The Unmet Medical Needs of Correctional Populations in the United States
Karen L. Cropsey, PsyD, Ingrid A. Binswanger, MD, MPH, [...], and Faye S. Taxman, PhD
Abstract
The goal of this study was to document the health needs of members in the criminal justice system and the capacity of the system to meet those needs. Using data from the National Criminal Justice Treatment Practices survey, we estimated the number of adults under correctional control who need medical care and the capacity of the correctional system to provide needed care. A mailed survey of 431 adult correctional agencies and administrators was used to define the capacity and techniques of the correctional system to meet the medical needs of the offender population. Most offenders in jail and prison received tuberculosis screening, physical health services, and mental health screening and treatment. Screening for sexually transmitted diseases (STDs) and provision of detoxification or methadone maintenance were universally absent, regardless of criminal justice setting. Community corrections settings were lacking in most health care areas. Prisons and jails are constitutionally mandated to provide health care; however, community corrections agencies are not federally required to provide health services. While community correction settings have the lowest provision of health care services, prisons and jails also demonstrate a deficiency in most services, but particularly for STD screening, substance abuse detoxification, and opioid maintenance therapies.
INTRODUCTION:
More than 8 million offenders are under the control of US correctional agencies, and they have poor health on most major measures of wellbeing. For instance, former inmates tend to have higher death rates1 and suffer from many chronic health, mental health, and substance abuse conditions at higher rates compared to normative peers.1 The time under correctional control is a “window of opportunity” to provide health promotion and prevention messages and interventions,2 yet the public health community and policy makers have been slow to implement strategies to reduce and effectively manage the health burden of correctional populations.
Infectious Diseases
Correctional populations have much higher rates of infectious diseases compared to the general population. For example, the prevalence of chlamydia is approximately 18 to 50 times higher in adult prisoners compared to the general population,3,4 and rates of gonorrhea are 18 to 32 times higher in adult offenders than in the general population.3,4 Approximately 3.7% of male and 5.2% of female inmates test positive for syphilis, compared to less than 0.001% of adults in the general population,3,4 and the prevalence of AIDS was 2.4 times higher in adult correctional populations compared to adults outside of correctional facilities5,6 in 2007. Further, about a third of prisoners are infected with hepatitis C, while general adult rates7,8 are less than 2%. Finally, approximately 20% to 25% of inmates test positive for latent tuberculosis infection (LTBI), while only about 0.0048% of the general population test positive for LTBI.9,10 The infectious diseases burden among inmates has been well established, but less attention has been paid to effective management strategies of these infections in criminal justice populations both in and out of jails and prisons and during their transitions between settings.
Mental illness and Substance Abuse
Compared to the general population, rates of mental illness are approximately 2 to 3 times higher,11 and suicide rates are approximately 2 to 4 times higher among incarcerated adults.12,13 Analogous to rates of mental illness, substance abuse rates are 4 times higher among correctional populations compared to the general population,14–16 and smoking rates among offenders are approximately 2 to 4 times higher than the general population.17–21 The rates of co-occurring mental and substance use disorders for the criminal justice population are in excess of 50%—6 to 10 times higher than those of their noncorrectional peers.16
While it has been formally recognized that jails and prison have a constitutional requirement to provide health care,22 the standard of care remains ambiguous.23 In addition, this legal requirement does not apply to community corrections where more than 80% of the correctional population is served. While health care is not central to the corrections mission, it is a de facto responsibility for correctional institutions and potentially an unmet opportunity for community corrections, as well as a critical point for intervention across the entire system.
This article provides a framework for understanding the unmet health needs of individuals involved in the correctional system. The purpose of this article is to: (1) use nationally collected representative data to describe the health services infrastructure (including physical, mental health, and substance abuse services); (2) compare the findings on health services infrastructure to 3 indicators of the need for services at each stage of the justice system (condition prevalence, population size, guidelines for service provision); and (3) use these comparisons to identify the most critical gaps in our justice system’s ability to meet the service needs of this large and critical public health population.
methods
A mailed survey of 431 correctional agencies conducted in 2004–2005 was used to define the capacity and techniques of the correctional system to meet the needs of the offender population. It was an organizational survey of administrators from all vantages of the correctional system—juvenile and adult—as well as jails, prison, probation and/or parole offices, and alternative-to-incarceration (diversion) programs and addiction treatment programs. The survey focused on the nature of the service delivery system in the adult correctional system and the linkages to other organizations.24 This project was approved by the following institutional review boards: Virginia Common wealth University; University of Maryland at College Park, Bureau of Governmental Research; Brown University; Lifespan Hospital; Connecticut Department of Mental Health and Addiction Services; National Development and Research Institutes Inc; Center for Therapeutic Community Research; National Development and Research Institutes Inc; Center for the Integration of Research and Practice; Texas Christian University, Institute of Behavioral Research; University of Delaware, Center for Drug and Alcohol Studies; University of Kentucky, Center on Drug and Alcohol Research; University of California at Los Angeles, Integrated Substance Abuse Programs; and University of Miami, Center for Treatment Research on Adolescent Drug Abuse.
Sampling Frame
The sampling frame involved: (1) a representative sampling of adult prisons and (2) a representative sample of counties and all correctional services provided in those counties. The representative sample of prisons was taken from the frame developed by the Bureau of Justice Statistics.25 The sampling frame of community agencies consisted of 72 counties based on region of the country and size of the community. Within each county, all criminal justice agencies, including probation, parole, local jail, regional services, and other community correctional agencies, and up to 5 drug treatment programs were selected. The response rate for returning the surveys was 67.4%, for a resulting sample size of 431 adult correctional agencies.
Measures
The study collected data on the nature of medical services provided in the correctional agencies, either directly by their staff or another agency. The focus was on a cluster of health service measures such as human immunodeficiency virus (HIV), tuberculosis, physical health, and sexually transmitted infections (STIs).
Average daily population.
Average daily population refers to the number of offenders that were reported to be in the facility or in a specific program the day that the administrator completed the survey.
Percent with program.
Administrators reported whether a service was offered either by their staff, contract, or agreement with another agency.
Number in program.
Administrators reported the number of offenders that were offered the service during the study period or the number of offenders that can be served at any given time. The administrator also indicated the frequency that the service was offered.
Percent of average daily population (access rate).
Based on the annual estimate of those who can benefit from the service, percent of average daily population was the capacity of the system to serve offenders (see discussion).26
For the following conditions, it was estimated that 100% of the sample could benefit from the following health services based on the recommendations of The Health Status of Soon-To-Be-Released Inmates27. HIV testing, HIV counseling, tuberculosis screening, hepatitis screening, general medical services, mental health assessment, co-occurring mental health and substance abuse disorders assessment, detoxification and/or methadone treatment, and STI screening. To determine the actual access rate, we used the above-cited prevalence rates in the correctional population and multiplied these percentages by the total populations in each setting to estimate the actual need for services. All calculations were conducted on weighted data to provide national point prevalence estimates.28
RESULTS
Prevalence of Health Care Services in Correctional Settings
Table 1 provides information about the availability of specific health care services, point estimates of the offenders currently being served in programs, and the percent of their average daily population served. Prisons and jails reported more availability of medical services for their adult population compared to community corrections agencies. Almost all prison and jails provided screening services for HIV, hepatitis C, tuberculosis, mental health, and co-occurring disorders, although fewer jails had these services. The exception was detoxification and methadone maintenance, which was offered more frequently in jails than other institutions. Community corrections were the least likely to offer any of these services. Screening for STIs was also not widely available in most correctional settings.
We were also interested in the capacity of these programs and services. Prisons were able to serve the largest percentage of the average daily population compared to jails and community corrections. Prisons were generally able to provide services to the majority of their population for tuberculosis and hepatitis screening, physical health services, and mental health assessment and treatment. For other services such as HIV testing and counseling, co-occurring mental and substance use disorders assessment and treatment, and STI screening, prisons generally were able to provide these services to about a third to half of their offenders. Jails and community corrections generally had much less capacity to deliver these services.
Service Gaps for Health Care Services to Offenders
Table 2 shows the number of offenders who had access to various health services and the estimated number of individuals who were likely to receive needed services across criminal justice settings. Generally, most offenders in prison could receive tuberculosis screening, physical health services, and mental health screening and treatment. Most offenders in jail could receive tuberculosis screening and other medical services. About two-thirds of prisoners can receive needed hepatitis C screening, while few in jail or community corrections received similar screening. Screening for STIs was universally absent from the criminal justice setting, with very few individuals likely to receive needed services. Similarly, few offenders could receive detoxification or methadone maintenance, regardless of criminal justice setting.
DISCUSSION
The National Criminal Justice Treatment Practices survey provides the first national portrait of medical screening and treatment services offered across the criminal justice system. While certain services such as tuberculosis screening, HIV testing, and physical health services are provided almost universally in correctional settings, there are notable gaps for most other medical services, and these gaps are most pronounced in the community corrections setting, where approximately 80% of the criminal justice population is served. Few screening and other medical services were provided in community corrections, presumably because community corrections are not under a mandate to provide these services, and there is generally no budget allocated to community corrections for health services by local governments. While offenders in the community can theoretically access these screening and other health services through community health facilities, the barriers to care, including insurance, transportation, and competing needs, are significant for individuals in community corrections. Based on our results, few individuals in community corrections were provided with medical services screening for STIs, detoxification, and methadone maintenance.
While the rates of medical conditions among correctional populations are higher than among the general population, mortality rates vary considerably by condition, including some conditions where the rates were similar or slightly higher among correctional populations. For example, while mortality rates from drug overdoses are general higher among correctional populations compared to the general population,4,9,29 offenders are less likely to die from motor vehicle or other accidents due to incarceration. Former inmates on community supervision after release (ie, parole)1 and on probation12 also have an elevated risk of death. The lack of access to health services among individuals on probation and parole may contribute to their elevated risk of death, particularly their inability to access substance abuse services in the community.
This study was important for providing the first national estimates of gaps in available health services for adult members of the criminal justice population. This information can be important in developing new policy and public health initiatives and in assessing the potential impact of health care reform, which can improve medical access and expand needed medical services to address chronic diseases. For example, suspension, rather than discontinuation, of Medicaid coverage during incarceration may improve access to care for former inmates returning to the community. Colocated health services and community corrections services may help reduce barriers to care and improve continuity of care. Funding for health services for the high needs of offenders in the community may reduce the spread of infectious diseases in the community.
Our study had some limitations. While we tried to base prevalence rates of particular disorders in the criminal justice system on national estimates and epidemiological data, gaps and incomplete data limited our ability to so this. Better epidemiological data on the rates of infectious and other diseases among criminal justice populations are also needed. Our review of the literature illustrates the limited epidemiological data on criminal justice populations. Finally, some of our estimates of prevalence were based on single-site studies, which may not accurately measure the health disorders among a broader range of offender populations across the United States.
This study only addressed the medical services for which the criminal justice and community corrections agencies provided offenders through various means; it did not include any medical services that offenders may have accessed on their own accord. In some situations, it illustrated that correctional agencies have formed partnerships with community health clinics, such as the 44.8% of community correctional agencies that offer myriad services at their office such as blood pressure screening, HIV prevention talks, etc. The high mortality rates of prisoners after release would suggest that newly released inmates may not have direct access to adequate or appropriate services in the community or that the population is not sufficiently prepared to manage their own care after release.30
A recent call for epidemiology studies devoted to criminology31 appears warranted, given that nearly 4.5% of the adult population in the Unites States is involved in the justice system. The health status of justice-involved individuals deserves attention from the public health system. Expanding the mission of the correctional system to include optimizing the health status of justice- involved individuals may help ameliorate the problem. A revised mission for correctional agencies should recognize the role in improving the public health of individuals and the community. Correctional systems should develop relationships with health care providers in the community to enhance access to care for individuals under community supervision.
ACKNOWLEDGMENT
The authors thank Matt Perdoni and Carolyn Watson.
Funding/Support:
This study was funded under a cooperative agreement from National Institute on Drug Abuse to George Mason University (U01 DA016213–01 and U01 DA016213 to Dr Taxman, principal investigator). The funding was supplemented by the Center for Substance Abuse Treatment, Bureau of Justice Assistance, Centers for Disease Control and Prevention, and National Institute on Alcohol Abuse and Alcoholism. Other members of the collaborative participated in this study.
Footnotes
Disclaimer:
The contents are solely the responsibility of the authors and do not necessarily represent the official views of National Institutes of Health/National Institute on Alcohol Abuse and Alcoholism.
Contributor Information
Karen L. Cropsey, Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham.
Ingrid A. Binswanger, School of Medicine, Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado (Dr Binswanger);
C. Brendan Clark, Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham.
Faye S. Taxman, Criminology, Law and Society Department, George Mason University, Fairfax, Virginia.