POSITION PAPER

Annals of Internal Medicine

Health Care During Incarceration: A Policy Position Paper From the
American College of Physicians
Newton E. Kendig, MD; Renee Butkus, BA; Suja Mathew, MD; and David Hilden, MD, MPH; for the Health and Public Policy
Committee of the American College of Physicians*

The American College of Physicians (ACP) has a long-standing
commitment to improving the health of all Americans and
opposes any form of discrimination in the delivery of health
care services. ACP is committed to working toward fully understanding and supporting the unique needs of the incarcerated
population and eliminating health disparities for these persons. In this position paper, ACP offers recommendations to

T

he American College of Physicians (ACP) has a longstanding commitment to improving the health of all
Americans and opposes any form of discrimination in the
delivery of health care services (1–4). Millions of patients
in America receive their primary health care in a carceral
setting. During 2020, 8.7 million persons were admitted
to local U.S. jails, and, at year-end, state and federal prisons incarcerated 1 215 800 persons (5, 6). Racial and ethnic minority populations are disproportionately affected
by these incarceration rates, which are the highest in the
world (7). At year-end 2020, combined state and federal
imprisonment rates were 938 per 100 000 for Black U.S.
residents, 778 per 100 000 for American Indian and
Alaska Native U.S. residents, 446 per 100 000 for Hispanic
U.S. residents, and 183 per 100 000 for White U.S. residents. Thus, for many Black, Indigenous, and Latinx persons in particular, the experience of incarceration is a
major social determinant of health.
Incarceration can have a sustained and recurrent
effect on the health and well-being of persons sentenced
to prison. Incarcerated persons released from state prisons in 2018 had served an average time of 2.7 years (8).
Moreover, a 2008 to 2018 recidivism study of persons
incarcerated in state prisons found that about 61% returned
to prison within 10 years of release (9). As a result of substantial prison sentences and recurrent incarcerations, correctional health care professionals become major primary
care providers for these patients. In contrast to the prison
setting, jail populations are detained for much shorter
periods of time. In 2020, U.S. jail populations had a weekly
turnover rate of 50% with persons spending an average of
28 days in jail (5). Thus, correctional health care professionals provide limited longitudinal care in the short-term jail
setting but are pivotal for ensuring continuity of care to a
highly dynamic patient population.

policymakers and administrators to improve the health
and well-being of persons incarcerated in adult correctional
facilities.
Ann Intern Med. doi:10.7326/M22-2370
Annals.org
For author, article, and disclosure information, see end of text.
This article was published at Annals.org on 22 November 2022.

Justice-involved persons entering jail or prison are
frequently disengaged from the U.S. health care system,
in part because of intergenerational poverty and societal
barriers to health care access. Many are coping with substantial unmet health care needs. Chronic medical conditions, infectious diseases, substance use disorders,
mental health conditions, and personal exposure to violence are of particular concern. In Bureau of Justice
Statistics surveys from 2016, 51% of state prisoners
reported having a chronic medical condition, 65%
reported using at least 1 drug during the 30 days before
arrest, and 43% reported a history of a mental health
problem (10–12). These data highlight the importance
of correctional medicine for both addressing health
care disparities in an underserved patient population
and advancing our nation's public health. Tackling public health priorities such as treating opioid use disorder,
curing hepatitis C, eliminating HIV infection, and more
humanely caring for patients with serious mental illness
requires correctional medicine excellence in U.S. jails
and prisons and the strategic engagement of health
care partners in the community.

METHODS
This policy paper was drafted by the ACP Health
and Public Policy Committee, which is charged with
addressing issues that affect the health care of the U.S.
public and the practice of internal medicine and its
subspecialties, with the assistance of Newton E. Kendig,
MD, the College's liaison to the National Commission on
Correctional Health Care (NCCHC). We reviewed available studies, reports, and surveys related to correctional
medicine from PubMed and Google Scholar published
between 2000 and 2022, and also reviewed relevant news
articles, policy documents, websites, and other sources.
Recommendations were based on reviewed literature

* This paper, authored by Newton E. Kendig, MD; Renee Butkus, BA; Suja Mathew, MD; and David Hilden, MD, MPH, was developed for the Health and Public
Policy Committee of the American College of Physicians. Individuals who served on the Health and Public Policy Committee at the time of the paper's approval
were Suja Mathew, MD (Chair); David Hilden, MD, MPH (Vice Chair); Micah Beachy, DO; William Curry, MD; Matthew Hollon, MD, MPH; Cynthia Jumper, MD,
MPH; Pranav Mellacheruvu; Marianne Parshley, MD; Ankita Sagar, MD, MPH; Jamar Slocum, MD; Michael Tan, MD; Vanessa Van Doren, MD; and Elham Yousef,
MD. Drs. Mathew and Hilden are authors; other committee members are nonauthor contributors. Approved by the ACP Board of Regents on 20 September
2022.
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Health Care During Incarceration

and input from ACP's Board of Governors; Board of
Regents; Ethics, Professionalism and Human Rights
Committee; Council of Early Career Physicians; Council
of Resident/Fellow Members; Council of Student Members;
and Council of Subspecialty Societies. The policy paper and
related recommendations were reviewed and approved
by the ACP Board of Regents on 20 September 2022.
This executive summary provides a synopsis of the
position paper. The full background and rationale are
provided in the Appendix (available at Annals.org).

POLICY RECOMMENDATIONS
Correctional Medicine and Clinician Engagement
Position 1: ACP recommends that U.S. jails and prisons and policymakers adopt adequately funded policies
and procedures to promote the engagement of dynamic
clinical care teams.
a. The quality of care and ethical principles of professional engagement must be consistent with that provided
to community-based patient populations.
b. U.S. jails and prisons must ensure that clinicians
meet credentialing requirements and are granted privileges in accordance with standards required for community-based clinicians.
Administration of Correctional Medicine
Position 2: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure that U.S. jails and prisons provide
patients timely access to necessary health care services
that are based on evidence-based medicine and meet
prevailing community standards.
a. Local, state, and federal entities contracting to private entities for correctional health care services must
provide the necessary oversight to evaluate the medical
care provided to incarcerated patients to ensure quality,
evidence-based medicine that meets prevailing community standards.
b. U.S jails and prisons should forge strong partnerships with local and state public health and emergency
response authorities including developing pandemic
response plans for emerging pathogens and planning for
potential natural disasters.
Nutrition, Physical Activity, and Preventive
Health Care
Position 3: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure U.S. jails and prisons provide incarcerated persons nutritious, safe, medically appropriate,
and appetizing food and beverages.
Position 4: ACP recommends that policymakers and
administrators ensure that U.S. jails and prisons offer incarcerated persons regular opportunities for healthy exercise
as recommended by federal Physical Activity Guidelines.
Position 5: ACP recommends that policymakers and
administrators enact and enforce smoke-free policies in
U.S. jails and prisons and provide access to smoking cessation interventions for those with tobacco use disorder.

Position 6: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure incarcerated persons have access
to preventive health services recommended by the U.S.
Preventive Services Task Force (USPSTF) and the Centers
for Disease Control and Prevention (CDC) Advisory
Committee on Immunization Practices (ACIP).
Chronic Noncommunicable Diseases
Position 7: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure incarcerated patients with chronic
noncommunicable diseases are provided quality medical
care in accordance with evidence-based treatment guidelines.
Infectious Diseases
Position 8: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure that U.S. jails and prisons adopt
infection prevention and control programs to promote
the prevention, detection, containment, and treatment of
communicable diseases. These programs should be
developed in coordination and consultation with local
and state public health authorities.
Substance Use Disorders
Position 9: ACP reaffirms its support for public policies that promote the treatment of patients with substance use disorders as an alternative to incarceration.
Position 10: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures that require screening of all persons entering
U.S. jails and prisons for a history of substance use disorders and provide voluntary access to evidence-based
treatments for substance use disorders, including behavioral counseling services and U.S. Food and Drug
Administration (FDA)-approved medications for the treatment of opioid use disorder.
Behavioral Health Care
Position 11: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure screening of all persons entering
U.S. jails for behavioral health conditions—including suicide
risk, history of serious mental illness, need for prescribed
psychotropic medications, exposure to emotional or physical trauma, and co-occurring substance use disorder—and
institute evidence-based policies to provide appropriate
care, treatment, housing, and support to incarcerated persons with behavioral health conditions.
Women's Health Care
Position 12: ACP recommends that policymakers and
administrators adopt adequately funded policies and procedures to ensure U.S. jails and prisons provide comprehensive reproductive health services and trauma-informed
care strategies when counseling, treating, and providing
programs to incarcerated women.
Position 13: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure that menstruating women and transgender

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Health Care During Incarceration

men in U.S. jails and prisons have free and timely access to
an adequate supply of menstrual products.
Position 14: ACP recommends prohibiting the use of
custody restraints on incarcerated pregnant women during labor and delivery and avoiding the use of restraints
during postpartum recovery and throughout pregnancy.
Position 15: ACP believes that incarcerated women
should have sufficient access to evidence-based family
planning and sexual health information and to pregnancy
care services, and should have the ability to continue and
initiate the full range of FDA-approved forms of reversible
contraception.
LGBTQ+ Patient Care
Position 16: ACP recommends that policymakers and
administrators ensure all incarcerated persons who identify
as lesbian, gay, bisexual, transgender, queer, and others
(LGBTQ+) be treated with dignity and respect in a correctional environment that is safe, nondiscriminatory, and
gender-affirming.
Aging Patients and Those Living With Disabilities
and Life-Limiting Illnesses
Position 17: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure that aging incarcerated patients
and those living with disabilities and life-limiting illnesses
are treated with respect in a correctional environment
that is safe, accommodates their special needs, and provides evidence-based geriatric, palliative, and end-of-life
care.
Immigrant Populations
Position 18: ACP recommends policymakers and
administrators adopt adequately funded policies and
procedures to ensure immigrant detainees are treated
with dignity and respect in an environment that is safe,
nondiscriminatory, and culturally sensitive, including the
provision of language translation and interpretation services, as needed, to promote health literacy.
Position 19: ACP reaffirms its opposition to the forced
separation of children from their family members held in
immigrant detention facilities. ACP reaffirms its opposition to the indefinite holding of children with their parents
or adult caregivers in immigrant detention facilities.
Position 20: ACP supports efforts to enhance governmental oversight of health care services provided to
immigrant detainees, including compliance with National
Detention Standards.
Community Reentry Planning
Position 21: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure all U.S. jails and prisons provide
reentry planning that helps ensure the continuity of health
care and social services for incarcerated patients returning to the community.
Position 22: ACP recommends that state Medicaid
authorities adopt policies that suspend rather than terminate enrollees who become incarcerated, and support
electronic, automated data exchange with correctional
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systems that facilitates state Medicaid enrollment or reinstatement. ACP supports public policy discussions for expanding
Medicaid coverage for incarcerated populations.

CONCLUSION
ACP recognizes that reducing health disparities in
the quality of or access to health care for incarcerated
populations will take concerted efforts by policymakers,
administrators, legislative authorities, the medical community, and society as a whole. Achieving this goal will
require funding and implementation of a national public
policy agenda that recognizes the vital importance of correctional health care toward achieving health equity for all
and promoting the public health of our communities.
From School of Medicine and Health Sciences, George
Washington University, Washington, DC (N.E.K.); American
College of Physicians, Washington, DC (R.B.); Atlantic Health
System, Morristown, New Jersey (S.M.); and Hennepin Healthcare,
Minneapolis, Minnesota (D.H.).
Note: Dr. Kendig's contributions to the paper are his own and

are not necessarily those of the NCCHC.
Financial Support: Financial support for the development of

this position paper came exclusively from the ACP operating
budget.
Disclosures: Disclosures can be viewed at www.acponline.org/
authors/icmje/ConflictOfInterestForms.do?msNum=M22-2370.
Corresponding Author: Renee Butkus, BA, American College of
Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington,
DC 20001.

Author contributions are available at Annals.org.

References
1. Serchen J, Doherty R, Atiq O, et al; Health and Public Policy
Committee of the American College of Physicians. A comprehensive policy framework to understand and address disparities and
discrimination in health and health care: a policy paper from the
American College of Physicians. Ann Intern Med. 2021;174:529-32.
[PMID: 33428444] doi:10.7326/M20-7219
2. Butkus R, Rapp K, Cooney TG, et al; Health and Public Policy
Committee of the American College of Physicians. Envisioning a
better U.S. health care system for all: reducing barriers to care and
addressing social determinants of health. Ann Intern Med. 2020;172:
S50-9. [PMID: 31958803] doi:10.7326/M19-2410
3. Serchen J, Doherty R, Atiq O, et al; Health and Public Policy
Committee of the American College of Physicians. Racism and
health in the United States: a policy statement from the American
College of Physicians. Ann Intern Med. 2020;173:556-7. [PMID:
32559145] doi:10.7326/M20-4195
4. American College of Physicians. Understanding and Addressing
Disparities and Discrimination in Law Enforcement and Criminal
Justice Affecting the Health of At-Risk Persons and Populations.
ACP Position Paper; 2021. Accessed at www.acponline.org/acp_
policy/policies/understanding_discrimination_law_enforcement_
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criminal_justice_affecting_health_at-risk_persons_populations_2021.
pdf on 1 May 2022.
5. Minton TD, Zeng Z. Jail Inmates in 2020—Statistical Tables. U.S.
Department of Justice, Office of Justice Programs, Bureau of
Justice Statistics; December 2021. Publication no. NCJ 303308.
6. Carson EA. Prisoners in 2020—Statistical Tables. U.S. Department
of Justice, Office of Justice Programs, Bureau of Justice Statistics;
December 2021. Publication no. NCJ 302776.
7. Institute for Crime & Justice Policy Research. World Prison Brief
data. Accessed at www.prisonstudies.org/world-prison-brief-data
on 14 September 2022.
8. Kaeble D. Time Served in State Prisons, 2018. U.S. Department
of Justice, Office of Justice Programs, Bureau of Justice Statistics;
March 2021. Publication no. NCJ 255662.
9. Antenangeli L, Durose MR. Recidivism of Prisoners Released in
24 States in 2008: A 10-Year Follow-Up Period (2008–2018). U.S.

Department of Justice, Office of Justice Programs, Bureau of
Justice Statistics; September 2021. Publication no. NCJ 256094.
10. Maruschak LM, Bronson J, Alper M. Medical Problems Reported
by Prisoners: Survey of Prison Inmates, 2016. U.S. Department of
Justice, Office of Justice Programs, Bureau of Justice Statistics; June
2021. Publication no. NCJ 252644.
11. Maruschak LM, Bronson J, Alper M. Alcohol and Drug Use
and Treatment Reported by Prisoners: Survey of Prison Inmates,
2016. U.S. Department of Justice, Office of Justice Programs,
Bureau of Justice Statistics; July 2021. Publication no. NCJ
252641.
12. Maruschak LM, Bronson J, Alper M. Indicators of Mental
Health Problems Reported by Prisoners: Survey of Prison
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Programs, Bureau of Justice Statistics; June 2021. Publication
no. NCJ 252643.

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Author Contributions: Conception and design: N.E. Kendig,
R. Butkus, D. Hilden.
Drafting of the article: N.E. Kendig, R. Butkus, S. Mathew.
Critical revision of the article for important intellectual content:
N.E. Kendig, R. Butkus, D. Hilden.
Final approval of the article: N.E. Kendig, R. Butkus, S. Mathew,
D. Hilden.
Administrative, technical, or logistic support: R. Butkus.

APPENDIX
Correctional Medicine and Clinician Engagement
Position 1: ACP recommends that U.S. jails and prisons and policymakers adopt adequately funded policies
and procedures to promote the engagement of dynamic
clinical care teams.
a. The quality of care and ethical principles of professional engagement must be consistent with that provided to community-based patient populations.
b. U.S. jails and prisons must ensure that clinicians
meet credentialing requirements and are granted privileges in accordance with standards required for community-based clinicians.
ACP endorses correctional medicine excellence as
an important U.S. strategy for reducing health care disparities, addressing social determinants of health, and
promoting the public health of our communities. Given
the frequency of complex medical conditions in this
patient population, the expertise of internal medicine
specialists and subspecialists plays a pivotal role in clinical care teams.
Administration of Correctional Medicine
Position 2: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure that U.S. jails and prisons provide
patients timely access to necessary health care services
that are based on evidenced-based medicine and meet
prevailing community standards.
a. Local, state, and federal entities contracting to private entities for correctional health care services must
provide the necessary oversight to evaluate the medical
care provided to incarcerated patients to ensure quality,
evidence-based medicine that meets prevailing community standards.
b. U.S jails and prisons should forge strong partnerships with local and state public health and emergency
response authorities including developing pandemic
response plans for emerging pathogens and planning
for potential natural disasters.
The 1976 landmark Supreme Court decision, Estelle v
Gamble, granted incarcerated persons a constitutional right
to health care (13). The ruling affirmed that deliberate indifference to the serious medical needs of prisoners was a violation of the Eighth Amendment and served as a major
impetus for prison health care reform (14). Subsequent
advances in correctional health care have included the
establishment of national accreditation standards, the
increasing adoption of evidence-based clinical practice
guidelines, and the broader engagement of academic
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medicine in some settings (15, 16). Despite these notable
gains, more recent court rulings, such as Brown v Plata,
highlight ongoing concerns with correctional health care in
some jurisdictions (17). Many factors contribute to the divergence of health care quality provided to patients experiencing incarceration. Correctional facilities are often located in
remote locations with limited access to local health care
services, patients may have complex medical and mental
health conditions that present management challenges, financial requirements may serve as an additional barrier to
health care access, staffing shortages and budgetary
restraints may impact health care operations, and jails and
prisons may not seek health care accreditation or have
other external assessments of health care quality. These
challenges highlight the need for capable correctional
health care administration, sufficiently supported by the
public and private sectors; broader correctional engagement with community health partners; and continued
community advocacy for incarcerated persons. Specific priorities for correctional health care administrators should
include ensuring health care staffing is sufficient to meet
the medical and behavioral health needs of their patients;
providing patients unimpeded access to necessary health
care services; adopting a trauma-informed approach for all
patient care; implementing evidence-based clinical practice
guidelines; pursuing health care accreditation from
national bodies, such as the National Commission on
Correctional Health Care (NCCHC) and the American
Correctional Association (ACA); providing effective contractual oversight of privatized correctional health care services;
building academic partnerships to support patient care;
and partnering with public health and emergency response
authorities to plan for potential natural disasters and emerging pandemics.
Nutrition, Physical Activity, and Preventive
Health Care
Position 3: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure U.S. jails and prisons provide incarcerated persons nutritious, safe, medically appropriate,
and appetizing food and beverages.
Providing a nutritious and appealing diet to incarcerated persons is fundamental to their personal wellbeing and important for chronic disease prevention and
maintenance of a healthy weight (18–20). Incarcerated
persons may have reduced opportunities to make
healthy food choices. Correctional menus may be quite
restrictive in their food offerings, may rely largely on
processed foods, may be high in sodium and caloric
content, may be lacking in fresh fruits and vegetables,
and may be unappetizing. Access to nutritious food and
beverages in jail and prison commissaries may also be
quite limited. Barriers to providing healthier meals to
incarcerated persons include budget limitations, security concerns, lack of skilled food service staff, and the
adoption of menus that do not meet federal nutrition
guidelines (21, 22).
Correctional health care professionals can promote
the health of their patients by adopting health care policies that consider access to a healthy diet a medical
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necessity; evaluating institutional menus for nutritional
adequacy through dietitian review; counseling patients
on healthy dietary choices; promoting a heart-healthy
diet as a standard menu option; providing medically
appropriate diets for patients with temporary or permanent health conditions; providing access to labeled,
healthy commissary selections; and addressing food
insecurity concerns as a core component of reentry planning (23, 24). Limiting access to food and providing certain types of food should never be disciplinary in nature.
Position 4: ACP recommends that policymakers and
administrators ensure that U.S. jails and prisons offer
incarcerated persons regular opportunities for healthy
exercise as recommended by federal Physical Activity
Guidelines.
The Physical Activity Guidelines for Americans recommend that adults engage in regular aerobic and muscle
strengthening physical activities (25). The health benefits
of exercise include chronic disease prevention, assistance
with weight maintenance, improvements in functional
capacity, and enhanced emotional well-being. Physical
exercise can also favorably impact substance use disorder
treatment, a key health concern for many incarcerated
persons (26). Many U.S. jails and prisons provide a wide
range of indoor and outdoor supervised recreational
activities. Active participation in these exercise opportunities may be affected by security constraints, such as lockdowns, or lack of patient engagement (27). Correctional
health care professionals can promote physical activity
opportunities for their patients by adopting health care
policies that consider access to physical activity a medically necessary treatment option; counseling patients to
engage in healthy exercise, particularly those patients with
cardiovascular disease risk factors and obesity; and providing physical and recreational therapist services to
implement physical activity recommendations for specific
patient populations (28).
Position 5: ACP recommends that policymakers and
administrators enact and enforce smoke-free policies in
U.S. jails and prisons and provide access to smoking cessation interventions for those with tobacco use disorder.
Providing a smoke-free environment for incarcerated persons is a critical preventive health measure.
Permitting smoking in state prisons contributes significantly to excess mortality from diseases related to smoking such as lung cancer, ischemic heart disease, and
chronic obstructive lung disease (29). Smoking bans
have been adopted in most state prisons and many jails,
however, these policies are not universal and policy noncompliance is a concern in some jurisdictions (30).
Correctional administrators should support incarcerated
persons coping with tobacco smoking cessation through
the provision of evidence-based interventions (31).
Position 6: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure incarcerated persons have access
to preventive health services recommended by the U.S.
Preventive Services Task Force (USPSTF) and the Centers
for Disease Control and Prevention (CDC) Advisory
Committee on Immunization Practices (ACIP).
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Incarcerated persons should be provided equitable
access to recommended immunizations, as they both protect individual patients and reduce infectious disease
transmission within the correctional setting and surrounding communities. Vaccinating incarcerated persons has
been an effective public health strategy for preventing
and containing COVID-19, influenza, mumps, measles,
and hepatitis B virus (HBV) infections (32–35). Screening
for cancer types and chronic diseases, such as hypertension and diabetes, is also a recommended preventive
health strategy, particularly for those incarcerated persons
who are priority candidates for screening based on risk.
Early detection and treatment of chronic diseases and
cancer types can be life sustaining for these persons as
well as a value-based intervention for the health care
system.
Chronic Noncommunicable Diseases
Position 7: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure incarcerated patients with chronic
noncommunicable diseases are provided quality medical
care in accordance with evidence-based treatment
guidelines.
Incarcerated populations have a higher burden of
certain chronic health conditions compared with the
noninstitutionalized U.S. population (36). In a Bureau of
Justice Statistics 2011 to 2012 survey, state and federal
prisoners were about 1.5 times more likely to report
ever having high blood pressure, diabetes, or asthma
(37). Effectively managing these patients can be challenging within a public safety environment. Potential
concerns include the institutional limitations on the frequency and timing of medication administration, security restrictions that may prohibit access to personal
equipment and devices, the variable timing of meals
and snack availability for patients with diabetes, patient
financial requirements in some jurisdictions, and the
potential lack of internal medicine and subspecialty
medicine expertise (38). Conversely, the highly structured environment of U.S. prisons can provide an opportunity for closely monitoring patients with chronic
diseases, including, as needed, the direct observation of
medication administration. Correctional medicine can
further advance chronic disease management by removing financial barriers for accessing care; adopting
patient education strategies that promote health care literacy and foster shared decision making; adopting evidence-based clinical practice guidelines; deploying a
physician-led multidisciplinary care team that includes
nurse educators, advanced practice clinicians, and clinical pharmacists; providing the expertise of internists and
subspecialists to guide care, including telehealth services; and measuring clinical outcomes to drive improvements in health care quality.
Infectious Diseases
Position 8: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure that U.S. jails and prisons adopt
infection prevention and control programs to promote
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the prevention, detection, containment, and treatment of
communicable diseases. These programs should be
developed in coordination and consultation with local
and state public health authorities.
U.S. jails and prisons can be instrumental in detecting and treating communicable diseases in affected
patient populations that may elude traditional health
care networks (39, 40). CDC-recommended screening
strategies for newly incarcerated persons include optout testing for HIV, hepatitis B virus (HBV), and hepatitis
C virus (HCV) infections, and disease-specific screening
approaches for other sexually transmitted infections and
tuberculosis (41–45). In addition, newly incarcerated persons should have a thorough skin examination for communicable bacterial and ectoparasite infections. Patients
diagnosed with infectious diseases on intake, or thereafter during incarceration, should have timely access to
evidence-based antimicrobial regimens with follow-up
assessments as clinically warranted. The effective treatment of communicable diseases, such as tuberculosis,
syphilis, HIV infection, and hepatitis C, is achievable in
the carceral setting and benefits both patients and the
public health at-large (46–49).
U.S. jails and prisons also require tailored infection
prevention and control measures to help ensure the
health and safety of incarcerated persons and correctional workers. Correctional administrators must, for
example, develop a facility-specific exposure control plan
for preventing and managing exposures to bloodborne
pathogens in compliance with federal regulations; implement a tuberculosis control plan in accordance with CDC
guidelines; adopt measures for safely isolating potentially
contagious incarcerated persons in accordance with transmission-based precautions; and institute procedures for
monitoring hand hygiene adherence and facility sanitation
(50, 51).
The COVID-19 pandemic, which resulted in SARSCoV-2 outbreaks in correctional settings nationwide,
highlighted the vulnerability of carceral populations
to communicable diseases and the potential public
health consequences (52, 53). Experience from 1 large
urban jail demonstrated how COVID-19 outbreaks in congregate settings could spread to the local community or
be significantly controlled through recommended infection control and prevention interventions (54–56). The unprecedented impact of COVID-19 on U.S. jails and prisons
further reinforces the critical importance of partnerships
between correctional systems and public health authorities for implementing effective infection prevention and
control programs and planning for future pandemics.
Substance Use Disorders
Position 9: ACP reaffirms its support for public policies that promote the treatment of patients with substance use disorders as an alternative to incarceration.
Position 10: ACP recommends that policymakers
and administrators adopt adequately funded policies
and procedures that require screening of all persons
entering U.S. jails and prisons for a history of substance
use disorders and provide voluntary access to evidenceAnnals.org

based treatments for substance use disorders, including
behavioral counseling services and U.S. Food and Drug
Administration (FDA)-approved medications for the treatment of opioid use disorder.
Substance use disorders are a chronic health condition for many incarcerated patients. In a 2016 survey of
state prisoners, 40% met the criteria for having a drug
use disorder and 21% met the criteria for having an alcohol use disorder in the 12 months before prison admission (11). In an earlier jail survey, 63% of sentenced jail
inmates met the criteria for drug dependence or misuse
(57). Key strategies for managing these patients include
screening for substance use disorders on incarceration
using validated tools, carefully managing clinically indicated drug withdrawal using evidence-based protocols,
and providing behavioral counseling services and medical treatment options (58). An array of interventions for
substance use disorders has proven efficacy, including
treatments for alcohol use disorder, tobacco smoking
cessation, and medications for the treatment of opioid
use disorder (MOUDs) (31, 59–62). MOUDs can prevent
relapse, overdose, and death, yet access to MOUDs in
U.S. jails and prisons has been historically quite limited.
One simulation model estimates that 4400 patient lives
would be saved if MOUDs were provided to incarcerated persons when clinically indicated and continued
postrelease (63). Broader provision of MOUDs in correctional settings has been limited by several factors,
including regulatory and logistic hurdles, the need for
more qualified primary care physicians, the cost and
availability of medications, and diversion concerns.
Despite these challenges, MOUDs are a medically necessary treatment intervention that should be continued
on entry to jail or prison and made available to persons
during incarceration when clinically indicated (64). In
2021, U.S. drug overdose deaths exceeded 100 000
over a 12-month period for the first time (65). Correctional
medicine's broader commitment to substance use prevention and treatment can be instrumental in reversing
this lethal trajectory.
Behavioral Health Care
Position 11: ACP recommends that policymakers and
administrators adopt adequately funded policies and procedures to ensure screening of all persons entering U.S.
jails for behavioral health conditions—including suicide risk,
history of serious mental illness, need for prescribed psychotropic medications, exposure to emotional or physical
trauma, and co-occurring substance use disorder—and
institute evidence-based policies to provide appropriate
care, treatment, housing, and support to incarcerated persons with behavioral health conditions.
In Bureau of Justice Statistics surveys, 43% of state
prisoners and 44% of jail inmates self-report being told
they had a mental health problem by a mental health
professional (12, 66). Caring for these patients in the
carceral setting should include screening for mental
health conditions and co-occurring substance use disorders at intake using validated screening tools, conducting comprehensive intake mental health appraisals, and
implementing individual treatment plans for patients
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with serious mental illness that provide access to psychiatric and behavioral counseling services (58, 67). The
intensity of treatment interventions for serious mental illness should match patient needs, including appropriately
assigned housing in outpatient settings, residential units
(such as modified therapeutic communities), or inpatient
mental health units. Reentry planning should begin soon
after incarceration because patients with serious mental illness often face substantial hurdles when transitioning to the
community. Challenges may include linking to psychiatric
services, which are often unavailable; coping with psychotic
symptoms that thwart social reintegration; encountering programmatic barriers to accessing substance use disorder
treatment; and experiencing discrimination when seeking
housing and employment opportunities. Correctional health
care professionals can provide vital support to these patients
by stabilizing their psychiatric illness before release and providing cognitive–behavioral interventions that promote selfsufficiency in medication adherence and problem solving
with activities of community living. Discharge planning
should include patient linkages to behavioral health care
clinicians, a sufficient supply of medications to bridge care,
assistance with needed housing, and arrangements for
essential social services. More structured reentry support is
available for patients with serious mental illnesses in some
jurisdictions. For example, the forensic assertive community
treatment (FACT) model provides patients intensive, continuous support from a multidisciplinary team in close therapeutic coordination with the criminal justice system (68).
Correctional health care professionals are also key to
mitigating mental health risk management concerns such
as suicide prevention, an ongoing concern for all U.S. jails
and prisons. In the 2 decades preceding 2020, 6217 suicides occurred in local jails and 4523 suicides occurred in
state and federal prisons (69). Most suicides occur within
the first 30 days of incarceration in jails and after at least 1
year of incarceration in prisons. Recommended suicide prevention program elements include thoroughly assessing
suicide risk at intake and thereafter as indicated; monitoring
of high-risk persons in housing that is suicide resistant with
visibility that allows constant observation; having individualized treatment plans made by qualified mental health
professionals; assessing suicides and serious attempts to
identify opportunities for future prevention; and annual
training for all correctional staff on recognizing suicidality in
incarcerated persons and responding appropriately (70).
Identifying the negative psychological effects of restrictive housing or solitary confinement on incarcerated
persons is also a risk management priority for correctional
health care (71). Behavioral health care professionals are
pivotal for evaluating persons placed in restrictive housing
units and closely monitoring them for psychological distress and suicidality so that alternative housing and medically indicated treatments can be provided. Importantly,
more and more U.S. jails and prisons are adopting policies
that more broadly limit the placement of incarcerated persons in restrictive housing units. Correctional behavioral
health professionals can be instrumental in therapeutically
addressing maladaptive behaviors in these patients to
facilitate their safe integration into stepdown or general
housing units.
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Women's Health Care
Position 12: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure U.S. jails and prisons provide comprehensive reproductive health services and traumainformed care strategies when counseling, treating, and
providing programs to incarcerated women.
Position 13: ACP recommends that policymakers and
administrators adopt adequately funded policies and procedures to ensure that menstruating women and transgender men in U.S. jails and prisons have free and timely
access to an adequate supply of menstrual products.
Position 14: ACP recommends prohibiting the use of
custody restraints on incarcerated pregnant women during labor and delivery and avoiding the use of restraints
during postpartum recovery and throughout pregnancy.
Position 15: ACP believes that incarcerated women
should have sufficient access to evidence-based family
planning and sexual health information and to pregnancy
care services, and should have the ability to continue and
initiate the full range of FDA-approved forms of reversible contraception.
Women residing in U.S. jails and prisons have substantial health care needs. In a survey of state prisoners
from 2016, 60% reported having chronic medical conditions, 59% met criteria for having substance use disorders, and 69% reported a history of mental health
problems (10–12). Even greater percentages of incarcerated women report past trauma and abuse, including
intimate partner violence (72). Most incarcerated women
are also of childbearing age with reproductive health
needs that can be difficult to meet within the carceral
setting. These observations highlight the importance of
adopting correctional policies that support the genderspecific health care needs of incarcerated women (73).
Fundamental to caring for women in the carceral setting is the adoption of a trauma-informed care philosophy that recognizes the high prevalence of prior trauma
for justice-involved women, the potential for retraumatization during incarceration, and the impact of trauma on
physical and emotional well-being (74). Adopting this
philosophy is essential for building trust as a correctional
health care practitioner and capably caring for incarcerated women. This includes practices such as avoiding
unnecessary pelvic examinations and maintaining patient
privacy from correctional officers during pelvic and breast
examinations or during childbirth.
Correctional medicine must also be responsive to the
reproductive health needs of incarcerated women who
may have had limited access to family planning services in
the community and may have high rates of unplanned
pregnancies (75). Correctional policies should ensure
ready access to the full range of FDA-approved forms of
reversible contraception. Incarcerated women who are
pregnant may experience serious health-related consequences, including the lack of access to adequate
obstetric care; the insufficient availability of MOUDs in
pregnancy; shackling before, during, and after delivery;
inability to provide breast milk to their infants; and a lack
of emotional support when separated from their newborns (76). Correctional health care professionals
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should ensure that newly incarcerated women of reproductive age are screened for pregnancy and that pregnant women have ready access to comprehensive
pregnancy care services. Due to the medical risks of
restraints in pregnancy, they should be prohibited during labor and delivery and avoided throughout pregnancy and postpartum recovery. If custody restraints are
deemed absolutely necessary, they should be the least restrictive means that do not interfere with leg movement or
ability to break a fall and should never be used during labor
and delivery (77). Policies and programs to better support
pregnant women and their infants should be considered,
including providing one-on-one doula support of incarcerated pregnant women, before, during, and after delivery;
facilitating frequent contact visits of mothers with their newborns; supporting lactation programs that provide newborn
access to pumped breastmilk; proactively screening new
mothers for postpartum depression; and enacting legislation
that allows alternatives to incarceration for sentenced women
who are pregnant or who have newborn children.

primary care physicians through ongoing continuing medical education, establishing on-site or virtual clinician mentoring programs, and through LGBTQ+ consultative
services, via direct patient care or telehealth. The provision
of gender-affirming care to incarcerated transgender
patients presents its own unique challenges. Correctional
health administrators must determine the approved scope
of health services for a wide variety of transition-related
services for transgender patients in the midst of ongoing
litigation in some jurisdictions. Comprehensive genderaffirming care, supported by evidence-based treatment
guidelines, is increasingly covered by public and private
payers and should also be available to incarcerated transgender patients. Treatment plans should be individualized
and include, as clinically indicated, behavioral health interventions, the continuation and initiation of hormonal
therapies, and access to gender-affirming surgeries and
other transition-related services as warranted (82).

LGBTQ+ Patient Care
Position 16: ACP recommends that policymakers and
administrators ensure all incarcerated persons who identify as lesbian, gay, bisexual, transgender, queer, and
others (LGBTQ+) be treated with dignity and respect in a
correctional environment that is safe, nondiscriminatory,
and gender-affirming.
Ensuring the safety, respectful treatment, and health
of incarcerated LGBTQ+ persons should be a priority,
supported by correctional policies, for U.S. jails and prisons (78). LGBTQ+ persons frequently face substantial
health care challenges, including discrimination, stigma,
and lack of access to culturally competent care. These
concerns may be more acute for incarcerated LGBTQ+
persons and extend to fear for personal safety. National
surveys of incarcerated populations have consistently
found that LGBTQ+ persons have the highest rates of
sexual victimization (79). Standards implementing the
Prison Rape Elimination Act (PREA) afford some protections to incarcerated LGBTQ+ persons. These include
screening newly incarcerated persons for risk for victimization based on LGBTQ+ identity, training staff on the
respectful treatment of LGBTQ+ persons, and housing
transgender persons based on an individualized assessment of health and safety concerns, including careful
consideration of the person's own views (80). LGBTQ+
persons, however, remain vulnerable to sexual victimization during incarceration, in part because not all U.S. jails
and prisons seek or achieve compliance with PREA
standards.
Beyond concerns for personal safety, LGBTQ+ persons
have unique medical and behavioral health care needs that
may not be adequately addressed during incarceration (81).
Providing culturally sensitive and clinically competent care
can be challenging in the correctional setting. Correctional
health care practitioners may have limited personal experience caring for LGBTQ+ patients. Moreover, clinical expertise in LGBTQ+ care may not be readily available in the
local community. Clinical competencies can be augmented
through several strategies, including training correctional

Aging Patients and Those Living With Disabilities
and Life-Limiting Illnesses
Position 17: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure that aging incarcerated patients
and those living with disabilities and life-limiting illnesses
are treated with respect in a correctional environment
that is safe, accommodates their special needs, and provides evidence-based geriatric, palliative, and end-of-life
care.
Between 1993 and 2013, the number of state prisoners, aged 55 years or older, sentenced to 1 year or more
increased 400% from 26 000 to 131 000 (83). In 2016,
38% of state and federal prisoners self-reported at least
1 disability compared with 15% in the adult U.S. general
population. The most reported types of disabilities were
cognitive (23%), ambulatory (12%), and vision (11%) disabilities (84). The correctional setting can pose substantial challenges for these patients with special needs.
Institutional activities of daily living may include sleeping
in an upper bunk bed, taking long walks to access medical care or the dining hall, physically coping with security
devices, and hearing, understanding, and obeying correctional orders.
Within this highly structured and restrictive environment, correctional health care professionals are instrumental in supporting persons who are aging or who are
living with disabilities. Key responsibilities include the
early identification of the physical and cognitive limitations of their patients; the provision of evidence-based
geriatric, rehabilitative, and palliative care medicine; the
determination of needed durable equipment, adaptive
devices, and living accommodations; and reentry plans
that address unique patient limitations and needs.
Correctional health care professionals can also provide
training to correctional officers to recognize normative
age-associated conditions in incarcerated persons that
might require correctional accommodations, vulnerability assessments, or medical evaluations (85).

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Correctional administrators are also responsible for
the end-of-life care for patients with life-limiting illnesses.
They should therefore adopt policies that require the discussion and documentation of advance directives and
medical orders for life-sustaining treatment (MOLSTs) for
all persons soon after their incarceration (86). Between
2001 and 2019, more than 72 000 persons died in state
and federal prisons predominantly from natural causes
(87). A portion of these patients died after long illnesses
and were candidates for palliative care and hospice care
services. Optimally, correctional systems should integrate
best practices from community-based hospice care, such
as adopting interdisciplinary patient care teams that
include psychosocial and spiritual services; implementing
evidence-based palliative care guidelines; and providing
bereavement support for incarcerated persons, volunteers, and correctional staff. Correctional hospice programs may also include elements unique to the carceral
setting, such as round-the-clock bedside support provided by peer caretakers, and patient contact visits with
family and friends within a confined setting (88, 89).
Early release from prison for medical reasons may
also be an option for incarcerated patients with life-limiting illnesses or those who are otherwise incapacitated.
Some eligible patients, however, are never released despite supportive policies and regulations. Barriers to
early medical release include limited patient self-advocacy due to cognitive impairments and health literacy
limitations, time-consuming logistic hurdles, difficulties
arranging viable reentry plans, and political opposition.
The advocacy of correctional health care professionals
can be critical in providing timely and accurate diagnostic information that meets early medical release eligibility criteria and securing community-based medical and
psychosocial services to help ensure continuity of care
on release (90).
Immigrant Populations
Position 18: ACP recommends policymakers and
administrators adopt adequately funded policies and
procedures to ensure immigrant detainees are treated
with dignity and respect in an environment that is safe,
nondiscriminatory, and culturally sensitive, including the
provision of language translation and interpretation services, as needed, to promote health literacy.
Position 19: ACP reaffirms its opposition to the
forced separation of children from their family members
held in immigrant detention facilities. ACP reaffirms its
opposition to the indefinite holding of children with their
parents or adult caregivers in immigrant detention
facilities.
Position 20: ACP supports efforts to enhance governmental oversight of health care services provided to
immigrant detainees, including compliance with National
Detention Standards.
Detained immigrant populations in the United
States are managed by the Immigration and Customs
Enforcement (ICE) Health Service Corps (IHSC). In fiscal
year 2020, the IHSC provided health care to nearly
100 000 detainees in 20 IHSC-staffed facilities and provided administrative oversight to more than 169 000
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detainees in 148 non-IHSC–staffed detention facilities
(91). Health care provided to detained immigrants is
governed by ICE National Detention Standards (92).
Caring for immigrant detainees poses many challenges for correctional medicine. Promoting the health
care literacy of patients is especially difficult. Detained
immigrants originate from more than 180 countries and
have a wide variety of first languages and cultural backgrounds. Patient communication can be enhanced by
employing a multilingual health care workforce and
using language translation and interpretation services
for patient encounters.
International populations also have a higher prevalence of certain communicable diseases, such as tuberculosis, mumps, and measles, which are highly transmissible
in congregate settings and pose substantial public health
threats. Containment strategies have included universal
chest radiograph screening for tuberculosis in IHSCstaffed facilities and the immunization of detainees to prevent and control mumps and measles outbreaks (35, 93,
94). COVID-19 outbreaks have also affected detained
immigrant populations. Recommended containment
measures have included adapting CDC infection prevention and control recommendations to the immigrant
detention setting, decreasing the detainee population to
reduce overcrowding and increase physical distancing,
and offering COVID-19 vaccinations to all non–fully vaccinated immigrants soon after detention (56, 95). The public
health importance of identifying, preventing, and containing communicable diseases in immigrant detention facilities cannot be overstated. Emerging infectious diseases
are occurring globally and often first become evident in
congregate settings.
Behavioral health concerns affect nearly all immigrant detainees and are thus a major priority for correctional health care. Posttraumatic stress syndrome and
depressive symptoms are especially prevalent due to
traumatic exposures to physical, emotional, and sexual
violence; family separations; and histories of extreme
poverty (96, 97). Immigrant families should not be further traumatized by the forced separation of children
from their parents or caregivers, or by forced family
detentions that indefinitely confine adult parents or caregivers with their children (98).
Providing quality health care to immigrant detainees
is complicated by their frequent movement in and out of
detention facilities, the seriousness of their medical and
psychosocial needs, and their health literacy concerns.
These challenges highlight the importance of governmental oversight of health care services provided to
immigrant detainees, including ensuring compliance
with National Detention Standards, expanding requirements for NCCHC accreditation, and promoting greater
transparency.
Community Reentry Planning
Position 21: ACP recommends that policymakers and
administrators adopt adequately funded policies and
procedures to ensure all U.S. jails and prisons provide
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reentry planning that helps ensure the continuity of
health care and social services for incarcerated patients
returning to the community.
State and federal prisons released 549 600 persons in
2020 while millions more persons were released from
local jails (6). Many persons leaving jail or prison have serious medical or behavioral health conditions that warrant
individualized reentry plans to help ensure continuity of
care. Linkages to community physicians and other clinicians are particularly important for patients with chronic
noncommunicable diseases, infectious diseases, serious
mental illness, and substance use disorders. Patients
returning to the community often face substantial barriers
to health care access that may result in preventable and
sometimes serious health consequences. Reported concerns include relapse to substance use, potentially resulting in drug overdoses and death; preventable emergency
department visits and hospitalizations from untreated
chronic medical conditions and serious mental illnesses;
lapses in antiretroviral medications and loss of viral suppression for patients with HIV infection; and acquisition of
sexually transmitted infections (47, 99–104).
Providing patient-centered reentry plans can help
prevent these poor clinical outcomes. Reentry plans
should be created soon after incarceration and regularly
updated in close coordination with community practitioners and social service organizations (105). The plans
should ensure patient linkages with community-based
physicians and other clinicians. Key elements of the
plans should include summarizing pertinent health information; conducting medication reconciliation and providing a sufficient supply of prescription medications at
the time of release to bridge care; continuing prescribed
MOUDs and making referrals for treatment of substance
use disorder as indicated; providing overdose education and naloxone distribution; securing and updating
personal identification documents; assisting with health
benefit applications, such as Medicaid enrollment; and
coordinating with social service organizations to secure
safe housing, provide employment opportunities, and
address food insecurity (106, 107). Other community
transition strategies should be considered, such as referrals to “health homes” that have co-located community
health care services; pairing peer navigators with incarcerated persons as part of the reentry process; staffing
social workers with parole and probation offices; and
providing HIV preexposure prophylaxis (PrEP) medications for at-risk persons returning to their communities
(108–111).
Position 22: ACP recommends that state Medicaid
authorities adopt policies that suspend rather than terminate
enrollees who become incarcerated, and support electronic,
automated data exchange with correctional systems that facilitates state Medicaid enrollment or reinstatement. ACP supports public policy discussions for expanding Medicaid
coverage for incarcerated populations.
Many persons who are incarcerated are Medicaid eligible, however, federal law precludes Medicaid coverage
of ambulatory health care services provided to persons in
jails or prisons. Public policy initiatives can be instrumental
in providing Medicaid coverage for these persons
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returning to the community. State Medicaid policies that
suspend rather than terminate Medicaid benefits during
incarceration will facilitate Medicaid reinstatement for
incarcerated persons soon after their release. Similarly,
policies that promote the electronic exchange of data
between correctional systems and a state's Medicaid
authorities will facilitate state Medicaid enrollment or reinstatement for incarcerated persons soon after release
(112). Many incarcerated persons return to their communities with limited social support while facing insurmountable barriers for accessing essential health care services. A
coordinated reentry plan with engaged community partners and ready access to Medicaid benefits can be lifesaving and life changing for these persons.
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