop Summary

Amy Smith, Rapporteur
Committee on Causes and Consequences of High Rates of Incarceration
Committee on Law and Justice
Division of Behavioral and Social Sciences and Education
Board on the Health of Select Populations
Institute of Medicine

Health and Incarceration: A Workshop Summary

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
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This study was supported by Grant No. 70863 from the Robert Wood Johnson
Foundation, Grant No. 99472-0 from the John D. and Catherine T. MacArthur
Foundation, and Grant No. 2011-DJ-BX-2029 from the National Institute of Justice. Any opinions, findings, conclusions, or recommendations expressed in this
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Suggested citation: National Research Council and Institute of Medicine. (2013).
Health and Incarceration: A Workshop Summary. A. Smith, Rapporteur. Committee
on Law and Justice, Division of Behavioral and Social Sciences and Education and
Board on the Health of Select Populations, Institute of Medicine. Washington, DC:
The National Academies Press.

Health and Incarceration: A Workshop Summary

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Health and Incarceration: A Workshop Summary

COMMITTEE ON CAUSES AND CONSEQUENCES
OF HIGH RATES OF INCARCERATION
JEREMY TRAVIS (Chair), John Jay College of Criminal Justice, City
University of New York
BRUCE WESTERN (Vice Chair), Department of Sociology and the
Malcolm Wiener Center for Social Policy at the Harvard University
Kennedy School of Government
JEFFREY BEARD, California Department of Corrections and
Rehabilitation
ROBERT D. CRUTCHFIELD, Department of Sociology, University of
Washington
TONY FABELO, Council of State Governments Justice Center
MARIE GOTTSCHALK, Department of Political Science, University of
Pennsylvania
CRAIG HANEY, Department of Psychology, Graduate Program in
Social Psychology, and Program in Legal Studies, University of
California, Santa Cruz
RICHARDO H. HINOJOSA, U.S. District Court, Southern District of
Texas
GLENN C. LOURY, Department of Economics, Brown University
SARA S. McLANAHAN, Department of Sociology and Public Affairs,
Princeton University
LAWRENCE M. MEAD, Department of Politics and Public Policy,
New York University
KHALIL GIBRAN MUHAMMAD, Schomburg Center for Research in
Black Culture, New York Public Library
DANIEL S. NAGIN, Department of Public Policy and Statistics,
Carnegie Mellon University
DEVAH PAGER, Department of Sociology and the Joint Degree
Program in Social Policy, Princeton University
ANNE MORRISON PIEHL, Department of Economics and Program in
Criminal Justice, Rutgers University
JOSIAH D. RICH, Department of Medicine and Epidemiology,
Warren Alpert Medical School of Brown University, and the Center
for Prisoner Health and Human Rights at the Miriam Hospital
Immunology Center
ROBERT J. SAMPSON, Department of Sociology, Harvard University
HEATHER ANN THOMPSON, Department of History, Temple
University
MICHAEL TONRY, University of Minnesota Law School
AVELARDO VALDEZ, School of Social Work, University of Southern
California
v

Health and Incarceration: A Workshop Summary

STEVE REDBURN, Study Director
MALAY MAJMUNDAR, Senior Program Officer
JULIE SCHUCK, Senior Program Associate
BARBARA BOYD, Administrative Coordinator

Health and Incarceration: A Workshop Summary

COMMITTEE ON LAW AND JUSTICE
2013
JEREMY TRAVIS (Chair), John Jay College of Criminal Justice,
City University of New York
RUTH D. PETERSON (Vice Chair), Department of Sociology, Ohio State
University
CARL C. BELL, Community Mental Health Council, Inc.
JOHN J. DONOHUE III, Stanford Law School
MARK A.R. KLEIMAN, Department of Public Policy, University of
California, Los Angeles
GARY LAFREE, Department of Criminology and Criminal Justice,
University of Maryland, College Park
JANET L. LAURITSEN, Department of Criminology and Criminal
Justice, University of Missouri
GLENN LOURY, Department of Economics, Brown University
CHARLES F. MANSKI, Department of Economics, Northwestern
University
DANIEL S. NAGIN, Department of Public Policy and Statistics,
Carnegie Mellon University
ANNE MORRISON PIEHL, Department of Economics and Program in
Criminal Justice, Rutgers University
DANIEL B. PRIETO, Public Sector Strategy and Innovation, IBM
Global Business Services, Washington, DC
DAVID WEISBURD, Center for Evidence-Based Crime Policy, George
Mason University
PAUL K. WORMELI, Integrated Justice Information Systems,
Ashburn, VA
CATHY SPATZ WIDOM, Psychology Department, John Jay College of
Criminal Justice, City University of New York
ARLENE LEE, Director

vii

Health and Incarceration: A Workshop Summary

BOARD ON THE HEALTH OF SELECT POPULATIONS
2013
DAN G. BLAZER (Chair), Duke University Medical Center
KATHLEEN BRADY, Department of Psychiatry and Behavioral
Sciences, Medical University of South Carolina
JOHN C.S. BREITNER, Department of Psychiatry, McGill University,
Montreal, Quebec, Canada
MICHAEL L. COWAN, Broadlands, VA
WALTER R. FRONTERA, Vanderbilt University School of Medicine
and Vanderbilt University Medical Center
GREGORY C. GRAY, Department of Environmental and Global Health
and Department of Infectious Diseases and Pathology, University of
Florida, Gainesville
KURT KROENKE, Department of Medicine, Indiana University School
of Medicine
JANICE L. KRUPNICK, Department of Psychiatry, Georgetown
University School of Medicine
STANLEY M. LEMON, Department of Medicine and Microbiology and
Immunology Inflammatory Diseases Institute, University of North
Carolina at Chapel Hill
VICKIE M. MAYS, Department of Psychology, University of California,
Los Angeles, Fielding School of Public Health
M. JEANNE MIRANDA, Center for Health Services and Society,
University of California, Los Angeles
FRANCES M. MURPHY, Sigma Health Consulting, LLC, Silver Spring,
MD
KENNETH OLDEN, National Center for Environmental Assessment
and Human Health Risk Assessment Research Program,
Environmental Protection Agency
MICHAEL D. PARKINSON, UPMC Health Plan and WorkPartners,
Pittsburgh, PA
JENNIFER D. PECK, Department of Biostatistics and Epidemiology,
University of Oklahoma Health Sciences Center
CAROL K. REDMOND, Department of Public Health, University of
Pittsburgh
GRACE S. ROZYCKI, Emory University School of Medicine/Grady
Memorial Hospital
GEORGE W. RUTHERFORD, Department of Epidemiology, University
of California, San Francisco School of Medicine
MURRAY B. STEIN, Department of Psychiatry and Family and
Preventive Medicine, University of California, San Diego
FREDERICK (RICK) ERDTMANN, Director
viii

Health and Incarceration: A Workshop Summary

Preface

ver the past four decades, the rate of incarceration in the United
States has skyrocketed to unprecedented heights, both historically and in comparison to that of other developed nations. At far
higher rates than the general population, those in or entering U.S. jails and
prisons are prone to many health problems. This is a problem not just for
them, but also for the communities from which they come and to which,
in nearly all cases, they will return.
A changing policy environment calls for a fresh look at the connections between health and incarceration. Costs of providing care to
prisoners are rising, driven partly by an aging of that population. Fiscal
pressures, litigation, and judicial oversight are pushing states to look for
alternatives that better meet health needs of the incarcerated. The Patient
Protection and Affordable Care Act (ACA), in addition to insuring millions of previously uninsured people, creates specific new opportunities
to ensure continuity of medical coverage and care when prisoners are
released.
On December 5, 2012, the Committee on Law and Justice of the
National Research Council (NRC) and the Board on Health and Select
Populations of the Institute of Medicine (IOM) sponsored a workshop
on health and incarceration that brought together leading academic and
practicing experts to review what is known about these health issues and
what appear to be the best opportunities to improve healthcare for those
who are now or will be incarcerated. The workshop was designed as a

Health and Incarceration: A Workshop Summary

x PREFACE
roundtable with brief presentations from 16 experts and time for group
discussion.
The purpose of the workshop was to inform a current consensus
study by the NRC Committee on Causes and Consequences of High
Rates of Incarceration. In addition, participants hoped that a stand-alone
document of the workshop proceedings could educate the healthcare and
policy communities and provide a platform for visions of how the world
of incarceration health can be a better place. I thank the Robert Wood
Johnson Foundation for the generous support to enable this publication. This summary provides an objective report of what occurred at the
workshop, drawing on views presented by individual participants and
focusing on the possibilities for improving the health of incarcerated and
formerly incarcerated populations and implications of the implementation of the ACA on public health.
As the vice chair of the committee that co-organized the workshop, I
extend our thanks, first to committee member Josiah (Jody) Rich, Department of Medicine and Epidemiology, Warren Alpert Medical School of
Brown University, and the Center for Prisoner Health and Human Rights
at the Miriam Hospital Immunology Center, for his key role in identifying the expert participants and moderating the event. The success of
the workshop was a result of a talented and thoughtful group who gave
generously of their knowledge and time, whom we thank: Scott Allen,
University of California, Riverside; Redonna Chandler, National Institute on Drug Abuse; Jennifer Clarke, Brown University Medical Center;
Jamie Fellner, Human Rights Watch; Robert Greifinger, John Jay College
of Criminal Justice, City University of New York; Newton Kendig, Federal Bureau of Prisons; Marc Mauer, The Sentencing Project; Fred Osher,
Council of State Governments; Steven Rosenberg, Community Oriented
Correctional Health Services; Faye Taxman, George Mason University;
Emily Wang, Yale University; Christopher Wildeman, Yale University;
and Brie Williams, University of California, San Francisco. In addition, my
fellow committee member, Craig Haney, University of California, Santa
Cruz, joined Jody Rich and me at the workshop.
I also thank Steve Redburn, study director for the committee, and
Rick Erdtmann, director of IOM’s Board on Health and Select Populations, for their ongoing consultation in preparation for the workshop.
Barbara Boyd and Julie Schuck from the NRC’s Committee on Law and
Justice also provided valuable support to the workshop and production
of the workshop summary. I also thank the executive office reports staff
of the Division of Behavioral and Social Sciences and Education, especially Eugenia Grohman, who provided consultation with staff and the
rapporteur on the writing and editing of this summary; Kirsten Sampson

Health and Incarceration: A Workshop Summary

PREFACE

Snyder, who managed the report review process; and Yvonne Wise, who
managed the production process.
Finally, I thank our rapporteur, Amy Smith, who did a wonderful job
capturing the many visions presented at the workshop.
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose
of this independent review is to provide candid and critical comments
that will assist the institution in making its published report as sound as
possible and to ensure that the report meets institutional standards for
objectivity, evidence, and responsiveness to the study charge. The review
comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for
their review of this report: Ingrid Binswanger, Primary Care Residency
Research, School of Medicine, University of Colorado, Denver; Josiah D.
Rich, Department of Medicine and Epidemiology, Warren Alpert Medical School of Brown University, and the Center for Prisoner Health and
Human Rights at the Miriam Hospital Immunology Center; Emily Wang,
General Internal Medicine, Yale School of Medicine; Brie Williams, Division of Geriatrics, University of California, San Francisco; and Lester N.
Wright, Discipline of Public Health, University of Adelaide.
Although the reviewers listed above provided many constructive
comments and suggestions, they were not asked to endorse the content of
the report nor did they see the final draft of the report before its release.
The review of this report was overseen by Philip J. Cook, Sanford School
of Public Policy, Duke University. Appointed by the NRC, he was responsible for making certain that an independent examination of this report
was carried out in accordance with institutional procedures and that all
review comments were carefully considered. Responsibility for the final
content of this report rests entirely with the author and the institution.
Bruce Western, Vice Chair
Committee on Causes and Consequences of
High Rates of Incarceration

Health and Incarceration: A Workshop Summary

Contents

INTRODUCTION 1
1

IMPACT OF INCARCERATION ON HEALTH
Inmate Health, 7
The Legal Basis for Healthcare for Inmates, 9
Continuity of Care, 10
Quality of Correctional Healthcare, 12
Healthcare Providers, 13

2
VULNERABLE POPULATIONS AND OPPORTUNITIES FOR
REDUCING HEALTH RISKS
15

Mental Illness and Addiction, 16

Older Adults, 21

Women, 23

Youth, 25

Families, 25

Release and Re-Entry, 26

Cultures of Care, 28
3

ACCESS TO HEALTHCARE
Medicaid Enrollment, 31
Workforce, 33
Quality of Care and Accountability, 34
States and Health Plans, 35
xiii

Health and Incarceration: A Workshop Summary

xiv CONTENTS

Cost Shifts, Savings, and Recidivism, 35
Equity and Rights, 36

CLOSING 37
BIBLIOGRAPHY 41
APPENDIX: Workshop Agenda and Participants

Health and Incarceration: A Workshop Summary

Introduction

ncarceration rates in the United States are remarkably high. Those
incarcerated present an array of poor health conditions, including
mental illness, addiction, and chronic disease. While incarcerated, they
can face additional health challenges. Unfortunately, there is a dearth of
knowledge about the quantity, quality, or outcomes of healthcare within
correctional systems. The situation of prisoners has a public health impact
on their families and communities, both while they are incarcerated and
after their release. Upon release, these individuals’ health needs continue,
although their access to care can be interrupted or limited. A changing
policy environment, particularly the pending implementation of the
Patient Protection and Affordable Care Act (ACA), creates an opportunity
to improve outcomes both for public safety and for public health.
A half-day workshop was held on December 5, 2012, to address the
challenges and opportunities for improving health and healthcare of the
incarcerated. Sixteen invited presenters spoke in a roundtable fashion
(see Appendix for workshop agenda and participants). An additional 25
people attended the workshop to observe the discussion. Participants
included academics, practitioners, state officials, and nongovernmental
organization representatives from the fields of healthcare, prisoner advocacy, and corrections. This report summarizes the presentations and discussion during the workshop. It also refers to the background paper
distributed prior to the workshop, “Incarceration and Health,” by Josiah
Rich, Dora Dumont, and Scott Allen, as well as to participants’ slide
presentations shared at the workshop (Rich, Dumont, and Allen, 2012).
1

Health and Incarceration: A Workshop Summary

HEALTH AND INCARCERATION

One purpose of the workshop was to inform a consensus committee
pulled together by the National Research Council (NRC), which is now
examining the causes and consequences of high rates of incarceration in
the United States. The charge given to that study committee is provided
in Box I-1 and covers a broad range of consequences, including those on
the health, both physical and mental, of incarcerated populations. The
committee will produce its own report at the conclusion of its study. The
committee asked workshop presenters to review what is known about the
health of incarcerated individuals, the healthcare they receive, and effects

BOX I-1
Committee on Causes and Consequences of
High Rates of Incarceration
Statement of Task
An ad hoc panel will conduct a study and prepare a report that will focus on
the scientific evidence that exists on the use of incarceration in the United States
and will propose a research agenda on the use of incarceration and alternatives
to incarceration for the future. The study will explore the causes of the dramatic
increases in incarceration rates since the 1970s, the costs and benefits of the
nation’s current sentencing and incarceration policies, and whether there is evidence that alternative policies would more effectively promote public safety and
community wellbeing.
Recognizing that research evidence will vary in its strength and consistency,
the panel will undertake the following tasks:
1. Describe and assess the existing research on the causes, drivers, and social context of incarceration in the United States over the past 30-40 years.
To what extent does existing research suggest that incarceration rates were
influenced by historical and contemporary changes in:
a. operations of criminal justice system and other public sector systems
that may affect rates of arrest or conviction, and nature and severity of
sanctions: such as patterns of policing, prosecution, sentencing, prison
operations, and parole practices;
b. legal and judicial policies: such as changes in law, institutional policies
and practices, and judicial rulings affecting conditions for arrest, sanctions for various crimes, drug enforcement policies, and policies regarding parole and parole revocation; and
c. social and economic structure and political conditions: such as criminal behavior, cultural shifts, changes in political attitudes and behavior,
changes in public opinion, demographic changes, and changes in the
structure of economic opportunity.

Health and Incarceration: A Workshop Summary

INTRODUCTION

of incarceration on public health; and based on that evidence to identify
opportunities to improve healthcare for these populations.
This report has been prepared by the workshop rapporteur as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views
contained in the report are those of individual workshop participants and
do not necessarily represent the views of all workshop participants, the
planning committee, or the NRC and IOM.
The committee’s study and the workshop have taken place during a
period of unprecedented increase in the levels of imprisonment within

2. Describe and assess the existing research on the consequences of current
U.S. incarceration policies. To what extent does the research suggest that
incarceration rates have effects on:
a. crime rates: such as to what extent this is due to deterrence and incapacitation, to rehabilitation, or to criminogenic effects of incarceration;
b. individual behavior and outcomes, during imprisonment and afterward:
such as changes in mental and physical health, prospects for future
employment, civic participation, and desistance/reoffending;
c. families: such as effects on intimate partners and children, patterns of
marriage and dating, and intergenerational effects;
d. communities: such as geographic concentrations, neighborhood effects,
effects on specific racial and ethnic communities, high rates of re-entry
and return in some communities, labor markets, and patterns of crime
and policing; and
e. society: such as (in addition to effects on the crime rate) the financial
and economic costs of incarceration, effects on U.S. civic life and governance, and other near-term and longer-term social costs and benefits.
3. Explore the public policy implications of the analysis of causes and consequences, including evidence for the effectiveness and costs of alternative
policies affecting incarceration rates. What does the research tell us about:
a. efficacy of policies that may affect incarceration or serve as alternatives
to incarceration, including their effects on public safety and their other
social benefits and costs;
b. cost-effectiveness of specific programmatic approaches to reducing the
rate of incarceration;
c. how best to measure and assess the potential costs and benefits of
alternative policies and programs; and
d. ways to improve oversight and administration of policies, institutions, and
programs affecting the rate of incarceration.

Health and Incarceration: A Workshop Summary

HEALTH AND INCARCERATION
800

U.S. Incarceration Rate per 100,000 Residents

700

Includes jail in addition to
prison incarceration rate
600

500

400

300

200

100

0
1925

1930

1940

1950

1960

1970

1980

1990

2000

2010

Year

FIGURE I-1 Growth in U.S. incarceration rate.
SOURCE: Created from data in Maguire (2011).

the United States. Any accounting of the numbers involved in the U.S.
correctional system shows the remarkable and historically high rates
of incarceration in the United States (see, for example, Figure I-1). The
Bureau of Justice Statistics reports that nearly 7 million individuals were
under the supervision of the U.S. adult correctional system at year-end
in 2011. This total figure includes 2.2 million inmates, with 1.5 million in
prison and 700,000 in jail. Of the remaining 4.8 million, 4 million were on
probation and 800,000 on parole (Carson and Sabol, 2012). Although the
number of individuals in jail at any point in time is much lower than the
number in prison, a great many more people flow through jails (James,
2004). For example, the Bureau of Justice Statistics reports that in the 12
months from June 2010 to June 2011, the average daily confined inmate
population in county and city jails was about 735,000. However all admissions reported for that same period totaled 11.8 million, or about 16 times
the size of the daily jail inmate population (Minton, 2012).
The authors of the workshop background paper argue that the failure
of the U.S. healthcare system to adequately treat mental illness and addiction contributed to the escalation of the incarceration rate (Rich, Dumont,

Health and Incarceration: A Workshop Summary

INTRODUCTION

and Allen, 2012). Closing of mental hospitals in the 1970s (deinstitutionalization) was intended to shift patients to more humane care in the
community; however, the authors argue that insufficient funding left
many people without access to treatment. They note that individuals with
mental health problems may engage in behaviors that draw attention and
police responses and assert that many health professionals now feel such
behavioral disorders have become criminalized.
The background paper provides evidence that many of those incarcerated have substance dependence as defined by the Diagnostic and
Statistical Manual (Rich, Dumont, and Allen, 2012). Despite a body of
evidence demonstrating that addiction is a chronic brain disease that can
be effectively treated, the authors argue, substance dependence is often
viewed as a moral failing rather than a medical issue. They believe this
perception contributes to the low availability of treatment in the community. As a result, they assert drug dependence remains largely in the
hands of the criminal justice system rather than the healthcare system and
is criminalized rather than medicalized.
Jails provide unique challenges and opportunities for health. The
stays are often too short to provide much screening or treatment; however,
the very large numbers of people passing through jails with a tremendous burden of disease provide opportunities to have a significant public
health impact. Healthcare opportunities and challenges for vulnerable
populations who enter jails or have contact with other parts of the criminal justice system were discussed throughout the workshop.
This workshop summary has three chapters. Chapter 1 provides a
brief overview of prisoner health, including the impact of incarceration
on health. It then considers healthcare, including the legal basis for its
provision, some aspects of its availability during incarceration, and the
dilemmas experienced by many healthcare practitioners as they seek to
provide quality care within correctional facilities. Chapter 2 considers a
variety of proposals and models for improving the health and healthcare
of vulnerable populations affected by incarceration, with particular attention to workforce issues and the importance of the continuity of care.
And finally, Chapter 3 is devoted to the ACA, which received considerable attention in the workshop for its perceived potential to significantly
improve inmates’ access to healthcare, support changes in the workforce,
reach inmates’ families and communities, and possibly lead to a shift in
inmates’ right to care.

Health and Incarceration: A Workshop Summary

1
Impact of Incarceration on Health

s reported by several participants, individuals enter correctional
facilities with many health problems; and incarceration has an
impact on their health. Evidence was presented that many are
released (especially from jails, given the high turnover rate)—and too
often are re-incarcerated—with pressing health needs. Participants in the
workshop discussed the impact of incarceration on inmate health and
the healthcare they receive. Attention was given to possible improvement as well as deterioration in inmates’ health, the legal basis for such
care, the provision of it, and the context for delivering healthcare. In
particular, the discussion explored the dilemmas that arise in trying to
improve health within correctional institutions and the responsibility of
healthcare providers to engage in improving the healthcare of incarcerated populations and the health of the communities they come from.
INMATE HEALTH
As observed in the background paper, in the absence of systematic
review, perhaps it can simply be said that overall physical health probably
improves during incarceration in some ways but deteriorates in others.
For people living especially chaotic lives, incarceration can provide a
respite and stabilization: available meals, a structured day, and reduced
access to alcohol, drugs, and cigarettes, in addition to access to healthcare,
especially for black men who on average have lower access than white
men outside of prison (Rich, Dumont, and Allen, 2012).
7

Health and Incarceration: A Workshop Summary

HEALTH AND INCARCERATION

Christopher Wildeman (Yale University) suggested that correctional
facilities may present “a unique opportunity” to provide these individuals
with “at least some medical care that they haven’t gotten otherwise.”
Indeed, as Bruce Western (Harvard University) observed in his introductory remarks, “Prisons are coming to function as a massive organ of
delivery for public health for people who are involved in the criminal
justice system.” Newton Kendig (Federal Bureau of Prisons) outlined
the public health opportunities for both jails and prisons. He noted that
jails provide a strategic public health opportunity to screen and diagnose
infectious diseases among persons who often evade traditional healthcare
systems and yet are at high risk for illnesses, such as HIV infection and
viral hepatitis, and prisons provide an opportunity to diagnose and treat
chronic diseases, such as diabetes, hypertension, addiction, and mental
illness among persons who frequently have not sought or had access to
treatment prior to incarceration. The structured life of prison provides
an opportunity for better compliance with taking prescribed medications
and eating a healthy diet as well as engagement in drug treatment services, frequent recreation, and increasingly a tobacco-free environment.
On the other hand, the prison environment may have adverse effects
on health as discussed in the background paper (Rich, Dumont, Allen,
2012). The nutritional value of meals is far from ideal, because energydense (high-fat, high-calorie) foods are still common in prison meals.
Smoking also remains a serious problem, despite the trend toward smokefree correctional facilities. Poor ventilation, overcrowding, and stress may
exacerbate chronic health conditions. More evidence is available regarding
the effects of incarceration on mental health. Two conditions are especially
associated with a serious degeneration of mental health: overcrowding
and isolation units. The association between crowding and suicide or
psychiatric commitment has been noted at least since the 1980s. Strains
on staffing and facilities have particularly serious repercussions on wait
times and holding conditions for the mentally ill. Case studies have also
revealed widespread and serious reactions to segregation units, in which
inmates are restricted to isolation cells for 23 hours a day. The restriction
of movement and deprivation of human contact triggers psychological
responses, ranging from anxiety and panic to hallucination. A review of
health effects of incarceration also must consider sexual assault and intentional injury, either self-inflicted or resulting from assault.
Prison health conditions and impacts were further discussed at the
workshop. Jamie Fellner (Human Rights Watch) described prisons as
“toxic environments” with a negative impact on inmate health. She
underscored the damage that can result from isolated confinement: “We
know that [solitary confinement] is bad for people who are mentally ill
and can cause adverse symptoms for those who didn’t have prior symp-

Health and Incarceration: A Workshop Summary

IMPACT OF INCARCERATION ON HEALTH

toms of mental illness.” Fellner also shared research findings on other
aspects of prison experience, including violence (noting that one in ten
state prisoners is injured in a fight) and sexual abuse (about 9.6 percent
of former prisoners self-report that they were sexually abused by staff or
inmates [Bureau of Justice Statistics, 2012]; those abuses were frequently
accompanied by physical injuries in addition to any injury that came
from penetration itself). Excessive use of force by staff is also a problem,
she noted, from “old-fashioned beating” to the use of tasers and pepper
sprays that can cause serious injury, particularly depending on inmates’
physical conditions. “Obviously brutality has declined markedly in U.S.
prisons in the last 20 years,” Fellner observed, “but it still exists and it
still has health consequences.” Fellner also reviewed a range of other
conditions in prisons that can be detrimental to inmate physical and
mental health, including poor diets, poor sanitation, infestations with
bugs and vermin, poor ventilation, tension, noise, lack of privacy, lack
of family visits, and cross-gender pat searches (traumatizing especially
for the high percentage of women in prison who have been previously
sexually abused). Fellner offered these as “just some of the examples of
the kinds of conditions, some caused by inattention and poor management by prison staff, and some caused by prison policies” that can be
harmful to inmate health.
THE LEGAL BASIS FOR HEALTHCARE FOR INMATES
In prisons and jails, according to Robert Greifinger (John Jay College
of Criminal Justice, City University of New York), “we have a litigationdriven healthcare system.” Craig Haney (University of California, Santa
Cruz) echoed this view, noting that “for better or worse, a lot of the access
that I have into prisons has come in the context of litigation. I get called in
to look at prison systems, what’s happening to people in them, how those
systems are functioning when—in at least someone’s opinion—they’re not
functioning very well.”
The 1976 Supreme Court decision in Estelle v. Gamble found that
deliberate indifference to serious medical needs constitutes a violation
of the Eighth Amendment prohibition of cruel and unusual punishment.
Estelle v. Gamble led to expanded healthcare services, especially through a
series of subsequent lawsuits or threatened litigation. The duty of correctional facilities to provide healthcare was recently reinforced in Brown v.
Plata (2011), which ordered California to reduce overcrowding in prisons
because of the associated failure to provide adequate healthcare to all
inmates.
Acknowledging that litigation under the U.S. Constitution has driven
much of the provision of healthcare services in prisons, Fellner nonethe-

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less asserted that “the U.S. constitutional floor is so low that it is not
one to which the medical profession should limit itself, and nor should
government officials limit themselves to that.” She cited elements from a
number of international human rights treaties and guidelines addressing
prisoners.1 They call for prisoners to be treated with dignity and respect
for their humanity; “Starting and ending there would be a huge step forward in many prisons, I’m afraid,” she said. International treaties forbid
torture or cruel, inhuman, or degrading treatment of prisoners. They also
affirm that rehabilitation must be the paramount goal of incarceration
and that prisoners have a right to healthcare that is accessible, available,
and meets community standards. Feller noted that such standards are not
strictly enforceable by U.S. judges. In some instances, the United States
has signed but not ratified treaties. The elements of these international
treaties are nonetheless available, and Feller urged workshop participants
to heed them when generating implications for program and policy.
While the Supreme Court decision directs healthcare provision for
incarcerated populations in both prisons and jails, it does not extend to
those under supervision (on parole, probation, or home confinement)
within the criminal justice system. As Faye Taxman (George Mason University) underscored, “People in community corrections are the largest
population in the justice system, and they don’t have the constitutional
mandate for care that people who are incarcerated have.”
CONTINUITY OF CARE
Some correctional facilities are important public health collaborators
in the screening and diagnosis of infectious and other diseases, and many
correctional healthcare providers across the country are highly trained
and deeply committed to their patients’ wellbeing. Some correctional
facilities have sought partnerships with community-based medical and
public health practitioners to ensure that care begun during incarceration
is continued following release. Overall, however, as discussed and documented in the background paper, a disconnect exists between correctional
healthcare and state or local public health departments in planning and
delivering care to inmates while incarcerated and upon release (Rich,
Dumont, and Allen, 2012). In particular:

1These treaties include the International Covenant on Civil and Political Rights (ICCPR),
the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT), the International Covenant on Economic and Social Rights (ICESR), and the
Convention on the Rights of People with Disabilities.

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IMPACT OF INCARCERATION ON HEALTH

• Testing policies and procedures remain inconsistent across states
and facilities. Even wide-scale screening does not ensure that
appropriate treatment is being provided once conditions have been
diagnosed. In jails, where many people remain for under 48 hours,
testing follow-through (delivery of results and establishment of a
treatment regime) is especially challenging.
• Limited resources and resultant understaffing appear widespread
across correctional facilities. However, there is a lack of data
and appropriate measures sufficient to determine the extent
of shortcomings in correctional healthcare. Health outcomes
associated with staffing shortages were highlighted in testimony
in Brown v. Plata, which specifically linked overcrowding and
insufficient healthcare provider staffing. Brown v. Plata further
noted that the conditions of care created by overcrowding had
created a staff culture of “cynicism and fear,” which made it even
more difficult to attract competent clinicians, and presumably
affected the care provided by existing staff.
• Treatment for substance dependence is consistently insufficient to
meet prisoner need. Despite a body of evidence demonstrating that
addiction is a chronic brain disease that can be effectively treated,
surveys have found that few correctional facilities have adopted
evidence-based treatments, relying more frequently upon lesseffective drug education services (Chandler, Fletcher, and Volkow,
2009; McCarty and Chandler, 2009). Moreover, detoxification and
symptoms of withdrawal are most often treated with analgesics.
This does not address the underlying addiction and leaves
prisoners vulnerable to relapse and overdose upon release.
As workshop participants discussed healthcare provided in different
settings and to different populations, transitions were a recurring shared
concern. Haney declared transitions to be “the weakest points,” as “the
very best intentions flounder at the point at which there is a pass off.”
Haney noted this weakness at every stage: when the inmate enters the
system, then “when somebody moves from one facility to another, or
even within a facility to another part of the institution, and certainly
when somebody moves from the general [prison] population to a segregated housing unit.” Release is a further highly vulnerable transition. In
Haney’s assessment, “No matter how good the care was, no matter how
much information and intelligence was gathered about the patient, even
in [well] functioning systems, there is a tremendous falloff in terms of
the quality of care” at transition points. As “sometimes those transitional
moments are the moments of greatest vulnerability,” Haney asserted “that

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drop-off in care occurs at exactly the moment at which the patient needs
the most care or the most attention.”
QUALITY OF CORRECTIONAL HEALTHCARE
A recurrent and sustained theme throughout the workshop concerned
the dilemma inherent in providing healthcare within environments that
may in many ways undermine inmate health.
Haney offered a blunt statement of “the elephant in the room: prisons
are not just hospitals with electrified fences around them.” As he elaborated, correctional facilities are for the most part characterized by a
culture that tends to create limited communication and collaboration
between healthcare providers and the custody staff who operate the
facility. In this setting, healthcare providers have less authority, unlike in
any other setting in which they are accustomed to practicing. This affects
both their ability to do their job and patients’ confidence in healthcare
providers. And that, observed Haney, “cycles back oftentimes even in
the best trained and most well-intentioned care providers to a change in
attitude about the patient.” However, it should be noted that the healthcare providers at the workshop welcomed the incarcerated population as
patients in need of care.
Furthermore, in Haney’s view, some prison environments “are so
inhospitable that it is impossible to deliver effective medical and mental
health care.” Citing particularly the “two extremes of confinement: hopelessly overcrowded prison systems and conditions of long-term segregation or isolation,” Haney argued that the norms, policies, culture,
and even architecture of prisons can worsen health problems among
the ill, and even generate problems among the healthy. Thus, it simply
“becomes impossible to effectively deliver treatment in those kinds of
environments.”
Fellner offered a similar account of the environment and culture
within correctional facilities, and the resulting dilemma for doctors. In her
view, “prisons are ill-equipped by virtue of [a broad] mission, their culture, their training, their reward systems, their bureaucracies” to undertake the delivery of healthcare services to all prisoners who need them.
Therefore, while correctional facilities aim to provide adequate healthcare
and may even recognize their interests are served by having a healthier
inmate population, other purposes, environments complicated by the
rise in incarceration rates, and limited resources compromise reaching
that end.

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IMPACT OF INCARCERATION ON HEALTH

HEALTHCARE PROVIDERS
The workshop discussion sharpened to focus on providers’ professional and ethical responsibilities to advance the quality of correctional
healthcare. Greifinger added two factors to the difficulty of providing
healthcare effectively within correctional facilities. One is the lack of leadership, as “the commissioners, secretaries, and wardens often are not
providing the leadership to allow the modern innovative value-driven
physicians and other healthcare practitioners to do their jobs.” Another
is the pronounced isolation of healthcare providers in prison and jail settings, as they are often separated from their peers practicing in the general
public.
Above all, however, Greifinger underscored the adverse effects of the
culture of correctional facilities, particularly the “stereotyping and cynicism that results in distrust.” As Greifinger reflected, “I’ve been involved
in a lot of litigation over the years, class-action suits and individual cases.
I can tell you that in the individual cases, 99 percent of the time the reasons there was unconstitutional care was because there was mistrust and
cynicism of what the patient was saying. So I think we have a real danger
of a lot of harm continuing unless we change the system of care.”
Scott Allen (University of California, Riverside) directly addressed
the medical profession’s responsibility in establishing the current system.
Declaring that the system was created “on our watch,” Allen explained
that historically doctors were involved in the initiation of both prisons
and asylums, and that “doctors remain essential, and even we would
argue foundational, to the continued existence of jails and prisons.” Allen
described the crux of the dilemma as the effort to provide care with and
within institutions with practices that can be more punitive rather than
therapeutic. As the system became established, “the medical profession
went along for the ride.” Indeed, declared Allen, “I see this as a failure of
the medical profession as a whole.”
Specifically, Allen reviewed four aspects of medical professionalism
and how they are tested by the prison system: (1) altruism and commitment to patient interest; (2) physician self-regulation; (3) maintenance of
technical competence; and (4) civic engagement. In Allen’s view, within
correctional institutions, “altruism and loyalty to the patient’s interest is
fine as long as they don’t come into conflict with the institutional mission.” There is some support for physicians’ self-regulation, and a good
deal of emphasis on technical competence. Civic engagement, however, is
“the first to go,” as doctors providing healthcare within correctional facilities are “often reminded whether directly or indirectly to stay in our lane,
that we’re not there to make policy suggestions, just treat the patients,
just take care of them.” In Allen’s view, to accept that constriction of civil
engagement is to forgo both the moral authority and the legal authority

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HEALTH AND INCARCERATION

of the medical profession within the criminal justice system. To Allen’s
dismay, “I don’t think historically we have leveraged that or asserted that
[authority].”
Haney puzzled over this situation, calling for “help figuring out how
to operate effectively” in such adverse environments. Fellner agreed,
noting that this is “something which medical professionals have to work
on.” She articulated a challenge to healthcare providers: “You’re no longer
guests in the house of corrections, you have as much right to be there as
the guards, you’re constitutionally required, and it means speaking up
more.” Healthcare professionals working within correctional facilities
and those observing the situation from the outside have, in her view, “an
obligation to inform themselves and speak out” on conditions of confinement and impediments to appropriate healthcare delivery.
Speaking from the vantage point of a medical professional seeking
to provide healthcare within correctional facilities, Allen affirmed “it’s
important we take ownership of our role. We went along for the ride, we
were always integrated as a profession, and we need to take ownership
and acknowledge that.” The next step is to “assert our medical leadership,” including exercising both moral and legal authority. Noting the
medical profession’s past “failure to civically engage on both the policy
and political level,” Allen called for doctors to become engaged “in greater
number, with greater emphasis, and greater authority, so that we move
forward and promote policies that are in the interest of our patients.” Such
policies, Allen asserted, will address not only conditions of confinement
and delivery of healthcare within correctional facilities, but also transition
of care for those released back to the community, and above all, “all the
things that lead to the risk of incarceration in the first place.”

Health and Incarceration: A Workshop Summary

2
Vulnerable Populations
and Opportunities for
Reducing Health Risks

orkshop participants identified many immediate opportunities
and models for addressing health needs of those involved in
the criminal justice system. Proposals addressed care and health
interventions for a range of vulnerable populations, including not only
inmates but also their families as well as those recently released. Many
of these proposals involved changes to the workforce, such as retraining
parole officers, educating judges, raising the skill of screeners, and hiring
former inmates as community health workers. Throughout the discussion, workshop participants expressed awareness of the potential of many
measures to perform a threefold function: prevent incarceration in the first
place; treat the health needs of the currently incarcerated, their families,
and the released; and prevent recidivism.
As a preliminary note, Newton Kendig reminded participants of the
great range of inmates: “Incarcerated populations are extremely diverse,
depending on geography, ethnicity, gender, and healthcare needs.” Correctional facilities are also very varied, from prisons holding inmates
serving lengthy sentences to local jails with their “hyperdynamic population movement.” Finally, regional variations are also significant. For
example, “in Appalachia, methamphetamine oral healthcare could be
the number one issue at intake. In an inner city area, it could be HIV and
Hepatitis C. On the border of Mexico it’s drug-resistant TB.” Thus, Kendig
warned, it is likely not all proposals or priorities will apply across the
correctional system.
The health needs of inmates with a history of mental illness or addic15

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tion received considerable attention in the workshop, as did the health
profile of older adults, women, and youth in prisons and jails, and families of those incarcerated, as well as individuals recently released from
prisons or jails.
MENTAL ILLNESS AND ADDICTION
Overrepresentation
The overrepresentation of people with behavioral disorders in the
correction systems was the focus of a workshop presentation by Fred
Osher (Council of State Governments’ Justice Center). Osher explained
that 5 percent of the general population are estimated to have a serious
mental illness (Kessler et al., 1996); and while the rates are not directly
comparable, other studies have shown that the rate is much higher among
the incarcerated population, and especially so among women. In state
prisons, 24 percent of women and 16 percent of men have a serious mental
illness (Ditton, 1999). In jails, 31 percent of women and 15 percent of men
have a serious mental illness (Steadman et al., 2009). Osher noted, “We
don’t understand that exactly, but we’ve clearly got a big challenge with
this gender disparity and responding in appropriate ways to the needs of
women in correctional settings.”
Osher also offered estimates for substance abuse among prisoners,
observing that while less than 20 percent of the general population suffer
addiction, the figure in prisons and jails approaches 50 percent (Karberg
and James, 2005; Mumola and Karberg, 2006). Co-occurring mental disorder and substance abuse is also very high. In the general population,
about 25 percent of those with a serious mental illness have a co-occurring
disorder, while in jails, more than 70 percent of those with a serious
mental illness have a co-occurring disorder (Kessler et al., 1996; Ditton,
1999; James and Glaze, 2006; Steadman et al., 2009). Again, the rates are
not directly comparable across different studies and time periods, but the
potential differences are striking. The co-occurrence of mental disorder
and substance abuse can complicate the detection of either, particularly
when staff or diagnostic instruments are insufficiently sensitive, or where
overcrowding and/or understaffing reduces the time spent on medical
screening. Osher termed such co-occurrence a “critical issue” that needs to
be addressed at points of both entry and exit from the correctional system.
While Osher’s figures highlighted those with serious mental illness
(e.g., major affective disorders or schizophrenia), Fellner broadened attention to inmates whose mental health problems are less severe but might
still lead to significant functional disabilities. This describes over half
the incarcerated population. Fellner provided figures indicating that 56

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VULNERABLE POPULATIONS

percent of state prisoners have a mental health problem. Again, rates are
substantially higher among women inmates, as 73 percent of women and
55 percent of men in state prisons have mental health problems (James
and Glaze, 2006).
The overrepresentation of the mentally ill among the incarcerated is
a prominent trend across the country though rates of mental illness vary
somewhat across state and federal prisons and local jails. As Shannon
Murphy (Montgomery County’s Prerelease and Reentry Center, Rockville, Maryland) observed, in the relative paucity of either mental health
facilities or community support systems, prisons are now “the de facto
chronic mental health system” in the United States. Craig Haney further suggested that the magnitude of the problem is undercounted and
underestimated. In Haney’s view, the underestimate “creates a kind of
ripple effect through the problem. If resources aren’t adequate to the task
at hand then there is a way in which that unsolved problem tends to get
greater rather than simply stay in its underestimated size.” Haney cited
as an example the “so-called California overcrowding case” that culminated at the Supreme Court (Brown v. Plata), but which actually began as
a mental health case. Litigation to ensure constitutionally adequate care
for mentally ill prisoners brought attention to runaway overcrowding that
exacerbated mental health and medical problems and caused the level of
care to fall below constitutional standards.
Reflecting on the disproportionate numbers of people with untreated
or undertreated mental health problems and addiction in the prison population, Allen noted that, given the lack of adequate care, “what we’re left
with is a very large number of people with compelling health needs who
are ultimately incarcerated in institutions whose mission is security and
where [medical] treatment is an afterthought if it even occurs at all.” This
theme of an inherent tension of attempting to provide therapeutic care
within institutions organized for security recurred throughout the workshop (see further discussion below).
Treatment
Redonna Chandler (National Institute on Drug Abuse, National Institutes of Health) framed the value of addressing mental illness and addiction succinctly: “What are the health issues that if we addressed them
could help to deal with some of the root causes of incarceration? Addiction and mental health are two of the primary health conditions. If those
can be effectively addressed within the community, then you can lower
the number of people who are incarcerated and the number of people who
are re-incarcerated because of violating conditions of supervised release.”

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Participants offered several proposals to address mental illness and addiction before, during, and after incarceration.
Osher offered a somewhat different perspective: “What I want to say
as a main point here is that it’s just not as simple as we’d like it to be.
Just treating mental illness or substance abuse disorders may not in and
of itself be our solution to [reducing the prevalence of individuals with
behavioral disorders in the criminal justice system].” Osher grounded this
view in results of a study of inmates in Hawaii with schizophrenia spectrum disorder. The study suggested that for two-thirds of these inmates,
factors other than mental illness or substance abuse had led to their initial
incarceration or recidivism. Those factors, Osher emphasized, are the
very same factors that explain why people without behavioral disorders
become incarcerated. Osher identified these as the “central eight dynamic
risk factors” that account for much of the variance in people becoming
incarcerated: antisocial attitudes, antisocial friends and peers, antisocial
personality patterns, substance abuse, family and marital factors, lack
of education, poor employment history, and lack of pro-social leisure
activities. Each of these risk factors, Osher emphasized, can be addressed
through interventions. Osher further acknowledged that people with
mental illness tend to have significantly more of the central eight dynamic
risk factors.
To address these dynamic risk factors, Osher proposed adherence to
the principles of the Risk-Needs-Responsivity Model (Andrews, 2006;
Andrews and Bonta, 2006). The Risk Principle consists of screening an
individual inmate’s risk of reoffending and matching the intervention to
that level of risk. The Needs Principle consists of targeting the inmate’s
criminogenic needs. According to Osher, the more criminogenic needs
are targeted, the larger the effect of the intervention. The Responsivity
Principle calls for tailoring the intervention to the learning style, motivation, culture, demographic, and abilities of the individual inmate. Osher
clarified that while mental illness itself is not a criminogenic risk, and not
one of the central eight dynamic risk factors, it can have a major impact
on responsivity. Thus, “mental illness must be addressed so that the
individual can fully engage in the interventions that are associated with
reduced recidivism.”
Osher offered further advice on applying the Risk-Needs-Responsivity
Model, particularly because of the potential to actually increase the rate
of recidivism. According to Osher, “we know in fact that if you don’t
attend to risk that you can actually do harm. We know that the largest
impact on recidivism takes place when the focus is those individuals
with [higher risk levels] and that one can actually increase recidivism if
low risk individuals are the focus of treatment.” Osher referred to results
from a study in Ohio to support this view (Latessa, 2012). He concluded

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VULNERABLE POPULATIONS

that “we should prioritize and use scarce resources most effectively to
get the public health and public safety outcomes that we want.” That
will involve developing the skillsets of those involved in providing the
interventions, particularly interventions based in cognitive behavioral
therapy. In Osher’s view, “there’s a large workforce development issue
that we need to be mindful of.”
During discussion, Taxman highlighted the varying definitions of
and perspectives on the concept of an antisocial personality, as well as
the “diverse and inconsistent measurement of that particular domain.”
Taxman also observed that it is a “very controversial issue in the field,
whether or not mental illness is a criminogenic need or not, whether or
not treating mental illness will reduce recidivism rates.” Her sense is that
“over the last ten years I think the field has moved in a direction recognizing that [mental illness and criminogenic risk] are different entities.”
Taxman concurred with Osher regarding the imperative of developing the workforce to provide effective behavioral interventions. She
particularly discussed retraining probation officers and parole officers to
undertake roles as social workers and behavioral managers, rather than
perform as agents of enforcement and security. “When probation officers and parole officers use behavioral management techniques,” Taxman
declared, “it works.” In accordance with the Risk-Needs-Responsivity
Model, Taxman suggested that correctional staff should identify the
risks and needs of individuals, and then work with them to develop
“problem-solving techniques.” An essential component of the process is
instilling a sense of responsibility in the individual. According to Taxman,
if the individual is to be compliant “for everything from [not] offending
through [following through with] primary healthcare, then really the
individual needs to have much more responsibility.” She therefore advocated less of a focus on any particular program for inmates, and greater
effort to have probation and parole officers “help people make choices
in their lives, how they are going to get through probation successfully.”
Taxman saw great potential when supervising officers are trained less
as agents of social control, and more as facilitators of behavioral change
with an emphasis on helping individuals exercise responsibility and selfdetermination. According to Taxman, “If we don’t change the criminal
justice policies . . . that focus just on monitoring conditions of release,
then we’re not going to make progress toward a system so that people
can take care of their own needs outside of the criminal justice system.”
If this could be accomplished, Taxman argued, inmates could “find a way
to become more contributing members of society and find value in their
own lives.” Currently, however, “that’s not something the criminal justice
system is invested in doing.”
Addressing substance abuse effectively was another priority

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addressed in the workshop. Participants noted that there are many
evidence-based treatments for substance abuse, both behavioral treatments and medication-assisted treatments. As Chandler lamented,
however, “the capacity for delivering those treatments is limited and
fragmented.” The delivery of evidence-based behavioral treatments is
poor; the delivery of medication-assisted treatments is even worse. This is
the case even though, explained Chandler, “we know that medication can
help address opiate addiction, alcohol, as well as nicotine. It’s one of the
most effective interventions we have. Yet when you look at the number
of individuals that could potentially benefit, only a very small portion
is being served.” Thus, expanding substance abuse treatment, including
medication-assisted treatment, is critical.
Chandler dwelt further on the imperative of providing continuing
treatment during re-entry. As she explained, “Study after study after
study has shown that if you only provide treatment to an individual while
they’re incarcerated and you don’t follow that up with ongoing care when
they re-enter the community, you are not going to be able to significantly
impact their drug use.” Two factors are closely linked to relapse. One is
the cue-rich environments to which addicts return, cues that the underlying neurobiological mechanisms in their brains have associated with
their drug use, triggering craving. The second is the incredibly stressful
situation of re-entry itself, which also triggers neurobiological responses
that lead to an increased risk of relapse.
Workforce issues also figured in the discussion of substance abuse
treatment. “It’s really important,” Chandler affirmed, “to make sure that
criminal justice actors, and especially leaders, understand the underlying and important health problems of this population.” Unfortunately,
addiction is widely misunderstood. In her assessment, “very few people
outside of the healthcare field—and even within the healthcare field—
understand the underlying neurobiological principles of addictive disorders. If they don’t understand that they see it as moral failing, they
blame the individual, and then they’re reticent to provide treatment or
to be open to other types of models of care.” Because of her years of
involvement in training judges, Chandler appreciates the value of such
training. She described, “seeing the light bulb go off in their heads,” and
their subsequent return to their jurisdictions to enact “radical changes in
the way they deal with the problem of drug abuse because they understand the underlying biological processes that are occurring.” Chandler
concluded, “Where there is ignorance I think we have the opportunity
to shed some light, and that’s going to be really important if you want
these partnerships and collaborations, and if you really want to be able
to optimize outcomes.”

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OLDER ADULTS
The proportion of older adults in the criminal justice system, and
resultant healthcare concerns, have increased sharply (see Figure 2-1). In
her presentation, Brie Williams (University of California, San Francisco)
described the trend. From 1990 to 2012, the U.S. population age 55 or
older increased by about 50 percent. In that same period, the U.S. prisoner population age 55 or older in the state and federal prison systems
increased by some 550 percent as the prison population doubled. “This
increasing number of older adults,” Williams declared, “really changes
the entire health landscape of the correctional system.”
Williams explored several characteristics of the disease burden of
older adult inmates. First, as in the general population, older inmates
have the highest rates of typical chronic health conditions (congestive
heart failure, diabetes, chronic obstructive pulmonary disease, etc.) and
serious life-limiting illnesses. Second, older inmates also have very high
rates of additional geriatric syndromes such as cognitive impairment or
dementia, and disabilities or impaired ability to perform activities of daily
living. Some of this disability is common to the general population, such

600

U.S. Population 55+

% Growth from 1990 Populations

550

U.S. Prison Population (Total)

500

U.S. Prisoners 55+

450
400
350
300
250
200
150
100
50
0

1990

1992

1994

1996

1998

2000

2002

2004

2006 2008

2010

Year

FIGURE 2-1 Rate of growth of older adults in the criminal justice system.
SOURCE: Williams et al. (2012a).

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as impaired mobility or the need for assistance with eating or bathing.
Other disabilities are unique to the prison environment, such as not being
able to drop to the floor as instructed in response to an alarm or, worse,
not being able to get back up again after the alarm is over, or difficulty
climbing on or off one’s assigned bunk. Because of the unique challenges
of a prison environment and the resulting disabilities, Williams explained,
“In older adults, simply cataloguing chronic disease is insufficient.” Given
aging trends of the incarcerated population and their associated health
conditions, Williams observed that “correctional institutions are increasingly becoming a critical delivery site for long-term care or nursing homelevel care, as well as palliative care or care for people with serious chronic
illnesses.”
In confronting and meeting the needs of the rapidly increasing older
adult inmate population, Williams underscored the importance of examining both health and nonhealth policies of the criminal justice system.
Beginning with health-related policies, Williams advocated four immediate changes. First is to screen for and address cognitive impairment and
dementia, and then incorporate these screening results into court proceedings, healthcare delivery, parole, probation, and release planning. This
would have extensive repercussions for workforce training, as it would
involve “everyone from police and judges and attorneys, through jail and
prison clinicians, and then people responsible for probation and parole.”
A second imperative is to define and address disability, with attention to “what disability looks like in the correctional setting.” This would
involve delineating the basic physical tasks that are necessary for a person
to function with independence by housing unit, and then matching these
physical tasks to prisoner abilities when housing is assigned. “This seems
very basic,” Williams observed, “and [surprising] how infrequently it
happens.” A re-screening schedule should then be implemented, especially because sentences have grown longer. Very often the only disability
assessment is performed at intake, even if an individual is incarcerated
for decades.
Williams’ third suggestion was to develop plans for long-term care
and nursing home-level care, essentially a continuum of care across the
spectrum of disability, with criteria for classification in different care
levels. This would include enhanced palliative care or symptom-based
chronic care management for people who are seriously ill. “I would love
to see [the rate of incarceration decrease],” Williams remarked, “but until
it does, I think we need to make these plans.”
Her fourth health-related policy proposal was to create a national
medical release or so-called compassionate release guideline. These uniform guidelines would be based in scientific evidence from palliative
and geriatric medicine and clinical medicine in general. Barriers that

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prevent medically eligible persons from obtaining release would have
to be addressed. Fellner concurred on the significance of compassionate
release and noted that the Federal Bureau of Prisons and most states
have provisions for releasing inmates in extraordinary and compelling
circumstances, but that these are “greatly underutilized.” Fellner urged
that healthcare providers “be involved in trying to make those [provisions] work.”
Williams expanded her suggestions to the nonhealth policies that
have unanticipated health consequences on the growing older adult
inmate population. “Good people can take different sides of each of these
issues,” she acknowledged. “My point is not to say which [side] of these
issues is correct or not correct, but to say that these points need to be
debated given the changing demographic of the population.” Williams
highlighted three such policies as meriting re-examination. First is sentencing decisions, as “three strikes [policies] and life without possibility
of parole have really resulted in a higher concentration, very simply, of
older and sicker persons across the nation in the correctional setting.”
Second is facility policies, such as lockdowns and administrative segregation, because “evidence suggests that these may increase disability and
deconditioning specifically for older prisoners or for those with chronic
impairments.” Finally, a careful review of “well-meaning state-wide reorganization efforts that can be dramatic and really large in scope,” but
may have unintended effects—such as shifting older adult inmates from
prisons to jails, “which [often] have fewer healthcare resources, especially
for chronic disease management.” In concluding, Williams affirmed the
responsibility of the medical profession to “help with criminal justice
policy, and be at the table to anticipate potential health consequences
[of] both health policies [and] nonhealth policies.”
WOMEN
Although female inmates are only about 10 percent of the correctional
population, they present higher rates of disease and additional reproductive health issues. As noted earlier, mental health disease burden is considerably higher for women than men. Very high rates of childhood sexual
abuse and post-traumatic stress disorder are prevalent among female
inmates. Given the disproportionate burden of mental illness borne by
women inmates, the proposals for addressing the mental health needs,
discussed above, are particularly applicable to this population.
Jennifer Clarke (Brown University Medical Center) addressed health
issues of incarcerated women, particularly reproductive health. Clarke
estimated that 5 to 6 percent of women coming into prisons or jails are
pregnant. The data on birth outcomes vary, but in general, babies weigh

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more the longer a woman is incarcerated. Reasons for better birth outcomes are likely better access to prenatal care, decrease in substance
use, and, for some, stable housing and regular meals. Clarke hastened
to note, “I always have to follow that by clarifying I am not advocating
incarcerating pregnant women but rather underscoring the need for this
population to have services in the community.”
Clarke also commented on the research finding that most of the
women who enter incarceration pregnant had conceived within three
months of leaving a prior incarceration. This emphasizes the need for correctional facilities to provide family planning services, as most so-called
“pregnant women days” within prisons are from women who have been
imprisoned previously where a more stable diet and less access to drugs
may have improved fertility, and upon release, without family planning services, conceived promptly. The stress of an unplanned pregnancy
could add to their difficulty of getting re-established in the community,
and some are soon re-incarcerated. Clarke shared research that indicated
that about 70 percent of women in the criminal justice system who are at
risk for an unplanned pregnancy indicated they want to start a contraceptive method.
Sexually transmitted infections (tested on entry to prison or jail) are
about 10 to 20 times higher in the incarcerated female population than the
general population, and at least twice as high as that of the incarcerated
male population. As health consequences of such infections for women
are much greater than they are for men, Clarke affirmed the paramount
importance of screening and treating women for such infections as they
enter prisons and jails.
Clarke also offered observations on the rise in obesity. Women on
average gain over a pound a week when incarcerated. A year’s incarceration thus results in over a 50-pound weight gain, with considerable
consequences for both the physical and mental health of women inmates.
Clarke underscored the imperative of providing reproductive healthcare, with attention to continuing care after release. Recalling evidence
that women expressed interest in starting a contraceptive method and
also acknowledging that “there have been a lot of abuses in the past of
reproductive freedom,” Clarke advocated the availability of reversible
contraceptive methods.
Asked about the provision of nurseries in correctional facilities, Clarke
noted “great outcomes,” including better bonding and more breastfeeding,
when this is possible. Given the small size, limited resources, and security
concerns of many facilities, however, Clarke acknowledged that nurseries
are not universally feasible. She therefore concluded, “I think it’s in the
best interest of correctional facilities to do the preventive healthcare to
prevent needing a nursery later on.”

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YOUTH
Youth were not a focus of presentations in the workshop. However,
Chandler remarked on this lacuna, asserting “we’re missing a tremendous opportunity by not talking about adolescents and juvenile justice.”
Taxman observed that there are more youths in the juvenile justice system
than in foster care. Chandler provided figures indicating that approximately 1.5 million adolescents are involved in the juvenile justice system,
either in community programs or detention centers. These youth have
tremendous healthcare needs, including addiction, mental health problems, and infectious disease. If those needs are not addressed effectively,
Chandler affirmed, there are two outcomes for these youth: premature
violent death or involvement in the adult correctional system.
What initiatives could be undertaken to address the health needs of
youths in the criminal justice system? According to Chandler, “This is
the only population that we can name where we can safely say that all
of the individuals in this population merit [screening for addiction and
identifying] a drug abuse intervention.” She advocated “comprehensive
screening for all adolescents in juvenile justice to determine the severity
of their substance abuse problem,” to be followed by “either an indicated
prevention intervention or a drug use treatment intervention.” Chandler
estimated that half of youth in the juvenile justice system have a substance
abuse problem severe enough to warrant a diagnosis; thus, “you’re going
to be providing treatment to a large number of adolescents.”
FAMILIES
The public health impacts of soaring incarceration rates are manifold.
Relevant vulnerable populations include not only the incarcerated, but
their family members as well. Christopher Wildeman (Yale University)
offered several insights in his presentation on the effects of incarceration on the health of family members. Prisoners are embedded in social
networks. Thus, Wildeman emphasized, for every individual inmate,
a far greater number of family members may be affected. As the incarceration rate soars, so does the number of family members affected by
incarceration. All of these people—the partners, children, and siblings of
inmates—are drawn into the correctional system when a family member
is incarcerated.
Considering the health of this population, Wildeman began by noting
that they are exposed to the same risk factors for poor health as are the
individuals who actually experience incarceration: the same socioeconomic status, education levels, and neighborhood exposures. This suggests a probable overlap in health problems, including mental health
problems. In Wildeman’s view, this is “a tremendously vulnerable popu-

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lation even if you assume having a family member incarcerated has no
health impact on them.” Increasing evidence, however, suggests that
incarceration does compromise the health of family members, amplifying
the public health impact of increased rate of incarceration.
Wildeman considered the potential of using the criminal justice
system to find ways to improve the health of this population, even though
they are not directly involved in it. He particularly proposed that the
process of prisoner release might be an opportunity to gather information about family members. This could facilitate enrolling them in social
services, Medicaid, or other programs. In this way, indirect contact with
the criminal justice system might have some benefit for this population,
particularly as the bulk of this population is not now enrolled in any
healthcare plan.
RELEASE AND RE-ENTRY
As explained in the background paper, the period immediately following release from prison or jail is especially risky (Rich, Dumont, and
Allen, 2012). While mortality rates within prisons and jails are comparable to those of the general population for white males and lower than
their nonincarcerated peers for black males, former prisoners are nearly
13 times more likely to die in the two weeks following release than the
general population (Binswanger et al., 2007). In particular, former prisoners are 129 times more likely than the general population to die of an
overdose during that period. This reflects both the challenges faced upon
return to communities and the insufficient nature of substance abuse
treatment during incarceration, during which prisoners may not realize
their tolerance to opiates has declined. Despite efforts to improve the outcomes of prisoner re-entry through assistance with employment, housing,
and other transitional needs that ultimately affect health, only about 10
percent of prisoners from state prisons in need of discharge planning actually receive it (Mellow and Greifinger, 2007). In general, mentally ill prisoners and those with HIV are more likely than others to receive discharge
planning. Nonetheless, they are also more likely to be homeless and rely
on extensive emergency department healthcare post-release. Although
inmates with mental illnesses are generally given a supply of medications
upon release, medication adherence falls off rapidly upon release.
Emily Wang (Yale University) addressed the health of the newly
released based on her experience and research with the Transitions Clinic
Network. This is a national network of programs currently operating in
six states, the District of Columbia, and Puerto Rico, based in community
health centers and providing primary care to individuals post-prison.
Wang confirmed that the immediate aftermath of release is a particularly

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risky period. She noted a worsening of chronic medical conditions and
substance abuse, and a high risk of hospitalization and risk of death
among the newly released. Based on her research among clients of the
Transitions Clinic in San Francisco, Wang observed that many had not
received any discharge planning, and had either short or no supply of
medications. Among the clinic’s patients, 69 percent were uninsured. For
those who had been enrolled, Medicaid or Medicare Part B had lapsed
while they were incarcerated. Finally, drug felons faced additional barriers to meeting their basic needs and getting access to food stamps or
housing assistance. Immediately post-release, 93 percent were homeless
or at risk for being homeless. Wang also discovered that 39 percent of the
clinic’s patients went a whole day without food.
An overriding priority in dealing with release is providing continuity
of care, whatever care that might be, whether it is for treatment for addiction or mental illness, for reproductive care, or for management of chronic
disease. The risks involved at the moment of re-entry, and the likelihood
that healthcare would be interrupted, were reiterated several times during
the workshop. Wang offered other insights from the focus groups that
Transitions Clinic Network has conducted. Participants in these groups
consistently express three preferences. They asked that primary care providers possess relevant cultural competence, and specifically that they
have past experience caring for patients with a history of incarceration.
They also requested community health workers with a history of incarceration to assist with patient navigation of the social service system and
the healthcare system, as well as provide support in care management and
chronic disease management. Their third request was access to primary
care within the first two weeks after release.
Wang incorporated these preferences in developing suggestions
for addressing the needs of inmates upon release. Her first proposal
was that individuals with a past history of incarceration be involved
in improving the healthcare of returning prisoners. This is an issue of
workforce training and cultural competence, as well as providing former
prisoners with a role in decision making or “having a seat at the table.”
Addressing all these issues would entail “people with experience of incarceration coupled with proper training as a community health worker to
help patients navigate the healthcare system following release, and really
deal with all the social issues that might emerge in those days, weeks,
months post-release.”
Wang’s second suggestion was to improve transitions from prison to
community healthcare systems. Relevant evidence-based steps start with
basic discharge planning, refilling medications, and ensuring availability
of medical records. Several workshop participants mentioned the possibility that electronic medical records might ease this last task. Wang also

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cited evidence-based methods for preparing community health centers to
facilitate early access to care in the primary care setting.
As discussed more fully below in the context of the Patient Protection
and Affordable Care Act, Wang’s third suggestion was to eliminate barriers to Medicaid enrollment and reinstatement. Her final suggestion was
to eliminate full or partial food-stamp bans and barriers to housing and
employment. Even where barriers are not formal or direct, regulations—
such as the requirement of specific forms of identification—can block
access to food aid or other services. “Time and time again, among the
patients that I’m seeing, post-release, two weeks on,” Wang explained,
“they’ve already come to the physician, they’re interested in their health,
and the really crippling part is there are so many other needs there that
they’re unable to attend to their health in the best possible way.” She cited
evidence of access to food, “just the barebones importance of food,” as
particularly crucial for this population.
Wildeman concurred, adding “if we just improve the medical care
that [former inmates] receive but we don’t attend to their homelessness as
a passive result of incarceration, or economic instability, or labor market
outcomes, or family life,” then we miss much that has “a really profound
effect on their health over the life course as well.”
CULTURES OF CARE
A further set of suggestions emerged during workshop discussions.
They dealt less with any particular inmate population, and more with
how healthcare and criminal justice professionals approach the provision and context of care. Much of this involved education. For example,
Williams advocated that healthcare professionals educate others about the
health needs of aging inmates. She noted that as her team trains police,
judges, public defenders, district attorneys, and correctional officers about
dementia, “across the board people are [often] relieved to be finally getting healthcare information that [can] make their jobs both better, more
rewarding, and less stressful.”
In response, Wang noted that healthcare providers need to be educated about many aspects of the criminal justice system. She lamented
that primary care providers practicing in federally qualified health centers
are seeing patients with a past history of incarceration, perhaps recently
released, and yet have no idea of the type of care these patients have
received during incarceration. Wang suggested that both criminal justice
professionals and healthcare providers need to develop cultural competence when dealing with this population.
Steven Rosenberg (Community Oriented Correctional Health Services) pursued the theme of cultural competence, suggesting that health-

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care providers should attempt to understand not only the conditions
faced by inmates while incarcerated and upon release, but also the pressures faced by criminal justice professionals—thus becoming “cross culturally competent” so as to avoid possible conflict. Allen challenged this
perspective, suggesting that no change of cultural frame would eliminate
the innate conflict between providing care while simultaneously fulfilling
a goal of security. Such conflicts cannot be navigated past: “They’re baked
into the pie. There are two functions and they come into conflict.”
Yet Allen agreed on the imperative of mutual respect between corrections officers and healthcare providers: “It’s really important while we
demand respect from custody [staff], that we’re also able to return it and
learn to speak their language as much as we ask them to speak ours.” This
is a matter of practical importance, “because you can talk all day about the
ideals of medicine, but if you can’t translate it into how they can actually
apply what you’re recommending in a way that they will still have their
job at the end of the year, you’re just spinning your wheels.”

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3
Access to Healthcare

he Patient Protection and Affordable Care Act (ACA) was recognized throughout the workshop as an unprecedented opportunity
to expand health services to the population involved in the criminal justice system. Discussion was informed by both the background
paper and additional papers by Regenstein and Christie-Maples (2012)
and Phillips (2012). The implications of ACA were explored within the
workshop, with discussion focusing on aspects of enrollment, workforce,
quality of care, costs, and equity.
MEDICAID ENROLLMENT
Many prison and jail inmates are poor, lack insurance, and are in
need of health services. By federal law, inmates already enrolled in Medicaid are precluded from receiving benefits while incarcerated. 1 That
will not change under ACA, as currently written. As discussed in the
background paper, in order to see a healthcare provider, inmates generally must submit sick call slips and often pay a fee. Such fees have been
implemented in the federal system, in about 70 percent of state prisons,
and an unknown number of jails. While the sums involved are usually
small (e.g., $2 to $5), even this low cost has been a substantial deterrent for inmates making from 7¢ to 13¢ an hour in prison work assign1 Note in some states, prisoners can be covered by Medicaid when they are hospitalized
outside the prison.

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ments (Rich, Dumont, and Allen, 2012). Some systems provide waivers
for copayments, at least for some types of care such as communicable
diseases and true emergency and follow-up care; copayments can also
be waived for incarcerated people who are medically indigent. A 2003
Centers for Disease Control and Prevention report on a multistate outbreak of antibiotic-resistant staph infections in correctional facilities
listed copays along with staff shortages as hindering access to timely
care, contributing to the spread of the infection. Further, in most states,
individuals entering incarceration already enrolled in Medicaid face
disenrollment from the program, despite federal guidance that Medicaid
coverage only be suspended, not terminated, as a result of incarceration
(Phillips, 2012). With this pattern of disenrollment, almost 80 percent of
those previously covered are without private or public insurance when
released, exactly during the high-risk re-entry period when access to
health services can be critical.
The ACA presents a major opportunity for millions of poor people
to obtain insurance coverage. When fully enacted in 2014, ACA will raise
Medicaid eligibility levels to 133 percent of the poverty line for all adults.
States will receive a 100 percent federal subsidy to cover the expansion
of Medicaid enrollment for the first three years and a tapering subsidy
thereafter. A substantial percentage of those newly eligible for Medicaid
will have some involvement with prisons or jails. The potential of the
ACA to reach these individuals is great but also has limits. Some of these
limits are formal, including legal restrictions on accessing benefits. Other
possible barriers may include limits to the ability to facilitate the Medicaid
enrollment process within correctional facilities.
As delineated in the paper by Regenstein and Christie-Maples (2012),
jail inmates who are held pending disposition (estimated at from onehalf to two-thirds of the jail population) may face formal restrictions to
accessing benefits. The authors make the following distinctions among
inmates pending disposition:
• Incarcerated individuals pending disposition are qualified to enroll
in and receive services from health plans participating in state
health insurance exchanges if they otherwise qualify for such
coverage.
• Individuals pending dispositions who satisfy bail requirements
and are released into the community will be eligible to enroll in
Medicaid and receive services so long as they meet the program
requirements.

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• Individuals who are pending disposition and remain in jail because
they are unable to meet bail conditions may enroll in Medicaid
if they satisfy the program requirements but will be ineligible to
receive Medicaid services.
Workshop participants discussed the value of eliminating the restriction imposed in the third category. Even if the restriction were maintained,
simply ceasing to disenroll the incarcerated from Medicaid could have a
substantial impact on continuity of care for them upon release to society.
Further discussion addressed the imperative of facilitating enrollment, particularly among the large and fluid population moving through
jails. Jails are viewed as a particularly valuable point of contact for both
inmates and their families. Jails might also be able to facilitate the process
of enrollment, which can be cumbersome and even overwhelming for a
low-resource population. Some inmates and their families have been hampered by low literacy as they attempt to complete paperwork. They often
lack essential documentation (government-issued identification, recent
paystubs, or bank statements). Homelessness or unstable housing can
interfere with communication from the Social Security Administration.
Jails may also be in contact with persons who would otherwise avoid
interacting with officials—due, for example, to unpaid child support or
immigration status. If jail staff made an effort to enroll inmates, this
could make a substantial difference to realizing the potential of ACA to
provide access to healthcare for uninsured individuals and open reimbursement streams for the localities providing care to inmates, arguably improving equity and health while lowering both health costs and
recidivism. This also applies to visiting family members who may be
just as vulnerable and underinsured and could benefit from enrollment
into health insurance plans under the ACA as well. As Steven Rosenberg
affirmed, “Getting people enrolled is the first issue in terms of leveraging
the implications of ACA.”
WORKFORCE
The workshop also explored implications of the ACA for expanding,
improving, and funding the health-related workforce interacting with
inmates. Discussion reflected changes in the workforce needed in order to
address the needs of inmates. This included not only professional medical
care providers, but a range of other actors, such as skilled screeners to
work in prisons and jails to screen inmates at intake for mental illness
and substance abuse, dementia and age-related disease and disabilities,
reproductive health and sexually transmitted infections, health and insurance status of family members, and a range of other issues. For meeting

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the needs of those on probation and parole, correctional staff trained
in cognitive behavioral management and motivational techniques was
also discussed. The handling of release and re-entry would also entail
a capable workforce to improve continuity of care, ongoing medication
and treatment, and enrollment of families in health plans or Medicaid.
In particular, this might include community health workers with incarceration experience to help those recently released navigate the complexities of accessing social services and manage their healthcare in the
risky period of re-entry. If these services were provided to those newly
enrolled under the ACA, would any of these screeners, corrections staff,
or community health workers be able to bill their services to Medicaid?
Several participants explicitly wondered whether expansion of coverage
under ACA would make this possible. If so, Osher commented, “We may
have funding streams available within the community that can pick up
the slack that historically has increased the budgetary pressure on our
correction environments.”
QUALITY OF CARE AND ACCOUNTABILITY
The ACA could also conceivably have an impact on the quality of care
that medical professionals provide to inmates, particularly if doctors are
encouraged or required to participate in accountable care organizations.
At present, several workshop participants observed, doctors providing
care within correctional facilities are often isolated, practicing in “islands”
separated from their peers providing care in the community. As such, they
become susceptible to the “culture of fear and cynicism” that was identified as characterizing many correctional environments. Further, their
professionalism is unsupported and may atrophy. If practicing outside
of health plans or Medicaid, they may also be missed by metrics used to
measure and evaluate performance.
All of these might be addressed as the ACA is implemented, with
more inmates participating in health plans and Medicaid. This could
result in individuals seeing their regular healthcare providers, whether
inside or outside correctional facilities. Scott Allen referred to this continuity as the “ideal.” Josiah Rich (Department of Medicine and Epidemiology, Warren Alpert Medical School of Brown University, and the
Center for Prisoner Health and Human Rights at the Miriam Hospital
Immunology Center,) concurred from his own experience providing care,
noting that “just seeing a familiar face” improves the experience for both
doctor and patient, bolstering trust.
Furthermore, if seeing patients enrolled in Medicaid (whether postrelease, on parole or probation, or even during incarceration if the restrictions are changed), then doctors would become “part of the metric,”

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Allen explained, and healthcare provided in correctional facilities would
no longer be “carved out” of performance and outcome measures. This
is also the case for inmates on health plans. Rosenberg observed, “By
maintaining coverage for individuals within their health plans while
they are within a correctional environment, the health plan’s measurements will include the outcome measures.” This could help improve the
quality of care provided to inmates. Robert Greifinger suggested using
the ACA as “leverage to encourage the participation of correctional health
professionals in accountable care organizations, which will increase their
contact with community healthcare folks.” Allen affirmed the potential for
improved quality of care when healthcare providers within correctional
facilities are “answerable to the community standard.”
STATES AND HEALTH PLANS
How much of the potential impact of the ACA is realized will depend
in part on how states respond to the law and what initiatives they take to
implement it, as well as on the strategies and practices of private health
plans. States have recently decided whether to create their own health
exchanges (the formal structure through which residents will choose
among available plans), coordinate with a health exchange established
by the federal government, or opt out and allow residents to utilize the
federal health exchange. State choices may influence the effort they put
into enrolling inmates, coordinating with Medicaid to make benefits available, and incentivizing health plans to provide care to this population.
In Rich’s view, “You can have all the Medicaid you want, but if there
isn’t a doctor who will see you, or if insurance plans are running away
from you,” then what good is such coverage? Rosenberg expressed the
concern that health plans would shun the inmate population as “a tough
reach,” and suggested that health plans’ “general attitude is ‘we don’t
know anything about caring for this population, and where do we hide?’”
The potential for cost savings may help motivate states to implement ACA
fully and encourage the participation of health plans.
COST SHIFTS, SAVINGS, AND RECIDIVISM
Greifinger noted that as the federal government will fully subsidize
states for the cost of new Medicaid enrollees for the first three years, this
will constitute a considerable cost shift away from state and local governments to the federal government. Although incarcerated individuals will
still not be eligible to receive Medicaid benefits as the law is currently
written, many others involved in the correctional system—including those
pending disposition in the community, those on probation and parole, on

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home confinement, or released, and the families of all these individuals—
could access benefits. “That’s one of the many reasons I think that state
and county criminal justice policy people should be paying attention,”
Greifinger observed. “There will be a favorable shift from the perspective
of the states and the counties.”
Rosenberg shared the results of research conducted in the state of
Washington (which expends some of its own general fund dollars to
provide substance abuse services) that indicates that treating substance
abuse results in a decline in arrest rates of between 16 and 33 percent.
The overall cost of healthcare to the impacted population also declined.
Rosenberg asserted that while the full fiscal and correctional impact of the
ACA cannot be predicted, this research suggests if its enactment makes
more funds available for substance abuse treatment, the impact could be
substantial on both costs and recidivism.
EQUITY AND RIGHTS
By improving access to healthcare for those transitioning out of the
criminal justice system, might the ACA also help redress some of the racial
and socioeconomic disparities in health and healthcare? When this question was posed, Rosenberg offered a pessimistic answer for the near term.
In his assessment, because states face so many challenges in implementing
the new law, actions that will improve care specifically for inmates will
probably be a low priority. “From where we sit,” Rosenberg offered, “this
is a promise that ACA could fulfill,” but based on his monitoring of state
actions thus far, “we’re not seeing it yet.”
Rosenberg did, however, suggest a provocative route to eventually
fulfilling that promise. In prisons, he noted, “Currently, if I’m an offender
the sole right I have to care is covered by my constitutional right under
the Eighth Amendment as interpreted by the Supreme Court in Estelle
v. Gamble. On January 1, 2014, if I’m a member of an exchange, I have
another right, I have a contractual right between me and the exchange for
care. All of a sudden, a different set of rights enters into this.” Rosenberg
foresees considerable effort on the part of lawyers to determine just how
such rights will be exercised. Debates will no doubt address whether the
current restriction against receiving Medicaid benefits while incarcerated
is maintained, and may also be shaped by whether healthcare providers
are employees of the state or of private health plans. Foreseeing an “interesting dynamic,” Rosenberg suggested that “the implicit contractual right
of the ACA may create some significant changes; we just don’t know what
they’re going to look like yet.”

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Closing

s the discussion continued, several participants reflected on the
relationship between incarceration policies and various aspects
of public safety. Several challenged the use of the term as a cover
for a moral or political agenda—or confusion. Josiah Rich puzzled that
“we as a nation haven’t really resolved why we’re locking people up.
We’re not clear about that. Are we rehabilitating, or are we punishing
them, or are we doing both?” Jamie Fellner argued, “there is a role for
retribution and punishment in a criminal justice system,” but that the
current rates of incarceration and lengths of sentences go “far beyond
legitimate penological goals either of retribution or of incapacitation or
of deterrence.” Marc Mauer (The Sentencing Project) concurred, “There’s
something fundamentally off when the wealthiest society in the world
maintains the world’s largest prison population.” Mauer stated that many
now believe the United States incarcerates far too many people and keeps
them incarcerated for far too long—beyond the point of providing public
safety, and at significant opportunity cost to other methods of promoting
both public safety and public health.
In practical terms, Faye Taxman pointed out that incarceration has
lost its deterrent effect exactly because it has become so widespread. The
criminological and sociological literature confirms that, because of current
rates, incarceration has “become more normalized in the general population,” thus diminishing its value for public safety. Rich also suggested
that regardless of moral perspective, a practical assessment of the current
system reveals its ineffectiveness in serving public safety. Referring to
37

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the mentally ill who are so disproportionately represented in the inmate
population, Rich observed a pattern of “somebody incarcerated, and then
come[s] back, and then incarcerated again, and then come[s] back, and
then incarcerated again. Something’s wrong.” Rich proposed an outlook
“instead of trying to punish people for punishment’s sake, let’s try and
look at it as what are the outcomes we want” because the current system
“doesn’t make sense if you want public safety.”
Mauer also affirmed, “In terms of public safety, we’re well past the
point of diminishing returns in terms of what we get out of high rates of
incarceration.” He further emphasized that the choice “is not building
prisons or doing nothing” but rather using resources in a variety of other
ways to promote public safety. This would involve a “fundamental shift in
approach,” beginning with a substantial reduction in the prison population overall. Mauer referred to “credible scenarios and policy analysis that
suggest a reduction of 50 percent or so in the prison population would not
have adverse effects on public safety and would be eminently doable if we
have the political will.” Mauer cited ongoing efforts in California, New
Jersey, and New York, through either policy initiatives or court orders,
to produce substantial reductions in prison populations. Learning from
these experiences will help guide subsequent efforts. Ceasing the current
overinvestment in incarceration, making a 50 percent reduction in the
prison population, will permit resources to be redirected toward disadvantaged communities, allowing “justice reinvestments” to redress health
and socioeconomic disparities. Mauer acknowledged this is a “challenging
shift both politically and practically to make. It seems like the time is ripe
to start thinking about how we go about making that shift and what that
would look like, and what outcomes we might expect to see.”
Bruce Western brought the workshop to a close, articulating several insights that had emerged over the course of discussion. He began
by acknowledging that the growth of the incarcerated population in
recent decades is partly “in response to a very substantial public health
problem.” Essentially, he observed, “we wound up to an important degree
punishing illness and poverty.” Thus, the issues of public health and
public safety are deeply intertwined.
Western went on to describe prisons and jails as “Janus-faced institutions.” They perpetuate social damage even as they simultaneously
deliver much-needed treatment. Thus, “there’s a deep paradox in the
character of these institutions that we have to come to grips with.” To do
so, Western proposed a “virtuous circle” in which correctional facilities
are actively involved in improving public health and the resulting gains in
public health reduce prison populations. How could such a virtuous circle
be generated and sustained? Western identified three ideas emerging from
the workshop discussion.

Health and Incarceration: A Workshop Summary

CLOSING

First, he noted, the logic of treatment is fundamentally different from
the logic of custody, especially as “there is a significant suspension of
moral judgment about the status of the patient compared to moral judgment about the status of the prison inmate.” Promoting the logic of treatment could help foster the virtuous circle.
Second, Western commented on the depth of the discussion regarding
the ethical and political responsibilities of the healthcare community
itself (see the section titled “Healthcare Providers” earlier in this report).
Acknowledging that he had become far more cognizant of this issue
because of the workshop, Western suggested that deeper civic and political
engagement on the part of healthcare providers could have tremendous
impact on establishing and maximizing the virtuous circle he described.
Finally, Western emphasized the value of making transparent the
impact of public health on public safety, broadly conceived. If the link
between the two were more widely perceived, this would help sustain
the virtuous circle, improving both health and safety.

Health and Incarceration: A Workshop Summary

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Appendix
Workshop Agenda and Participants

he rate of incarceration in the United States is very high both historically and in comparison to that of other developed nations. Those
in or entering U.S. jails and prisons experience symptoms of drug
dependence or abuse, severe mental illness, HIV infection, diabetes mellitus, and other chronic medical conditions at far higher rates than the
general population. This is a problem not just for them but for the communities from which they come and to which, in nearly all cases, they
will return.
To explore and expand the knowledge basis for policies to address
the health needs of those in prison and benefit them and their home communities, a public workshop will bring together leading academic and
practicing experts, to summarize what is known about these issues, what
critical gaps in our knowledge should be filled with new research, and
what appear to be the best opportunities to improve healthcare for those
who are now or will be incarcerated. The half-day workshop will be held
at the National Academy of Sciences’ (NAS’) Keck Center, Room 110, 500
5th Street NW, Washington, DC, from 12:30 to 4:30 p.m., on Wednesday,
December 5, 2012.
This workshop is jointly sponsored by the Institute of Medicine’s
Board on the Health of Select Populations and the National Research
Council’s (NRC’s) Committee on Law and Justice. Its products will inform
a current study by an ad hoc committee of the NRC on causes, consequences, and alternatives to high rates of incarceration in the United
States.
49

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HEALTH AND INCARCERATION

Presentations and discussion will address one or more of the following questions:
1. What can we say with confidence about the incidence and
sources of major health problems among the population subject
to incarceration? What are the critical gaps in our knowledge of
these questions?
2. What is the status and range of variation in the quality of care,
including screening and treatment, provided upon incarceration,
while in jail or prison, and linkage to care upon release? What are
the characteristics of high-performing systems (i.e., best practices)
providing screening and care to prisoners, coordinating access to
care during and following incarceration, and transferring medical
information and records to and from other medical care providers?
How are these related empirically to the health of prisoners and
communities with a high incidence of incarceration and release?
3. What is and what determines the impact of incarceration and release
on the health of populations where incarceration and release are
concentrated? What are their effects on racial or ethnic disparities in
healthcare and health?
4. From a public health standpoint, what are the best opportunities
for improving both the health of those in prisons and jails and the
health risks they present when released? How can implementation
of the Affordable Care Act ensure continuity of medical care for
those released from prison? What existing programs at the federal,
state, and local/community levels are novel and evidence promise
of reducing morbidity among prisoners and ensuring continuity of
care following release?
5. What promising innovative outreach and engagement models
exist such as successfully employing prisoners or former prisoners
in peer health education and/or in caretaker programs directed
toward elderly/disabled prisoners and those with substance abuse
histories?
Invited participants include
Bruce Western, Harvard University*
Josiah Rich, M.D., Warren Alpert Medical School of Brown University*
Craig Haney, University of California, Santa Cruz*

*Indicates a member of the National Research Council and Institute of Medicine Committee on Causes and Consequences of High Rates of Incarceration.

Health and Incarceration: A Workshop Summary

APPENDIX A

Scott Allen, University of California, Riverside
Redonna Chandler, National Institute on Drug Abuse
Jennifer Clarke, M.D., Brown University Medical Center
Jamie Fellner, Human Rights Watch
Robert Greifinger, M.D., John Jay College of Criminal Justice,
City University of New York
Newton Kendig, M.D., Federal Bureau of Prisons
Marc Mauer, The Sentencing Project
Fred Osher, M.D., Council of State Governments
Steven Rosenberg, Community Oriented Correctional Health Services
Faye Taxman, George Mason University
Emily Wang, M.D., Yale University
Chris Wildeman, Yale University
Brie Williams, M.D., University of California, San Francisco
The workshop will be in a roundtable format. Brief presentations will
be followed by questions and discussion organized to address the questions posed above.

Health and Incarceration: A Workshop Summary

HEALTH AND INCARCERATION

AGENDA
12:30 p.m. Welcome, Plan for the Afternoon, and Overview
Moderating:
Josiah Rich, Committee on Causes and Consequences of
High Rates of Incarceration
1:00 p.m. Incidence and Sources of Health Problems of the
Population Subject to Incarceration

Discussants:
Scott Allen, University of California, Riverside
Jennifer Clarke, Brown University Medical Center
Emily Wang, Yale University
Brie Williams, University of California, San Francisco
1:45 p.m.
Care, Screening, and Treatment in Prison and On Release

Discussants:
Jamie Fellner, Human Rights Watch
Craig Haney, University of California, Santa Cruz
Newton Kendig, Federal Bureau of Prisons
Fred Osher, University of Maryland
2:30 p.m.
Public Health Impacts
Discussants:
Robert Greifinger, John Jay College of Criminal Justice,
CUNY
Steven Rosenberg, Community Oriented Correctional
Health Services
Christopher Wildeman, Yale University
3:15 p.m. Opportunities and Models for Improving Health and
Reducing Health Risks—Innovative Care Models and
Evidence of Effects

Discussants:
Redonna Chandler, National Institute on Drug Abuse
Marc Mauer, The Sentencing Project
Faye Taxman, George Mason University
4:00 p.m.

General Discussion and Conclusions
Bruce Western and Josiah Rich

4:30 p.m.

Adjourn