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Health Behind Bars — How the U.S. Could Improve Care for Incarcerated People

Illustration of incarcerated people and people in the community

Illustration by Rose Wong

Illustration by Rose Wong

  • Shanoor Seervai
    Shanoor Seervai

    Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

  • Shanoor Seervai
    Shanoor Seervai

    Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

Toplines
  • What would it take to ensure people cycling in and out of the criminal justice system have access to health care, both in prison and when they return to their communities? Listen to the latest #TheDosePodcast for more.

  • For some incarcerated people, the first time they receive health care is behind bars. But when they transition back into their communities, this care often vanishes. @ewang422 explains why ensuring continuity of care is critical.

Access to health care is a constitutional right for the 2 million Americans in our criminal justice system. For some of those incarcerated — overwhelmingly people with low income and people of color — the first time they receive care is behind bars.

But when individuals transition back into their communities, this care often vanishes.

On the latest episode of The Dose podcast, Emily Wang, M.D., director of the SEICHE Center for Health and Justice at Yale University, explains why we need to ensure continuity of care for people cycling in and out of the criminal justice system.

The first few weeks after release are critical, she says. “You want people to return home to reintegrate . . . to reestablish a life, get a house, get a job, contribute meaningfully as a member of our community.”

Transcript

SHANOOR SEERVAI: In the U.S., every incarcerated person has a right to health care. How well, or even if, people in jails and prisons are treated for medical issues is sometimes studied. But we don’t talk enough about how being incarcerated has its own impact on a person’s health.

That, and what happens to people when they are released is the focus of today’s episode of The Dose. I’m Shanoor Seervai, and my guest is Emily Wang, a physician and director of the SEICHE Center for Health and Justice at Yale University. Dr. Wang and her team are working to improve the health of individuals and communities impacted by mass incarceration. The COVID-19 pandemic made things worse and made it starkly clear that the U.S. needs a new approach to caring for people in the criminal justice system.

We’ll talk about all that and more today with Dr. Wang. Thank you so much for joining me.

EMILY WANG: Thank you so much for having me.

SHANOOR SEERVAI: Low-income people and people of color are overrepresented in the prison population in the U.S. And that means our prisons and jails are filled with people who may not have received good health care earlier in their lives. How does that manifest once an individual is in a jail or prison setting?

EMILY WANG: I appreciate this question as a starting point, because I think it’s a place where we don’t often talk about how our health care system writ large is structured for low-income individuals. Given the constitutional guarantee for health care, oftentimes what you have are adults that are incarcerated, and because of their incarceration and because of this constitutional guarantee, accessing health care for the first time as adults behind bars. Research shows that it’s anywhere from about 40 percent of individuals are newly diagnosed with a chronic health condition while they’re incarcerated. And so it means that they’re learning about how to manage their diabetes, what it is that they need to do to treat hepatitis C, even kind of thoughts about how you treat opioid use disorder first while they’re incarcerated.

SHANOOR SEERVAI: What are the conditions or diseases that are most commonly seen or treated in the criminal justice system?

EMILY WANG: Right. I guess one way to look at it is taking a lens on who we incarcerate. And so for the past 50 years through the kind of history of mass incarceration, we’ve concocted a set of laws, policies that really push forward the incarceration of people with drug use disorders, and also all the conditions that go along with these drug use disorders. And so it means that of course, that people that are incarcerated have opioid use disorder, alcohol use disorder, cocaine use disorder. And then with that, what comes are higher rates of infectious diseases like HIV, hepatitis C.

We also see because of who we’ve incarcerated and we have disproportionately incarcerated poor folks of color, many chronic health conditions that are more common among poor folks. Those include conditions like heart disease, diabetes, hypertension, asthma. And then lastly, we have kind of a whole set of other chronic health conditions, mental health conditions that are also disproportionately represented. In part, given the deinstitutionalization of hospitals that cared for people that were mentally ill. And so you see a host of chronic health conditions that are overrepresented behind bars.

SHANOOR SEERVAI: And so now let’s talk about what happens behind bars. How does confinement complicate these various diagnoses?

EMILY WANG: A first place of starting is really thinking about when you think about seeing a doctor in the community, you’re thinking about going, making an appointment, seeing a physician, maybe of your choice, maybe under your insurance plan’s. And this, of course isn’t the case, right? Access is just really different. Oftentimes, and it depends on what prison and jail you’re referring to, to get access to a doctor you often have to kind of write a note. A note, sometimes that’s first overseen by a correctional officer. If the correctional officer thinks that this warrants care, then a nurse oversees it. And then finally the nurse passes it on to a doctor. So you can’t actually kind of just walk in and go see a doctor. There’s many steps and barriers to getting there.

Another piece that I think is important to think about is that oftentimes in health care systems, and this was the case, you imagine in COVID, right? That a patient has to pay a $3 copayment often to see a doctor. Three bucks doesn’t sound like a lot of cash. But it’s equivalent if you have a job to four days’ worth of salary for a person that’s incarcerated, that has a job while they’re incarcerated. And so there’s a real barrier to getting access.

The last example that I might give is for patients, let’s say with diabetes. They’re newly diagnosed inside. There’s almost 100 percent adherence to the medications. You’re called up by a correctional officer. You have to get up in the crack of dawn and a nurse is going to administer your insulin for you. But what you never have to do is learn how to manage your insulin dose in light of what you’re eating. You never actually draw up insulin in a syringe. And so the very ways that you understand your own chronic health conditions while you’re incarcerated is almost diametrically opposite to what we ask of patients when they return home from the carceral system. And so it’s a real passive system of care that really doesn’t create kind of knowledge nor practice that patients need to kind of manage these chronic health conditions when they return home.

SHANOOR SEERVAI: So what you’re saying is that compliance or adherence to a medical regime is actually pretty good in the criminal justice system. But then how does being incarcerated exacerbate, perhaps, health conditions? You touched upon some of the mental or behavioral health challenges that people have, chronic conditions perhaps get worse under the stress of being behind bars.

EMILY WANG: One of the hypotheses that we explore in our research team at Yale is really thinking about how the stress of incarceration may augment the worsening of chronic health conditions like heart disease. How that might both catalyze disease, but also worsen disease over time. And that’s certainly seen in the research, which is that among those that are incarcerated, especially those that cycle in and out of prisons and jails over time, over their life course, they have a worsening of chronic health conditions compared to those that just go in once or compared to those that certainly have never gone in ever.

SHANOOR SEERVAI: So just to be clear, this is already the sections of our population, low-income people of color, who have worse health to begin with. And then we put them behind bars and then they actually get even sicker because of that.

EMILY WANG: Right. And I think that there is a complexity to that, which is this tension that you’ve brought up right at the beginning, which is that maybe it gets a little better when they’re incarcerated and then gets much worse when they’re released and then maybe returns to a little bit better when they’re incarcerated and much better upon release. And so that’s a pattern that we see and there’s reasons that you can maybe think about, which is that you’re housed. You have a roof over your head. There is food and someone is kind of forcing you to take your medications. But upon release, those conditions don’t exist and there’s even more difficulties securing those basic needs for people that return home from prisons and jails.

SHANOOR SEERVAI: Is there any way to limit the impacts of confinement on an individual’s physical or mental health?

EMILY WANG: Well, I think that this is a critical piece for doctors and researchers to dig into. Some of it is around the actual conditions of confinement and some of this is really around how health care is delivered. And so there is abundant literature, for instance, that shows that solitary confinement — so being confined to an 8x10-foot cell for 23 hours of the day — is terrible for one’s health, and many correctional systems outside of the U.S., but even within the U.S., have limited the amounts of time that individuals can spend incarcerated in solitary confinement in administrative segregation. Other conditions of confinement include how much contact they might have with their loved ones, et cetera. And so these are all correctional policies that could be changed to improve the health-harming impacts of incarceration.

From the health care side, one thing that’s really important to think about is that there is no system of federal oversight or state-mandated oversight of the health care system practices, of the quality of health care for those who are incarcerated. So for these 5,000 jails and prisons that we have all over the country, there’s no single body that says, “Man, that’s good care,” or “That’s pretty good care,” or “That’s equivalent to the community.” And so the changes that can really take place there are having a system of oversight and accountability for the care that’s delivered.

SHANOOR SEERVAI: So it’s actually two separate systems entirely. You’re in one system when you’re incarcerated and you’re in a totally different system when you’re not.

EMILY WANG: Precisely. That’s exactly how I would look at this. And even more so, you can move from a local jail, which is overseen by one jail system, right? A county health care system, perhaps, or someone they’ve contracted with their private, for-profit health care system. Then be sentenced to a crime and sent to a prison, within your state typically. And that’s another health care system. Then the other health care system, let’s say you get transferred and sometimes there’s intrastate transfers and then you move in and out and in and out. Those are all different health care systems. And for the most part, those systems also don’t communicate. They don’t communicate between each other. And then there’s no communication just about once you’re released.

SHANOOR SEERVAI: So now let’s talk about what’s happening to individuals who are cycling in and out of the criminal justice system. Maybe let’s try to understand the care continuum for someone who is back home. What does that look like?

EMILY WANG: Something important to think about first is that the vast majority of people that are incarcerated in our correctional systems ultimately do return home to our community health care system. So it’s 95 percent of individuals. When people are released from correctional systems and this is inclusive of jails, which are short stays and then prisons, which are typically stays of longer than a year. In the vast majority of correctional systems, you don’t actually have a discharge plan. And what that means is if you’re hospitalized in a community health care system, even if you’ve been there for just 24 hours, let’s say, you come home and you have kind of a sheet that summarizes what happened. Medication maybe is called for you to the pharmacy. And then you have some appointment set up for you at a primary care clinic for you to get follow-up. The majority of individuals who are incarcerated don’t have that. And you could have been there for two years, 20 years, 30 years, and you don’t have a transition of care.

SHANOOR SEERVAI: Why? Why is that?

EMILY WANG: Yeah, in part, because it’s this hole in the system. Who pays for that? Who’s responsible for that? As a community health care provider, we don’t really reach in, so they don’t even know how to connect to individuals. That’s one. So there’s really just not a culture of communication between these two health care systems. The second is that the actual payment structures really prevent that. So again, when you’re incarcerated, typically it’s the county or the state or the federal government, depending on what correctional facility you’re in, is paying for that health care. And when you’re released, even in states, again, this is a mostly low-income population that would qualify for Medicaid, if there is Medicaid expansion in your state. But typically people have either been suspended from Medicaid. So they’re off health insurance is the bottom line. And so when they’re released, they need to kind of reapply for health insurance or apply for it for the first time. And so how do you get a health care appointment? How do you get your medications if you don’t have health insurance in this country?

SHANOOR SEERVAI: Right. And I imagine that for an individual who has recently been released, there’s a lot going on and maybe going to see a doctor is one of several priorities that doesn’t get the urgent attention it requires.

EMILY WANG: Man, there is a lot going on. I’m a practicing physician. I have a family. I feel like I’m pretty with it. But oftentimes when I have to see what my patients have to go through following, just having come home, post release, and this includes just getting their basic needs attended to, but also meeting the terms of parole, probation. It is nearly impossible to think about managing this. People come home and oftentimes they come home without identification. So think about all the ways you need to move through this world with an ID card. Even just to get Medicaid set up. To get your food stamps, to get housing. To get anything, right? To get a phone set up. You need ID. They don’t even have identification.

And then in almost every community, there’s a host of laws that kind of really restrict their ability to meet basic needs, to get food, to get housing, to get employment: they’re called collateral consequences. But they’re laws that, for instance, in certain states that you return home to, if you’ve been convicted of a drug felony, you have a lifetime ban on getting food stamps. Even if you’ve served your time. Or there’s bans on living in public housing, again, for people that have been convicted of drug felonies. Again, even if you’ve served your time.

And so there’s even barriers to, of course, voting. Barriers to becoming a barber in certain places. And it really varies community by community. But all this is to say is that there’s a system of intricate laws, policies, and practices that kind of pervade our communities that make it really deeply hard for people to move through their lives, to just kind of get their basic needs going. And so, that on top of meeting the terms and conditions of parole and probation, put health and health care at the kind of, for many folks, bottom of the line, even if they know it’s important. Even if it’s critical to their health. Right?

SHANOOR SEERVAI: Right. What has your work identified as being the most acute health needs of people who are transitioning out of correctional facilities?

EMILY WANG: There are beautiful studies that have been conducted by colleagues of ours and some of which our team has also done really showing that the first days, weeks, month are critical to people’s lives. And in fact, kind of a seminal study published in the New England Journal of Medicine, using data from Washington State prisons, show that within the first two weeks, post release from a state prison system in Washington, there’s about a 12 times increased risk of dying. In those first two weeks that persists on even through a year. And when you look at the causes of death, they are maybe not a surprise, but holy, when I think about it as a primary care doctor, they’re preventable. So it’s overdose, heart disease, cancer, dying from suicide, and dying from homicide.

And other studies since that study in the New England Journal have since come out also showing elevated risks in different states confirming what we know to be true, is that time post release is incredibly fragile for the individuals and a really high-risk time for needing acute care for preventable conditions. We did a study also looking at individuals that are on Medicare and found that lot of the hospitalizations that happen following release are ones that are really preventable. Poorly controlled diabetes, poorly controlled hypertension, really speaks to, I think, kind of the real precarity of that time of transition.

SHANOOR SEERVAI: And how is the organization that you founded, the Transitions Clinic Network, addressing the needs you just enumerated?

EMILY WANG: About 15 years ago, I had the opportunity of cofounding a first program in San Francisco, really focusing on the health care needs, and at that time really the transitional health care needs, of people that are returning home from prisons and jails in San Francisco. And one of the things that we thought it was critical to this is that there are leaders that have been incarcerated that really are civil rights leaders, especially in San Francisco. Really kind of tap into their perspectives, their values, and needs. And so built a program, the First Transitions Clinic Program, we identified kind of four key components of providing transitional care for people that return home from correctional facilities. And I’d say the key piece of that was that all these focus groups that we ran, what individuals really wanted was having a person based within the health care system that had been incarcerated themselves.

A community health worker that could be the first face, the first step of getting to know a primary care practice. That person, the community health worker would understand the new stress of coming home. The mistrust that people that have been incarcerated may have in the health care system, given their experiences, both in the community and also in the correctional health care system, and could shepherd the patient in through health care, but also through the social services that are required post release.

And so we started this first program in San Francisco and it has grown now to the largest network of programs in the country. We have 45 and growing programs. And we’ve had the opportunity to really study this and has shown that, not surprisingly, I don’t think, that it reduces emergency department utilization. Reduces kind of future contact even with the criminal justice system. And so designing programs that are based with, again, the preferences and the values, and really the needs of people that have been incarcerated has been helpful in having individuals better navigate the health care system and importantly not returned back into a correctional system.

SHANOOR SEERVAI: And these programs, where are they based? In the communities?

EMILY WANG: Yes. They’re based in local primary care programs. And so in federally qualified health centers, at times in hospital-based clinics. And so I’m a physician at Yale University and so ours is within our Yale Primary Care Practice. Each of these programs are kind of based within different community health centers.

SHANOOR SEERVAI: And how does the individual get to the program?

EMILY WANG: In kind of the ideal scenario, we’ve built connections over time between the community health system and the correctional health system. And so in the largest statewide network, our network is run by the executive director, Dr. Shira Shavit, she’s a faculty at the University of California, San Francisco. They have over 20 programs in the state of California, and they have a centralized hub within the Department of Corrections that does all the discharge planning. That then refers patients into our Transitions Clinic Programs in California.

In states where there isn’t kind of a centralized hub, oftentimes it’s the community health worker and the clinic itself that makes inroads into the correctional systems and is really trying to meet patients prior to release one by one and introduce them to the program and return them into the community, kind of, health care system and save hands. And so slowly over time iteratively, what the network really is aiming towards transforming our health care system. Really acknowledging that it shouldn’t just be on the backs of a single community health worker, but really a health system merging with another health system to improve the quality of care for patients that cycle in and out of prisons and jails.

SHANOOR SEERVAI: So it’s really attempting to build this bridge or fill this gap that we talked about earlier.

EMILY WANG: Precisely, precisely. I have to say, 15 years ago, I thought, well, this is low-hanging fruit, right? This should be easy to do. It’s just a transition of care. We do this all the time. And in fact, because the culture of medicine and the culture of correctional systems throughout the country is so kind of individualized, right? The laws are really different, let’s say, in Minnesota than they are in Texas than they are in Puerto Rico. But also secondly, because it’s been so siloed, nothing’s been easy about this.

SHANOOR SEERVAI: Right. I feel like I would be remiss if I did not ask how the pandemic has impacted this really important work. Because we know that some of the worst outbreaks of COVID-19, especially early on, were happening in jails and prisons, and then obviously community rates of infection would drive or reflect disease in incarcerated populations. So tell me a little bit about that.

EMILY WANG: The pandemic kind of just illuminated, brought to the fore, what we already knew to be true. Was that the ways that we’ve structured our correctional systems in this country really have been hotspots for disease, and especially for respiratory viruses. There are very few prisons and jails, if any, that were involved from the beginning in pandemic preparedness, in resource allocation, and thinking about kind of vaccine distribution from the get.

And this to me speaks to kind of, again, larger structural issues about how we resource and how we finance the care behind bars. I do think it has raised new attention to the importance of really starting to see incarcerated populations as warranting more transparency and hopefully accountability. And so newly, what you can see right now is more bipartisan supportive thinking about how Medicaid may extend into correctional systems. There’s the Medicaid Reentry Act that’s been discussed multiple times in Congress, and also many new state amendment plans through Medicaid’s 1115 waiver programs. Really trying to start think about how payment and how at least attending to the transitions of care can be improved by having Medicaid coverage extend into correctional systems. And so if there’s maybe any silver lining to this is that the conversation has yet again renewed. And there’s more energies behind how it is that we have to improve the transition of care for people that are incarcerated.

SHANOOR SEERVAI: Right. And as we think about improving this transition, I did also want to ask about the role that the people who were formerly incarcerated and others in their community are impacted. One option that’s suggested is that formerly incarcerated individuals could be employed in these systems. What’s the potential there? How is it working?

EMILY WANG: Given the laws and given a lot of practices that are baked into health care systems, hospital systems, there are significant barriers to hiring people with criminal records into work in the health care system. And so these are barriers that can be overcome. We’ve shown that within our Transitions Clinic Network and their states, even that are currently looking to certify community health worker programs at a state level that are even really now considering whether or not there should be explicit bans on having people with criminal records work as community health workers. And a lot of advocacy, from community organizations and especially people with histories of incarceration, really saying that this should not be a barrier, having a criminal record. In fact, this is probably a plus for community health workers, in particular that are working to transition people out.

SHANOOR SEERVAI: Are there explicit legal bans on them doing this work?

EMILY WANG: There are in certain states, correct. Oftentimes they’re kind of buried in statutes, but there should be more nuance to the hiring. There should be more nuance in understanding. You want people to return home to reintegrate as they do. To come back, to reestablish a life, get a house, get a job, contribute meaningfully as a member of our community. And also there are all these barriers to meeting these goals. It’s a system that really is working in opposition to what I would say is kind of our overall goals, which is a community that’s thriving and that’s safe and that’s healthy.

SHANOOR SEERVAI: Dr. Emily Wang, thank you so much for joining me today.

EMILY WANG: Thank you. I really appreciate the opportunity.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.

Show Notes

Emily Wang, M.D.

Transitions Clinic Network

Publication Details

Date

Contact

Shanoor Seervai, Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

[email protected]

Citation

Shanoor Seervai, “Health Behind Bars — How the U.S. Could Improve Care for Incarcerated People,” Apr. 8, 2022, in The Dose, produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman, podcast, MP3 audio, 26:22. https://doi.org/10.26099/xqf6-dn34