The role of health care in criminal justice reform

July 17, 2018

Mass incarceration continues to be problem in United States with over 2.2 million people incarcerated, costing approximately $80 billion in taxes annually. As a result of the coalescence of social policy researchers, restorative justice policies, civil rights activists, and economists, there is recognition that incarceration is not a financially sustainable ‘solution’ to crime.

Evidence supports that over-incarceration does not lead to reductions in crime and safer communities, and people of color are disproportionately represented in prisons and jails. Criminal justice reform aimed at reducing these disparities and mass incarceration receives national attention and largely bipartisan support. Compared to other similarly situated countries, we over-incarcerate individuals and are left treating severe public health issues behind ‘the wall,’ often with inadequate funding and in a system inherently designed to negatively affect health outcomes for individuals and communities.1 Moreover, about 95% of individuals who are incarcerated return to the community, often with significant health problems exacerbated by incarceration. 

Public health research has demonstrated deficiencies in the correctional healthcare systems, the inconsistencies in treatment policies and protocols, as well as the harmful effects of jail and prison environment on one’s overall wellness. Specifically, noise pollution, crowded housing, poor sanitation, poor nutrition, physical inactivity, solitary confinement, and inadequate access to the community standards for health and behavioral health treatments have been shown to contribute to poor health and behavioral health outcomes.2 Incarcerated individuals have disproportionately higher rates of infectious diseases—Hepatitis C, HIV—and chronic medical conditions such as hypertension, asthma, arthritis, and cervical cancer.

Approximately 50% of incarcerated population are diagnosed with a mental health problem, and 70% with a history of substance used disorder.3 Many were unable to access appropriate care in the community because of lack of treatment capacity, and financial barriers to treatment. By the time these individuals are entangled in the criminal justice system, they often present with a myriad of co-morbid conditions.

As interest in individuals with behavioral health issues, and advocacy for them to access community-based alternatives has increased, Drs. Mark Munetz and Patricia Griffin developed the Sequential Intercept Model (SIM). This model identifies five points where community-based alternatives can be in interposed in standard criminal procedures: (1) law enforcement/emergency services; (2) initial detention/initial court hearings; (3) jails/courts; (4) re-entry; and (5) community corrections/support. Healthcare has a role at each juncture of the SIM.

Within law enforcement, there are opportunities to divert individuals experiencing acute mental health and substance abuse issues to appropriate treatment settings. Crisis Intervention Teams composed of law enforcement and behavioral health specialists are specifically trained to de-escalate crisis and facilitate communication techniques that reduce the risk of violence and improve safety outcomes for consumers, law enforcement officers and the community.4 The challenge and opportunity remain, however, with limited community capacity to treat individuals, long inpatient wait lists, and uninsured individuals’ inability to access care.

The Courts also provide opportunities for community alternatives to incarceration through alternative to bail programs, diversion programs, drug courts, and mental health courts. These programs offer community-based supervision when legally appropriate and allow individuals the opportunity to address underlying health and behavioral health issues that may be contributing to one’s criminogenic risk profile. 

Jails and prisons need standardized models of care that mirror community standards and allow for appropriate screening, timely treatment, and patient centered, integrated care management and coordination. Treatment standards need to be premised on evidenced-based practices.  Substance use disorders should be treated as chronic medical conditions, and treatment should be integrated with mental health and medical care. Access to all FDA-approved medicated assisted treatment modalities must be available for individuals who are incarcerated. It is essential that medical care be gender-specific, and trauma informed. It is necessary to integrate sexual and reproductive health into integrated care plans. Compassionate release ought to be considered for end of life care, and facilities need to be available to accommodate hospice patients.

Reentry planning should begin early in one’s incarceration with coordinated care plans, Medicaid applications and—when appropriate—Social Security disability requests submitted prior to release, adequate medication supplies and accessible health records for community providers. Reentry coordinators must ensure medical and behavioral health appointments are established prior to release and individuals have a level of comfort with accessing that care.

Finally, community-based supervision—both probation and parole—offer opportunities to address health and behavioral health concerns. Supervising officers can provide referrals and linkages to primary and behavioral health care, inpatient facilities and general wellness resources. Relapse to substance use should be identified as part of the chronicity of the disease, and medical and behavioral health interventions have to be the first-line approach, rather than incarceration or re-incarceration.

Healthcare researchers and providers could affect criminal justice reform using public health strategies to address healthcare issues that can exacerbate criminogenic risk, as well as be exacerbated by the criminal justice system. Healthcare plays a key role throughout criminal justice reform in the United States, and as such, healthcare leaders need to be at any table addressing policy reform.