The very premise of prison invites members of society to think of the people there as walled-off and removed. But more than 95 percent of prisoners will return to the community, often carrying significant health burdens and associated costs with them. In an article in the March issue of the journal Health Affairs, several experts who participated in a scientific workshop convened by the National Research Council and the Institute of Medicine recommend several steps and ideas consistent with health reform to improve care for prisoners while they are incarcerated and after they return to society.
"The general public doesn't pay attention to what's going on behind bars," said lead author Dr. Josiah Rich, professor of medicine and epidemiology at Brown University and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital. "But this is very important if you are concerned about the health of our population and health care costs."
Researchers have found that about two in five prisoners have a chronic medical condition (often first diagnosed in prison) and more than seven in 10 prisoners of state systems need substance abuse treatment. In fact, the illness of addiction is what lands many people in prison in the first place.
But four in five prisoners don't have health insurance when they leave.
"Prisons and jails are necessary for the protection of society," Rich and his co-authors wrote. "For decades, though, the U.S. health and criminal justice systems have operated in a vicious cycle that in essence punishes illness and poverty in ways that, in turn, generate further illness and poverty."
Within that bleak situation, however, lies opportunity because incarceration allows for diagnosis and delivery of care that, if continued in the community, would reduce the onslaught of health problems for individuals and ensuing costs for society, Rich said. The authors' recommendations, which build on discussion from a December 2012 joint workshop in which they participated, are meant to turn that vicious cycle into a virtuous one.
The recommendations could make the difference illustrated by two scenarios, Rich said. Both begin with the imprisonment of a 28-year-old man with severe hypertension. In one case the condition is diagnosed and treated in prison. Treatment with inexpensive medications continues after release a decade later because the man has health insurance and access to a doctor who understands his medical and personal history. In the other case, either the hypertension is left untreated in prison or it's not managed after he's released because he has no insurance or continuity of care. A decade later he develops kidney failure and goes on dialysis, costing the health care system a lot more money.
Recommendations for prison and after
The authoring group's primary recommendation is to find alternatives to imprisonment when possible, given that the United States incarcerated more than 2.3 million of its 313 million residents in 2012. While the group divided the rest of its recommendations between health care in prison and after release, in many cases the ideas are meant to improve integration of care between the two settings. Specifically they make the following recommendations.
- improved oversight and accountability of prison health care, including making accreditation of prison health care mandatory and enforceable;
- inclusion of prisoners in accountable care organization health plans to increase provider incentives for providing good care;
- medical profession advocacy for legislation and programs that would benefit prisoner health, such as programs that improve care as prisoners transition to the community.
- employment of a "risk-needs-responsivity" model to triage prisoners, based on their personal history, to the most appropriate care;
- assistance for released prisoners to help them enroll in Medicaid as it expands under the Affordable Care Act. In recent research, Rich has found that this activity may already be underway and is co-author of a separate paper in Health Affairs on what's needed to transition prisoners on Medicaid back into the community;
- policies requiring electronic health records from within prison be available to community health providers;
- incentives for community providers to deliver mental health care to released prisoners;
- improved cultural competence among community physicians to understand the specific medical needs and risk factors of released prisoners. Transition Clinic medical homes provide a worthwhile example, the authors write.
In a separate paper in the journal, Rich and co-authors including Brown and Miriam researchers Brian Montague and Curt Beckwith also find that prisons could do more to test prisoners for HIV and ensure care after release, as the CDC recommends.
Recognizing that prisoners never stop mattering to the community from the standpoint of health could lead to better medical and economic outcomes, the experts argue.
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