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

Episode Date: April 8, 2022

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, 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.”

The Dose is a production of the Commonwealth Fund, a foundation dedicated to health care for everyone. 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 Shanwar Sirvai and my guest is Emily Wong, a physician and director of the SESH Center for Health and Justice at Yale University.

Dr. Wong 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. Thank you so much for having me. 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? 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 healthcare, oftentimes what you have are adults that are incarcerated and because of their incarceration and because of this constitutional guarantee, accessing healthcare for the first time as adults behind bars. Research shows that it's anywhere from, you know, about 40% 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. What are the conditions or diseases that are most commonly seen or treated in the criminal justice system? 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 know, you see a host of chronic health conditions that are overrepresented behind bars. And so now let's talk about what happens behind bars. How does confinement complicate these various diagnoses? A first place of starting is really thinking about when you think about seeing a doctor in the community, you know, you're thinking about going, making an appointment, seeing a physician, maybe of your choice, maybe under your insurance plans. 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, you know, 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. And $3 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. You know, they're newly diagnosed inside. There's almost 100% adherence to the medications. You know, 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. 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 know, 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. 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, you know, just go in once or compared to those that certainly have never gone in ever. So just to be clear, this is already the sections of our population, low income people of color who have worse health to 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, you know, there's reasons that you can maybe, you know, 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 difficulty securing those basic needs for people that return home from prisons and jails. Is there any way to limit the impacts of confinement on an individual's physical or mental health? 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 8 by 10 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 and administrative segregation. Other conditions of confinement include, you know, how much contact they might have with their loved ones, etc. And so these are all correctional policies that could be changed to improve the health-harming impacts

of incarceration. From the healthcare 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 healthcare system practices of the quality of healthcare 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. 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. 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 healthcare system, perhaps, or someone they've contracted with or a private for-profit healthcare system, then be sentenced to a crime and sent to a prison within your state typically typically, and that's another healthcare system. Then the other healthcare 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 healthcare 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. 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? 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% 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. Why? Why is that? 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 individuals. That's one. So, you know, 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? Right. And so how do you get a healthcare appointment? How do you get your medications if you don't have health insurance in this country? 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. Man, there is a lot going on. You know, 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, you know, think about all the ways that you need to move through this world with an ID card, like 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 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, you know, barriers to, of course, voting, barriers to, you know, 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, you know, that on top of meeting the terms and conditions of parole and probation, put health and healthcare at the kind of, you know, for many folks, bottom of the line, even if they know it's important, even if it's critical to their health, right? Right. What has your work identified as being the most acute health needs of people who are transitioning out of correctional facilities? 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, months 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 wholly when I think about 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 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 a lot of the hospitalizations that happen following release are ones that are really preventable, you know, poorly controlled diabetes, poorly controlled hypertension, and really speaks to, I think, kind of the real precarity of that time of transition.

And how is the organization that you founded, the Transitions Clinic Network, addressing the needs you just enumerated? About 15 years ago, I had the opportunity of co-founding a first program in San Francisco, really focusing on the health care needs, and at that time, really, the transitional healthcare needs of people that are returning home from prisons and jails in San Francisco. And one of the things that we thought was critical to this is that there are leaders that have been incarcerated that really are, you know, 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,

where 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 healthcare 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 stress of coming home, the mistrust that people that have been incarcerated may have in the healthcare system, given their experiences both in the community and also in the correctional healthcare

system, and could shepherd the patient in through healthcare, 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 healthcare system and,

importantly, not return back into a correctional system. And these programs, where are they based? In the communities or? Yes, they're based in local primary care programs. And so in federally qualified health centers, at times in hospital-based clinics. And so, you know, I'm a physician at Yale University, and so ours within our Yale Paramedic Care practice, each of these programs are kind of based within different community health centers. And how does the individual get to the program? 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. Shir 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 a 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 healthcare system and

save hands. And so slowly over time, iteratively, the network really is aiming towards transforming our healthcare 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. So it's really attempting to build this bridge or fill this gap that we talked about earlier. Precisely, precisely. I have to say, you know, 15 years ago, I thought, well, this is low-hanging fruit, right? Like 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. Right. I feel like I would be remiss if I did not ask how the pandemic has impacted this really important work. Because, you know, 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. that we've structured, our correctional systems in this country really have been hot spots 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 and 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,

you know, newly, what you can see right now is more bipartisan support of 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 thinking 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. 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. You know, 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? 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 healthcare system. And so these are barriers that can be overcome. We've shown that within our Transitions Clinic Network, and there's 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, is probably a plus for community health workers in particular that are working to transition people home. Are there explicit legal bans on them doing this work? 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 and understanding. You want people to return home, to reintegrate as they do, you know, 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 kind of meeting kind of these goals. It's a system that really is working in opposition to what I'd say is kind of our overall goals, which is, you know, a community that's thriving and that's safe and that's healthy. Dr. Emily Wong, thank you so much for joining me today. Thank you. I really appreciate the opportunity. This episode of The Dose was produced by Jody Becker, Mickey Kapper, Naomi Leibovitz, 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 Shana Urseervai. Thank you for listening.