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Public Health Support for People Reentering Communities from Prisons and Jails
Policy Date: 11/5/2013
Policy Number: 201311
Related APHA Policy Statements
APHA Policy Statement 8817 – A Public Health Response to the War on Drugs, Reducing Alcohol, Tobacco and Other Drug Problems among the Nation’s Youth
APHA Policy Statement 9016 – HIV Housing and Access to Care for HIV Infected Inmates
APHA Policy Statement 9017 – HIV Education and Condoms in Correctional Facilities
APHA Policy Statement 9123 – The Social Practice of Mass Imprisonment
APHA Policy Statement 9928 – Understanding Responding to Health and Substance Abuse Treatment
APHA Policy Statement 9929 – Diversion from Jail for Non-Violent Arrestees with Serious Mental Illness
APHA Policy Statement 200027 – Encourage Health Behavior by Adolescents
APHA Policy Statement 2005-1 – Condemning Torture of Military Prisoners and Detainees
APHA Policy Statement 200914 – Building a Public Health Infrastructure for Youth Violence Prevention
At present, there are nearly 7 million US citizens in jail, in prison, or on probation or parole. This number exceeds the number of incarcerated citizens in any other country in the world. There is mass incarceration of minorities in the United States. The criminal justice system is in crisis, as reflected in the system’s current exhaustion of resources, overtaxed budgets, and overcrowded facilities. Almost 700,000 citizens leave prisons and jail each year and need health, mental health, and support services in order to rejoin their families and live in communities. People with infectious diseases including HIV, hepatitis C virus, and tuberculosis need health care services, including medications. People discharged with mental and substance use disorders need therapeutic services as well as other essential services and opportunities such as housing, health insurance, and employment. Organized reentry programs are few, and returning citizens experience health disparities and barriers to accessing social assistance programs, thus perpetuating the revolving door of recidivism. This policy statement calls for a public health approach to the provision of health, mental health, and social services for people reentering communities from prisons and jails.
Michelle Alexander, an associate professor of law at Ohio State University and a civil rights advocate, has chronicled the increased rate of incarceration that began as a political call for a “law and order society” in the post-riot periods of the 1960s and 1970s and intensified at the advent of the “war on drugs” in the 1980s. Thirty years of a combination of “tough on crime” and “war on drugs” public policies has resulted in mass incarceration of minorities, primarily Black and Latino males.
Mass incarceration has become a national phenomenon. More than 6 million people have contact with the criminal justice system in prison, in jails, or on probation or parole. Male offenders account for 87% of this population and women 13%. While immigrants represent 11% of the incarcerated population, they endure an ever-increasing amount of scrutiny under the criminal justice system. Housing immigrants awaiting disposition and deportation accounts for much of the new for-profit prison construction in a number of states. People returning from incarceration to communities have higher rates of chronic diseases, mental health disorders, and infectious diseases; reentry planning programs are inadequate, and people relying on public assistance can be prevented from accessing services and are likely to experience recidivism. People discharged from prisons and jails are more at risk of dying from drug overdoses or from unnatural causes. A study by Phillips and Lindsay of people reentering society showed that individual judgment can play a role in community reentry. Ex-offenders who use problem-focused strategies have better reentry experiences than those who use emotion-focused or avoidance strategies. There is evidence that reentry programs are effective, and we in the public health community need support to plan for such programs.
Rates of mental health disabilities, substance use disorders, and co-occurring disorders are high, and few treatment options are available to stabilize disorders among reentering citizens. Discharge planning falls short of need.
Problems associated with infectious diseases, health care, housing, and other social determinants of health: Housing is fundamental to the stability of returning citizens as a first step toward community normalcy and successful reentry. Varying housing options are needed for returning citizens. Often people who lived in public housing or other subsidized Section 8 housing before their incarceration may be prevented from living with relatives because of a drug charge. Lack of money and lack of connections to community support are other barriers to securing housing. The failure to find affordable and available housing can be a primary reason why returning citizens may not be able to reunite with their families and gain employment. Tierney states that incarceration can reduce people’s wages by 40% when they are released from prison and cannot find comparable employment. Recidivism rates are high, and a majority of people reoffend within 3 years.
Returning citizens who are homeless and have infectious diseases, such as HIV, hepatitis C virus, or tuberculosis, must have integrated services if they are to become stable both medically and socially once in the community. The Centers for Disease Control and Prevention reports increased HIV rates in neighborhoods with higher rates of unemployment and lower median incomes. Unstable housing also increases the risk of HIV acquisition and decreases the likelihood of medication adherence. People with HIV can be treated in prisons and jails and, upon release, are often given a 30-day supply of medicine until they are able to link to a regular source of medical care. Obtaining Medicaid or other health insurance coverage and connecting with a medical provider can require longer than 30 days, especially when applications are not completed until the person is discharged from the institution. A retrospective study of 1,750 discharges from a Texas prison focusing on the rate of enrollment in outpatient care among released inmates showed that, without intensive treatment before release to the community, only 20% of ex-offenders enrolled in an HIV clinic within 30 days, and 28% enrolled within 90 days. Ex-offenders more than 30 years of age who were on antiretroviral therapy (ART) and those with mental disabilities enrolled in outpatient care at a higher rate than their counterparts. Returning citizens managing chronic illnesses face some of the same bureaucratic problems with respect to qualifying for health insurance in the community. Because prison sentences are longer and the prison population is aging, more ex-offenders are leaving institutions with chronic illnesses.
Challenges faced by returning citizens with mental disabilities and substance use disorders: There are more mentally ill people in jails and prisons than in psychiatric hospitals. More than 16% of the prison population is estimated to have a mental disability. Barriers exist for returning citizens, especially men and women of color, in accessing mental health services. Health insurance resources and opportunities for placement in community-based programs and longer term psychiatric hospital care are sparse relative to the level of need in low-income communities. The criminal justice system has replaced the psychiatric system, and police are often the first line of contact. For ex-offenders with mental disabilities, there is a revolving door between the community, the hospital emergency room, and the local jail. Whereas there is a “constitutional right” for offenders to have health and mental health care while in prison or jails, there is not a similar right for transitional services in the community, although legal challenges have established that continued obligations exist for the criminal justice system with respect to seriously mentally ill individuals. The interactions between mental health professionals and patients in low-income communities can be characterized by distrust of mental health services, stereotyping of poor or minority patients by mental health professionals, and differences in cultures between professionals and patients that result in treatment being difficult.[22–24]
More than 70% of individuals in the criminal justice system have a co-occurring mental disability and substance use disorders. And not enough people with substance use disorders receive treatment in the community. As of 2010, only 11% of people needing treatment for illicit drug use or alcoholism received treatment at a specialty facility. Individuals with a combination of a mental disability and a substance use disorder must be treated for both conditions if they are to function successfully in the community.
There is a great need for integrated community-based mental health services and the linking of mental health to substance use services for populations reentering communities from prisons and jails. Drug courts and mental health courts, which are increasingly being used as alternatives to incarceration for people with mental disabilities and substance use disorders, have shown effects on recidivism. As of 2009, there were 2,038 drug courts and 175 mental health courts in the country. These resources need to be expanded if they are to make a difference with respect to diversion from incarceration for these populations. It has been shown that ex-offenders in treatment for substance use disorders do not commit as many crimes as those not in treatment.[21,27] It has also been shown that mental health treatment can have a positive impact on people with substance use disorders.
Criminal justice funding and political issues: The Vera Institute of Justice developed a cost-benefit analysis comparing the costs of prisons among different states. The institute discovered that the actual costs of corrections budgets are unpredictable and can range from 1% to 34% higher than the projected amount owing to unbudgeted expenses such as personnel fringe benefits and prisoner health care. In 2011, the criminal justice system received more than $50 billion in public funding.[28–31] In this era of government austerity, states are easing their criminal justice budgets by closing facilities, transferring inmates to prisons in the private sector, and releasing nonviolent offenders. California is under a court order to reduce its population by 17% in a 2-year period. Increasingly, jails and prisons are incorporating video instead of in-person visits and attempting to reduce personnel costs. At the federal level, President Obama has used executive powers to enact the Fair Sentencing Act, which addresses the disparities caused by the 5- and 10-year minimum sentences for possessing and selling crack and powdered cocaine. In August 2013, the attorney general announced an easing of mandatory sentencing and prosecutions for drugs of abuse, and the Justice Department promoted the concept of compassionate release for elderly infirmed prisoners.[32–35] States have developed alternatives to incarceration by funding mental health and substance use treatment courts. It is hoped that these measures will also help curb costs.
Support of the public health system: The federal government is sponsoring efforts that will assist people reentering communities from prisons and jails. The Federal Second Chance Act has as its goal reducing recidivism and increasing public safety by funding research, programs, and community-based support services. A grant awarded to the District of Columbia has funded a one-stop location providing support for returning citizens. The Mayor’s Office of Returning Citizen Affairs is assisting returning citizens with employment training, health care referrals, substance use and mental health services, housing services, and voter registration. The Offender Reentry Program, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), is a long-term substance use treatment program that begins within the institution and follows the ex-offender in the community. The Department of Justice and the Department of Health and Human Services are working to develop programs for those with mental disabilities and substance use disorders through drug court initiatives.
Studies indicate that citizens who find stable housing in communities are less likely to return to prisons and jails. Appropriate housing for a returning citizen can be a solid platform for successful reentry into community living.[38,39] Other elements of community living, such as managing the payment of child support and changing job applications so that a criminal justice history is not the first feature seen by a prospective employer, will also benefit returning citizens. With the implementation of the Affordable Care Act (ACA) in Maryland and other states with expanded Medicaid coverage, returning citizens who are eligible under the Medicaid expansion and those able to buy insurance on the health exchange will have more direct access to health and mental health care. The public health system can advocate for expansion of public medical care across the country under the ACA.
Self-help and advocacy by and for reentering citizens: Peer organizations created and managed by returning citizens, who serve as both board members and staff, are actively addressing the needs of returning citizens. These transition programs are community resources for health care, job training, and housing, and they also address issues associated with the trauma of incarceration and struggles in reentry. Examples of such organizations are the Fortune Society, a full-service program in Long Island City, NY, with a board of directors and a staff of 200, and the University Legal Services PEERS (Promoting Empowerment, Education, and Reentry Solutions) Consortium in the District of Columbia, an advocacy group that assists people with mental disabilities who have been incarcerated.
Proposed Recommendations Statement
Concepts of fairness and equity should be the priorities for a national and local response to developing services and programs in the public sector for returning citizens from prisons and jails. The health in all policies (HiAP) approach promotes successful reentry into communities. An example of this evidence-based approach is the transition from prison to community model, which is operating as a pilot in 6 jurisdictions (Douglas County, KS; Denver, CO; Orange County, CA; Kent County, MI; Davidson County, TN; and La Crosse County, WI). This model includes a Web-based implementation tool kit that provides technical assistance and transition strategies specific to each jurisdiction.
Alternatives to incarceration such as mental health and drug courts and assisted outpatient treatment can decriminalize mental disability and promote provision of appropriate care. Evidence-based programs such as trauma-informed treatment for people with posttraumatic stress disorder and substance use and mental health problems are showing some success in preventing recidivism.
In this expanded public health system, health and social service practitioners will need to be appropriately trained to work effectively with returning citizens. Such training should be based on national standards for culturally and linguistically appropriate services in health and health care, as well as principles of cultural competency, and there should be a focus on respecting the health beliefs and practices of returning citizens and their families.
It will be difficult to make fundamental changes in the agencies of the criminal justice system, which has grown into a “prison-industrial complex” to handle the mass radicalized incarcerations of the past 30 years. Although the system is slowly shrinking, it still consumes a large share of state budgets, and the budget of the federal prison system continues to increase. The system is self-perpetuating: prison-based industry systems provide income for the facilities and are also sources of cheap labor for major corporations. Closing prisons will also mean a reduction in employment opportunities for people trained as corrections officers, who largely live in rural areas of the country.
There is a perception that releasing offenders into the community will cause rates of crime to increase, although there is evidence of a decline in the number of offenses over the past 10 years. The contention is that lowering incarceration rates would place society at greater risk of rising criminal activity and, eventually, rising costs to imprison a new wave of offenders.
While transitional programs from institutions to communities are designed to reduce recidivism and enhance community functioning, not all programs have been successful. For instance, an assessment of a social investment in community living program that seeks to reintegrate incarcerated individuals with mental illness and substance use problems demonstrated the difficulty of community living for returning citizens, who need both close supervision and support to maintain sobriety after discharge. In another example, an evaluation of a reentry program in Los Angeles Country supported by the Vera Institute showed that few people received reentry services while in jail to help them in transitioning to the community.
Therefore, the American Public Health Association, which has addressed the needs of incarcerated populations in the past, makes the following recommendations with respect to promoting health and social services for returning citizens:
1. The US Department of Labor should advocate for policies to remove the check box on employment applications asking individuals whether they have been convicted of a crime, support Housing First and other programs that provide stable housing for returning citizens, support programs that link returning citizens to medical homes and primary care providers in their communities, and oppose probation policies that require reentering citizens to have stable housing and jobs to avoid jail.
2. The US Department of Health and Human Services and the new addiction services division should convene mental health and substance abuse service researchers and policymakers to determine how to effectively scale up alternatives to incarceration for those with mental illnesses and substance use disorders.
3. State and local health and criminal justice agencies should begin discharge planning for offenders at the point of incarceration, given that more than 90% of men and women will return to communities.
4. Public health advocates should support local, state, and national measures that increase access to services, benefits, and civil rights, such as food subsidies, public housing, voting rights, health care, and employment, and support policies that decriminalize drug use and possession to reduce rates of incarceration and recidivism.
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