Behind Bars, Beyond Health.

**IMPORTANT: This article discusses topics related to incarceration. If you feel uncomfortable with these topics, please refrain from reading.

The US suffers from an incarceration problem: while the US represents only 4.2% of the global population, roughly 24.7% of all incarcerated individuals are in the US. (1) Furthermore, in the past 50 years, the incarcerated population in the US grew over 500%, exceeding crime and population growth. (2)

In fact, the US has an incarceration rate of 573 per 100,000 individuals, one of the highest incarceration rates per capita in the world. (3) The majority of incarcerated individuals in the US reside in state prisons and were charged with violent crimes. However, it is important to note that a relatively large percent of incarcerated individuals reside in local jails and have not yet been convicted of any crime.

So why have I chosen to focus on this topic in a health policy journal? While mental illness, substance abuse, communicable and noncommunicable disease prevalence tends to be higher amongst incarcerated populations, incarcerated individuals often report low quality care and higher costs. (4, 5) Empirically, prior to the COVID pandemic, the cumulative mortality rate ratio of prisoner deaths was 2.5 times that of the rest of the US population. (6) Alarmingly, these trends continue even post-incarceration; individuals who were previously incarcerated have higher mortality rates than the rest of the US population. (7) Unfortunately, this disparity in access and quality of care is only worsening: between 2016 and 2018, prison mortality rates increased from 0.303% to 0.344%, and a larger share of prison mortality is now being attributed to “preventable deaths”. (8)

As I explore this issue further, I hope to dissect differences in US healthcare policy for incarcerated and non-incarcerated individuals, ethical concerns when providing healthcare to incarcerated individuals, and the effects these concerns have on healthcare outcomes.

While the US Constitution does not guarantee healthcare to any individual, government programs like Medicare and Medicaid provide partial to full coverage to select individuals for certain healthcare services. (9) Many public health and legal specialists have argued that the 8th Amendment's protection against “cruel and unusual punishment” provides incarcerated individuals with a health care guarantee, but it is near impossible to enforce high healthcare standards across the nation. (10)

While incarcerated individuals can use the Federal Government’s Marketplace to apply for Medicaid and compare plans, they are not eligible for coverage until they are released. (11) What does this mean? Well, the Marketplace is the Federal Government’s platform to track healthcare coverage and plans for individuals and small businesses. This means that while an individual is in jail or prison, they are responsible for their own healthcare; yet after they leave, they may receive Medicaid or other healthcare benefits. This legislation is known as the Medicaid Inmate Exclusion Policy and restricts Medicaid funding for hospital visits of less than 24 hours. (12)

While Inmate Exclusion is the national healthcare policy, states have the ability to provide additional healthcare coverage. For example, the Medi-Cal Inmate Program (MCIP) provides incarcerated individuals in specific facilities in California with coverage for select inpatient psychiatric services, hospital visits, diagnostic procedures, and prescription medications. (13) This program differs from standard California Medicare since it is paid for by the Department of Corrections and Rehabilitation instead of the Department for Health Care Services.

From a policy perspective, it’s easy to pinpoint gaps in care for incarcerated individuals. Yet, this is only half the story. Data suggests that incarcerated individuals tend to have greater need for healthcare. (14) This lack of access plus increased need are reflected in healthcare outcome data for incarcerated versus non-incarcerated individuals in the US.

So what do healthcare outcomes look like for incarcerated individuals?

1. The prevalence of certain chronic diseases is higher amongst incarcerated individuals when compared to the general population. For example, incarcerated individuals are significantly more likely to develop diabetes, high blood pressure, and HIV, as well as other substance abuse and mental health conditions. (15) Thus, it makes sense that chronic diseases including cancer, heart and liver disease, and respiratory illness are among the leading causes of death for incarcerated individuals.

2. Incarcerated individuals often report lower quality healthcare with fewer options to seek specialty care. (16) While prisons and jails are mandated to provide healthcare to incarcerated individuals, it is difficult to enforce quality standards. Thus, many individuals go without healthcare, contributing to the prevalence of chronic, preventable disease. (17) After reviewing the limitations imposed by the federal government on healthcare for incarcerated individuals, it might seem even more worrisome that in some private prisons, individuals report even lower quality care. (18) In many private prisons, the burden of providing care has shifted to private firms that have an incentive to reduce costs at the expense of quality care.

3. Another barrier to care for incarcerated individuals is high copayments. If you read my article about Medicare for All and Jake’s hospital visit, you might remember that I defined a patient’s copay as the fixed cost they pay for their visit (this cost may vary based on the type of visit). (19) While copays for incarcerated individuals tend to average between $2 to $5, their average income varies between 14 and 63 cents an hour (thus, the real copay cost is 3 to 36 hours of work). (20) This cost makes healthcare prohibitively expensive for many individuals, again contributing to the higher prevalence of preventative disease.

   Before I continue this article with a discussion of disease prevalence and mortality rate, I wanted to include a section about the ethical considerations when providing healthcare to this population, especially because incarcerated individuals lack full autonomy over their lives.

Although incarcerated individuals tend to have less control over their lives (or autonomy) while in jail or prison, healthcare providers must consider their patient’s opinions and obtain their informed consent prior to providing care. (21, 22) This means that the patient must be aware of the potential risks of treatment and must decide for themselves whether they want to proceed with care before the provider makes a decision. Additionally, incarcerated individuals are often the subject of stigma and discrimination; healthcare providers must attempt to provide the same quality of care and care options for incarcerated individuals as compared to the rest of the population.

In the previous section of this article, I discuss how healthcare outcome data reflect a convergence of lack of access and heightened healthcare need for this population. Let’s explore this further:

• The Bureau of Justice Statistics finds that mortality rates in state and federal prisons increased from 250 to 303 deaths per 100,000 prisoners from 2001 to 2019. (23)

• Five-year survival rates from screenable cancers (preventable or detectable at an early stage) are 77.6% for non-incarcerated individuals but only 67.4% for incarcerated individuals. (24)

• A 2013 study finds that incarceration shortens life expectancy at an average rate of 1 year incarceration per 2 years of life expectancy. (25)

• In a study conducted in 2021, researchers discovered that incarceration rates affect short and medium term rates of maternal, neonatal, and nutritional illness while affecting non-communicable and chronic disease rates in the short, medium, and long term. (26)

Moving forward, there are many steps the US government can take to improve the healthcare of incarcerated individuals, increasing access and strengthening outcomes. The US government can reduce co-pays and other extra costs of receiving care. The US government could also provide more healthcare options by incentivizing healthcare specialists to establish more comprehensive plans for incarcerated populations. The US government could also set up systems to improve healthcare quality using specific metrics to track progress (one of the failures of the current system is the inability to measure and maintain high quality care). Another strategy the US government can opt for is to incorporate healthcare for incarcerated individuals within a national healthcare system, similar to other nations like the Netherlands. (27) This would provide incarcerated individuals with similar healthcare benefits as the rest of the population, reducing disparities in outcomes.

Regardless, by prioritizing the development of a comprehensive healthcare plan and establishing more affordable and effective care for incarcerated individuals, the US government can improve healthcare outcomes and save lives.