Access to Surgery and Health Care for Justice-Involved Individuals

Abstract

Justice-involved individuals, encompassing those with prior interactions with the correctional system, represent a population with significant unmet healthcare needs. Approximately 95% of incarcerated individuals return to society, often with unresolved chronic conditions or infectious diseases such as HIV and Hepatitis C, and face considerable barriers to accessing healthcare. Institutional constraints, logistical complications, inadequate resources, and cultural biases exacerbate disparities, contributing to suboptimal health outcomes and public health risks. Healthcare access for justice-involved individuals is hindered by multiple factors, including limited availability of medications like opioid use disorder treatments, restricted surgical and preventive care, and systemic challenges in initiating healthcare. The suspension of Medicaid during incarceration, compounded by high uninsurance rates post-release, further exacerbates these inequities. Despite legislative efforts such as the Affordable Care Act and state-level policies addressing restraint use, healthcare services for this population remain inadequate and inconsistent. Recommendations include leveraging correctional facilities to enhance healthcare delivery, incorporating justice-involved populations in hospital design and planning, and fostering collaborations between correctional facilities and healthcare organizations. Training healthcare professionals in correctional medicine and tailoring care programs to justice-involved patients’ needs are critical. Research should focus on improving care models, expanding insurance enrollment initiatives, and addressing long-term health outcomes for this vulnerable group. Efforts to integrate justice-involved individuals into broader healthcare frameworks can reduce health disparities, improve public health, and promote equitable access to care. Addressing these systemic issues requires collaborative approaches across healthcare, correctional, and policy sectors.

Introduction

The term “justice-involved” refers to individuals with previous interactions with the correctional system as defendants and comprises those who may have been detained, arraigned, or imprisoned. ¹ Approximately 95% of the incarcerated population return to society, bringing with them any unresolved health issues. These may include infectious diseases such as HIV, hepatitis C, and other sexually transmitted infections, which all display an increased prevalence among incarcerated individuals. Additionally, up to 43% of justice-involved individuals have at least 1 chronic condition, such as diabetes or hypertension. ² With approximately 2.1 million justice-involved individuals incarcerated, the quality of health services provided in prisons significantly impacts a large segment of the population. ³ Consequently, establishing and enforcing health care for justice-involved individuals is important not only to the individuals themselves but also to the population at large.

Despite this need, justice-involved individuals access health care at far lower rates than the general population. ⁴ This disparity leads to suboptimal health outcomes, posing not only a violation of their human right but a long-term health risk to the general population. As such, medical practitioners are duty-bound to address this gap in health services in pursuit of personal and public health.

Institutional Barriers to Health Care

Providing health care services to incarcerated patients involves several significant challenges, which include logistical complications, initiation of health care, access to medication and health insurance, limited resources, continuity of care, and cultural perceptions. Furthermore, hospitalization of a justice-involved patient incurs further expenditures such as secure roundtrip transportation to and from the hospital and patient security. Correctional facilities usually have designated housing arrangements for different groups of inmates, including those with health complications. However, the on-site facilities and equipment of many correctional organizations are inadequate, necessitating reliance on hospitals for consultations, surgeries, and treatment. ⁵ Addressing these challenges requires collaboration between correctional facilities, health care providers, policymakers, and the incarcerated individuals themselves to create a more equitable and effective health care system.

Several examples highlight the implications regarding the care justice-involved patients receive within medical facilities. Imprisoned populations are often constrained while obtaining health care solely due to their criminal legal status. ⁶ Shackling justice-involved patients in health care settings can significantly limit their physical movement and health and technical care for reasons that are not clinically crucial. This practice is sometimes applied to incarcerated expectant mothers during the peripartum period, which may put the health of both the mother and fetus at risk and hinder the clinician’s ability to provide safe and effective care. ⁷ Importantly, similar practices with implications for health equity are beginning to be addressed through legislation. As of January 2024, 42 states and Washington D.C. have passed regulations that restrict the use of restraints for a limited duration. ⁷ Furthermore, New York City guidelines disallow standard shackling of imprisoned patients besides protected health areas in metropolitan health facilities. ⁶

The neglect of the significance of justice-involved individuals in literature has perpetuated health disparities and missed opportunities to address behaviors leading to imprisonment. One crucial focus should be the treatment of incarcerated patients within hospital systems to assess and address their unique needs. Despite ongoing legislative efforts to address issues of health disparities on state and federal levels, the care essentials of the justice-involved still go unrecognized across the country. ⁸

Surgical Logistical Complications

The surgical care of justice-involved patients entails specific challenges that require careful planning and adjustments to standard practices. Scheduling surgeries without informing the patient of the exact date is often necessary to maintain security and reduce the risk of escape or violence; however, this approach can increase patient anxiety and complicate preoperative preparation, affecting both patient experience and procedural outcomes. ⁹ Additionally, critical cancer screenings—such as colonoscopies, mammograms, and PSA testing for colorectal, breast, and prostate cancer, respectively—often face delays due to logistical constraints and security protocols within correctional facilities. ⁶ These delays hinder early detection and timely intervention, potentially worsening health outcomes in an already vulnerable population. ² To address these challenges, it is essential to implement tailored scheduling protocols, improve access to screenings, and address the logistical barriers that hinder justice-involved patients from receiving timely, high-quality surgical and preventive care.

Initiation of Health Care

Along the access to health care timeline, the first issue encountered in bridging the gap in health services faced by justice-involved individuals is the initiation of health care, which is influenced by medical and security staff in Correctional Service facilities. Agencies may prioritize community safety over encounters, leading to a perception that health care testing and treatment are not a duty of their role. ¹⁰ Additionally, medical staff shortages within correctional service agencies, combined with the overcrowding of these facilities, may foster an attitude of ambivalence toward the health care management of the justice-involved individuals and create a culture of cynicism and fear.^2,11 Such a culture may not only impede the initiation of health care by prisoners but encourage an apathy to health follow-up and maintenance. It is, however, pertinent to note that since the 1976 Supreme Court decision in Estelle v Gamble, which deemed a deliberate indifference to the medical needs of prisoners as a violation of the Eighth Amendment’s prohibition of cruel and unusual punishment, there has been a significant increase in the access to health care by justice-involved individuals. ¹² Despite this progress, justice-involved individuals continue to access health care at lower rates than the general population, highlighting the need for further reform and evaluation of the services provided to this vulnerable population.

Access to Medication

A further—but similarly concerning—issue affecting justice-involved individuals’ ability to access health care services is their access to medication. Up to 70% of justice-involved individuals suffer from some form of substance use disorder, a significant portion of which is opioid dependency.^13,14 Opioid use disorder, for example, is treated very effectively by methadone and buprenorphine as first-line medications^15,16 and has been demonstrated to be associated with reduced heroin use, likelihood of repeat overdose, and mortality.^16,17 Despite their documented merits, vulnerable populations receive these treatments at far lower rates than their counterparts. Given that increased opioid usage has been associated with higher rates of involvement with the justice system, ¹⁸ this population has a higher prevalence of opioid use disorders. ¹⁹ Access to certain medications is restricted or unavailable simply by virtue of being provided in incarcerated settings, ²⁰ while some health care providers are hesitant to prescribe them due to concerns about non-prescribed applications of medications or the re-sale of these medications by justice-involved individuals. ²¹

The limitation on opioid medications is especially pertinent to surgical patients, in whom opioid medications serve a critical role in pain management and recovery. Increasing importance has been placed on effective pain control post-operatively to improve post-surgical outcomes and recovery, yet medical staff in correctional facilities may be hesitant to or resist administering these necessary medications to inmates. Care needs to be taken by medical practitioners in all settings to provide optimal care for these patients, regardless of their context, which will require both systematic and cultural re-adjustment.

Constitutional Implications and Access to Health Insurance

Finally, the right to treatment is afforded to prisoners under the Supreme Court’s interpretation of the Eighth Amendment (protection against cruel and unusual punishment) and the Fourteenth Amendment (equal protection and due process clauses.) ¹² As such, the cost of care while incarcerated is not a concern for justice-involved individuals, given that it is covered by the state. Federal regulations also dictate that Medicaid funds cannot be applied to incarcerated populations and, hence, must be either suspended or terminated during their term.^22,23 However, as mentioned previously, 95% of prisoners return to society, and up to 80% of them are without health care insurance coverage upon re-entry. ² Consequently, this population has historically been identified as having inadequate access to health care due to their lack of coverage.^14,24-26 Furthermore, impedance to their care includes factors such as difficulty in navigating and understanding the health care system after release, discontinuity in medication access during incarceration, and a paucity of behavioral health services. ¹⁴ Studies have also demonstrated that mortality rates among inmates approach 13 times higher than the general populace in the first 2 weeks following release. ²²

The Affordable Care Act, implemented in 2010, has made it easier for justice-involved individuals to be able to attain health insurance post-release ²⁷ and has, in fact, resulted in a decrease in the uninsurance rate of all ages directly as a result of increased Medicaid enrollment following the Medicaid expansion and the individual mandate under the Affordable Care Act in 2014. Nonetheless, uninsurance rates among justice-involved individuals remain twice as high as the general population. It has also been demonstrated that despite the decreased rate of uninsurance among this vulnerable population, treatment for issues such as substance use disorder remained lower, which suggests further hindrances in health care access for the justice-involved. ¹⁴

Even before the implementation of the Affordable Care Act, enrollment in Medicaid for the justice-involved with severe mental illnesses demonstrated an increased utilization of health services and decreased recidivism.^28,29 This demonstrates that dedicated efforts to enroll such populations can not only improve health equity but also decrease crime and re-incarceration rates. ²² This realization increased efforts to mitigate the difficulty of post-release inmates to obtain health insurance. Such initiatives include the following:

(1) The suspension of Medicaid upon incarceration instead of termination.

(2) Presumptive eligibility, wherein inmates are presumed to be eligible for health insurance and may receive health care under this premise instead of having to wait to be approved to engage health care services.

(3) Pre-emptively authorizing enrollment while incarcerated.

(4) Accepting alternative forms of identification, where the conventionally required forms of identification for enrollment in Medicaid may not be easily accessible for inmates. ²²

Even with the knowledge that the increased availability of enrollment in Medicaid and other health insurance schemes increases health care access and health equity among justice-involved individuals, only 64 programs in the United States have been identified as taking extra measures to afford these services to such a vulnerable population. ²² Not only is it pertinent to employ such measures more ubiquitously, but more research needs to be done to identify novel ways of improving access to health care in justice-involved individuals at both the state and individual levels.

Recommendations

(1) Penitentiaries hold significant latent potential to play a substantial role in refining health care in a historically and institutionally vulnerable population. ² Correctional facilities should aim to deliver administration to support admission efforts but also to utilize funding for the justice-involved to increase collaborations with Managed Care Organizations (MCOs) either in person, by videoconference, or telephonically. ³⁰

(2) To date, no studies have examined how integrating justice-involved into the planning stages of new hospital constructions can improve clinical care outcomes. By examining the current level of justice-involved literacy among facility designers, we can identify the best practices for training and facility design that can serve this population.

(3) Some individuals in custody require a higher level of care than can be provided in jail, yet their conditions are not acute enough to warrant inpatient hospitalization. Addressing the health care needs of the justice-involved while making significant investments in health through hospital facilities could pioneer a new approach to justice reform ³¹ and afford an increased availability of facilities to treat patients at varying levels of health care needs. For the population studied, corrections officials should aim to assess the costs and feasibility of utilizing specialized services off-site vs on-site. ⁵

(4) When planning new hospitals, incorporating justice-involved considerations is essential. Medical facilities have identified improving patient outcomes and approval scores as especially significant objectives for space restructuring. ³² Based on the findings, it is recommended that hospitals should involve considerations for all stakeholders, including justice-involved individuals, in decision-making processes.

(5) Health care professionals, including psychologists, psychiatrists, surgeons, and nurses, would benefit from early exposure to the justice-involved population or additional training in correctional medicine to better understand the public health needs in this field. ³³ Additionally, programs should be tailored to the individual health care needs of justice-involved patients to receive proper health care services.

Conclusion

There are several types of health care services available outside of prisons, including off-site care, inpatient hospitalization, and outpatient care. ⁵ Regardless of the type of health care provided, the training of medical staff within the context of justice-involved individuals is crucial for the safety and preparedness of the health care community. ³⁴ Future research should aim to investigate how we better acknowledge and provide for the existence of justice-involved populations within medical settings. More importantly, data-driven measures need to be elucidated and employed to improve access to health care in vulnerable populations such as these. Longitudinal studies are also required to understand the long-term benefits and outcomes of justice-involved patients within hospitals where hospital staff are specifically trained to work with such populations.