Editor’s Note: Mass incarceration in the United States has been called a public health crisis. Today in Health Affairs, we are featuring several pieces on the health-related challenges of people as they enter the criminal justice system and as they transition back into communities following incarceration. Please also see “Medical Legal Partnerships’ Role in Improving Health among People Released from Incarceration” in today’s Health Affairs Blog, and our newest Health Policy Brief, “Prison and Jail Reentry and Health.”
In the United States, individuals are held in jail while awaiting sentencing on a conviction, awaiting court action, or if their sentence is less than one year. In contrast, prisons house convicted individuals that are serving longer-term sentences. In 2019, there were a total of 10.3 million jail admissions with an average daily census of 741,900 across the United States. With a mean stay of 26 days, care for chronic medical conditions can be interrupted, jeopardizing the health and well-being of the incarcerated individual. Additionally, one in four jailed individuals will be arrested again, and these periodic short stays in jail introduce chaos into ongoing medical care. This is particularly concerning because the incarcerated population has a higher prevalence of chronic conditions such as diabetes mellitus, hypertension, and asthma compared to the general population, as shown in exhibit 1.
Exhibit 1: Prevalence of chronic medical conditions of the jail population and the general population, 2011–12
Source: Authors’ analysis of data from Bureau of Justice Statistics National Inmate Survey (NIS), 2011-2012. Notes: *Difference with the general population value is significant at the 95 percent confidence interval. †General population values were standardized to match the jail population by sex, age, race, and Hispanic origin. ‡Heart problems include angina, arrhythmia, arteriosclerosis, heart attack, coronary, congenital, or rheumatic heart disease, heart valve damage, or tachycardia.
Moreover, there has been a 282 percent jump in the average age of the jailed population, increasing the demand for adequate health care and prompting the need for standardized comprehensive health assessments at jail entry. In the era of COVID-19, it is even more important to properly screen newly admitted individuals to assess their current health status and prevent further harm to this vulnerable population.
Legal Rights And Protections
The Eighth Amendment and Due Process Clause of The US Constitution state that all incarcerated individuals are entitled to health care in some form. Rulings in Estelle v. Gamble (1967) and the United States v. DeCologero (1987) helped further define these health care protections by barring “deliberate indifference to serious medical needs of prisoners.” Bell v. Wolfish (1979) and Butler v. Fletcher (2006) took this one step further by specifically protecting pre-trial detainees from deliberate indifference to their medical needs by citing the Fourteenth Amendment, claiming that failure to provide adequate health care to a non-convicted person was essentially a punishment itself. Despite these landmark decisions, the provision of correctional health care continues to be inconsistent. It remains a challenge to prove “deliberate indifference” as this requires medical and correctional personnel to understand the risk of harm by not providing medical treatment.
The American Bar Association has attempted to clarify when the provision of health care is required for incarcerated individuals by stating that “necessary care” includes preventive, routine, and emergency care that is consistent with community health care standards. Despite this progress, interpretations of the relevant laws are still convoluted and leave much judgement up to jail and prison physicians and administrators.
Exacerbation Of Disease In Jails And Upon Reentry
It is well established that entry into the criminal justice system can worsen the health status of individuals, disrupt continuity of care, and lead to adverse health outcomes. Recent incarceration, whether in jail or prison, is associated with having a higher likelihood of uncontrolled hypertension compared to individuals who were never incarcerated. Incarceration can also lead to unhealthy weight gain. Additionally, individuals with alcohol or opioid dependence are at high risk of experiencing withdrawal while incarcerated, with studies reporting that only 28 percent of jail facilities offer supportive detoxification from alcohol or opioids.
Individuals being released from prison or jail face further challenges in reestablishing care within the community. Programs for formerly incarcerated individuals addressing psychiatric disorders or infectious conditions such as human immunodeficiency virus (HIV) have been established, but much work remains. To address these issues, corrections institutions have emphasized admission screening and treatment for communicable diseases and substance use disorder with success, but there is little focus on other chronic illnesses. As a result, many individuals with chronic conditions fall through the cracks and suffer adverse outcomes as a consequence of poor health care delivery while incarcerated.
Lack Of Health Screening Upon Jail Entry
There are several reasons for the lack of appropriate health screening for jailed individuals. First and foremost, jails, unlike prisons, are operated and regulated by county or municipal authorities, and each entity can adopt and maintain its own set of standards for health care delivery. In fact, as of 2019, there were 2,850 active jail jurisdictions in the country, all of which can make their own determinations about what type of intake screening must be provided and for whom. This allows for significant variation in admission guidelines and practices for individuals entering jail.
Additionally, each correctional facility varies in its capacity to offer medical services. Facilities have the option to provide all services in-house, out of house through private providers, or a combination of both. Finally, while constitutionally mandated to offer health care services, jails may not have the necessary resources for a comprehensive health care screening for all individuals at all times. For example, although jails accept admissions at all hours, most do not have medical professionals on staff 24 hours per day to perform screenings.
A lack of comprehensive screening for chronic medical conditions poses challenges for jail occupants, as missing doses of many medications can result in severe complications. Nearly 70 percent of persons newly admitted to jail report the absence of an admission health screen. Without an initial standardized screening protocol within correctional facilities, it is impossible to account for all acute and chronic conditions, potentially leading to increased cost and likelihood of harm in both the short and long term.
Mandating Protocols
To combat the lack of comprehensive chronic disease screening in jail and poor continuity of care, we propose universal adoption and strict enforcement of the National Commission on Correctional Health Care (NCCHC) guidelines for basic health screens and health assessments. These guidelines were developed to ensure high-quality care and uphold basic human rights. According to the NCCHC, jails should perform an initial medical clearance upon arrival followed by a receiving screening and later health assessment including the items listed in exhibit 2. Successful implementation could ensure continuity of care for the patient and help prevent medical emergencies.
Exhibit 2: National Commission on Correctional Health Care guidelines for jail health screening and documentation
Source: National Commission on Correctional Health Care. Standards for Health Services in Jails. Chicago (IL): NCCHC; 2018. Note: *New patients with altered mental status, active bleeding, severe intoxication, exhibiting symptoms of alcohol or drug withdrawal, mental instability, or signs of urgent illness require immediate medical attention.
According to the NCCHC, proper health care for this population incorporates an initial screening, thorough health assessment, and access to outside medical records. Results of all health assessments should be standardized and saved in facility health records or a computer database for easy access. Additionally, the NCCHC guidelines state that all incarcerated persons should be provided electronic, written, or video information on how to access all medical, dental, and mental health services.
Currently, adoption of the NCCHC guidelines is voluntary. Institutions that elect to adopt the NCCHC guidelines undergo an extensive accrediting process that examines staffing, health care resources, and the needs of jail occupants via review of patient health records. Following accreditation, the facility is monitored for compliance periodically by health professional surveyors. With this in mind, we propose mandatory adoption of these guidelines with the NCCHC acting as the primary regulating body that oversees jail health care delivery.
Obstacles To Implementation
Staffing is an obstacle to successful implementation of the 2018 NCCHC guidelines. As noted, individuals are taken into custody 24 hours a day, and many facilities may only have health care staff present during the day, if at all. Implementation of telehealth with local physicians could be an efficacious answer to staffing and resource shortages and would also expand access to subspecialists for individuals with complex chronic conditions. Several correctional facilities have already begun to implement telemedicine to increase access to psychiatry, addiction medicine, and infectious disease care.
An additional obstacle is the relatively short stay in jail. Incarcerated individuals are held in jail an average of 26 days with a weekly jail turnover rate of 53 percent. This creates a challenge in testing and verifying a large volume of self-reported past medical histories and medications. Furthermore, ensuring proper discharge and follow-up is complex. Individuals are frequently transferred to prison or released into the community, leading to difficulties in continuity of care and exacerbating comorbidities. A solution to this, however, is the establishment and expansion of community health programs that emphasize the transition of care from incarceration back into the community. Clinics such as the Bronx Transitions Clinic and the Transition Clinic Network have been established and have shown some success for health care follow-up. Further development of these clinics and increased referrals from both jails and prisons could better manage chronic health conditions for this marginalized population.
COVID-19 Considerations
In light of the COVID-19 pandemic, appropriate health screening is more important than ever as individuals with comorbidities such as hypertension, diabetes, and cardiovascular and pulmonary diseases are at far greater risk of hospitalization and mortality from COVID-19, compared to those in better health. In recent years, jails have become extremely overcrowded. With increased population density, there is a greater risk for the spread of respiratory viruses, as recommendations such as social distancing and frequent handwashing cannot be followed. Additionally, with the high turnover rates for jail occupants, each individual is exposed to a large number of people. Thus, there is an inflated risk of possible exposure to infectious disease, including COVID-19. From March to June 2020, 23,020 individuals in US jails tested positive for COVID-19 during their stay; however, this number likely underestimates the true total as only 9 percent of individuals in jail were tested. Because so many individuals in jail suffer from chronic medical conditions, and COVID-19 spreads so widely and quickly, it is imperative that these at-risk individuals are in areas with reduced COVID-19 exposure. If jails were able to routinely screen for chronic illnesses upon admission, special considerations could be taken immediately.
Conclusion
We urge the universal adoption of NCCHC recommendations to improve health care screening and management of chronic medical conditions upon admission to jail. If these standardized protocols were in place, we believe that adverse health outcomes could be avoided, continuity of care could be maintained, and harm would be minimized.
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Lack Of Standardized Chronic Condition Screening For Individuals In Jail - Health Affairs
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