Introduction

Incarceration 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).



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Introduction I 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 advo- cacy, and corrections. This report summarizes the presentations and dis- cussion 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

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2 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 evi- dence 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.  escribe and assess the existing research on the causes, drivers, and so- D cial 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, sanc- tions for various crimes, drug enforcement policies, and policies regard- ing parole and parole revocation; and c.  social and economic structure and political conditions: such as crimi- nal behavior, cultural shifts, changes in political attitudes and behavior, changes in public opinion, demographic changes, and changes in the structure of economic opportunity.

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INTRODUCTION 3 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 fac- tual summary of what occurred at the workshop. The planning commit- tee’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 inca- pacitation, 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 gov- ernance, and other near-term and longer-term social costs and benefits. 3.  Explore the public policy implications of the analysis of causes and conse- quences, 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.

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4 HEALTH AND INCARCERATION 800 700 U.S. Incarceration Rate per 100,000 Residents 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 admis- sions 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 addic- tion contributed to the escalation of the incarceration rate (Rich, Dumont,

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INTRODUCTION 5 and Allen, 2012). Closing of mental hospitals in the 1970s (deinstitu- tionalization) 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 incar- cerated 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 com- munity. 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 tremen- dous 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 crim- inal 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 atten- tion to workforce issues and the importance of the continuity of care. And finally, Chapter 3 is devoted to the ACA, which received consider- able 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.

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