Decarcerating America

by Ernest Drucker

  Thus, the routine of repeated incarceration and release of this subgroup represents a set of disruptive and traumatic transitions that could be addressed through a focus on supportive housing—if it were more widely available. First, we must understand that this population is not disengaged from services broadly; rather, the natures of the services they access do not address the underlying housing problem. In New York City, 96 percent of the frequently incarcerated had at some point had a Medicaid number—far higher than the cross-sectional jail population. Qualitative work suggests that these patients are so engaged in services that various institutions often become their housing. They cycle through jails, but also emergency departments, inpatient hospitalization, psychiatric hospitalization, nursing homes, shelters, and inpatient drug rehab centers, such that these coalesce to become their housing, a phenomenon described by medical anthropologist Kim Hopper as the institutional circuit.6 At the same time, supportive housing interventions often require involved application processes that this disabled population cannot successfully navigate, and incarceration often interferes. Further, eligibility for supportive housing may be broad, such that those in the pool with best control of their mental illness or substance use secure placement to the exclusion of those most in need, who remain too disabled to navigate the bureaucracy.

  Approaching supportive housing as a decarceration intervention requires a novel strategy. Localities can identify their most frequently incarcerated populations using modern data systems and define this group of specific individuals as the group eligible for a reserved set of supportive housing slots. These same data systems can be used to identify the frequently incarcerated when they are next arrested and can expedite their warm handoff into supportive housing directly from jail discharge. Though it should not preclude other supportive housing efforts, this targeted approach is fundamentally different from investing in supportive housing efforts with broad eligibility criteria. With per-bed annual costs exceeding $160,000 in a large urban jail, such efforts could readily reduce public outlay, or at least represent a highly cost-effective health intervention.7

  Barriers to such a cost-effective policy, however, are powerful. Costs are relatively invisible to the public when the criminal justice system or police consign the homeless to jail, whereas no-cost scatter-site housing for this marginalized group could be met with public scrutiny. Budgetary silos make the savings garnered from reduced jail populations difficult to redirect to supportive housing. Such savings also represent loss to the vested interests that defend criminal justice spending.

  The criminal justice system itself should have access to supportive tools rather than just punitive ones. The balance of evidence suggests that supportive housing as an intervention for the frequently incarcerated would be more effective than frequent jailing in addressing criminal justice outcomes—protecting public safety, reducing petty crime and public nuisance—and at markedly lower cost.8 This approach could improve community safety and quality of life while saving taxpayer money, but it requires a cultural frame shift on the part of judges, prosecutors, and legislators. These stakeholders must also release drug urine screening back to the purview of medical professionals and accept that community-dwelling adults must be allowed to struggle with drug relapse without returning to jail based on use alone. Such supportive interventions might be best housed within dedicated decarceration courts.9

  Employment and Incarceration

  In addition to addressing housing status, the project of more rapid decarceration will require examination of other traditional social determinants of health, including poverty and race. The frequently incarcerated group we have described has a very different set of needs than a young man caught up in the entrepreneurship of the drug trade and the crime organizations that operate this industry. For such a young man, the prospect of viable employment in the mainstream economy is the common pathway that might protect him from years of life lost to incarceration and to gun violence. For the two groups, the appropriate interventions that impact social determinants of both health and incarceration can be doubly cost-effective investments for society.

  Correctional Health Care and Decarceration

  Substance use and mental health disorders represent the two most common types of diagnoses among the incarcerated. They also reflect how poor and minority people with these problems come to be incarcerated, and reveal the importance of correctional health care in undoing the American error of mass incarceration. The United States has more beds allocated to incarceration than to substance treatment and inpatient psychiatric care combined. With 2.3 million people incarcerated, the United States has approximately 720 beds of incarceration per 100,000 people. The total number of inpatient psychiatric beds in the United States has declined from 550,000 in 1960 to about 43,000 in 2011, yielding a rate of 13 beds of inpatient psychiatric care per 100,000 people.10 A 2012 review of inpatient substance use disorder facilities in 2012 revealed approximately 1.2 million people in care for drug or alcohol use disorder, reflecting a rate of 480 per 100,000 people.11 Taken together, this reflects a rate of approximately 493 per 100,000 for treatment of these concerns. While this reflects about 32 percent fewer beds dedicated to treatment versus incarceration, it is important to remember not only that incarceration is much more expensive than treatment but also that treatment is associated with financial savings to the community and incarceration is associated with increases in overdose and death immediately after release.

  At the same time, the need to reduce American incarceration rates is also widely acknowledged. There are two important areas where both goals can be pursued together. First, the scope of correctional health services should be expanded, especially to support diversion efforts before incarceration and also to include medication-assisted therapy (e.g., opioid maintenance treatment with methadone or buprenorphine) during incarceration, thereby reducing risk of death after release. In the case of diversion, comprehensive health data for frequently incarcerated people can help formulate an alternative to detention.

  A second nexus between improving correctional health and decarceration is the funding mechanism of correctional health. Currently, correctional health is funded almost exclusively by local tax levy of cities, counties, and states. In jails and prisons, spending priorities and quality measurement usually fall to sheriffs and departments of correction instead of the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission. As a consequence, the care delivered during twelve million incarcerations each year is essentially hidden from the rest of American health care quality assessment and improvement.

  In order to integrate evidence-based practices into correctional health, states should be allowed to utilize some Medicaid funds to reimburse for care inside jails and prisons. The most pressing case for this approach is for treatment of hepatitis C. New drug regimens make treatment and cure of hepatitis C realistic for millions of Americans, many of whom also have criminal justice involvement. However, most correctional settings lack the funds to pay for these medications, which cost approximately $60,000 for a twelve-week regimen. For community health systems and CMS, the prospect of treatment interruption, failure, and restarting during incarceration is likely more costly than simply continuing treatment.

  Funding this work would bring in the robust quality assessment and improvements that are standard in virtually every other American health care setting. This approach, and other similar efforts, would allow community health systems to understand the true costs of incarceration and take the dual approach of promoting continuity of care for their incarcerated patients and also weighing in on the core decisions that lead so many people with mental health and substance use problems to end up incarcerated.

  Discharge Health Planning

  The weeks immediately following incarceration in jails or prisons represent a high-risk time for death, most commonly due to overdose, followed by suicide and homicide.12 The magnitude of the increased risk for death is variable across different
studies but has been demonstrated across a wide range of geographic locations and populations and in both prisons and jails.13 The World Health Organization identifies access to opioid substitution therapy (e.g., methadone or buprenorphine) as an essential element of a strategy to combat this health risk of incarceration.14 However, most American jails and prisons appear not to offer this evidence-based treatment except in limited circumstances.15 Afflicting substance users most prominently, post-release death demonstrates how drug war policy aimed at mitigating the consequences of illicit drug use can have the opposite effect.

  Though in-custody death is widely tracked and reported, post-release death has traditionally been described only in epidemiologic terms. Modern data systems could track post-release deaths, which could help interested localities to improve jail-based health services and discharge planning.16 Such investigations could draw attention to the high rates of post-release overdose death and may lead to implementation of new jail-or prison-based opioid treatment programs, or quality improvement initiatives within those programs that already exist. For example, every person with serious mental illness or substance abuse concerns should be linked to community health resources. This linkage requires much more than simply making an appointment and should include medications dispensed at the time of the intervention; transportation to home, social service hubs, or other initial points of reentry; and communication of essential health information with patient consent. Because the length of stay in jail is relatively short and hard to predict, effective reentry work requires notification of local health homes, care coordinators, or other community health partners when incarceration begins. This would allow for a shared plan of care that could involve coordinated reentry but is also poised to react to the unexpected discharge of people from jail. Our own efforts in these areas have shown that comprehensive discharge planning can promote improved health outcomes as well as decreased homelessness, food insecurity, and use of emergency services.17

  The documentation of the health risks of incarceration is an important component of the decarceration movement. Incarcerated people experience new health risks that contribute to death, injury, and other adverse health outcomes both during and after incarceration—especially in jails. In addition, the repeated incarceration of some groups (e.g., people with substance use and housing concerns) is a costly and ineffective use of resources. Increasing supportive housing must be an essential part of ending American mass incarceration if the cycling of individuals from jail to homeless shelters to inpatient psychiatric settings is to be broken. Correctional health services will also need to come into the modern age of evidence-based addiction treatment, including methadone and buprenorphine, as a means to improve survival and reduce recidivism. Finally, making fundamental reforms in the provision of health care in prisons and jails will bring improved health outcomes for the incarcerated, and allow those health systems to join with community partners at key decision points along the criminal justice pipeline.

  In order to realize this potential, correctional health services in jail and prison will need to develop robust reentry teams that can also partner with drug, decarceration, and mental health courts to facilitate diversion as well as reentry.

  Notes

  1. L. Glaze and D. Kaeble, Correctional Populations in the United States, Bureau of Justice Statistics, Department of Justice, NCJ 248479, December 19, 2014.

  2. S. Glowa-Kollisch, K. Andrade, R. Stazesky, P. Teixeira, F. Kaba, R. MacDonald, Z. Rosner, D. Selling, A. Parsons, and H. Venters, “Data-Driven Human Rights: Using the Electronic Health Record to Promote Human Rights in Jail,” Health and Human Rights 16, no. 1 (2014): 157–65.

  3. F. Kaba, A. Lewsi, S. Glowa-Kollisch, J. Hadler, D. Lee, H. Alper, D. Selling, R. MacDonald, A. Solimo, A. Parsons, and H. Venters, “Solitary Confinement and Risk of Self-Harm Among Jail Inmates,” American Journal of Public Health 104, no. 3 (2014): 442–47.

  4. F. Kaba, A. Solimo, J. Graves, S. Glowa-Kollisch, A. Vise, R. MacDonald, A. Waters, Z. Rosner, N. Dickey, S. Angell, and H. Venters, “Disparities in Mental Health Referral and Diagnosis in the NYC Jail Mental Health Service,” American Journal of Public Health 105, no. 9 (September 2015): e27–e34.

  5. R. MacDonald, F. Kaba, Z. Rosner, A. Vise, M. Skerker, D. Weiss, M. Brittner, N. Dickey, and H. Venters, “The Rikers Island Hot Spotters: Defining the Needs of the Most Frequently Incarcerated,” American Journal of Public Health 105, no. 11 (November 2015): 2262–8.

  6. K. Hopper, J. Jost, T. Hay, S. Welber, and G. Haugland, “Homelessness, Severe Mental Illness, and the Institutional Circuit,” Psychiatric Services 48, no. 5 (1997): 659–65.

  7. Independent Budget Office of the City of New York, “NYC’s Jail Population: Who’s There and Why?,” August 22, 2013, http://ibo.nyc.ny.us/cgi-park2/2013/08/nycs-jail-population-whos-there-and-why.

  8. A. Aidala, W. McAllister, M. Yomogida, and V. Shubert, New York City Frequent User Service Enhancement (FUSE) Initiative, “New York City FUSE II Evaluation Report,” http://www.csh.org/wp-content/uploads/2014/01/FUSE-Eval-Report-Final_Linked.pdf, accessed July 23, 2017.

  9. A.M. McLeod, “Decarceration Courts: Possibilities and Perils of a Shifting Criminal Law,” Georgetown Law Journal 100 (2012): 1587–674.

  10. No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals 2005–2010, Treatment Advocacy Center, July 19, 2012, available at http://www.treatmentadvocacycenter.org/storage/documents/no_room_at_the_inn-2012.pdf.

  11. National Survey of Substance Abuse Treatment Services (N-SSATS): 2012, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, SMA 14-4809, 2013.

  12. J. Zlodre and S. Fazel, “All-Cause and External Mortality in Released Prisoners: Systematic Review and Meta-analysis,” American Journal of Public Health 102, no. 12 (December 2012): e67–75.

  13. On prisons: I.A. Binswanger, M.F. Stern, R.A. Deyo, P.J. Heagerty, A. Cheadle, J.G. Elmore, and T.D. Koepsell, “Release from Prison—A High Risk of Death for Former Inmates,” New England Journal of Medicine 356, no. 2 (January 11, 2007): 157–65, erratum in New England Journal of Medicine 356, no. 5 (February 1, 2007): 536. On jails: S. Lim, A.L. Seligson, F.M. Parvez, C.W. Luther, M.P. Mavinkurve, I.A. Binswanger, and B.D. Kerker, “Risks of Drug-Related Death, Suicide, and Homicide During the Immediate Post-Release Period Among People Released from New York City Jails, 2001–2005,” American Journal of Epidemiology 175, no. 6 (March 15, 2012): 519–26.

  14. Prevention of Acute Drug-related Mortality in Prison Populations During the Immediate Post-Release Period (Copenhagen: World Health Organization, 2010).

  15. A. Nunn, N. Zaller, S. Dickman, C. Trimbur, A. Nijhawan, and J.D. Rich, “Methadone and Buprenorphine Prescribing and Referral Practices in US Prison Systems: Results from a Nationwide Survey,” Drug and Alcohol Dependence 105, nos. 1–2 (November 1, 2009): 83–88, erratum in Drug and Alcohol Dependence 113, nos. 2–3 (January 15, 2011): 252.

  16. B. Alex, D.B. Weiss, F. Kaba, Z. Rosner, D. Lee, S. Lim, H. Venters, and R. MacDonald, “Death After Jail Release,” Journal of Correctional Health Care 23, no. 1 (January 2017): 83–87.

  17. P.A. Teixeira, A.O. Jordan, N. Zaller, D. Shah, and H. Venters, “Health Outcomes for HIV-Infected Persons Released from the New York City Jail System with a Transitional Care-Coordination Plan,” Am J Public Health 105, no. 2 (February 2015):351–7.

  10

  Release Aging People in Prison

  MUJAHID FARID AND LAURA WHITEHORN

  Mass incarceration in the United States has emerged as one of the most urgent human rights issues of the twenty-first century. The United States is the most incarcerated nation on the planet, bar none—a reality rendered all the more demoralizing because this country holds itself out as the beacon of democracy for the rest of the world. Whatever democracy really means in America, it cannot be overlooked that at the root of mass incarceration is the long-standing issue of racism. Black people are incarcerated
at a rate six times higher than whites, and Latinos are nearly twice as likely to be incarcerated as whites.

  Also largely inspired by race is the propensity to punish. This is a driving force behind mass incarceration, and it has become so pervasive that some researchers note it has metastasized into a “carceral state,” infecting almost every other social institution with negative collateral consequences and turning the United States into a nation defined by its repressive apparatus.1

  Public health scholars have begun classifying mass incarceration as a public health crisis because of its widespread and devastating social impact.2 Noting that it has developed epidemic proportions, some have employed an epidemiological framework to study its causes and consequences.

  Though it is widely recognized that mass incarceration in the United States portends a bleak future for the society as a whole, and bipartisan commissions have arisen to address the crisis, there has been strong resistance to credible initiatives that could substantially contribute to solutions. The failure to consider and implement concrete solutions to the crisis of mass incarceration has caused the number of people aging in prison to continue to skyrocket, confining thousands of seniors in cruel and degrading conditions.

  In New York State, as a result of a failure to confront the punishment paradigm, the number of people over fifty years of age who are confined increased by more than 84 percent between 2004 and 2014, even as the total number of people locked up fell by 23 percent during the same period.3

  What Needs to Change

  To commence the process of ushering in real change, government leaders and policy makers must accept that it is not possible to substantially reduce the deadly impact of this “disease” through strategies that focus solely on releasing people confined for low-level crimes—that is, people who are imprisoned for nonviolent, nonsexual, and nonserious drug-related offenses.