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On Life Support: Public Health in the Age of Mass Incarceration, Vera Inst., 2014

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On Life Support:
Public Health in the Age of Mass

David Cloud

Vera’s Justice Reform for Healthy Communities initiative aims to improve
the health and well-being of communities that have been most impacted by
decades of mass incarceration. Guided by a national advisory board comprised
of public health and criminal justice policymakers, practitioners, researchers, and
advocates, the initiative advances its mission through public education, coalition
building, briefings, and publications. It will examine the role of mass incarceration
as a driver of health disparities—both behind bars and in communities—and it
will look at opportunities to apply a public health framework to address aspects
of the criminal justice system that deepen social inequalities and exacerbate
health disparities.
This work is a logical next step for Vera, as we have long explored the intersection
of justice and health systems for the betterment of disadvantaged communities.
National healthcare reform efforts under the Affordable Care Act, combined with
national, state, - and local leaders seeking ways to reduce incarceration, provide
an ideal opportunity for Vera to build on that body of work.
This report is the first in a series of publications Vera will release to inform
policymakers on opportunities created by the ACA to enhance public safety
and reform sentencing and corrections practices by advancing public health. By
fostering new ideas and more effective solutions, we can reduce costs, strengthen
and expand services, and improve public health outcomes for families and

Nicholas Turner
President and Director
Vera Institute of Justice



4	Introduction

The Burden of Disease Behind Bars

12	 Conditions of Confinement and Health
15	 The Health of Communities
19	 A Political Landscape Ripe for Reform
21	 The Potential of the Affordable Care Act
29	Conclusion



Over the past century, the U.S. population as a whole has benefited from continuous gains in health and longevity, such as longer life expectancy and lower
infant mortality rates, but these gains have not been distributed evenly across
the nation’s populace. For example, between 1980 and 2000, people in higher
socioeconomic groups experienced larger gains in life expectancy than those
in poorer groups, and the gaps in health between poor and wealthy Americans
widened. Research in epidemiology shows that growing inequalities in health
outcomes parallel rising trends in U.S. income inequality.1
Health disparities persist deeply in American society. For all of U.S. history, racial and ethnic minorities and other historically marginalized groups, especially
those living in poverty, have faced more barriers in accessing care, received

Health disparities
persist deeply in
American society.


poorer quality care, and experienced worse health outcomes than the rest of
the population.2
In society, the social determinants of health (SDH)—defined by the World Health
Organization as ”the circumstances in which people are born, grow up, live, work,
and age, as well as systems designed to deal with illness”—are major contributors
to health disparities. Thus, major social, political, and economic changes and social
safety net policies impacting living conditions in communities shape health disparities.3 For example, the gap in health outcomes between black and white Americans narrowed in the years following historic advances in equality achieved by
the Civil Rights Movement in the 1960s.4 Conversely, disparities widened between
1980 and 1991 amidst deep cuts to social safety net programs and publicly-funded
health services that benefit low-income minority populations.5
The large-scale expansion of incarceration has become one such factor in
the constellation of social determinants of health.6 Over the last 40 years the
criminal justice system has expanded to such a degree that, today, mass incarceration is one of the major contributors to poor health in communities.7 Since
the 1970s, the correctional population in the U.S. has grown by 700 percent
and, from 1982 to 2001, state expenditures on corrections increased each year,
outpacing overall budget growth, and swelling from $15 billion to $53.5 billion,
adjusted for inflation. Since then, expenditures on incarceration have hovered
around $50 billion.8
Mass incarceration is one of a series of interrelated factors that has stretched
the social and economic fabric of communities, contributing to diminished
educational opportunities, fractured family structures, stagnated economic mobility, limited housing options, restricted access to essential social entitlements,
and reduced neighborhood cohesiveness.9 In turn, these collateral consequences
have widened the gap in health outcomes along racial and socioeconomic gradients in significant ways. For example, research in epidemiology indicates that
had the U.S. incarceration rate remained at its 1973 level, then the infant mortality rate would have been 7.8 percent lower than it was in 2003, and disparity
between black and white infant deaths nearly 15 percent lower.10


The millions of people who cycle through the nation’s courts, jails, and prisons
experience chronic health conditions, infectious diseases, substance use, and
mental illness at much higher rates than the general population. The conditions
of confinement inside jails and prisons, such as overcrowding, violence, sexual
victimization, use of solitary confinement, and lower standards of medical care
are harmful to the physical and mental health of incarcerated individuals.
There is, however, growing interest among health and justice system leaders to
work together in the pursuit of health equity, public safety, and social justice. In
many states and localities, health and justice agencies are already working collaboratively to enroll eligible people into health plans in different justice settings,
bolster diversion programs at the front door of the criminal justice system that
aim to steer people away from incarceration and into community-based services,
and build the information-sharing frameworks that are needed to promote continuity in care and improve health and public safety outcomes.
This report describes the public health implications of mass incarceration. It
summarizes what is known about the burden of disease among people who
experience incarceration, identifies the conditions of confinement that are
deleterious for health, and discusses the various ways in which the continuous
expansion of the criminal justice system has contributed to health disparities
over the past 40 years. It then explains why now is an opportune moment to
support and expand bipartisan efforts to implement a public health approach
to reducing mass incarceration.

The Burden of Disease
Behind Bars
While people in correctional facilities are mostly excluded from national health
surveys, an extensive literature review reveals that this population has dramatically higher rates of disease than the general population, and that correctional
facilities too often serve as ill-equipped treatment providers of last resort for
medically underserved, marginalized people.11

For nearly a century, state psychiatric hospitals were the primary institutions
for treating people with mental health problems. These state asylums were
established as the result of a 19th-century national crusade to decrease the extent that people with mental illness were being housed and abused in jails and
poorhouses. Unfortunately, these institutions created further problems, often
warehousing patients in deplorable living conditions against their will. In the
late 1950s, states began closing their asylums in large numbers with the promise that they would be replaced with a robust network of behavioral health care



The Burden of Dis
Infectious diseases

are more prevalent among people who are incarcerated
than in the general population.

is 2 to 7 times

more prevalent and an
estimated 17 percent of all
people with HIV living in the
U.S. pass through a correctional
facility each year.

(sexually transmitted diseases),
such as chlamydia and
gonorrhea, are more prevalent,
especially among incarcerated
women who have significant
histories of sexual trauma
and/or engage in sex work.

Hepatitis C
occurs at rates
8 to 21 times

One third
of women

higher among incarcerated
people, and accounts for more
deaths in the community
than HIV/AIDS.

is more than

4 times

as prevalent.


Common STDs


admitted into jails
who receive a screen for STDs
test positive for syphilis.

Syphilis rates

among women incarcerated
in New York City are

1,000 times

that of the general population.

sease Behind Bars
substance use


all jail



in state



fewer than
receive appropriate treatment


of people in jail with
a serious mental illness
also have substance
use disorders.

Serious mental illnesses
in jails
14.5 %




Chronic Disease
In state prisons, prevalence of serious mental
illness is 2 to 4 times higher than in the

Between 39 and 43 percent of
people in custody have at least
one chronic condition.

Graying Behind Bars

Suicide and Violence

Suicide accounts for one-third of deaths
in jails. 15 percent of state prisoners
reported violence-related injuries and
22 percent reported accidental injuries.

People aged 55 years and older
are among the fastest growing
segments of the incarcerated
population. Older adults
have higher rates of chronic
conditions and mental and
physical disabilities.




centers where people could receive the services they needed, while continuing
to live in the community—a movement known as deinstitutionalization.
Deinstitutionalization was the result of advances in psychotropic medication, stronger due process protections against civil commitment, the growing
influence of community psychiatry, and the enactment of Medicaid in 1965. The
newly created community centers were envisioned to offer a range of services:
inpatient, outpatient, emergency, partial hospitalization, and consultation and
education on mental health.12
Unfortunately, the promise of the community mental health movement fell
short of its ambitions due to underfunding at the federal and state levels, preventing many people from accessing the services they needed. Dramatic cuts
to a variety of social safety net programs in the 1980s—which led to increases
in homelessness and the number of people with untreated mental illness on
the street—coincided with massive government spending on the War on Drugs
and prison construction.13 Figure 1 illustrates how continued declines in state
asylum populations coincided with the rise of mass incarceration.14

Figure 1: State Asylum and Incarcerated Populations, 1934–2001

Harcourt, Bernard E. “Reducing mass incarceration: Lessons from the deinstitutionalization of mental hospitals in the 1960s.”
Ohio St. J. Crim. L. 9 (2011): 53.



These changes contributed to a disproportionate number of underserved people with mental health problems becoming entangled in the criminal justice
system and correctional facilities becoming their default treatment providers.15
Today, about 14.5 percent of men and 31 percent of women in jails have a serious
mental illness, such as schizophrenia, major depression, or bipolar disorder,
compared to 3.2 and 4.9 percent respectively in the general population.16 While
estimates vary, the prevalence of serious mental illnesses is at least two to four
times higher among state prisoners than in community populations.17

The punitive sentencing laws and aggressive policing practices that emerged out
of the national War on Drugs were perhaps the single greatest factor responsible
for surging prison populations. Starting in the early 1970s, and accelerating over the

following decades, a series of new punitive state and federal policies led to unprecedented numbers of people being sent to prison to serve long custodial sentences for
drug offenses. The concentration of drug arrests in urban communities of color is a
primary driver of pervasive racial disparities in the criminal justice system (see Figure 2). African Americans are significantly more likely to be arrested, 13 times more
likely than whites to go to prison for a drug conviction, and comprise 62 percent of
people imprisoned for a drug conviction, despite negligible differences in reported
drug use. The increase in incarceration following arrest on drug charges accounted
for about two-thirds of the increase in the federal prison population and one-half of
the increase in the state prison populations between 1985 and 2000.18

Figure 2: Drug Possession/Use Arrest Rates by Race, 1980-2009
American Indian Alaska Native
Asian Pacific Islander

Source: Snyder, Howard N. Arrest in the United States, 1980-2009. US Department of Justice, Office of Justice Programs, Bureau of
Justice Statistics, 2011



Today, nearly 68 percent of people in jail overall and more than 50 percent of
those in state prisons have a diagnosable substance use disorder, compared to 9
percent of the general population.19 Moreover, most people who have a serious
mental illness also have a co-occurring substance use diagnosis. For instance, in
jails an estimated 72 percent of people with a serious mental illness also have a
substance use disorder.20
Despite this high need, less than 15 percent of people who are incarcerated
receive appropriate treatment.21 For instance, although a significant body of
research shows that pharmacological treatments such as methadone and buprenorphine effectively treat opioid addictions, most correctional facilities choose
not to offer them, subjecting people with chronic addictions to higher risk of
withdrawal while in custody and of overdose when released to the community.22

Infectious diseases are also more prevalent among incarcerated populations
than in the general population. For instance:
>>HIV/AIDS is 2 to 7 times more prevalent among people in correctional facilities than in the community, and an estimated 17 percent of all people with
HIV living in the U.S. pass through a correctional facility each year.23
>>The Hepatitis C virus (HCV)—which accounts for more deaths in the
community than HIV/AIDS—occurs at rates between 8 to 21 times higher
among incarcerated people than in the general population.24
>> Tuberculosis (TB) studies have found 29.4 cases of tuberculosis per 100,000
prisoners compared to 6.7 cases per 100,000 people in the general population.25
>>Common sexually transmitted diseases (STDs), such as chlamydia and
gonorrhea, are more prevalent in correctional environments than any other
setting, especially among women.26 For instance, in 2011, the Centers for
Disease Control and Prevention reported that one-third of women admitted
into jails who receive a screen for STDs test seropositive for syphilis. One
study found the rates of syphilis among women incarcerated in New York
City to be 1,000 times that seen in the general population.27



In the U.S. and other industrialized nations, chronic diseases, such as cardiovascular diseases and diabetes, are amongst the primary causes of death and
disability.28 While more research is needed, existing studies reveal disproportionately high rates of chronic physical conditions among correctional populations. One nationally representative survey found higher rates of hypertension,
asthma, arthritis, cancer, and cervical cancer among correctional populations
compared to the general population, even after controlling for a range of socioeconomic factors.29

Violence and injuries are among the most common health problem in correc-

tional environments.30 Suicide remains a leading cause of death, accounting
for one-third of deaths in jails between 2000 and 2009.31 Intentional and
accidental injuries to prisoners, corrections officers, and staff are rampant. In
a Bureau of Justice Statistics (BJS) survey, 15 percent of state prisoners reported violence-related injuries.32 The incidence of self-harm, injuries inflicted on
correctional staff, and suicide tend to be significantly higher in solitary confinement units than in the rest of correctional environments.33 Additionally, there
is growing concern over high rates of a history of traumatic brain injuries (TBIs)
among justice-involved populations. The neurological, emotional, and cognitive
deficits associated with TBIs can have considerable implications for both quality of life and recidivism.34

The number of women imprisoned in the U.S. increased nearly 6.5-fold from
1980 to 2010. Today, women comprise about 7 percent of all prisoners and 13
percent of all local jail populations, and face a greater burden of disease than
incarcerated men, which is partly explained by disturbingly high rates of sexual
victimization, substance use, and trauma.35 An estimated 6 percent are pregnant, with the majority having conceived within 3 months of release from a
prior incarceration.36 A significant percentage of these women have not seen
an obstetrician on a regular basis prior to incarceration and are in unhealthy
states due to substance use and malnutrition prior to entering custody. While
a structured environment, regular meals, and access to care can improve birth
outcomes, according to a recent survey, state prisons often fail to use best practices and established standards when caring for pregnant women.37



Finally, geriatric health behind bars is a growing public health problem. From 1990
to 2012, the number of people behind bars aged 55 years and older soared by 550
percent.38 Older adults have higher rates of chronic conditions and experience more
physically and mentally debilitating conditions, including neurodegenerative diseases associated with aging, such as mild-cognitive impairment (MCI), Alzheimer’s
disease, and dementias. Cognitive impairments and physical disabilities make
older prisoners extremely vulnerable in correctional environments, putting them
at an increased risk of injury, victimization, and cognitive and emotional decompensation. Prisons and jails are generally ill-equipped to meet the needs of elderly
patients who may require intensive services for these conditions.39

Conditions of Confinement
and Health
People held in correctional facilities are the only group in the U.S. with a constitutional right to healthcare.40 Yet, the overcrowded, unsanitary conditions inside
many correctional facilities combined with poor nutrition, lack of ventilation,
enforced idleness, and the impact of violence, trauma, and solitary confinement
can have long-term negative effects on health that infringe on the constitutional and human rights of prisoners and detainees.

Overcrowding underpins many of the poor living conditions in jails and prisons. Decades of sustained prison growth has resulted in severely overpopulated correctional facilities, which creates significant risks to the health and
safety of people living and working in these institutions.41 At the end of 2013,
17 states had more people in their prisons than their facilities were designed
to house. For example, Alabama’s prisons were originally designed for 13,318
people and currently house around 32,000 people.42 In a 2012 report, the federal Government Accountability Office (GAO) described how overcrowding in
federal prisons has led to increased use of double and triple bunking, expanded
waiting lists for education and drug treatment, reduced access to meaningful
work opportunities, and increased use of solitary confinement in response to
disciplinary infractions.43 In the early 1990s, severe overcrowding contributed
to spikes in the incidence of multidrug-resistant forms of TB in correctional systems. NYC’s jail on Rikers Island had one of the highest rates of TB in the country, which was largely attributable to severe overcrowding, poor ventilation,
and inadequate medical protocols to control the spread of the disease.44



The 2011 landmark Supreme Court case Plata v. Brown is emblematic of
the severe consequences that prison overcrowding can have on human
health. Plata uncovered pernicious impacts of overcrowding throughout
California’s prisons, including: increased violence and suicide, unsanitary
living conditions, spread of communicable diseases, psychiatric deterioration, and medical neglect resulting in injury, illness, and death.
Among the many appalling conditions detailed in the Court’s decision:
more than 200 prisoners living in a gymnasium space under the supervision of only two correctional officers; people with acute medical conditions on interminable waiting lists to see a doctor; an average of one
suicide per week and reports of suicidal prisoners being left in cages
the size of a telephone booth, soaking in pools of their own urine, with
no access to mental health treatment; doctors prescribing the wrong
medications to patients, causing harmful side effects and death; forced
closure of medical spaces due to unsanitary conditions; and spates of
inmate-on-inmate violence without accountability.
The Court upheld a federal mandate that required California to reduce
its prison population by at least 38,000 people to remedy multiple 8th
Amendment violations stemming from endemic overcrowding.

Today, at least 84,000
individuals live in conditions
of isolation, sensory deprivation,
and idleness in U.S. jails
and prisons.



The U.S. exposes more people to punitive and administrative segregation (i.e.
solitary confinement) than any other country. From 1995 to 2005, the number
of people in solitary confinement nationally increased by 40 percent, from
57,591 to 81,622 people, and the most recent estimates suggest at least 84,000
individuals live in conditions of isolation, sensory deprivation, and idleness in
U.S. jails and prisons.45 Prisoners housed in segregation units are held in a tiny
cell—with minimal access to natural sunlight, long periods of silence but also
at times continuous noise from things like clattering metal doors and loud, startling outbursts and distressed voices—for 23 hours each day, and are allowed
out for only one hour for exercise or a shower. They are mostly deprived of
human interaction and rarely receive opportunities for counseling, job training,
and educational programming to help them adapt after returning to society.
Many people live in these conditions for years or even decades and are often released directly from isolation to the community. The harmful effects of solitary
confinement on physical and mental health have been extensively document-







ed, and are especially pronounced for young people and those with a serious
mental illness. Nearly every scientific study on the effects of solitary confinement over the past 150 years has found that subjecting a person to more than
ten days of solitary confinement results in a distinct set of emotional, cognitive,
social, and physical pathologies. The incidences of self-harm and suicide among
prisoners, and injuries to correctional staff, are significantly higher in solitary
confinement units than in the general prison or jail population.46

Even following the passage of the Prison Rape Elimination Act (PREA) in 2003, sexual victimization remains a serious problem inside jails and prisons. Sexual assault
and harassment expose victims to physical injury, psychological trauma, STDs,
and can lead to self-harm and suicide.47 A 2012 BJS survey found that 10 percent

standards governing

of former state prisoners reported being sexually victimized while incarcerated.48
A separate survey found that 4 percent of people in state and federal prison and
3.2 percent of those in jail reported experiencing one or more incidents of sexual
victimization by another inmate or facility staff in the preceding year or since
admission to the facility. Women experience higher rates of sexual victimization
than men. A 2008 survey found three times as many females (13.7 percent) reported
being sexually victimized by another prisoner than males (4.2 percent); and that
twice as many women reported being sexually victimized by staff.49

correctional health


There is minimal
oversight and a lack
of uniform quality



The quality, availability, and organization of correctional health services influences
health outcomes among incarcerated populations, but have not been well studied. However, the standard of care lags far behind community health standards.50
Several organizations, including the National Commission on Correctional Health
Care, set standards and offer accreditation to correctional facilities for healthcare
services. Yet, only about 17 percent (500 of 3,000 correctional facilities) have been
accredited by these bodies.51 In effect, there is minimal oversight and a lack of uniform quality standards governing correctional health services. Moreover, correctional health providers are culturally and organizationally detached from mainstream healthcare systems. Physicians and medical professionals working behind
bars rarely coordinate care with community health providers. The lack of connectivity undermines continuity of care for people transitioning from correctional
facilities into community settings, as the first few days and weeks in the community following a period of incarceration are associated with a much higher risk of
serious injury or death.52 Poor communication also poses risks for people entering
correctional systems. Clinicians performing medical intake rarely have protocols to
obtain access to important diagnostic or clinical history from community providers, which increases the risk of clinical error or discontinuation of medications, and
can result in psychiatric deterioration for people with serious mental illnesses.


The Health of Communities
The negative consequences of incarceration are not limited
to those who experience the system firsthand. The vast
majority of incarcerated people will be released, and the
continuous cycling of people with high rates of disease
between corrections and communities poses risks to the
health of people living where incarceration is most endemic. Each year, the nation’s jails process more than 11 million
admissions, and prisons release nearly 700,000 people
to the community. While progress is being made in some
jurisdictions, coordination of healthcare services between
correctional and community health providers is often




of health

absent. At the point of release, most corrections agencies
Access to
do little more than make a medical referral or provide a
health care
and social
temporary supply of medication. For people with chronic
physical conditions or a serious psychiatric condition requiring regular care management, this service gap increases the chance that they will discontinue treatment regimens they started while incarcerated, greatly endangering
the health of these individuals. For people with a history of
injection drug use, failure to promote care continuity upon release increases risk
of relapse, overdose, and risky behaviors that spread HIV/AIDs and HCV disease
in communities.53
According to a widely-accepted public health model called the social determinants of health (SDH), human health is profoundly influenced by a range
of social, economic, and political forces beyond the control of the individual.54
Forty years of mass incarceration has had crippling, intergenerational effects on
SDH including:

and built


>>Altering the demographic composition of communities in ways that
fracture family structures and trap young children in poverty;
>>Diminishing the educational opportunities of youth;
>>Stagnating economic mobility and widening income inequality;
>>Exacerbating homelessness;
>>Restricting access to essential social benefits; and
>>Siphoning political capital from inner city communities through “prison
gerrymandering” and disenfranchisement.55



These are the communities that the majority of people exiting correctional facilities return to. For example, researchers from the Justice Mapping Center have
plotted rates of incarceration by census tract for a number of cities using a geospatial visualization technology that allows us to see the neighborhoods where
incarceration is most concentrated. When JMC’s map of New York City is viewed
along with health statistics collected by the NYC Department of Health and Mental Hygiene (DOHMH), it is too plain to see that the highest rates of incarceration
and the greatest rates of disease are concentrated in the same neighborhoods.
Central Brooklyn, the South Bronx, and Upper Manhattan—where incarceration
is most prevalent—also have disproportionately high infant mortality rates, HIV
incidence, STD prevalence, asthma rates, and hospitalizations due to assault.56
(See Figures 3 and 4.).

Figure 3: NYC People Admitted to Prison per
1000 Adults by Census Tract of Residence

Data Source: Justice Mapping Center (JMC), Rutgers University
Analysis of NYC DOCCS data. DOCCS not responsible for JMC findings.

Figure 4: NYC Average Infant Mortality by
Community District, 2009-2011

Source: New York City Department of Health and Mental Hygiene.

Strong family ties and social bonds are essential for good health. Mass incarceration has deeply changed the structure of families in many communities,
resulting in intergenerational effects that may only be beginning to manifest.
Most people who go to prison have children: 52 percent of people in state prison
and 63 percent in federal prison, leaving about 2.7 million children under the
age of 18 living in the U.S. with at least one parent in prison.57 Parental and
familial incarceration impacts so many lives that Sesame Street aired episodes



to educate children on the issue of familial incarceration and maintains information on its website.58
In certain situations, removing a parent from a household can benefit a
family, especially when the incarcerated parent is responsible for domestic or
child abuse. More commonly, however, parental incarceration perpetuates disadvantage for children and families. For example, studies have shown that the
growth in paternal incarceration has contributed to elevated rates of homelessness among black children by thinning family finances and placing additional
strains on mothers.59 Furthermore, imprisonment of a mother is less likely to
result in homelessness than incarceration of a father, but often results in foster
care placement. One study concluded that recent increases in female imprisonment rates explain 30 percent of the doubling of foster care caseloads between
1985 and 2000.60
Having a parent behind bars deepens financial hardships for fragile fami-

2.7 million children

under the age of 18
are living in the U.S.
with at least one
parent in prison.

lies already on the brink of poverty by removing a primary source of income.
Sociological research has shown that the concentrated removal of young men
through incarceration has significantly altered the demographic composition
of communities of color, contributing to lower marriage rates among African
American women and spurring an uptick in single-mother families living in
poverty.61 While some incarcerated parents are afforded opportunities to work
while in custody, the average hourly wage for state prisoners is about $0.89,
wholly insufficient to fulfill child support and other financial obligations. 62

Additional financial burdens for the families of incarcerated individuals include:
>>Depositing money into prison commissary accounts for use by their incarcerated family members.
>> Traveling costs and wages lost related to visiting correctional facilities that are
often located in rural locations several hours outside metropolitan centers.
>>The high cost of staying in touch by phone or video visitation, which can
force families to choose between paying to stay in touch and other basic
living expenses.
>>The emotional stress and financial commitment that comes with staying in
touch over time can foster familial conflict that is damaging to marriages
and parental-child bonds.63




It has been
estimated that

In the modern U.S. economy, educational attainment—and increasingly a
college degree—is critical to the economic stability of individuals and families. It is the surest path to steady employment, which is paramount to having adequate access to comprehensive health services and living conditions
that promote good health.64 For youth, an arrest or period of incarceration can
interrupt schooling and greatly hinder completing high school or getting into
college, and—with few exceptions—correctional institutions offer little in the
way of rigorous educational programs or vocational training that can help
individuals obtain employment on release. Most states impose legal restrictions
that prohibit people with felony records from working in specified industries,
and nearly all employers require job applicants to provide details on history
of arrest or conviction, which often automatically exclude otherwise qualified

penalizes an

applicants.65 It has been estimated that imprisonment penalizes an individual’s
annual wages by 40 percent, and that it results in a nearly four times greater
loss in aggregate lifetime earnings for black males than white males.66

individual’s annual


wages by 40 percent.

Incarceration is strongly associated with housing instability and homelessness.
Research shows that paternal incarceration has played “a silent but vital role in
the increasing risk of homelessness for American children even when the economy was healthy.”67 Children with an incarcerated father are at a significantly
higher risk of experiencing child homelessness during their lives.68
Policies such as banning people with a drug felony conviction from receiving
cash welfare, food stamps, and subsidized housing lead to housing instability
for justice-involved individuals and their families.69
>>Though the length of exclusions is shifting or being reduced in some jurisdictions, in the majority of cities, parolees are routinely barred from living in
public housing upon reentry as federal regulations allow local public housing
authorities to deny admission to any individual who is convicted of a felony.
>>Chronic health issues, such as HIV/AIDS and serious mental illness, can
compound the hardship of finding affordable housing post-release.70
>>The accumulation of legal debts during incarceration that people are unable
to pay can further diminish prospects of securing stable housing. Delinquency on debt damages credit scores that serve as the basis for obtaining
home purchasing loans. In some jurisdictions, state law permits government seizure of joint assets and property to relieve these unpaid debts.71



Lack of insurance is the most significant contributing factor to limited access to
adequate health care. Among adults, people of color are nearly twice as likely to
be uninsured than whites.72 The federal government prohibits use of Medicaid
dollars to pay for healthcare services delivered to people in correctional facilities and the ACA does not change this longstanding rule (also known as “the
inmate exclusion”).73 While the federal government encourages states and local
systems to suspend Medicaid during extended periods of incarceration and
reinstate benefits at release, all but 12 states still terminate Medicaid following a period of incarceration, typically longer than 30 days. The termination of
Medicaid without reinstating it prior to release creates a perilous service gap
for people as they reenter the community from jail or prison, a transition when
there is a significantly elevated risk of death and disabiity.74 Recent research

shows that for people with a serious psychiatric disease, having Medicaid at
the point of release increases utilization of community-based behavioral health
services and reduces recidivism.75

When residents from urban neighborhoods are incarcerated in rural areas, they
are counted in the national census as residents of those communities. This
reallocates political and economic capital from inner city communities of color
to rural communities. Not being counted as members of the communities they
are from in the census starves inner city communities of critical federal support while making the small towns where many prisons are based eligible for
additional federal subsidies. The manipulated census figures are further used to
gerrymander political boundaries in ways that boost the political power of rural
and suburban towns, while further depriving impoverished, inner city communities of political influence.76 The siphoning of political capital from these communities limits their ability to elect government representatives at the federal,
state, and local levels that serve their best interests.

A Political Landscape
Ripe for Reform
After more than 30 years of unrelenting growth, the U.S. incarcerated population modestly declined each year from 2009 through 2012. In 2013, while there
was a modest uptick in state prison populations, the number of people in federal prison dropped for the first time since 1980.77 Since 2006, a handful of states
(Michigan, Rhode Island, South Carolina, Wisconsin, and Virginia) have significantly reduced spending on corrections and reduced their prison populations.78
The downward trend has prompted some leading scholars to suggest that the



nation’s unrelenting reliance on incarceration and satiation with “tough on
crime” politics is waning.79
Indeed, there is growing bipartisan support for reforming and scaling back
the severity of sentencing regimes (e.g. mandatory minimum drug crimes, three
strikes laws) that fueled continuous prison growth for decades. For example, a
recent Vera study found that more than 29 states have amended, scaled down, or
repealed mandatory minimum sentencing laws that statutorily imposed lengthy
prison sentences for drug and other crimes.80 Similarly, in 2011, the Sentencing
Project reported that six states (Iowa, California, Connecticut, Missouri, Ohio, and
South Carolina) have taken steps toward abating disparities in sentences for crack
versus powder cocaine—emblematic laws passed during the acceleration of punitive drug laws that imprisoned large numbers of racial minorities.81
In the November 2014 elections, California voters passed Proposition 47 (The
Safe Neighborhoods and Schools Act), a ballot measure that downgrades minor
drug and property felonies to misdemeanors, permits people convicted of these
crimes to petition for release, and reinvests savings in education and behavioral
health services. The reforms are projected to reduce 40,000 felony convictions
to misdemeanors, permit 10,000 state prisoners to petition courts for immediate release, and generate hundreds of millions of dollars in correctional savings
to be reinvested in addiction treatment, education, and mental health.82 New
York and New Jersey have markedly decreased their jail and prison populations
by reducing felony drug arrests, changing sentencing practices, and investing in
community-based alternatives to incarceration, alongside significant decreases
in all major crimes.83
At the federal level, a 2013 speech by Attorney General Eric Holder to the
American Bar Association emphasized the need for state and local systems to
expand community-based alternatives to incarceration as a more humane and
effective response to drug crimes. In Congress, Senators Rand Paul (R-KY) and
Cory Booker (D-NJ) have co-authored the REDEEM Act, legislation intended to
reduce the stigma that people convicted of nonviolent drug crimes commonly
face by limiting the lifespan of criminal records that are huge impediments to
securing employment and public benefits.84 The passage and reauthorization
of the Second Chance Act (SCA) has provided substantial funding to states and
localities to assist people returning to society from incarceration seek employment, secure housing, and enroll in social entitlement programs that are shown
to protect against recidivism and improve reintegration into the community.85
While such legislation is not targeted to health per se, from a SDH perspective, it
holds great promise for the health of communities.
The U.S. Supreme Court’s landmark decision in Plata v Brown upholding a
mandate requiring California to reduce its prison population to redress constitutional infringements on prisoners’ right to basic medical and mental healthcare set a legal precedent for addressing prison overcrowding.86 In 2011, the
United Nations decried the use of solitary confinement in U.S. correctional facil-



ities as excessive and tantamount to torture under international norms.87 Since,
two Congressional hearings on the need to curb this practice in the Bureau of
Prisons and in the states have taken place. Additionally, audits for PREA, which
“creates policies and practices to ensure a zero tolerance for sexual assault in
prisons and corrections facilities by preventing, detecting, and responding to
sexual abuse,” are underway. Fiscal year of 2014 is the first year that states and
territories will have a percentage of federal grant funds withheld unless they
demonstrate an intention to comply with the law. Two states, New Hampshire
and New Jersey, have certified that they are in full compliance with PREA,
and 46 jurisdictions have submitted an assurance that they are spending the
required amount of resources to achieve and certify full compliance with the
standards in future years.88
The departure from policies predicated on severe punishment and retributive
justice is further evident in the proliferation of policing models such as crisis
intervention teams (CITs), jail and prison diversion programs, and specialized
courts founded on the idea of “therapeutic jurisprudence,” all of which involve
interdisciplinary collaborations between justice agencies and health and social
services providers to promote engagement in community services as an alternative to incarceration. For instance, as recently as 2003, there were fewer than
75 adult mental health courts (MHCs). A decade later, there are 346 adult and
51 juvenile MHCs and more than 2,700 adult and juvenile drug courts currently
operating in the United States.89 The effectiveness of these specialized courts
is still being debated, but their proliferation signifies a greater commitment to
providing community-based alternatives to incarceration.

The Potential of the
Affordable Care Act
The passage of the ACA in 2010 was a watershed moment in U.S. history. State
and local governments are increasingly realizing the opportunities created
by the ACA to develop partnerships between health and justice systems that
simultaneously abate health disparities and enhance public safety. A number of
the legislation’s key provisions—the expansion of Medicaid, increased coverage
and parity for mental health and substance use services, and incentives for creating innovative service delivery models for populations with complex health
needs—provide new funding streams and tools for policymakers to strengthen
existing programs and develop solutions to reduce mass incarceration.90 The
ACA creates critical opportunities for states, local governments, and healthcare
stakeholders to greatly expand the capacity of their community health systems
to better meet the needs of underserved populations, curb the flow of medically-underserved populations into jails and prisons, pursue collaborative pro-



gramming to plug service gaps between health and justice systems, and ensure
that people are able to receive services in the community that are essential for
health, as detailed below.

By extending health insurance to millions of people who previously lacked coverage and requiring health plans to provide a wider range of benefits, many people
with mental illness or substance use problems will gain coverage for the first
time.91 Over time, improved coverage has the potential to lead to greater capacity
in the community to provide mental health and addiction treatment and provide
jurisdictions with important opportunities to cease relying on jails and the criminal justice system as default behavioral health providers, in the following ways.92
>>Expanding Medicaid: The ACA expands Medicaid eligibility to people at
or below 138 percent of the Federal Poverty Level ($11,490 for an individual
and $23,550 for a family of four). The newly-eligible population includes
large numbers of young, childless adults who were previously excluded
from coverage. In 2010, the U.S. Supreme Court ruled that the ACA’s Medicaid expansion is optional for states. As of October 2014, 28 states and the
District of Columbia have opted to expand Medicaid, providing comprehen-

Figure 5: Status of State Medicaid Expansion Decisions (as of October 2014)



sive healthcare coverage to an estimated additional 10.5 million low-income
Americans. Under the new rules, a substantial percent of justice-involved
individuals living in expansion states are now able to enroll in Medicaid.93
>>Expands coverage and parity for behavioral health treatment: The ACA
provides one of the largest expansions of mental health and substance use
disorder coverage in U.S. history. Prior to the ACA, 47.5 million Americans
lacked health insurance coverage and 25 percent of adults without health
insurance had a mental health condition or substance use disorder or both.
For Medicaid and private insurance beneficiaries, the ACA requires insurers
to cover a range of health benefits, including mental health and substance
use disorder services, greatly improving access to behavioral healthcare for
large volumes of people who come into contact with the criminal justice
system due to an unmet health need. Additionally, the ACA mandates

health plans to provide parity between behavioral health and other medical services. Parity means that health plans cannot impose treatment limits
or financial coverage requirements that are more restrictive than what they
cover for physical health. The ACA goes a step further and prohibits insurance providers from imposing annual or lifetime dollar limits for mental
health and substance use services, such as counseling, psychotherapy, and
prescription drugs. The U.S. Department of Health and Human Services
estimated that the ACA will extend behavioral health coverage to 27 million
people who previously lacked health insurance, and provide federal parity
protections to 62 million U.S. citizens overall.94

>>Reducing health disparities: The ACA has the capacity to abate health disparities by providing new federal funds to expand community-based health
initiatives, requiring enhanced monitoring of disparities, creating incentives
for diversifying the healthcare workforce and offering financial incentives
for medical professionals to work in underserved areas—all which stand to
benefit the communities most impacted by mass incarceration. The federal government should include criminal justice populations into the larger
mission to abate health disparities. For example, including jails and prisons
in population health surveys and data collection efforts to monitor health
disparities would increase transparency inside correctional settings and potentially improve the quality of care available there. Furthermore, conducting
analyses that examined the relationship between conditions of confinement
and community health would provide impetus for programming that bridges community and correctional health systems.95




There are huge
opportunities for

Increasingly, police, correctional facilities, courts, and community corrections
are forming collaborative partnerships with community health providers and
social services systems to develop solutions that steer people with treatment
needs away from jail and prison. Many of these diversionary programs (e.g.,
CITs, alternatives to arrest, alternatives to incarceration, and problem-solving
courts) are showing promise for improving utilization of health services in the
community, reducing the number of people sent to jail or prison, and saving
money. However, in many jurisdictions the capacity of diversion programs is
insufficient to serve everyone who may benefit from participating, due to their
reliance on local funding streams and/or individual grants to support the provision of treatment.

to work together

Through Medicaid expansions and improved coverage for mental health and
substance use services, the ACA creates a critical funding stream that can be used
to support and expand these front-end diversion programs. As long as people
who are referred to these programs are enrolled in a health plan, then the mental
health and addiction services that they are diverted to as part of these programs
can likely be reimbursed by Medicaid or private insurance. Thus, there are huge
opportunities for police agencies, prosecutors, and community-based service
providers to work together to develop new responses to low-level crimes that do
not result in arrest, prosecution, or incarceration and instead serve as a vehicle for
referral to behavioral health and other social services.96

to develop new


police agencies,
prosecutors, and
service providers

responses to
low-level crimes.


Historically, community health and corrections systems have operated in silos
with different cultures, funding streams, and priorities. The ongoing cultural
and organizational divide between these systems undermines continuity in
care, leads to inefficiency, and results in preventable morbidity and mortality.
Even though many large metropolitan jails deliver a quantity of health services
comparable to a medium-sized hospital, correctional health providers are detached from services, standards, technologies, and ethics of mainstream health
systems. As discussed previously, the lack of connectivity and coordination between correctional and community health systems poses considerable risks to
the health of justice-involved individuals and the communities where they live.
The ACA provides the following important tools to help bridge this divide and
rethink the points along the criminal justice continuum as opportune moments
for outreach, enrollment in health insurance, and care coordination.


The ACA requires states to develop strategies for enrolling vulnerable populations—defined as “children, unaccompanied homeless youth, children and
youth with special health care needs, pregnant women, racial and ethnic minorities, rural populations, victims of abuse or trauma, individuals with mental
health or substance-related disorders, and individuals with HIV/AIDS”—into
health insurance plans and coordinated care.97 Care coordination—the conscious effort to gather and organize a patient’s medical information from multiple care providers—is essential for promoting continuity of care planning and
preventing adverse events, especially for patients with multiple chronic medical conditions, who receive care from several health professionals, take multiple
medications, and frequently transition from one care setting to another.98
Within this frame, the ACA creates opportunities to improve outreach and
care coordination and enhance connectivity between community and correctional health systems in several ways:

>>Establishing Medicaid Health Homes: The ACA provides incentives for
states to establish Medicaid Health Homes, which are entities designed to
coordinate services for Medicaid beneficiaries with one or more chronic
conditions, including serious mental illnesses and substance abuse conditions, asthma, diabetes, and heart disease that require coordinated care
between multiple providers.99 Health homes employ “care managers” to
help their patients access health and social services from multiple providers
needed to live healthy lifestyles and reduce emergency room visits. These
care managers should work in partnership with justice agencies to also
prevent unnecessary episodes of incarceration.
Enrolling eligible justice-involved individuals into health homes can open
new doors for diversion and improve outcomes at reentry. By working
together, health homes, community treatment providers, police agencies,
public defenders, and courts can devise policies and legal mechanisms for
redirecting health home participants who come into contact with law enforcement away from incarceration and into community-based services. For
example, if pretrial service agencies and prosecutors are able to determine
that a person arrested on a low-level quality-of-life crime is a health home
member, then they may be willing to decline prosecution and hand the individual off to a community case worker.
>>Providing funding for navigators: The ACA requires states to establish
a Navigator Program to conduct outreach and education to raise public
awareness about Health Insurance Marketplaces where individuals, families, and small businesses learn about their health coverage options, choose
a plan, and enroll in coverage.100 Navigators can be trained and deployed to



conduct Medicaid enrollment, plan selection, and care coordination in criminal justice settings. For example, the Illinois Health Exchange is currently
utilizing navigators to enroll justice-involved populations into Medicaid or
other health plans and connect them to community services.

While incarceration
has clear negative
impacts on
community health,
it is important
to acknowledge
that there are
many important
opportunities to
implement health
interventions in
justice settings that
can close service gaps
and increase access
to treatment.


>> Providing opportunities to increase the role of peers and community health
workers (CHWs): CHWs are defined as community members or peer-specialists
who work in community settings and perform many different roles including: delivering culturally competent health education, engaging community
residents in health and social services, providing counseling and social support,
advocating on behalf of individuals and communities for better health services,
and working across different community health and social service systems.101
• Research shows that CHWs offer a valuable addition to healthcare work-

forces, because they are rooted in the same communities as their patients,
and are better equipped to empathize with all of their patients’ needs and
establish rapport. Research also shows that formerly incarcerated CHWs
are highly effective in engaging patients who are transitioning from correctional environments to the community in healthcare services.102

• More states should emulate the state Medicaid policies of Maine, New
York, Oregon, South Dakota, Washington, and Wisconsin, which allow
CHWs to deliver services for Medicaid beneficiaries with complex health
needs.103 Jurisdictions should also continue exploring how to employ
CHWs in community courts, probation offices, diversion programs, and
other settings to identify and engage people in community services.

With more people eligible to enroll in Medicaid and subsidized health plans, there
is a huge opportunity to redefine jails, courts, and community corrections settings as points of access to care for justice-involved individuals and their families.
Community Oriented Correctional Health Services, Treatment Alternatives For
Safe Communities, and other entities across the country are working diligently to help correctional systems establish Medicaid enrollment protocols in jails,
courts, and probation offices. While incarceration has clear negative impacts on
community health, it is important to acknowledge that there are many important
opportunities to implement health interventions in justice settings that can close
service gaps and increase access to treatment. Because they admit and release large
numbers of people every day and are located close to communities, courts, and
pretrial service agencies, jails in particular are opportune settings where community health systems can work with criminal justice agencies to bolster screening for
infectious, behavioral, and chronic medical conditions; identify people who can be
diverted to community services and those eligible for other alternatives to incar-


ceration; and conduct outreach and care engagement to help people with complex
health needs who may also have a high risk of recidivism connect to appropriate
medical and social services in the community.

Medicaid waivers are one avenue for states to extend coverage to new populations,
cover additional services, and pursue experimental pilots and demonstration projects, beyond what is in federal rules.104 State policymakers and advocates should
work together to pursue novel Medicaid waivers that explicitly permit reimbursement for a range of services provided in the community that are designed to divert
people with behavioral health needs from arrest, detention, and incarceration.
The ACA also created the Center for Medicare and Medicaid Innovation to allocate

$10 billion in federal funds to states and local reformers pursuing new payment and
service delivery models. For example, states and local jurisdictions may apply for
these funds to support programs dedicated to diverting people with chronic health
needs away from arrest and incarceration and towards community healthcare,
housing, and other social services. If new models yield measurable gains in health
outcomes and lead to cost savings, then a strong case can be made to sustain them.

Center for Medicare and Medicaid Services (CMS) innovation funding
was used to launch the Transitions Clinic Network (TCN), a network of
community clinics that partner with correctional agencies to engage
people preparing to leave prison in primary care and other services following release.* TCN clinics employ formerly incarcerated CHWs, who
complete a specially-designed certification program at local community
colleges, to deliver culturally competent care coordination for prisoners.
In a randomized trial, the TCN model has proved to be highly effective in
increasing utilization of primary care services and reducing use of hospital emergency rooms among recently released prisoners.
* Emily A. Wang et al., “Transitions clinic: creating a community-based model of health care for
recently released California prisoners,” Public health Reports 125, no. 2 (2010): 171.

Advancing health information technology is a key component of national
healthcare reform efforts to improve the ability for clinical information to flow
seamlessly between treatment providers working in different settings, inform



clinical decision making by supplying timely access to accurate information,
and empower patients by giving them more control over their own health
information. A sister legislation to the ACA, the HITECH Act of 2009, provides
financial reimbursements for healthcare providers—including qualifying correctional institutions—to adopt electronic health records (EHRs). The Bureau of
Correctional Health Services (CHS) within the NYC DOHMH, which oversees the
care of all people in the NYC jail system, is the first correctional health agency to
successfully obtain these financial reimbursements.
Data from EHRs can be used to verify a person’s health needs before or immediately upon entering the justice system, thereby increasing opportunities for
diversion and alternatives to incarceration by providing timely access to accurate
information on mental health or substance use needs. More reliable and timely
transmission of health information from correctional to community settings also
allows community-based providers to improve health outcomes and continuity

If all states expanded

of care for people returning from incarceration. For people with mental health
and substance use problems, this can significantly reduce the risk of recidivism.105

Medicaid, the number


of uninsured in the
U.S. would fall by
another 10 million.


The ACA’s potential for justice system reform varies considerably by state, with
those not adopting the Medicaid expansion continuing to experience large inequities in coverage. Nearly two-thirds of people who were originally intended to
receive coverage under Medicaid expansion reside in these states, and while other
provisions of the ACA are reducing the number of uninsured residents (including
subsidies in health insurance exchanges, the requirement to purchase insurance,
and increased participation among those currently eligible for Medicaid), millions
of low-income individuals remain without access to health insurance—a significant percentage of whom are racial and ethnic minorities.
A recent study in the New England Journal of Medicine compared mortality rate,
coverage, access to care, and self-reported health outcomes between three states
that substantially expanded Medicaid eligibility since 2000 with neighboring
states that did not. This study found significant mortality reductions and improved
health equity in expansion states, especially among adults between the ages of 35
and 64 years, racial and ethnic minorities, and people living in poor counties. This
research demonstrates the enormous potential for Medicaid expansions under the
ACA to address health disparities among poor and underserved populations.106
According to the Kaiser Family Foundation, if all states expanded Medicaid, the
number of uninsured in the U.S. would fall by another 10 million, and in conjunction with other provisions of the ACA, the number of people without health insurance would be 47.6 percent lower nationally than before the ACA was enacted.107
Correctional systems in states where justice-involved individuals remain
ineligible for Medicaid will have more difficulty capitalizing on the benefits of
the ACA for justice system reform. A 2014 GAO report found that between 72
percent and 90 percent of inmates were Medicaid eligible in three expansion


states (New York, Colorado, and California), compared with just two percent in
non-expansion North Carolina.108

Mass incarceration is one of the great public health challenges of our times.
Going forward, it is essential to continue acknowledging that many of the laws,
policies, and practices set into motion during the acceleration of the prison
boom have exacerbated structural inequalities in communities where the majority of residents are from historically oppressed groups.109 It is also important
to continue examining how these inequalities manifest in population health
disparities. Doing so is important not only to understand the impact of the past
40 years of criminal justice policy on population health, but also as a tool to en-

ergize intersectoral commitment to design, implement, and evaluate reforms to
meaningfully reduce mass incarceration and improve the social environments
and health of the communities that have been most affected.
The burden of disease behind bars is unacceptably high and largely invisible
to the health system, and the negative impacts of incarceration on the health of
communities is a serious issue. Some states and local governments are making
progress in reducing their prison populations and implementing legal reforms
and programmatic interventions that help sustain lower rates of incarceration and, across the political divide, the appetite among governments to drive
down prison populations and invest in community solutions is growing. Health
reform through the ACA creates momentous opportunities to improve access
to health services in communities most impacted by mass incarceration in a
number of ways. It creates opportunities at the state and local level for leadership and innovation—which involves strategically using the funding streams of
the ACA to bolster diversion initiatives.
While the ACA offers unprecedented opportunities to advance a new wave of
criminal justice reform, it is not a panacea for abating the public health consequences of mass incarceration. Much more is needed to undo the now intergenerational damage done to whole communities by our overly punitive criminal
justice system.
The social determinants of health or SDH framework—whose central idea is
that human health is, in large part, determined by a range of social, economic,
and political forces beyond the control of the individual—offers a model for
states to dissect the current laws, policies, and practices that sustain overcrowded jails and prisons, undermining the prospects for economic security and
causing families and communities an unwarranted degree of suffering. It also
provides a platform for designing comprehensive plans to overhaul the justice
system and develop intersectoral solutions to put the nation on the path of exiting the era of mass incarceration and restoring the health and sense of justice
in communities that have felt its heavy hand.




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PPACA, Section 2703

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University Press, 2010).





The author would like to thank Nick Turner and Jim Parsons for their leadership
and commitment to advancing the Justice Reform for Healthy Communities
initiative. I would especially like to thank Mary Crowley, Chris Munzing, Patricia
Connelly, and David Hanbury for their invaluable contributions in editing, producing, and disseminating this publication.

© Vera Institute of Justice 2014. All rights reserved. An electronic version of this report is posted on Vera’s website

The Vera Institute of Justice is an independent nonprofit organization that combines expertise in research, demonstration projects,
and technical assistance to help leaders in government and civil society improve the systems people rely on for justice and safety.
For more information, visit

For more information about this report or Vera’s Justice Reform for Healthy Communities initiative, contact David Cloud, senior
program associate, Substance Use and Mental Health Program, at

About Justice Reform for Healthy Communities
Mass incarceration has become one of the major public health challenges
of our time. The millions of people who cycle through our nation’s courts,
jails, and prisons every year experience far higher rates of chronic health
problems, infectious diseases, substance use, and serious mental illness
than the general population. Justice Reform for Healthy Communities
is a year-long initiative of the Vera Institute of Justice that aims to
improve the health and well-being of individuals and communities most
affected by mass incarceration. Guided by a national advisory board
comprised of public health and criminal justice policymakers, practitioners,
researchers, and advocates, the initiative advances its mission through
public education, coalition building, briefings, and publications.
Suggested Citation
David Cloud. On Life Support: Public Health in the Age of Mass Incarceration. New
York, NY: Vera Institute of Justice, 2014.

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