Five Big Ideas From The Aspen Health Strategy Group

Our nation has the highest incarceration rate in the world with 10 million people incarcerated each year, yet the health of these individuals is truly an afterthought. We must recognize that their experiences and their health outcomes are not contained in a vacuum. These individuals are often struggling with undiagnosed or untreated behavioral health issues and chronic illnesses prior to being jailed or imprisoned, and their health challenges before and after incarceration have a ripple effect that substantially impacts the health and well-being of their families and communities, and ultimately our country.

We know incarcerated Americans are sicker – those who have been jailed or imprisoned are associated with having an elevated risk for nearly all diseases, and they touch a much larger percentage of our population than many realize. In fact, 45% percent of Americans have had an immediate family member who has been incarcerated, and for these Americans, this connection to an incarcerated individual is correlated to a life expectancy that is two years less than for those without a family member who has been incarcerated. The carceral system is taking years off Americans’ lives, even if they haven’t served time.

For these reasons, we at the Aspen Health Strategy Group (AHSG) – which I co-chair with former U.S. Health and Human Services Secretary Kathleen Sebelius – have determined, “Incarceration is a primary source of poor health for individuals, families, communities, and our nation as a whole.” This is the issue AHSG’s 24 multi-sectoral leaders chose to study in 2021 as part of the Health, Medicine & Society program at the Aspen Institute. Tasked with exploring some of our nation’s greatest health challenges and preparing actionable solutions, we lay out five big ideas on “Reducing the Health Harms of Incarceration,” which we arrived at after extensive consultation with experts in the field, as well as with those who have personally experienced the health impacts of incarceration.

Our “five big ideas” center around expanding health coverage, providing coordinated care, implementing quality standards, and rethinking certain justice system approaches to prioritize health.

In tackling health in the criminal justice system, we acknowledge that the size and scope of the problem is substantial. With 3,000 jails, 2,000 prison, 150 immigration detention centers, and 2,000 juvenile detention settings, we have a sprawling system that provides healthcare for millions daily with minimal regulation or quality oversight. Each year, 10.6 million people are released from correctional systems back into their communities (600,000 from prisons and 10 million from local jails). This includes individuals who have not been convicted of a crime, with nearly three-quarters of those in jails being those awaiting trial, who cannot afford cash bail, and are disproportionately Black.

The criminal justice system has become our main response to mental health and substance use disorders, serving as our nation’s largest provider of mental health services. In fact, the three biggest psychiatric facilities in America are jails in Los Angeles County, Cook County, Ill. (Chicago) and New York City’s Rikers Island jail. Suicide is the leading cause of death. Our carceral system is struggling with serious overcrowding, budget constraints, low employee morale and significant, sometimes dangerous staffing shortages. But by failing to prioritize health in these settings, for those whose criminal behavior is tied to mental health or addiction disorders, neglecting their health needs increases the likelihood of future repeat offenses, furthering our overcrowding crisis.

Studies have shown that the health consequences of these carceral experiences have a broad impact that reaches beyond the individual. Family members and romantic partners feel the effects from “psychological stress related to stigma, grief related to loss, relationship strain, and economic, food, and housing insecurity.” Their children are at greater risk of mental health and substance use disorders. And communities with high incarceration rates have notable health disadvantages, including chronic stress associated with population turnover.

To address these challenges related to health and incarceration, we recommend:

1. Eliminate the Medicaid exclusion. We identified this as “the simple step most likely to effect positive change in carceral health.” While the Supreme Court has ruled that incarcerated individuals have a legal right to healthcare, federal law prohibits Medicare and Medicaid dollars from going towards incarcerated Americans. As a result, individual carceral systems provide healthcare with little oversight or standards. Allowing for Medicaid coverage would alleviate some of the system’s competing budget pressures, allow for continuous coverage in and out of carceral settings (particularly in states that have expanded Medicaid), improve quality requirements, and increase information about the population with claims data.

2. Make health a priority in correctional systems. That means allowing for adjustments in inmate food, sleep, and activity schedules when necessary for disease management, eliminating use of solitary confinement, updating jail intake procedures to account for and better address the high frequency of mental health and substance use-related crises upon entry, increasing health related training of correctional staff, routinely using the carceral system for clinician training, and incorporating health needs into inmate release planning.

3. Bring population health and quality standards to carceral health. Our report explains that, “Despite providing healthcare services to a highly vulnerable population, prisons and jails operate completely outside the many systems designed to assure access and quality in the civilian healthcare system. What is most striking about carceral health is its lack of data, standards, quality reporting, and systems of quality improvement.” Electronic health records, for example, are almost unheard of in carceral settings, and there is no basic quality measurement or transparent reporting of quality metrics. To begin to address this, we recommend the CDC and state and local health departments review how their work considers the health of people who are incarcerated, and then modify programs accordingly to help meet their needs.

4. Coordinate care inside and outside carceral settings. Navigating care is especially challenging for those who have served time in jail or prison, since any health coverage they qualified for outside of incarceration, they lose upon entering. We recommend three steps to reduce harm: 1) CMS’s Center for Medicare and Medicaid Innovation should design a set of initiatives focused on improving outcomes for those who transition between the carceral system and the community; 2) The Office of the National Coordinator for Health Information Technology should establish goals for electronic health record interoperability within jails & prisons, and community providers that most frequently serve this population; and 3) Quality improvement & standards-setting organizations, as well as CMS, should develop care coordination metrics for those entering and leaving carceral settings.

5. Dramatically reduce the level and consequences of incarceration. The most effective and wide-reaching approach to reduce the harms caused by incarceration, is to reduce the number of people who are incarcerated. This is already something that our country must do to address dangerous prison overcrowding and understaffing, so improving health is an added benefit. Changing our approach for those with mental health and substance use disorders will require policy changes at the federal, state, and local levels, including expanding the use of diversion courts and developing monitoring centers as an alternative to jail for those who are intoxicated or experiencing a mental health crisis. In my hometown of Nashville, for example, we have for years successfully implemented a drug court diversion program that has been modeled around the country. And most recently, our Sheriff’s office launched a Behavioral Care Center providing responsive trauma-informed care to residents in a short-term residential setting as an alternative to jail.

By outlining effective approaches to reduce the health burdens of incarceration, it is our hope at the Aspen Health Strategy Group that leaders at the federal, state, and local levels will be motivated to act.