Prisoner Reentry

What Are the Public Health Challenges?

by Lois M. Davis, Sharon Pacchiana

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Research Brief

In the past 20 years, the number of ex-offenders released from state and federal prisons has increased threefold. In addition, a number of states are considering the early release of state prisoners as a way to reduce state budgets, which would accelerate the rate inmates are returned to communities.

These trends present some key public health challenges. A recent summary of reentry trends by the Bureau of Justice Statistics (BJS) revealed that almost 25 percent of state prisoners to be released by year-end 1999 were alcohol-dependent, 14 percent were mentally ill, and 12 percent were homeless at the time of arrest.

Because these data are self-reported, they likely underestimate the true prevalence of these conditions, but they do suggest that soon-to-be-released offenders may bring a host of medical problems upon reentry and that the public health burden may be significant.

To get a better sense of the problem, RAND researcher Lois Davis and a colleague reviewed the existing literature, looking at the changing characteristics of the reentry population and examining national estimates of the prevalence of certain chronic medical conditions, infectious diseases, mental illness, substance abuse and dependency, and co-occurring disorders in this population.

How Is the Reentry Population Changing?

SOURCE: Based on T. Hughes and D. J. Wilson, "Inmates Returning to Community After Serving Time in Prison," Characteristics of Releases, Bureau of Justice Statistics Reentry Trends in the U.S., October 2002.

During the past 10 years, the number of state prisoners being released each year has grown, with releases from state prisons concentrated in California, Florida, Illinois, New York, and Texas and in specific metropolitan areas. The length of time served in prison has increased in recent years, as have the number of released prisoners who are ex-drug offenders, the number of "churners" who cycle through prison and parole, and the number of unconditional releases. Finally, compared with ten years ago, fewer offenders are now participating in educational or vocational programs that could help prepare them for reintegration.

Persons released from state prisons on parole tended to be older (as shown in the figure), with the mean age rising from 31 to 34 during the past ten years. A growing number are female. While the racial composition of parole entries has stayed relatively unchanged, disparities in the amount of time served in prison remain, with black offenders more likely to have longer lengths of stay than other ethnic groups.

The above trends suggest that reintegration into the community is becoming more difficult and will have significant implications for the health care needs of soon-to-be-released offenders.

What Is the Health Status of Prisoners and Releasees?

Category Condition Prevalence Compared to U.S. Population
Infectious Diseases Active tuberculosis 4 times greater
Hepatitis C 9–10 times greater
AIDS 5 times greater
HIV infection 8–9 times greater
Chronic Diseases Asthma Higher
Diabetes/hypertension Lower
Mental Illness Schizophrenia or other psychotic disorder 3–5 times greater
Bipolar (depression) disorder 1.5–3 times greater
Major depression Roughly equivalent
Substance Abuse and Dependence Alcohol dependence 25% fit CAGE profile
Drug use 83% prior to offense; 33% at time of offense

SOURCES: NCCHC, "Prevalence of Communicable Disease, Chronic Disease, andMental Illness Among the Inmate Population," The Health Status of Soon-To-Be-Released Prisoners, A Report to Congress, 2002; BJS Special Report: SubstanceAbuse and Treatment, State and Federal Prisoners, 1997, NCJ 172871, 1999.

The table, which is primarily derived from research done by the National Commission on Correctional Health Care (NCCHC), compares the health status of soon-to-be-released offenders with that of the U.S. population in 1996. As the table shows, soon-to-be-released offenders tend to be sicker on average than the U.S. population. The increased prevalence of infectious diseases ranges from four times greater for active tuberculosis (TB) to 9–10 times greater for hepatitis C.

For chronic diseases, asthma prevalence was higher—8.5 percent versus 7.5 percent—and while the prevalence of diabetes and hypertension is lower for prison inmates, these prevalences are relatively high given that the prison population is younger as a whole and that these conditions are typically associated with older people. Because the prison population is aging, the prevalence of chronic diseases is likely to increase.

In terms of mental illness, the prevalence of schizophrenia and bipolar disorder in the prison population is about 1–5 times greater than in the population as a whole, except for major depression, where the prevalences are roughly equivalent.

The NCCHC did not estimate the prevalence of substance abuse and dependence among state prison inmates or soon-to-be-released offenders. However, according to the BJS, one-quarter of male and female state prison inmates fit the CAGE profile of alcohol dependence, while 83 percent of state prison inmates reported using drugs prior to their offense and 33 percent reported use at the time of their offense.

Policy Implications

The literature review raises a number of issues. Serious limitations exist in the data state prison systems have to assess the health status of soon-to-be released offenders; this hinders our ability to understand the true disease burden prisoners will have on the communities they are reentering. For example, we know little about the prevalence of co-occurring disorders in state prison populations, both because of inaccurate or missing data and because of variations in screening and discharge planning of soon-to-be released offenders. Yet we know that co-occurring disorders are common (e.g., mental illness and substance abuse, HIV and hepatitis B or C). We also do not know the extent to which medical conditions or mental illness may have been preexisting prior to prison admission, or the extent to which these conditions may have gone undiagnosed and/or untreated within the state prison systems. There is a need for improved screening, prevention, and treatment programs for state prison inmates; better tracking systems; and improved discharge and transitional planning for ex-offenders with special health care needs.

Improved screening and treatment programs for high-risk populations can protect the public health of those in communities where ex-offenders are released. For example, ex-offenders with untreated TB infection may contribute to its spread in a community and to the development of drug-resistant strains. Improved screening could be expensive for the prison system, because it is likely to increase the number of inmates who need treatment services and whose care will need to be transitioned to community health care providers upon release. Moreover, improved screening could lead to greater liability for the prison system—for example, screening could demonstrate that some inmates were infected with HIV while incarcerated and therefore might have been subjected to a cruel or unsafe environment. Who pays for improved screening and more treatment is a structural problem the system will need to address.

Ex-offenders rely heavily on the public sector for health care services; however, they will be returning to communities and neighborhoods with limited health care resources at a time when the public health system and America's "safety net" are severely strained.

Finally, while the geographic concentration of returnees within a few states and within urban areas poses challenges, it also offers some opportunities. By developing innovative responses to the public health challenge to prisoner reentry in those states alone, significant public health problems could be prevented.

This research brief describes work carried out by RAND Public and Safety Justice.

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