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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
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4

Community Systems for Decarceration

The COVID-19 pandemic has exacerbated the challenges faced by individuals reentering the community and the communities and families of formerly incarcerated individuals. Because incarcerated people are disproportionately from communities most affected by the COVID-19 pandemic, it is important to think of reentry and community safety as not only focused on individuals released from prison or jail but also concerned with the communities to which they will return. This chapter discusses discharge planning and how correctional systems can be supported by community health care and payment structures, housing, and other income support systems.

These community and social supports are important complements to decarceration efforts. Recognizing that communities are grappling with varying levels of viral transmission as well as potential resource limitations, this chapter highlights a number of community support services that can be leveraged to support individuals who return home. Reentry during the pandemic will require a unique set of discharge plans, including testing and quarantining individuals prior to release, as well as supports and resources from community health care and housing systems. Absent these considerations, efforts to decarcerate during the COVID-19 pandemic will fall short of their fullest potential to protect public health.

DISCHARGE PLANNING

Most prisons have a basic form of discharge planning services, which may include a limited supply of medications postrelease (< 30 days) and

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

questions about where a person will live following release. A few systems also provide referral to primary and specialty care, such as substance use treatment in the community (Mallik-Kane, 2005; Visher and Mallik-Kane, 2007). Jails less commonly have a formalized discharge planning system focused on housing or health concerns given the shorter lengths of incarceration and unknown date of release. Individuals can be released from court or in the middle of the night—without their belongings, medications, medical records, or referrals to community health care. Whether being released from prison or jail, people are rarely provided their medical records and, even in these circumstances, must pay for their records (Puglisi, Calderon, and Wang, 2017).

Discharge planning in correctional systems is often siloed from the community health system. A study of the Texas Department of Corrections shows that when the correctional system provided people with a prescription for antiretroviral medications at release, that initial prescription was filled by only 5.4 percent of individuals within 10 days of release (95% confidence interval [CI] = 4.5%–6.5%) and by only 30.0 percent of individuals within 60 days of release (95% CI = 28.1%–32.0%) (Baillargeon et al., 2009). Absent intentional coordination and linkages to the community health system, providing prescriptions alone did not ensure that formerly incarcerated individuals could engage with and access the needed care upon release. Many formerly incarcerated people have never navigated or received treatment from community-based health systems or may have little experience using a pharmacy or health insurance. One reason is that roughly 40 percent of individuals are newly diagnosed with a chronic health condition, including such conditions as HIV, while incarcerated (Shavit et al., 2017). People first learn how to manage chronic conditions within the rules and structures of jails and prisons, where they rely on correctional officers and health professionals to administer medications and check for daily adherence (Thomas et al., 2016).

Effective discharge planning during the COVID-19 pandemic requires additional considerations of a person’s risk of acquiring or transmitting SARS-CoV-2 and how this intersects with their access to community health care, noncongregate housing, and food and basic needs, especially when community rates of COVID-19 are high. First, given the high risk of transmission of the virus in prisons and jails, reentry planning will need to consider COVID-19 testing. Testing prior to discharge with timely return of results would reduce the risk of exposing others to the virus. Moreover, given false negatives and real-world implementation difficulties encountered with COVID-19 testing, a synergistic strategy would be to also provide individuals returning to congregate or crowded settings a place in the community to complete a 14-day quarantine in a safer environment, such as a subsidized hotel room (see Chapter 5). Continuing community transmis-

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

sion of COVID-19 also makes it important that people released from jail or prison are discharged with robust education about the disease and a connection to community-based health services, especially if they have a chronic health condition or have residual symptoms from COVID-19.

COVID-19 has placed significant strains on outpatient and inpatient services in community settings. Many primary care and behavioral health care providers have put a temporary halt on new appointments during the pandemic and are providing care only through telemedicine. Some correctional systems have started to distribute telephones with video capacity prior to release or even facilitate “warm handoffs” through video conferencing to improve access to health care for soon-to-be-released individuals (e.g., Connecticut Department of Corrections). Providing an adequate supply of medications as well as a link to primary care is important prior to release, as engagement in primary care has been shown to reduce reliance on emergency departments for ambulatory care needs (see Chapter 5). Prior to the pandemic, some prisons and jails were piloting programs designed to educate people on how to manage their chronic diseases in the community, including obtaining medication refills and using insulin for the first time (Reagan, Walsh, and Shelton, 2016). Continuing such programs may reduce unnecessary use of the community system during the pandemic.

Health Insurance Coverage

Without health insurance, obtaining primary care and substance use and mental health treatment immediately following release can be difficult. There are a number of opportunities within federal health insurance programs, including Medicaid, Medicare, and the Veterans Health Administration, for easing the transition from correctional to community health care, which is especially important during the pandemic. We focus on Medicaid, a state–federal health care program that covers low-income adults and acts as the primary mechanism for health insurance coverage of those directly impacted by incarceration. Importantly, Medicaid covers mental health and substance use treatment and services, including intensive case management, rehabilitation, and support services, which are heavily used among individuals recently released from correctional systems. Enrollment in Medicaid prior to release is associated with increased engagement in treatment among people with serious mental illnesses (Morrissey, Domino, and Cuddeback, 2016).

Beyond increased access to health care, Medicaid coverage may also affect crime, rearrest, and costly reincarcarceration. He and Barkowski (2020) recently found Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) to be negatively correlated with numerous types of crime, such that states with expanded coverage reported decreas-

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

ing levels of crime (including homicide) compared with states that did not expand coverage. Evidence also suggests that Medicaid expansion reduces recidivism for certain violent and public-order crimes (Aslim et al., 2020). Together, these findings suggest that losing or never gaining Medicaid coverage harms not only individuals involved in the criminal justice system but also their home communities.

Roughly two-thirds of the local jail population being held prior to trial who have not been convicted of a crime lose their Medicaid health benefits or are ineligible for Medicaid coverage (CMS, 2016) because of the Medicaid Inmate Exclusion Policy: under the Social Security Act (1905(a) (A)), that exclusion prohibits use of federal funds and services, including Medicaid, for medical care provided to “inmates of a public institution.”1 The law does not differentiate between individuals who have been convicted of a crime and those incarcerated prior to conviction. This means that individuals who can afford to “bail out” will remain covered by federal health care benefits, but poor defendants who are jailed for failing to pay bail may face a gap in health care coverage when released until they are able to reenroll for state health benefits. A joint report of the National Association of Counties and the National Sherriff’s Association, “Addressing the Federal Medicaid Inmate Exclusion Policy,” indicates that these interruptions result in poor care transitions, disruptions in treatment for chronic mental health and medical conditions (e.g., hepatitis C treatment or cancer care), limited exchange of health care information, and significant costs to county taxpayers.2

In accordance with Medicaid administrative rules, states could immediately institute a number of programs or policy changes which promote transition of health care during the COVID-19 pandemic, especially facilitating access to prescription medications, primary care, substance use and mental health treatment, and, in some instances, cover the costs of SARS-CoV-2 testing and related health needs prior to release; see Box 4-1 and Chapter 5.

Termination versus Suspension upon Incarceration

Under Medicaid administrative rules, states can choose to follow the rules promulgated by the Social Security Administration and suspend (rather than terminate) Medicaid benefits when a person is incarcerated. Payments for a person whose benefits have been suspended are meant to

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1 Federal law prohibits states from using federal Medicaid matching funds for health services provided to adults and juveniles in public institutions except when the person is admitted to an off-site hospital or other qualifying facility for at least 24 hours (Social Security Act § 1905(a)(30)(A)). This limitation in federal payment is called the “inmate coverage exclusion” (MACPAC, 2018).

2 See https://www.naco.org/resources/featured/naco-nsa-joint-task-force-report-addressingfederal-medicaid-inmate-exclusion-policy.

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

resume automatically after the individual is released from jail or prison, as long as the Social Security Administration is informed of the release and the person completes a standard form demonstrating that his or her income continues to meet Medicaid eligibility requirements, though this “automatic” process may take months. States that suspend (rather than terminate) Medicaid facilitate timely reactivation of Medicaid following release (Rosen et al., 2014). Suspension also has been shown to have financial benefits, as states can be reimbursed for inpatient medical services for incarcerated individuals enrolled in Medicaid. Numerous states, including Arkansas, Colorado, and Michigan, have reported cost savings through this mechanism, ranging from $3 million to $19 million per year.

Nine states terminate incarcerated individuals’ health benefits (KFF, 2020b), leaving the majority of released individuals in those states without health care coverage upon release and susceptible to poor health outcomes and recidivism during a particularly vulnerable transition period. Federal action is not necessary for states to change their termination policies. States currently have the authority to suspend, rather than terminate, a person’s Medicaid and Medicare enrollment during incarceration. States could change their policies at any point to expedite enrollment during the COVID-19 crisis, and such a change would be particularly helpful in states that are accelerating the release of medically vulnerable individuals in response to the pandemic.

Medicaid Enrollment during Incarceration

While the Medicaid Inmate Exclusion Policy prevents the use of federal Medicaid funds to cover care for individuals who are incarcerated, it does not explicitly limit individuals from being enrolled in Medicaid during incarceration (MACPAC, 2018). Prison and jail systems have attempted to ease the transition for newly released individuals by allowing them to apply for Medicaid (and also Medicare as appropriate) prior to release. According to an inventory conducted by the Center for Mental Health and Addiction Policy Research at The Johns Hopkins University, as of January 2015, 64 programs across 21 states had sought to enroll individuals living in correctional settings in Medicaid (Bandara et al., 2015). Evidence on these programs suggests some best practices for facilitating the enrollment process, including training correctional staff to serve as navigators to help incarcerated people complete applications, creating plans for direct handoffs from correctional health care providers to community health care providers following release, and providing individuals with information about Medicaid and community-based systems of care prior to their release (Ryan et al., 2016). Health insurance navigators in Maricopa County, Arizona, for example, provided education and enrollment assistance to more

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

than 1,000 individuals with complex health needs and serious mental illness who were eligible for release. In Massachusetts, with implementation of the MassHealth/Department of Corrections Prison Reintegration Pilot Program, more than 70 percent of individuals released from the state’s prisons in fiscal year 2015 had submitted a Medicaid application, and more than 75 percent of submitted applications had been approved. In Ohio, a partnership between the state’s Medicaid agency and the Department of Rehabilitation and Correction enrolled more than 700 individuals in Medicaid managed care plans within 90 days of their scheduled release (Beck, 2020; Ryan et al., 2016).

Even for the 12 states that have not expanded Medicaid under the ACA (approximately 730,000 individuals in jails and prisons and nearly 1.5 million on parole or probation),3 the state can provide Medicaid coverage for COVID-19 testing and related services to individuals who are uninsured if the state takes up the optional eligibility group provided in the Families First Coronavirus Response Act (FFCRA) of 2020. This pathway allows low-income adults in non-expansion states, including adults who are incarcerated, to apply for Medicaid and enroll. While the inmate exclusion provision would continue to apply (and thus make this limited eligibility option mostly irrelevant with respect to Medicaid payment during a person’s incarceration), this pathway would be helpful once incarcerated individuals had been released, accelerating and easing their access to Medicaid coverage.

HEALTH CARE

While health insurance is critical during the pandemic for people to access COVID-19 screening and testing, chronic disease management, and substance and mental health treatment, it is important to note that Medicaid coverage is not a panacea for improving health care access. Howell and colleagues (2020), Olfson and colleagues (2018), and Saloner and colleagues (2016) all found that among nationally representative samples of low-income individuals, Medicaid expansion corresponded with increased insurance coverage but failed to increase access to substance use or mental health treatment (Olfson et al., 2018; Saloner et al., 2016). Many of the treatment facilities that would be most used by formerly incarcerated people, including those providing substance use and mental health services, do not accept Medicaid, leaving patients at high risk of poor outcomes and recidivism (Grogan et al., 2016). People recently released from correctional facilities are less likely to have a primary care provider or mental health care provider and to have high levels of preventable hospital admissions

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3 See https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisionsinteractive-map/.

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

(American Academy of Family Physicians, n.d.) compared with the general population. An audit study conducted in British Columbia with universal health insurance found that recently incarcerated people were half as likely to be offered an appointment in primary care compared with those not recently incarcerated (Fahmy et al., 2018).

Active engagement of people just released from correctional facilities into the community health care system is an important complement of successful decarceration and efforts to flatten the curve during the COVID-19 pandemic. Health systems will need to rely on proven strategies to maximize access to and engagement in primary care and mental health and substance use treatment (Kouyoumdjian et al., 2015; Spaulding et al., 2018; Wohl et al., 2017). Evidence shows that practices tailored to the needs of newly released individuals can improve their retention in primary care, reduce preventable hospitalization, and lessen future contact with the criminal justice system. For example, a randomized controlled trial in Los Angeles has shown that peer navigation started while individuals are incarcerated and maintained following release is effective in improving engagement in HIV care and sustained viral load suppression. The LA LINK model is a peer navigator intervention in which participants share common experiences such as prior incarceration, living with HIV, or prior substance use disorder (Cunningham et al., 2018).

Another evidence-based intervention to engage recently released individuals in primary care is the Transitions Clinic Network (TCN), a national consortium of more than 40 primary care centers that serves the primary health care needs of individuals returning from incarceration (Shavit et al., 2017). TCN programs include interdisciplinary primary care teams with community health workers with personal histories of incarceration. In a randomized controlled trial, participants in the TCN program in San Francisco had 51 percent fewer visits to the emergency department in a year compared with those who were assigned to receive expedited primary care in safety net systems (Wang et al., 2012). TCN participation also impacts future criminal justice contact, specifically being associated with lower rates of returning to prison for a parole or probation technical violation and fewer incarceration days compared with the control group (Wang et al., 2019). During the COVID-19 pandemic, TCN programs in California, Connecticut, and North Carolina created statewide hotlines to facilitate collaborations with state prison systems and local jails and community health care systems so that people released from incarceration could receive a “bundle” of services that include expedited primary care appointments, as well as in some locations phones prior to their release, and connections to rapid rehousing.4

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4 See https://transitionsclinic.org/ and https://cceh.org/wp-content/uploads/2020/04/DOCRe-entry-Housing-Assistance-Program.pdf.

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

In addition, access to primary care, substance use treatment, and mental health care during the pandemic may be facilitated by giving patients access to telephones with video capabilities. During COVID-19, federal agencies issued new guidance about the use of telemedicine for health care delivery. The Centers for Medicare & Medicaid Services temporarily waived restrictions, allowing Medicare and Medicaid to cover additional telehealth services.5 And the Substance Abuse and Mental Health Services Administration and the U.S. Drug Enforcement Agency issued new guidance for opioid treatment programs, indicating these programs could prescribe buprenorphine via telehealth and liberalized the number of days of take-home medications for methadone, reducing in-person visits.6

Video communication is associated with higher patient understanding and satisfaction compared with telephone communication (Nouri et al., 2020). This is particularly important to consider in primary care and substance use and mental health treatment—where ongoing relationships and clear communication are essential to successful disease management. In some health systems, however, patient portal enrollment is a requirement for video visits. Because it is well documented that vulnerable populations are less likely to use patient portals, health care practices could remove requirements that patients enroll in patient portals prior to scheduling video visits (Grossman et al., 2019). Finally, because video communication can be challenging among populations with limited digital access or digital literacy (the ability to use and understand information from digital devices) (Khoong et al., 2020; Manganello et al., 2017), prioritizing populations just released from correctional facilities for in-person primary care visits, when possible, may improve access and engagement immediately postrelease.

HOUSING

Stable housing is important for facilitating the safe return of an incarcerated individual back into the community. Sirois (2019, p. 842) reports that “as many as 20 percent of men and women who leave prison are homeless after release.” Homelessness is associated with increased recidivism, poor health outcomes (Brown et al., 2017; Garibaldi, Conde-Martel, and O’Toole, 2005), increased use of acute health care (Fazel, Geddes, and Kushel, 2014; Hwang and Henderson, 2010; Hwang, Lee, and Kong, 2018; Raven et al., 2016), and mortality (Aldridge et al., 2018; Morrison, 2009; Roncarati et al., 2018).

During the pandemic, homelessness has also been shown to increase the risk of acquiring (and transmitting) SARS-CoV-2 (Baggett et al., 2020;

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5 See https://www.medicaid.gov/medicaid/benefits/telemed/index.html.

6 See https://www.samhsa.gov/coronavirus.

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

Mosites et al., 2020; Perri, Dosani, and Hwang, 2020; Tsai and Wilson, 2020). Congregate shelters, where a large proportion of people experiencing homelessness live, have been sites of major outbreaks of COVID-19, with infection rates similar to those seen in prisons and jails (Baggett et al., 2020; Hawks, Woolhandler, and McCormick, 2020; Imbert et al., 2020; Mosites et al., 2020). Adults experiencing homelessness often are unsheltered, have minimal access to hygiene facilities, are exposed to harsh natural conditions, and experience a high prevalence of food insecurity (Kuhn et al., 2020), and the COVID-19 pandemic has exacerbated these already poor conditions. To decrease the transmission of COVID-19, many homeless shelters have limited their capacity by exiting individuals to hotels or unsheltered settings and ceasing new entries, thereby adding to the numbers of individuals experiencing unsheltered homelessness. By some estimates, moreover, pandemic-related economic disruptions could increase homelessness by 40 to 45 percent over the next year (Community Solutions, 2020) as eviction moratoriums end (Community Solutions, 2020; Corinth, 2017). Essential to decarceration efforts is ensuring that they do not contribute to increases in homelessness.

There are many avenues to ensuring that returning people have access to housing, including efforts focused directly on the released individual, on families and social supports, and on modifications to the housing system writ large (Reentry and Housing Coalition, n.d.). These proven strategies, with the goal of minimizing homelessness, can complement decarceration efforts. It is important to reduce the potential for returning individuals or their family members and social supports to be placed at high risk of acquiring COVID-19 through community transmission when they return, and ensure that housing is not an impediment to the success of decarceration (see, e.g., Williams and Bertsch, 2020).

Returning Individuals

There are several options for reducing the chances that returning individuals will face homelessness. Individuals who were homeless upon entry into prison or jail and have no other housing option upon release are eligible for funding and programs designed for people experiencing homelessness. Those who met criteria for chronic homelessness before entering prison or jail—1 year of homelessness or four or more episodes in the prior 3 years that lasted a total of 1 year and a disabling diagnosis (HUD, 2015) and who would become homeless upon exit—qualify for permanent supportive housing (USICH, 2016). Permanent supportive housing or subsidized housing with associated voluntary supportive services has been shown effective in housing individuals with disabling diagnoses (Caton, Wilkins, and Anderson, 2007; Raven, Niedzwiecki, and Kushel, 2020). It is most

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

effective when used with a “housing first” approach, meaning that there are no preconditions for engagement with services prior to housing entry (Gulcur et al., 2003; Raven, Niedzwiecki, and Kushel, 2020). Permanent supportive housing can be scattered site (i.e., rental units with voluntary services attached) or project based (i.e., a building devoted to multiple units). It has been shown to enable the achievement of housing stability and decrease reliance on institutional care in numerous settings, including those with histories of involvement in the criminal justice system (Aidala et al., 2014; Stergiopoulos et al., 2015).

Permanent supportive housing is funded through a variety of mechanisms. Health-related support services as well as some housing-related services (i.e., housing transition, tenancy support) can be paid for by Medicaid (KFF, 2017), increasing the urgency of obtaining Medicaid eligibility prior to discharge. The housing subsidies can be provided through federal housing choice vouchers or state or local subsidies. The Veterans Affairs (VA) system provides permanent supportive housing for veterans through the U.S. Department of Housing and Urban Development (HUD-VA) Supportive Housing program, whereby HUD funds vouchers for housing and the VA system provides supports. While resources are limited, recent expansion of Emergency Services Grant funding through the Coronavirus Aid, Relief, and Economic Security (CARES) Act could present an opportunity to expand such programs (PDOCE, 2020).

For individuals who meet criteria for homelessness but not chronic homelessness, rapid rehousing is another strategy for providing housing. Rapid rehousing provides housing assistance and supportive services for up to 24 months (National Alliance to End Homelessness, n.d.; USICH, 2018), with the aim of assisting individuals in stabilizing their income so they can afford to continue the housing after the subsidy ends (HUD, 2013).

To access either permanent supportive housing or rapid rehousing, individuals must be engaged with the coordinated entry process for people experiencing homelessness. Coordinated entry programs are managed by the homeless continuum of care in the area where an individual will be discharged to (HUD, 2020). Long wait lists for access to either housing service could create barriers to reentry, particularly in the setting of the COVID-19 crisis, but increased coordination between correctional discharge planning and homeless continuum of care can improve the likelihood of successful discharge.

Family and Social Supports

Many people return from incarceration to live with families and friends, and they may be returning to families and communities facing unprecedented economic strain, perhaps with family members fearing or facing

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

eviction. In one study, 44 percent of Black renters and 41 percent of Hispanic renters reported having no or slight confidence that they could make their next month’s rent in early June, compared with 21 percent of White renters (Greene, 2020; U.S. Census Bureau, 2020). Thus, even those who are decarcerated to housing (i.e., to live with family or friends) may lose that housing because of pandemic-related economic pressures, especially given the overrepresentation of Black and Hispanic individuals among the incarcerated. In response to the threats to housing security, the U.S. Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services issued an emergency nationwide eviction moratorium in September to last through December 31, 2020. Another policy remedy is to offer monetary incentives to families for housing released individuals, as was done by New York City on a trial basis for relatives of homeless families in 2016 (Fermino, 2016). Programs could use the model of the Kinship Guardianship Assistance Payment Program, which provides financial assistance for relatives who become guardians for children exiting the child welfare system.

Even those families or friends not experiencing financial strain face additional barriers to supporting returning individuals. For example, families that rent housing, with or without subsidies, face limits on hosting family members. Families living in subsidized housing face strict limits on having nonleaseholders stay in their home—no more than 14 days in a row and 21 days in a year. To avoid this limit, householders would have to add individuals returning from prison or jail to their lease, but they may face numerous barriers to doing so. While HUD sets narrow limitations on this practice (i.e., excluding anyone from the property who has manufactured methamphetamine or has been convicted of a federal sex offense), local housing authorities have wide latitude to expand these exclusions, and many do so (24 C.F.R. § 960, 1995).

While many people exiting incarceration “live in the shadows,” staying with family without official permission, there are successful models for overcoming these housing restrictions. Since 2011, HUD has encouraged public housing authorities to create opportunities and reduce barriers for people with criminal records to live in Public Housing Authority– or Housing Choice–funded housing (Vera Institute of Justice, 2015). In 2016, HUD created the “It Starts with Housing” program to expedite public housing opportunities for individuals leaving correctional facilities. Demonstration projects included those that focused on family reunification and those that provided housing for high-risk individuals exiting without housing (Ramírez, 2016). The former projects were less resource intensive (Ramírez, 2016).

An example is the Family Reentry Pilot Project, implemented through a partnership among the New York City Housing Authority, the Vera Institute on Justice, the Corporation for Supportive Housing, and the New York

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

City Department of Homeless Services. In this project, individuals exiting prison or jail could join their families in public housing with temporary permission to do so and receive case management services from affiliated nonprofits (New York City Housing Authority, 2014). After program completion, individuals could either be added to the lease officially or allowed to stay in an unofficial capacity (New York City Housing Authority, 2014). This and similar models offer a roadmap for fostering the ability of families to assist in decarceration efforts without threatening the housing of the host household.

Individuals who rent on the private market also face challenges should they wish to house people just released from correctional facilities. Many leases specify the number and nature of visitors, and nonleaseholders are not allowed to stay permanently. Therefore, having a nonleaseholder stay in the home could constitute a lease violation, which in turn could threaten the stability of a household that in many cases could already be concerned about eviction. Generally, property owners are granted discretion in deciding who can be a renter and could use convictions to disallow an individual from being added to a lease. In 2016, HUD warned private landlords that discrimination on the basis of criminal history could violate fair housing laws (HUD, 2016); similar guidance could be issued again.

EMPLOYMENT AND INCOME SUPPORTS

Regular income generated through employment or government programs can help formerly incarcerated individuals meet basic health and housing needs. Employment income, in particular, can also help those with incarceration histories build pride, social status, and daily routine (Sullivan, 1989; Western, 2018), which can further assist them in socially reintegrating with family and community. The economic downturn brought on by the COVID-19 pandemic poses particular challenges for individuals who may be decarcerated during this period and require special considerations for social support systems related to employment, income support, and food security.

Employment

Although researchers often point to employment as the most important path to social and economic stability after incarceration (Sampson and Laub, 1993; Sullivan, 1989; Western, 2006), job seeking during the pandemic faces at least two obstacles. First, the employment crisis that has accompanied the broad shutdown of businesses has fueled unemployment among the recently incarcerated. Second, the low-wage jobs, often in service industries, filled by formerly incarcerated workers are currently treated as

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

“essential” and uncovered by the protections of a work-from-home schedule. If those released during the pandemic are more likely to be older or to have serious health problems, the “essential” employment that is available to them may carry significant COVID-19 risks.

Two employment-related benefits can be seen as particularly important for the economic well-being of low-income workers: the Earned Income Tax Credit (EITC) and unemployment insurance. The EITC could provide an important source of income support for people who have some earned income; however, researchers observe that its antipoverty effects are reduced by the very low level of benefits for single tax filers without children (Hoynes, 2019). Thus, while the EITC is now among the largest federal antipoverty programs, its benefits are small for the formerly incarcerated, who are often unmarried and living separately from their children. Unemployment insurance has not been a major source of support for recently incarcerated job seekers because few have a full-time employment history that enables the payment of those benefits. However, the CARES Act of 2020 expanded unemployment insurance to independent contractors and part-time workers who would normally be ineligible. The act also created Pandemic Unemployment Assistance for workers who have lost jobs because of the pandemic and for those caring for household or family members with COVID-19. Expanding the EITC to single filers and continuing expanded unemployment assistance could help provide economic stability for those who are diverted or released from incarceration.

Income Support

For released individuals who cannot find work, ensuring access to income support will be important for maintaining housing stability, food security, and safety as well as preventing reincarceration. This may be particularly relevant in the face of the widespread unemployment seen during the pandemic. Given the poor health and the high rate of disability among incarcerated men and women, Social Security Disability Income (SSDI) or Supplemental Security Income (SSI) may be important sources of income support, though SSDI and SSI applications can both be onerous. SSI is more readily available to people released from incarceration. As a social insurance program, SSDI requires a history of contribution to the program, whereas SSI is a needs-based program pegged to poverty status. SSDI benefits are more generous on average, but survey data indicate greater SSI income among formerly incarcerated respondents (Bryan, 2018). In both cases, successful application can take many months and access to correctional system medical records is needed to document a qualifying disability successfully, but obtaining such access can cause delays, especially during the pandemic.

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

There is no suspension of SSI benefits for brief periods of incarceration, less than 1 month, and benefit reinstatement is automatic for those incarcerated up to 1 year. For incarceration longer than 1 year, however, SSI benefits are not automatically reinstated. In contrast, SSDI benefits are automatically reinstated, and if the benefits were terminated prior to release individuals can apply for reinstatement. Individuals may meet criteria for SSI or SSDI because of disabilities identified, acquired, or exacerbated during incarceration. In such cases, applicants who were not eligible for SSI when they entered prison or jail may seek those benefits upon release.

Some institutions have prerelease agreements with Social Security offices that allow the application process to start several months prior to discharge. The SOAR (SSI/SSDI Outreach, Access, and Recovery) program has been shown to increase the success of obtaining SSI and SSDI benefits (Dennis et al., 2011). SOAR is designed to increase access to SSI/SSDI for people who are experiencing or at high risk of homelessness and have a mental health or substance use disability. When implemented in jails and prisons, it has achieved this aim (Lupfer and Ware, 2019; Ware, 2019). While there is no dedicated federal funding for SOAR programs, these programs exist in all 50 states through a variety of mechanisms, including collaboration with criminal justice institutions.

Food Insecurity

Food insecurity is defined by the U.S. Department of Agriculture as having limited access to adequate food (Coleman-Jensen et al., 2017; Ma et al., 2016). In 2019, approximately 13.7 million households (10.5% of all U.S. households) were food insecure at some point during the year (Economic Research Service, 2020). Early estimates of the effect of COVID-19 on food insecurity suggest that nearly one in four (23%) U.S. households were experiencing food insecurity as of April 2020 (Schanzenbach and Pitts, 2020). Food insecurity is associated with wide-ranging consequences for nutrition, health, and development (Seligman and Schillinger, 2010) and significantly greater health care utilization, including emergency department visits and inpatient admissions (Berkowitz et al., 2018). Research clearly suggests that Supplemental Nutrition Assistance Program (SNAP) benefits reduce health care costs (Berkowitz, Seligman, and Basu, 2017).

Food insecurity is particularly common and severe for those released from incarceration, intersecting with the challenges of housing, family support, and poverty. Research by Western and colleagues (2015) has revealed that formerly incarcerated individuals in Boston experienced a number of stressors and hardships during reintegration and often lacked the ability to meet basic needs, including food and housing (Western et al., 2015). Using

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×

data from the National Longitudinal Study of Adolescent to Adult Health, Testa and Jackson (2019) found that people with a history of incarceration have an increased likelihood of experiencing food insecurity, mediated in part by household income, depressive symptoms, and social isolation (Testa and Jackson, 2019). And a small study on food insecurity among people recently released from prisons in Texas, Connecticut, and California found that hunger (going 24 hours without food) was associated with increased HIV risk behaviors (Wang et al., 2013), including exchanging sex for money. Furthermore, hunger was worse among those living in states that limit SNAP benefits based on a criminal record.

In 1996, the U.S. Congress enacted a ban on eligibility for food stamps and other federal programs for people convicted of drug felonies as part of the Personal Responsibility and Work Opportunity Reconciliation Act (Mauer and McCalmont, 2013). Currently, only one state (South Carolina) has retained the full lifetime ban, but 24 states retain a partial ban, while 25 states and the District of Columbia enforce no ban (Government Accountability Office, 2005). Programs such as SNAP have been shown to significantly reduce poverty (NASEM, 2019), and they are also significantly associated with reduced recidivism among the formerly incarcerated (Yang, 2017). Given high rates of food insecurity and its strong association with increased health care utilization following release, enrolling individuals in SNAP prior to release from a correctional facility and eliminating this ban may reduce unnecessary use of the health care system during COVID-19 outbreaks.

CONCLUSION

Many of the challenges for meeting basic needs that individuals returning to the community confronted before the pandemic have been exacerbated during the COVID-19 period. The conditions to which individuals return home vary across communities and depend not only on the rates of community viral transmission but also on the available resources and supports for health care, housing, and income. Reentry planning will need to balance these considerations, as well as testing prior to release, the ability to quarantine in the community, and a complement of health care, housing, and income supports, as they are available; they are all important complements to decarceration efforts to maximize individual, family, and community health and safety. Decarceration will be most successful if correctional system leaders collaborate with community health care and social safety net systems to provide support to this population and eliminate barriers to existing resources and programs, including Medicaid, housing programs, and SNAP, which collectively can help mitigate both public health and public safety risks. We turn to these considerations in detail in the next chapter.

Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
Page 69
Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
Page 70
Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
Page 73
Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
Page 74
Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
Page 75
Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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Suggested Citation:"4 Community Systems for Decarceration." National Academies of Sciences, Engineering, and Medicine. 2020. Decarcerating Correctional Facilities during COVID-19: Advancing Health, Equity, and Safety. Washington, DC: The National Academies Press. doi: 10.17226/25945.
×
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The conditions and characteristics of correctional facilities - overcrowded with rapid population turnover, often in old and poorly ventilated structures, a spatially concentrated pattern of releases and admissions in low-income communities of color, and a health care system that is siloed from community public health - accelerates transmission of the novel coronavirus (SARS-CoV-2) responsible for COVID-19. Such conditions increase the risk of coming into contact with the virus for incarcerated people, correctional staff, and their families and communities. Relative to the general public, moreover, incarcerated individuals have a higher prevalence of chronic health conditions such as asthma, hypertension, and cardiovascular disease, making them susceptible to complications should they become infected. Indeed, cumulative COVID-19 case rates among incarcerated people and correctional staff have grown steadily higher than case rates in the general population.

Decarcerating Correctional Facilities during COVID-19 offers guidance on efforts to decarcerate, or reduce the incarcerated population, as a response to COIVD-19 pandemic. This report examines best practices for implementing decarceration as a response to the pandemic and the conditions that support safe and successful reentry of those decarcerated.

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