7


Consequences for Health and Mental Health

The incarcerated population overrepresents socially marginalized and disadvantaged individuals with a high burden of disease. Health and mental health are prominent issues in debates about incarceration, both because in many cases health issues contributed to incarcerated individuals’ involvement with the criminal justice system and because the vast majority of prisoners eventually return to the community (Travis, 2000), bringing their health conditions with them (Rich et al., 2011). In addition to the causes of incarceration described elsewhere, the inadequate community treatment of drug addiction and, to a lesser extent, mental illness can be viewed as underlying contributors to behaviors leading to incarceration (and reincarceration) in many cases (Rich et al., 2011).

The public health literature has documented the existence of a set of “social determinants of health,” meaning a wide range of factors beyond individual behaviors and conditions that affect health (Bambra et al., 2010; Braveman et al., 2011; Centers for Disease Control and Prevention, 2013; Commission on Social Determinants of Health, 2008; Marmot, 2005). An example is unemployment: people without jobs frequently lack the health insurance that allows them to seek medical care and the income that allows them to eat healthfully, buy medicines, and otherwise address their health needs. Housing is another example of a social determinant of health: people without access to stable, adequate housing are at higher risk of a host of physical and mental stressors, from asthma to anxiety. As discussed elsewhere in this report, prisoners, as well as jail inmates, are more likely than the general U.S. population to be unemployed, poor, black or Hispanic,



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7 Consequences for Health and Mental Health T he incarcerated population overrepresents socially marginalized and disadvantaged individuals with a high burden of disease. Health and mental health are prominent issues in debates about incarceration, both because in many cases health issues contributed to incarcerated indi- viduals’ involvement with the criminal justice system and because the vast majority of prisoners eventually return to the community (Travis, 2000), bringing their health conditions with them (Rich et al., 2011). In addition to the causes of incarceration described elsewhere, the inadequate commu- nity treatment of drug addiction and, to a lesser extent, mental illness can be viewed as underlying contributors to behaviors leading to incarceration (and reincarceration) in many cases (Rich et al., 2011). The public health literature has documented the existence of a set of “social determinants of health,” meaning a wide range of factors beyond individual behaviors and conditions that affect health (Bambra et al., 2010; Braveman et al., 2011; Centers for Disease Control and Prevention, 2013; Commission on Social Determinants of Health, 2008; Marmot, 2005). An example is unemployment: people without jobs frequently lack the health insurance that allows them to seek medical care and the income that allows them to eat healthfully, buy medicines, and otherwise address their health needs. Housing is another example of a social determinant of health: people without access to stable, adequate housing are at higher risk of a host of physical and mental stressors, from asthma to anxiety. As discussed else- where in this report, prisoners, as well as jail inmates, are more likely than the general U.S. population to be unemployed, poor, black or Hispanic, 202

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 203 homeless, and uninsured, and these social variables are all strongly associ- ated with poor health. Increasing incarceration rates have drawn greater attention among health care professionals to the relationships between incarceration and health.1 They have been presented with a dilemma in that the high rates of incarceration have offered an opportunity to identify and treat vulnerable people who might otherwise not have access to (or seek) health care; but at the same time, partly for the reasons discussed in Chapter 6, prisons are not the ideal setting for medical treatment (National Research Council and Institute of Medicine, 2013). In this chapter, we present the current state of knowledge on the health and health care of inmates and the postrelease health of prisoners and their communities. Although gaps in knowledge in this area remain, the evidence base compiled over the past 10 years makes clear that current challenges in incarceration and community health are strongly connected for some of the most vulnerable communities, and ideally should be addressed in concert. Increased rates of incarceration, affecting these communities in particular, have only magnified these challenges. We begin with a review of key aspects of the health profile of inmates. This is followed by a description of the health care provided in correctional facilities. Next, we look at the impact of incarceration on both physical and mental health, and then at health fol- lowing release. We conclude the chapter with a review of knowledge gaps in these areas and concluding remarks. The main focus of inquiry for this committee was incarceration in state and federal prisons. For this chapter’s discussion of health and incarcera- tion, however, we believe it is important to include inmates from both jails and prisons. Although there are important differences between the two types of institutions, the similarities are striking from a health perspective. Both jails and prisons house a high-risk population with a heavy burden of disease; both present health perils as well as health opportunities; and in nearly all cases, the individuals held in these institutions are then released back into the community. For jails, the turnover often is quite rapid and the numbers are much greater; although the average daily jail census in 2011 was under 750,000, there were nearly 12 million admissions to jails from July 2011 to June 2012 and as many releases (Minton, 2013). By contrast, there were under 700,000 releases from state and federal prisons in 2011 (Carson and Sabol, 2012). 1  These relationships were explored during a workshop conducted jointly by the Institute of Medicine and the National Research Council in December 2012. A summary of the views and analysis presented at this workshop informed this committee’s work, and this chapter in particular (National Research Council and Institute of Medicine, 2013).

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204 THE GROWTH OF INCARCERATION HEALTH PROFILE OF INMATES The high burden of disease among jail and prison inmates (Binswanger et al., 2009; Fazel and Baillargeon, 2011; Wilper et al., 2009) poses chal- lenges for the provision of care but also opportunities for screening, diag- nosis, treatment, and linkage to treatment after release. Much of the disease in incarcerated populations can be attributed to overlapping synergistic epidemics (syndemics) of substance use, infectious diseases, and mental illness in the context of poverty, violence, homelessness, and limited access to health care. In this section, we address in turn the following aspects of the health profile of the incarcerated population: mental health, substance abuse, infectious diseases, chronic conditions, aging prisoners, and the health of female inmates. Mental Health A recent survey by the Bureau of Justice Statistics (James and Glaze, 2006) found that more than half of all inmates had some kind of men- tal health problem (see Table 7-1). For the survey, identification of a mental health problem was based on either a clinical diagnosis or treat- ment by a mental health professional within the past 12 months or having presented with symptoms of a mental disorder based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi- tion (DSM-IV) (American Psychiatric Association, 1994). The prevalence of TABLE 7-1  Prevalence of Mental Illness and Drug and Alcohol Dependence and Abuse in U.S. Prisoners State Prisons Federal Prisons Condition Jails (%) (%) (%) Mental Illness 64 56 45 Drug and/or Alcohol Dependence or Abuse (combined total) 68 Drug Dependence or Abuse 53 53 45 Alcohol Dependence or Abuse 47 NOTES: James and Glaze (2006) use data from the Survey of Inmates in State and Federal Correctional Facilities, 2004, and the Survey of Inmates in Local Jails, 2002, to examine mental disorders among jail and prison inmates. Karberg and James (2005) use data from the Survey of Inmates in Local Jails, 2002, to study drug and alcohol dependence and abuse among jail inmates. Mumola and Karberg (2006) use data from the Survey of Inmates in State and Federal Correctional Facilities, 2004, to examine drug use, abuse, and dependence among state and federal prisoners. SOURCES: James and Glaze (2006); Karberg and James (2005); Mumola and Karberg (2006).

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 205 mental health problems is most striking in jails (64 percent); the prevalence is slightly lower in state and federal prisons but still is 56 percent and 45 percent, respectively. The prevalence of mental health problems is higher among whites than among blacks and Hispanics: 71 percent of whites in jails, compared with 63 percent of blacks and 51 percent of Hispanics, and 62 percent of whites in state prisons, compared with 55 percent of blacks and 46 percent of Hispanics. These figures may misrepresent the state of mental illness among the incarcerated as a result of self-reporting bias or to the extent that the accuracy of traditional measures of mental health varies by race and ethnicity (James and Glaze, 2006). By some estimates, 10-25 percent of prisoners in the United States suf- fer from serious mental health problems, such as major affective disorders or schizophrenia (Ditton, 1999; Fazel and Danesh, 2002; Haney, 2006; Steadman et al., 2009); corresponding estimates for jail inmates are nearly 15 percent for men and 31 percent for women (Steadman et al., 2009). By comparison, an earlier study estimates that 5 percent of the general population has a serious mental illness, although the rates are not directly comparable across different time periods and studies, given variations in survey questions and measures (Kessler et al., 1996). The presence of large concentrations of mentally ill persons within pris- ons and jails has been noted for almost a hundred years (Fazel and Danesh, 2002; Morgan et al., 2010; Torrey, 1995), but attention to this issue has increased since the closing of mental hospitals in the 1970s. Between 1970 and 2002, the number of public psychiatric hospital beds fell from 207 to 20 per 100,000 population (Yoon, 2011). Deinstitutionalization was intended to shift patients to more humane care in the community, but insufficient funding instead left many people without access to treatment altogether (Baillargeon et al., 2010b; Lamb and Weinberger, 2005; Lamb et al., 2004). As a result, mentally ill individuals likely became at greater risk of incarceration. Although nationwide studies are not available, small-scale studies show the high rate of criminal justice involvement among those with mental ill- ness who are receiving mental health services. In San Diego, for example, 12 percent of mental health service recipients were incarcerated during a 1-year period; in Los Angeles, 24 percent of Medicaid clients receiving mental health services were arrested over a 10-year period (Cuellar et al., 2007; Hawthorne et al., 2012). Mental illness frequently becomes de facto criminalized when those affected by it use illegal drugs, sometimes as a form of self-medication (Harris and Edlund, 2005), or engage in behaviors that draw attention and police response. Even with appropriate training, police have diverted such people into the criminal justice system rather than the mental health system because of time or resource constraints (e.g., through “mercy bookings,” when it appears that no mental health resources are

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206 THE GROWTH OF INCARCERATION available for a person in need) (Lamb and Weinberger, 2005; Lamb et al., 2004; Morabito, 2007; Yoon, 2011). Substance Abuse Given the contribution of the war on drugs to the dramatic rise in incarceration (see Chapters 2 and 3), high rates of drug addiction among prisoners can be expected. Estimates of inmates with a history of substance abuse are somewhat uncertain, in part because of reliance on multiple, sometimes unvalidated, diagnostic instruments (Belenko and Peugh, 2005; Mears et al., 2002). However, national estimates (James and Glaze, 2006; Karberg and James, 2005; Mumola and Karberg, 2006) can serve as a useful overview and enable comparisons between prisons and jails (see Table 7-1). Grant and colleagues (2004) report a 9 percent prevalence of substance use disorders within the U.S. population. In contrast, the Bureau of Justice Statistics reports that 68 percent of jail inmates have symptoms consistent with DSM-IV definitions of dependence or abuse. About 47 percent of jail inmates have alcohol dependence or abuse, compared with 54 percent of jail inmates with drug dependence or abuse, indicating a substantial popu- lation dealing with both substances simultaneously (Karberg and James, 2005). Among jail inmates, 78 percent of whites compared with 64 per- cent of blacks and 59 percent of Hispanics meet the criteria for substance dependence or abuse (Karberg and James, 2005). Rates are lower in state prisons—59 percent for whites, 50 percent for blacks, and 51 percent for Hispanics (Mumola and Karberg, 2006). In 2004, 17 percent of prison- ers and 18 percent of federal inmates reported that “they committed their current offense to obtain money for drugs” (Bureau of Justice Statistics, n.d.-a). Neuroscience research has demonstrated that addiction is a disease of the brain. Drug addiction is a chronic but treatable condition (see Box 7-1). Relapse is frequent, but with rates comparable to those for failure to adhere to treatment for other medical conditions, such as hypertension and diabe- tes (McLellan et al., 2000). The perception of addiction as a moral failing rather than a medical issue may have contributed to the low availability of treatment in the community. As a result, drug dependence remains left largely in the hands of the criminal justice system instead of the health care system—i.e., criminalized rather than medicalized. Simply incarcerating someone does not constitute effective treatment; without medical treat- ment, individuals are prone to relapse to drug use and too often to criminal behavior that results in reincarceration. The available evidence on drug treatment provided in correctional facilities is discussed later in this chapter.

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 207 BOX 7-1 Principles of Drug Abuse Treatment for Criminal Justice Populations   1. Drug addiction is a brain disease that affects behavior.   2. Recovery from drug addiction requires effective treatment, followed by man- agement of the problem over time.   3. Treatment must last long enough to produce stable behavioral changes.   4. Assessment is the first step in treatment.   5. Tailoring services to fit the needs of the individual is an important part of effective drug abuse treatment for criminal justice populations.   6. Drug use during treatment should be carefully monitored.   7. Treatment should target factors that are associated with criminal behavior.   8. Criminal justice supervision should incorporate treatment planning for drug abusing [individuals], and treatment providers should be aware of correc- tional supervision requirements.   9. Continuity of care is essential for drug abusers re-entering the community. 10. A balance of rewards and sanctions encourages pro-social behavior and treatment participation. 11. [Individuals] with co-occurring drug abuse and mental health problems often require an integrated treatment approach. 12. Medications are an important part of treatment for many drug abusing [individuals]. 13. Treatment planning for drug abusing [individuals] living in or re-entering the community should include strategies to prevent and treat serious, chronic medical conditions, such as HIV/AIDS, hepatitis B and C, and tuberculosis. SOURCE: Excerpted from National Institute on Drug Abuse (2012). Many inmates have both a mental illness and a history of substance abuse. In jails, more than 70 percent of those with a serious mental illness have a co-occurring substance abuse disorder; the corresponding percentage in the general population is about 25 percent (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 health care community finds the potential differences striking (National Research Council and Institute of Medicine, 2013). Co-occurring disorders can complicate detection and effective treatment, especially when staff or diagnostic instruments are insufficiently sensitive, or where overcrowding or understaffing reduces the time spent on medical screening.

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208 THE GROWTH OF INCARCERATION Infectious Diseases Contagious diseases such as tuberculosis (TB) have traditionally been a major health problem in correctional facilities. One study found that in 1997, an estimated 40 percent of all those in the United States with TB passed through a correctional facility, while another study found that jail and prison inmates, respectively, had up to 17 times and 4 times the TB prevalence of the general population (Hammett et al., 2002). More recently, however, TB has been largely controlled in the United States, in contrast with some other world regions. In 2010, the lowest ever rate (3.4 cases per 100,000 population) and number of cases (10,528) were reported, and only 4.3 percent of the cases diagnosed were in a correctional facility (Centers for Disease Control and Prevention, 2012). Outbreaks are still possible in prisons and jails, however, because the presence of large numbers of people in enclosed, poorly ventilated spaces is highly conducive to the spread of TB (Centers for Disease Control and Prevention, 2004). Worldwide, transmis- sion behind bars has been estimated to contribute to 6.3-8.5 percent of the TB cases in the community (Baussano et al., 2010). Rates of sexually transmitted diseases (STDs) among people who pass through correctional facilities, particularly jails,2 are higher than those in the general population (Centers for Disease Control and Prevention, 2011c; Hammett, 2006; Khan et al., 2011); according to the Centers for Disease Control and Prevention (CDC) (2011c), “prevalence rates for Chlamydia and gonorrhea in these settings are consistently among the highest observed in any venue.” Prevalence is especially high among female inmates, in whom syphilis seropositivity may be as high as 28 percent, compared with 10 percent among male inmates (Parece et al., 1999). However, reported rates may understate the true prevalence in facilities that do not perform universal screening or among sex workers, who often are released from jail before testing is conducted (National Commission on Correctional Health Care, 2002). HIV prevalence also is higher in correctional populations than in the population at large, although local and regional estimates vary substantially across facilities and states depending on testing policies and practices (Desai et al., 2002; Maruschak, 2012; Centers for Disease Control and Prevention, 2011b). States or facilities that test primarily when requested by the inmate will likely underdiagnose HIV compared with states with opt-out testing (i.e., testing is automatic unless the inmate refuses) or with mandatory testing. That said, the prevalence of diagnosed HIV in correctional facili- ties declined from 194 cases per 10,000 inmates in 2001 to 146 cases per 2  Screeningfor STDs is often conducted within jails for both those serving jail sentences and those who will be entering prison.

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 209 10,000 in 2010, but remains two to seven times higher than in the general population, with an overall prevalence of 1.5 percent (range 0.3 percent to 5.5 percent) among state and federal prisoners (Centers for Disease Control and Prevention, 2009; Maruschak, 2012). CDC recommends HIV testing for all inmates (Centers for Disease Control and Prevention, 2009). National surveys of prisons in 2004 and jails in 2002 revealed that 77 percent of federal prisoners, 69 percent of state prisoners, and 18.5 percent of jail inmates reported being tested for HIV since their incarceration (Maruschak, 2004, 2006). A large portion of incarcerated individuals are at risk for HIV because of addiction, injection drug use, sexual practices, and high-risk social networks. An estimated 17�������������������������������������������������������������������������  ������������������������������������������������������������������������ percent of all Americans living with HIV pass through a correctional fa- cility (jail or prison) annually. This includes 22-28 percent of all black men with HIV and 22-33 percent of all Hispanic men with HIV (Spaulding et al., 2009). Correctional facilities have played an important role in diagnosing HIV in people who have not previously been tested (Beckwith, 2010). They also are being studied as an important venue not only for diagnosing the 25 percent of people living with HIV that do not know they are infected but also, through treatment and linkage to care after release, for playing a critical role in the prevention of further HIV transmission (Granich et al., 2011). People living with HIV frequently have other health problems, includ- ing coexisting infectious diseases. Because injection drug use is a common route of transmission for both HIV and hepatitis C virus (HCV) infections, HIV/HCV coinfection is especially common; in one study, 65 percent of prisoners with HIV also had HCV (Solomon et al., 2004). HCV by itself (monoinfection) is a “silent” infection, often without symptoms; it can remain unsuspected and undiagnosed until a late stage. Point estimates of HCV prevalence among correctional populations vary widely. An estimated 16-41 percent of prisoners carry HCV antibodies, and 12-31 percent have advanced to chronic infection, a rate 8-20 times higher than in the general population (Boutwell et al., 2005; Centers for Disease Control and Preven- tion, 2011a; Larney et al., 2013; Spaulding et al., 2006). Although HCV now outpaces HIV in new cases and deaths in the com- munity (Ly et al., 2012), it has not yet gained the same awareness among the public, including correctional administrators, which may be one reason HCV testing remains far less frequent than testing HIV (Varan et al., 2012). In addition, CDC has yet to promulgate recommendations for universal testing of prisoners for HCV as it has for HIV (Macalino et al., 2005). The high price tag for a course of HCV treatment (well over $50,000 and rising) may also discourage prisons and jails from broad-based testing, because diagnosis could require treatment on the part of the correctional facility.

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210 THE GROWTH OF INCARCERATION Chronic Conditions and Special Populations Chronic diseases, such as hypertension, asthma, and diabetes, as well as health conditions in special populations, have only recently become a substantial focus for researchers in correctional health. Chronic conditions now constitute a growing percentage of correctional health care needs as the result of a confluence of trends, especially the increase in chronic disease among younger Americans and the aging of the correctional population (see below). One study estimates that 39-43 percent of all inmates have at least one chronic condition (Wilper et al., 2009). With few exceptions, the prevalence of almost all chronic conditions is higher among both prison and jail inmates than in the general population (Binswanger et al., 2009). In a national study, inmates had 1.2-fold more hypertension than the general population. Even in the youngest age group (18-33), 10 percent of jail inmates and 11 percent of prison inmates had hypertension, compared with 7 percent of nonincarcerated individuals in the same age group, and patterns were similar for other common chronic conditions (e.g., asthma) (Binswanger et al., 2009). Other local studies have found that inmates are similar to the general population on measures of hypertension, diabetes, and heart disease risk (Harzke et al., 2010; Khavjou et al., 2007). Since not all inmates receive medical screening for chronic conditions, however, these conditions may have been underreported among prisoners.3 Certain populations present unique health care challenges within cor- rectional facilities. Incarcerated juveniles generally are held separately from adults; however, about 10 percent are held in adult prisons (see Chapter 6). In either setting, they are highly vulnerable and, like adult prisoners, have a higher disease burden than their nonincarcerated peers. More than two- thirds of incarcerated adolescents report a health care need. Dental de- cay, injury, and prior abuse are common, and 20 percent are parents or expecting (American Academy of Pediatrics Committee on Adolescence, 2011). Studies have found a high prevalence of STDs among incarcerated adolescents, as well as engagement in high-risk behaviors associated with HIV, STDs, and hepatitis and limited access to health care (see the review by Joesoef et al., 2006). A study of adherence to standards of the National Commission on Correctional Health Care found that fewer than half of ju- venile detention facilities complied with recommended screening for health care needs upon admission (Gallagher and Dobrin, 2007). Prisoners with disabilities also tend to be overlooked. Disabilities that are relatively minor in society at large can constitute serious impediments to well-being in prison. Living in correctional facilities entails activities of 3  Note such conditions in the general population may also be underreported.

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 211 daily living (ADLs) that pose particular challenges to people with physical or developmental disabilities. For instance, regular ADLs include bathing and dressing, but ADLs in prison also can involve getting on and off an upper bunk, dropping to the floor for alarms, and hearing and promptly following orders against extensive background noise (Williams et al., 2006). Finally, incarcerated veterans generally are not less healthy than the correctional population as a whole, with the exception of high rates of posttraumatic stress disorder (PTSD) (Tsai et al., 2013a, 2013b; Greenberg and Rosenheck, 2009, 2012). At the same time, they have the advantage of access to resources in the Department of Veterans Affairs (VA) upon reentry. Some correctional systems coordinate with the VA to ensure that veterans succeed in linking to VA care following release from incarceration. The aging incarcerated population and women within correctional facilities are discussed further below.4 The Aging Incarcerated Population From 1990 to 2012, the U.S. population aged 55 or older increased by about 50 percent. In that same period, the U.S. incarcerated population aged 55 or older in the state and federal prison systems increased by some 550 percent as the prison population doubled (Williams et al., 2012). The overall percentage of older adults within prison systems remains small com- pared with the vast majority of those 40 and under; however, those 55 and older generally are in poorer health than those younger than 55 (Williams and Abraldes, 2010; Williams et al., 2012). As in the general population, older compared with younger inmates tend to have higher rates of typical chronic health conditions (e.g., conges- tive heart failure, diabetes, chronic obstructive pulmonary disease) and seri- ous life-limiting illnesses. A Texas study, for example, found that 41 percent of prisoners aged 45-54 had at least one chronic condition, compared with 65 percent of those 55 or older (Harzke et al., 2010).5 Older inmates also may have high rates of additional geriatric syndromes, such as cognitive impairment or dementia, and disabilities or impaired ability to perform ADLs. Like inmates with disabilities, older inmates may not be able to drop to the floor as instructed in response to an alarm or, worse, be unable to get back up again after the alarm is over, or have difficulty climbing on or 4  Much of the information in the next two sections comes from the aforementioned work- shop on health and incarceration (National Research Council and Institute of Medicine, 2013). 5  The prevalence of chronic diseases may be underestimated in this study because prisoners under age 50 were not screened for many conditions after intake. In addition, most studies are based on self-reported symptoms or diagnoses, and prisoners also may not trust correctional staff (Harzke et al., 2010), be concerned about stigma associated with some health problems, or be ignorant of their own health conditions.

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212 THE GROWTH OF INCARCERATION off their assigned bunk. Given the aging trend during the period of rising incarceration rates and the greater prevalence of health conditions among older inmates, prisons increasingly are becoming a critical delivery site for nursing home-level care and care for serious chronic illnesses (National Research Council and Institute of Medicine, 2013). As discussed later, many prisons lack the resources for such care. The rapidly increasing population of older adults in correctional fa- cilities underscores the importance of screening and, more important, re- screening, for cognitive impairment, dementia, and disability. Currently, a disability assessment generally is performed only at intake, even if an indi- vidual is incarcerated for decades. Older prisoners will best serve their time if placed in correctional housing appropriate to their cognitive and physical abilities. In the New York prison system, for example, as the proportion of inmates over 50 rose to 11 percent in 2006, a dementia unit was created when needs of the afflicted inmates were not served in general facilities. Many fear the need for nursing home-type care could be a growing trend if incarceration rates are not reduced (Becker, 2012; Hill, 2007). The Health of Female Inmates Although female inmates make up only about 10 percent of the cor- rectional population, they have higher rates of disease than male inmates and additional reproductive health issues. Rates of mental illness are sub- stantially higher among female than male inmates, particularly because they have high rates of childhood sexual abuse and PTSD (Binswanger et al., 2010; Lewis, 2006). A systematic review found particularly large variation in estimates of the prevalence of alcohol dependence/abuse by gender, in part because of multiple diagnostic instruments and methodologies. None- theless, 18-30 percent of male prison inmates exhibited alcohol dependence/ abuse, only slightly in excess of figures for the U.S. general public, while at 10-29 percent prevalence, female prisoners were two to four times as likely as nonincarcerated women to have alcohol dependence/abuse (Fazel et al., 2006). An estimated 5 to 6 percent of women entering prisons and jails are pregnant (Clarke and Adashi, 2011). The data on birth outcomes vary, but in general, babies weigh more the longer a woman is incarcerated. Reasons for these better birth outcomes likely include better access to prenatal care; decreased substance use; and for some, stable housing and regular meals. These outcomes for the incarcerated underscore the need for services in communities for highly vulnerable populations. Studies also have shown that most women who enter incarceration preg- nant conceived within 3 months of leaving a prior incarceration (Clarke et al., 2010). This finding suggests the value of correctional facilities providing

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222 THE GROWTH OF INCARCERATION Incarceration is related to the incidence of infectious diseases (i.e., new cases of infection) in complex ways. On the negative side, the near-capacity occupancy of many facilities and the overcrowding of others continue to raise concerns about transmission of airborne infections, especially diseases such as TB and influenza. On the positive side, compared with some other world regions, there is little incidence of infectious diseases, particularly those requiring blood-to-blood transmission, within U.S. correctional facili- ties. However, evidence is growing regarding postrelease transmission rates. For one thing, the primary paths of transmission for HIV and HCV—sex and drug use—are less frequent in than out of prison9 (Blankenship et al., 2005). Thus the vast majority of HIV and HCV incidence among the incarcerated population in the United States occurs before incarceration or shortly after release from prison or jail (Beckwith et al., 2010). HIV incidence is slightly higher among inmates than in the general population (0.08 per 100 person-years versus 0.02 per 100 person-years), but it is much higher among people who are released and reincarcerated (2.92 per 100 person-years), indicating that the highest risk is in the periods between release and reincarceration rather than during the prison or jail stay itself (Gough et al., 2010). Inmates with HIV who remain incarcerated have lower viral loads and higher CD4 counts (i.e., their HIV is better controlled) than those who have been released and reincarcerated, meaning that those cycling repeatedly through the correctional system are not only less healthy but also more infectious (Baillargeon et al., 2010a). The effects of incarceration on general health and chronic diseases are more difficult to evaluate. Aggregate information on health behaviors and associated changes in health during incarceration is lacking, and although health behaviors of the incarcerated (physical activity, nutrition, and smok- ing) are now receiving increased attention from researchers, their findings are mixed or limited. For example, studies from the United Kingdom and Australia provide contradictory evidence on the amount of physical activity among men and women in correctional facilities compared with the general population (Herbert et al., 2012; Plugge et al., 2009). With respect to nutrition, the nutritional value of prison meals is far from ideal because energy-dense (high-fat, high-calorie) foods are common, although prison meals may be better than those normally consumed by people living especially chaotic lives. One of the few studies to measure inmates more than once found that 71 percent of women gained weight over a 2-week period after admission to jail, on average 1.1 pounds per week (Clarke and Waring, 2012). 9  Note, however, that sex and drug use often are conducted in a riskier manner in prison than on the outside, given limited access to condoms and injection and sterilization equipment, limited privacy, and a coercive environment (Blankenship et al., 2005).

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 223 The prison environment may exacerbate health conditions such as asthma because of poor ventilation, overcrowding, and stress (which may trigger asthma attacks) (Wang and Green, 2010). Smoking is a serious problem, with a prevalence of 60-80 percent and secondhand smoke con- centrations from 1.5 to 12 times greater than in the average smoker’s home. There is an ongoing trend toward smoke-free correctional facilities, but although 60 percent of prison systems have total smoking bans and 27 per- cent more ban smoking inside, smoking remains common among prisoners (Kauffman et al., 2011). A survey of female inmates in Rhode Island also found a strong inverse correlation between the number of incarcerations and willingness to remain abstinent from smoking after release (Nijhawan et al., 2010). Thus despite some improvements with smoking bans (Ritter et al., 2012), both smoking and exposure to secondhand smoke during incarceration likely are contributors to ongoing deterioration of health, including asthma, among prisoners. More evidence is available regarding the effects of incarceration on mental health. Two conditions are particularly associated with a serious degeneration of mental health: overcrowding and confinement in isolation units (see the discussion in Chapter 6). Strains on staffing and facilities, mentioned above in the context of Brown v. Plata, have had serious reper- cussions for wait times and holding conditions for the mentally ill. In ad- dition to their often untreated illness, mentally ill prisoners are more likely than other prisoners to incur disciplinary infractions and suffer punishment as a result (James and Glaze, 2006; O’Keefe and Schnell, 2007), and they also are more likely to be victimized, including sexual victimization, in the course of their confinement (Beck et al., 2013; Blitz et al., 2008; Wolff et al., 2007). In extreme cases, some prisoners react to the psychic stresses of impris- onment by taking their own lives. Various studies have documented some- what higher rates of suicide among prisoners than in the general population (Bland et al., 1990; Hayes, 1989; Mumola and Noonan, 2007; Mumola, 2005).10 Significant reductions in the rate of suicides in U.S. prisons have been achieved over the past several decades. Thus, suicide rates in prison dropped from 34 per 100,000 in 1980 to 16 per 100,000 in 1990, and largely stabilized after that (Mumola, 2005). Most experts believe that the reduction occurred largely because of proactive steps taken by prison of- ficials and staff. For example, the main agency that accredits correctional 10  According to data from the National Center for Health Statistics and the Bureau of Justice Statistics, the overall rate of suicide in the United States in 2002 was 11 per 100,000, as com- pared with 14 per 100,000 for prisoners (McKeown et al., 2006; Mumola, 2005). A match of the rates according to the demographic makeup of the prisoner population would likely make this differential even smaller.

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224 THE GROWTH OF INCARCERATION facilities now requires, as a precondition for accreditation, that prisons screen incoming inmates for suicide risk and provide treatment for those found to be at risk and that they have implemented a program of suicide prevention (American Correctional Association, 2003, Standard 4-4373). Nonetheless, suicide remains the leading cause of death in local jails and in the top five causes of deaths in state prisons (among cancer, heart disease, liver disease, and respiratory disease) (Noonan, 2012). Rates of prison suicide appear to be a product both of the number of traumas and risk factors to which prisoners were exposed before incarcera- tion and the harshness of the prison conditions they experience during their confinement (Liebling, 1995). Thus, although researchers have identified individual factors and background characteristics that help predict suicide in different groups of incarcerated male prisoners, they also have identified institutional factors—the severity of environmental stressors—that play a significant role in the levels of anxiety, depression, and suicidality from which prisoners suffer (Cooper and Berwick, 2001). Many experts believe that, despite being one of the leading causes of prison fatalities, suicide is “potentially the most preventable cause of death in prisons” (Salive et al., 1989, p. 368) and that psychotherapeutic and other kinds of prison inter- ventions can have a significant effect in further reducing suicide rates (e.g., Patterson and Hughes, 2008). Violence and Health A review of the health effects of incarceration must take account of violence and injury, both self- or other-inflicted and accidental. Violence and injury are considered public health issues in free society but generally are viewed as disciplinary or management problems in correctional facili- ties (Sung, 2010). With the decline of HIV and TB rates, injuries are now the most common health problem in correctional facilities (Sung, 2012). Fifteen percent of state prisoners surveyed by the Bureau of Justice Statis- tics reported violence-related injuries, and 22 percent reported accidental injuries (Sung, 2010). A New York City jail study found that 66 percent of all inmate injuries were intentional, and 39 percent of those injuries were serious enough to require care beyond the means of the facility’s medical staff (Ludwig et al., 2012). Among jail inmates nationally, 13������������  percent���� re- ported being injured either through violence or accidentally (Sung, 2012). In a study of one jurisdiction, 32 percent of male prison inmates reported a physical assault in a 6-month period (Wolff and Jing, 2009). In a study among U.S. prisoners, 14 percent of white men and 18 percent of black men sustained fight-related injuries, although some may have forgone medical treatment for their injuries in keeping with prison culture (Rosen et al., 2012).

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 225 Certain types of injury are becoming the focus of concern. Traumatic brain injury (TBI) may have distinctive repercussions for not only long-term health but also recidivism, as it is associated with violence and criminal justice involvement (Farrer and Hedges, 2011). Although few data are available on TBIs suffered during incarceration, a meta-analysis found con- sistently and substantially higher lifetime prevalence among prisoners than in the general population (Farrer and Hedges, 2011), indicating the need for greater attention to targeted treatment and/or behavioral interventions for inmates with a TBI history. Self-injury also is common. According to one study, about 50 percent of female prison inmates engaged in self-injury (e.g., cutting or ingest- ing foreign objects, as distinct from suicidal behaviors), although only about half of respondent states kept data on this behavior. The study also found that self-injury was most common for those held in segregation units (Appelbaum et al., 2011). More data are available on sexual assault as a result of the 2003 Prison Rape Elimination Act, which required the collection and analysis of data on sexual assault in correctional facilities (Fellner, 2010). This important legislation is a good example of the federal government’s taking an active role in responding to a problem within the nation’s prisons. Sexual assault not only places victims at risk of physical injury during the assault but also increases the risk of STDs, including HIV, and mental health repercussions, including depression and suicide. Interviews with inmates reveal that many still do not report sexual assault, however, either because they fear reper- cussions from other inmates or correctional authorities or because they are unable to discuss the experience (Jenness et al., 2010). In a survey of parolees by the Bureau of Justice Statistics, nearly 10 percent of former state prisoners reported at least one episode of sexual victimization during their most recent incarceration (Bureau of Justice Statistics, 2012b). In a survey of current inmates, more than 4 percent of prison inmates and 3 percent of jail inmates reported sexual assault (Beck et al., 2013). The increase in data collection as a result of the Prison Rape Elimina- tion Act also has allowed a better understanding of both victims and perpe- trators. A substantial proportion of incidents involving staff were reported as consensual (without coercion or force) and between male inmates and female staff (Beck et al., 2010; Bureau of Justice Statistics, 2012b). How- ever, female inmates were far more likely than males to report being pres- sured into sexual activity by staff (82 percent of female victims versus 55 percent of male victims) (Beck et al., 2010). Based on self-report, women also were more subject to sexual victimization by other inmates; 14�����  ���� per- cent reported such assaults, compared with 4 percent of men (Bureau of Justice Statistics, 2012b). Women who have previously been abused are at especially heightened risk of sexual assault during incarceration (Beck and

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226 THE GROWTH OF INCARCERATION Harrison, 2008; Moloney et al., 2009). Inmates who reported their sexual orientation as other than heterosexual (12 percent of such prisoners and 8.5 percent of such jail inmates [Beck et al., 2013]) or who had experienced sexual victimization prior to incarceration also were at higher risk (Beck, 2010; Beck and Harrison, 2008; Beck et al., 2013; Wolff and Jing, 2009). Bisexual or gay men were 10 times as likely to be victimized as straight men (Bureau of Justice Statistics, 2012b). While the Prison Rape Elimination Act required all states to collect and report all allegations of such incidents and to note whether they had been “substantiated” through investigation, serious questions continue to be raised about the completeness and reliability of the data acquired. For example, the extreme state-by-state variability in numbers of “substanti- ated” claims of sexual abuse perpetrated by staff members against inmates reported in 2006 (e.g., none of 152 allegations substantiated in Florida as compared with 6 of 7 substantiated in West Virginia) led one researcher to conclude “that not only are state practices of dealing with the allega- tions of sexual abuse strikingly different, but that some of them are also suspiciously perfunctory in determining whether evidence was (in)sufficient to show that the alleged incident occurred” (Kutateladze, 2009, p. 201). HEALTH FOLLOWING RELEASE In this section, we discuss the importance of continuity of care during the transition from medical care in prisons or jails to that in the community. Unfortunately, such continuity often is absent. Some changes in health status may not fully manifest until long af- ter release from incarceration. Evidence on the longer-term outcomes for health conditions among former prisoners is limited, but some studies have found associations between previous incarceration and heightened risk of asthma, hypertension, and stress-related diseases (Massoglia, 2008a; Wang and Green, 2010; Wang et al., 2009; Mallik-Kane and Visher, 2008). For most, the period immediately following release from prison is especially risky. While, as discussed earlier, mortality rates within prisons and jails are comparable to those among the general population for white males and lower than among nonincarcerated peers for black males, ex-prisoners are nearly 13 times more likely than the general population to die in the 2 weeks following release (Binswanger et al., 2007; Patterson, 2010; Rosen et al., 2011; Spaulding et al., 2011). Studies show that prisoners are at great risk of suicide shortly after being released from prison (e.g., Pratt et al., 2006). In addition, those recently released are 129 times more likely than the general population to die of an overdose (Binswanger et al., 2007). Release from incarceration often is accompanied by stress and anxiety as people struggle to reestablish

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 227 housing, employment, and social relations. Often people return to the same situations and social networks in which they were involved before being incarcerated and end up returning to the same patterns of drug use and other criminal behavior. The elevated risk of overdose in the days follow- ing release reflects the insufficient nature of drug treatment during (and after) incarceration. During periods of absolute or relative abstinence from regular opiate use, such as incarceration, individuals lose their tolerance to opiates, which puts them at high risk for overdose and death. Drug treat- ment during incarceration often is undermined by a return to the original environment. Research in behavioral science has shown that environmental triggers can dominate individual motivation (Volkow et al., 2011). As dis- cussed earlier, interventions that follow in-prison drug treatment programs with postrelease treatment have been shown to be more effective. Access to Health Care After Release Almost 80 percent of inmates are without private or public insurance upon reentry, making it difficult for them to access health care services (Mallik-Kane and Visher, 2008). Because unemployment is high among those formerly incarcerated, Medicaid is a particularly important source of coverage; however, a large number of these individuals have been ineligible for Medicaid. Moreover, those who are enrolled in Medicaid often lose their coverage during incarceration (Wakeman et al., 2009). Despite federal guidance suggesting that states only suspend Medicaid during incarceration, many states terminate it altogether and take no steps to reenroll incarcer- ated individuals when they leave prison or jail. As a result, many lack health insurance and thus access to most health care during the critical reentry period. Implementation of the ACA in 2014 will extend Medicaid eligibil- ity to a substantial number of those previously without insurance (Phillips, 2012). It remains to be seen how many and how well states will coordinate between Medicaid and correctional systems to facilitate the enrollment of incarcerated individuals. Enrolling these newly eligible people in Medic- aid upon release should improve access to health care, reduce reliance on emergency departments, and sustain the benefit of care received in prison. The need to improve the outcomes of prisoner reentry through as- sistance with employment, housing, and other transitional needs that ul- timately affect health is receiving growing attention, as evidenced by the work of the Council of State Governments’ Reentry Policy Council, the National Governors Association, the Transition from Prison to Community Program of the National Institute of Corrections, and many others (Travis, 2007). Correctional authorities also are increasingly addressing the problem of linkage to community-based care through discharge planning, a term that refers broadly to the process of helping prisoners prepare to make

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228 THE GROWTH OF INCARCERATION the transition from incarceration back into the community. Until recently, however, only about 10 percent of those released from state prisons in need of discharge planning actually received it (Mellow and Greifinger, 2007). There are examples of relatively successful programs, such as the previously noted Hampden County jail program (Conklin et al., 2002), transition clinics (Wang et al., 2010), and specialty HIV programs (Rich et al., 2001; Booker et al., 2013). Even in these closely coordinated programs, however, through which community providers are incorporated into prerelease cor- rectional care, a number of inmates frequently fail to receive follow-up care upon release. In general, those diagnosed with mental illness are more likely than others to receive discharge planning (Baillargeon et al., 2010b), but they also are more likely to be homeless and to rely extensively on emer- gency department health care after release. Moreover, even though inmates with mental illnesses generally are given a short supply of medications upon release, their medication maintenance has been found to decline with time (Mallik-Kane and Visher, 2008). To date there have been only piecemeal studies of health care and health status upon return to the community for those diagnosed with HIV, although two major multisite studies, funded by the Health Resources and Services Administration and the National Institutes of Health, are currently under way (Draine et al., 2011; Montague et al., 2012). A study in Texas (2004-2007) found that even when a free prescription for HIV medica- tions was provided, only 5 percent filled it in time to avoid an interruption in their HIV treatment, and only 30 percent had filled it after 2 months (Baillargeon et al., 2009). Only 28 percent were enrolled in outpatient care in the community within 3 months of release (Baillargeon et al., 2010a). Qualitative studies elsewhere have identified factors ranging from trans- portation to provider attitudes that account for the failure to link to care even when financial assistance is provided (Fontana and Beckerman, 2007; Marlow et al., 2010; Nunn et al., 2010). Because people with HIV often have other health problems as well, the need to see multiple providers also can make treatment more difficult to sustain. Community Health Several studies are now examining networks of STD/HIV transmis- sion associated with incarceration. These networks have been linked to the removal of young men from the community or to their return; either way, they reflect the disruption of stable relationships and a sex-ratio imbalance, both of which are risk factors for STD/HIV transmission (Johnson and Raphael, 2009; Khan et al., 2008, 2011; Rogers et al., 2012; Thomas et al., 2008). Given the disproportionate incarceration rates of young black and Hispanic men discussed in earlier chapters, incarceration has been

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 229 speculated to contribute the lion’s share of racial disparities in HIV/AIDS rates (Johnson and Raphael, 2009), and its role in community health may hold true for other health disparities as well. This association between incarceration and racial disparities in rates of HIV/AIDS is not simply a reflection of drug use, as this study controlled for drug use. Furthermore, community rates of drug use are comparable between blacks and whites and consistently higher among incarcerated whites than among incarcer- ated blacks, which would decrease the impact of racial disparities on drug- related HIV transmission. The importance of partnering with correctional facilities in addressing community health was revealed in Chicago. There, following the discon- tinuation of universal jail-based screening, the number of male STD cases reported citywide plummeted—not because actual STDs were declining but because so many men were no longer being tested. The effects were visible in the accompanying rise in documented STD cases among women in Chicago, again the result of incarcerated men no longer being diagnosed and treated (Broad et al., 2009). In addition, a recent paper examines across states how growing popu- lations of former prisoners affect rates of communicable diseases, such as chlamydia, HIV, syphilis, and TB (Uggen et al., 2012b). The authors report that the prevalence of a given disease in communities with a high rate of individuals returning from prison decreases or increases, respectively, depending on whether the disease is routinely screened for and treated within prisons. This finding points to the importance of screening and treatment for vulnerable populations, and not necessarily to the value of incarceration. KNOWLEDGE GAPS As is evident from the discussion in this chapter, much remains un- known about the health and health care of the incarcerated. It is known, however, that this population bears a heavy burden of disease, and that there are many opportunities to improve the health not only of the incar- cerated but also of the communities to which they return. We offer the following areas as research priorities to fill knowledge gaps regarding the health and health care of the incarcerated. Public Health Opportunities There is need for systematic study of ways to capitalize on public health opportunities associated with incarceration, particularly for infectious dis- eases such as HIV, HCV, and STDs, and also for mental illness and substance abuse. Understanding which components of the criminal justice system are or

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230 THE GROWTH OF INCARCERATION can be beneficial to individual and public health and which are detrimental is a priority. Research should help in identifying and developing strategies and interventions that can optimize the former and minimize the latter. Furthermore, it is important to understand what is necessary to implement such interventions and what short- and long-term health, public health, and criminal justice outcomes can be expected. Research is needed to understand the extent to which underlying health issues, especially substance abuse and mental illness, contribute to incar- ceration and recidivism. Research in this area also needs to examine how treating those underlying conditions can prevent incarceration and reduce recidivism. The ACA presents an unprecedented opportunity to extend health insurance coverage to many who previously lacked it and to link them to medical care, mental health care, and addiction treatment services. Under- standing how best to capitalize on this opportunity and how to measure the outcomes is a top research priority. Several special populations that present unique challenges to providing optimal or even adequate health care in correctional settings need to be better understood. These populations include women prisoners, especially those who are pregnant; prisoners who are elderly and disabled; those with cognitive impairment, including TBI; those who are severely mentally ill; youth; and others. Data Standardization and Quality Improvement Research is needed to identify a set of universal measures of the qual- ity of health care and outcomes in correctional institutions. A system also is needed that fosters improvements over time in care within correctional institutions, as well as in the linkages between them and community health care. Ultimately, it would be ideal to have not only universal measures of the quality of care and outcomes, but also a fully integrated medical system with the same standards of care inside correctional facilities and out, as well as seamless care transitions. The quality and quantity of medical and mental health care provided in correctional institutions vary widely, and in the absence of standardized quality measures, the quality of the treatment provided cannot be known. CONCLUSION The incarcerated population bears a disproportionate burden of many diseases, not only posing challenges for the provision of care but also creating opportunities for screening, diagnosis, treatment, and linkage to treatment after release. The evidence suggests that improving the health of the vulnerable populations who become incarcerated and their communities

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CONSEQUENCES FOR HEALTH AND MENTAL HEALTH 231 will require integrating multiple strategies, including (1) diversion options, (2)  comprehensive screening and care, and (3) continuity of care after release. When asked about reducing correctional medical costs, a correctional administrator replied, “No problem, just stop sending me sick prisoners.”11 Correctional institutions have essentially no control over who enters and leaves. To reduce the burden of disease in correctional facilities, diversion strategies in the court system could potentially connect individuals to more appropriate treatment, particularly those with histories of mental illness and substance abuse given their high prevalence in incarcerated populations. In light of the high prevalence of infectious diseases such as HIV, HCV, and STDs and of mental illness and substance use disorders, as well as general medical problems, among disadvantaged populations that are in- carcerated, programs for comprehensive screening, diagnosis, and treatment of these individuals would likely improve their health while capitalizing on public health opportunities. Some prisons and a few jails have become im- portant public health partners by screening most inmates for various health conditions, but many facilities screen only a few inmates for a limited num- ber of health needs, so that many illnesses go undiagnosed and untreated. A strong focus on reentry services, including linkages to health insur- ance and medical care, also is needed. Given the statistics on mortality and morbidity, relapse to substance abuse, and high emergency room use after release, many have argued that linkage to care after release is criti- cally important to preserve individual and community health and reduce costly and often avoidable hospitalizations. Linkage to care postrelease can sustain treatments begun on the inside. In practice, however, such linkage rarely occurs in a systematic and comprehensive fashion. As a consequence, many of the diagnoses that are made and treatments that are begun during incarceration do not translate into improved health after release. Expensive and inefficient emergency room care and preventable hospitalizations result, and the investments made in health during incarceration are lost. The ACA promises to be a turning point in the nation’s health care, and—given the expansion of Medicaid eligibility; the mandate to enroll disadvantaged populations; and the inclusion of prevention, early interven- tion, and treatment for mental health problems and substance use disorders as essential health benefits—will provide unprecedented access to care for many people being released from correctional facilities. Yet while the ACA could remove some of the financial barriers to care, other structural and 11  Personal conversation with Scott Allen, MD, medical director, Rhode Island Department of Corrections.

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232 THE GROWTH OF INCARCERATION individual barriers, such as insufficient discharge planning, community care providers, and ancillary services, likely exist. Finally, monitoring the broader, population-level outcomes of reduced incarceration and improved screening, health care, and postrelease linkages to health insurance and care will be important to determine their societal benefits.