Incapacitating Debt: Investigating the Community-Wide Effects of Incarceration on Medical Debt

Abstract

This study examines the relationship between community incarceration rates and medical debt in the United States using annual county-level data from 2012 to 2019. We account for stable and varying county-level dynamics through fixed effects regression models with controls for demographics, socioeconomic status, insurance coverage, health, and crime rates. Nationally, we find increased incarceration is associated with reduced median medical debt and has no effect on the share of the population with medical debt, but we find that these patterns vary by racial and ethnic composition. Non-white communities experience worsening medical debt as incarceration rises while white communities do not. Our results suggest incarceration has a complicated relationship with medical debt and is detrimental for communities of color.

Keywords

community corrections spatial analysis quantitative

Get full access to this article

View all access options for this article.

References

Anderson

(2024). Medical debt behind bars: The punishing impact of copays, fees, and other carceral medical debt. National Consumer Law Center. https://www.nclc.org/wp-content/uploads/2024/09/202409_Report_Medical-Debt-Behind-Bars.pdf

Anderson

C. N.

Wooldredge

Cochran

J. C.

(2022). Can “race-neutral” program eligibility requirements in criminal justice have disparate effects? An examination of race, ethnicity, and prison industry employment. Criminology & Public Policy, 21(2), 405–432. https://doi.org/10.1111/1745-9133.12576

Archibald

M. E.

Putnam Rankin

(2013). A spatial analysis of community disadvantage and access to healthcare services in the U.S. Social Science & Medicine, 90, 11–23. https://doi.org/10.1016/j.socscimed.2013.04.023

Bares

K. J.

Mowen

T. J.

(2019). Examining the parole officer as a mechanism of social support during reentry from prison. Crime & Delinquency, 66(6–7), 1023–1051. https://doi.org/10.1177/0011128719881599 (Original work published 2020)

Bhutta

Chang

A. C.

Dettling

L. J.

Hsu

J. W.

(2020). Disparities in wealth by race and ethnicity in the 2019 Survey of Consumer Finances. FEDS Notes.Board of Governors of the Federal Reserve System. https://doi.org/10.17016/2380-7172.2797

Blavin

Braga

Johnson

Wekulom.

(2024). The changing medical debt landscape in the United States: Technical appendix. Urban Institute. https://urban-data-catalog.s3.amazonaws.com/drupal-root-live/2024/07/02/Technical%20Appendix%20Changing%20Medical%20Debt%20Landscape%20in%20the%20United%20States.pdf

Board of Governors of the Federal Reserve System. (2020). Report on the economic well-being of U.S. households in 2019, featuring supplemental data from April 2020. https://www.federalreserve.gov/publications/files/2019-report-economic-well-being-us-households-202005.pdf

Bounoua

Sadeh

Payne

Y. A.

Hitchens

B. K.

(2023). Structural barriers explain the link between negative community re-entry experiences and motives for illegal behavior in street-identified Black men and women. American Journal of Community Psychology, 73(1–2), 280–293. https://doi.org/10.1002/ajcp.12713

Calvert

J. M.

Dickson

M. F.

Tillson

Pike

Staton

(2021). Rural re-entry and opioid use: Identifying health-related predictors of relapse among formerly incarcerated women in Appalachia. Journal of Appalachian Health, 3(3), 22–35. https://doi.org/10.13023/jah.0303.03

10.

Carson

E. A.

Nadel

Gaes

(2022). Impact of COVID-19 on state and federal prisons, March 2020–February 2021. Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/icsfp2021.pdf

11.

Clear

T. R.

(2007). Imprisoning communities: How mass incarceration makes disadvantaged neighborhoods worse. Studies in Crime and Public Policy.

12.

Craigie

T. A.

Grawert

Kimble

(2020). Conviction, imprisonment, and lost earnings: How involvement with the criminal legal system deepens inequality. Brennan Center for Justice. https://www.brennancenter.org/our-work/research-reports/conviction-imprisonment-and-lost-earnings-how-involvement-criminal

13.

Dean

(2024, October 30). The racial wealth gap 1992 to 2022. National Community Reinvestment Coalition. https://ncrc.org/the-racial-wealth-gap-1992-to-2022/

14.

deVuono-powell

Schweidler

Walters

Zohrabi

(2015). Who pays? The true cost of incarceration on families. Ella Baker Center for Justice. https://ellabakercenter.org/wp-content/uploads/2022/09/Who-Pays-FINAL.pdf

15.

Elderbroom

Mayer

Rose

(2025). We can’t afford it: Mass incarceration and the family tax. FWD.Us.https://www.wecantaffordit.us/pdf/We%20Can't%20Afford%20It%20Report%20-%20FWD.us.pdf

16.

Fines & Fees Justice Center. (2022). Electronic monitoring fee: A 50-state survey of the costs assessed to people on E-supervision. https://finesandfeesjusticecenter.org/wp-content/uploads/2022/09/FFJC-Electronic-Monitoring-Fees-Survey-2022.pdf

17.

Ganong

Jones

Noel

P. J.

Greig

F. E.

Farrell

Wheat

(2020). Wealth, race, and consumption smoothing of typical income shocks (NBER Working Paper No. 27552). National Bureau of Economic Research. http://www.nber.org/papers/w27552

18.

Ghandnoosh

(2023). One in five: Ending racial inequity in incarceration. The Sentencing Project. https://www.sentencingproject.org/reports/one-in-five-ending-racial-inequity-in-incarceration/

19.

Ginapp

Aminawung

J. A.

Harper

Puglisi

L. B.

(2023). Exploring the Relationship between Debt and Health after Incarceration: A Survey Study. Journal of urban health: bulletin of the New York Academy of Medicine, 100(1), 181–189. https://doi.org/10.1007/s11524-022-00707-6

20.

Harper

Ginapp

Bardelli

Grimshaw

Justen

Mohamedali

Thomas

Puglisi

(2020). Debt, incarceration, and re-entry: A scoping review. American Journal of Criminal Justice, 46(2), 250–278. https://doi.org/10.1007/s12103-020-09559-9

21.

Heggie

Fuller

Goudreau

Paynter

(2025). Health outcomes and healthcare access experiences of incarcerated and recently released women in rural areas: a scoping review. Rural and remote health, 25(2), 9618. https://doi.org/10.22605/RRH9618

22.

Houle

J. N.

Addo

F. R.

(2018). Racial disparities in student debt and the reproduction of the fragile black middle class. Sociology of Race and Ethnicity, 5(4), 562–577. https://doi.org/10.1177/2332649218790989 (Original work published 2019)

23.

Jannetta

Breaux

Porter

(2014). Examining racial and ethnic disparities in probation revocation subtitle: Summary findings and implications from a multisite study. Urban Institute. https://www.urban.org/research/publication/examining-racial-and-ethnic-disparities-probation-revocation

24.

Kang-Brown

Zhang

(2024). People in jail and prison in 2024. Vera Institute. https://vera-institute.files.svdcdn.com/production/downloads/publications/People-in-Jail-and-Prison-in-2024-Full-Reportpdf.pdf?dm=1732209022

25.

Kaplan

(2024). Summary Reporting System (SRS) - Offenses known and clearances by arrest (Return A) (Version 4) [Data set]. Harvard Dataverse. https://doi.org/10.7910/DVN/OESSD1

26.

Kerrison

E. M.

(2017). An historical review of racial bias in prison-based substance abuse treatment design. Journal of Offender Rehabilitation, 56(8), 567–592. https://doi.org/10.1080/10509674.2017.1363114

27.

Martin

K. D.

Sykes

B. L.

Shannon

Edwards

Harris

(2018). Monetary sanctions: Legal financial obligations in US systems of justice. Annual Review of Criminology, 1(1), 471–495. https://doi.org/10.1146/annurev-criminol-032317-091915

28.

Maruschak

L. M.

Bronson

Apler

(2021). Survey of prison inmates, 2016: Medical problems reported by prisoners. Bureau of Justice Statistics. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/mprpspi16st.pdf

29.

Matz

A. K.

Conley

T. B.

Johanneson

(2017). What do supervision officers do? Adult probation/parole officer workloads in a rural Western state. Journal of Crime and Justice, 41(3), 294–309. https://doi.org/10.1080/0735648x.2017.1386119

30.

McCoy

E. F.

Russo

(2018). Implementing alternatives to incarceration for women in rural communities: Lessons learned from Campbell County, Tennessee. Urban Institute. https://www.urban.org/research/publication/implementing-alternatives-incarceration-women-rural-communities

31.

Mihaly

McCaffrey

Sass

T. R.

Lockwood

J. R.

(2012). Where you come from or where you go? Distinguishing between school quality and the effectiveness of teacher preparation program graduates (Working Paper 12-12). Andrew Young School of Policy Studies Research Paper Series. https://doi.org/10.2139/ssrn.2020722

32.

Mueller

(2024). Prisons report series: Preliminary data release, 2023. Bureau of Justice Statistics. Preliminary Data Release - Prisons, 2023 | Bureau of Justice Statistics.

33.

Puglisi

Calderon

J. P.

Wang

E. A.

(2017). What does health justice look like for people returning from incarceration? AMA Journal of Ethics, 19(9), 903–910. https://doi.org/10.1001/journalofethics.2017.19.9.ecas4-1709

34.

Rakshit

Rae

Claxton

Amin

Cox

(2024). The burden of medical debt in the United States. https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/

35.

Sawyer

Wagner

(2025, March 11). Mass incarceration: The whole pie 2025. Prison Policy Initiative. https://www.prisonpolicy.org/reports/pie2025.html

36.

Schaefer

Williamson

(2017). Probation and parole case management as opportunity-reduction supervision. Journal of Offender Rehabilitation, 56(7), 452–472. https://doi.org/10.1080/10509674.2017.1359225

37.

Spears

(2021, May 19). How medical debt affects health – A review of the evidence. The Sycamore Institute. https://sycamoretn.org/how-medical-debt-affects-health/

38.

Steinmetz

K. F.

Anderson

J. O.

(2016). A probation profanation: Race, ethnicity, and probation in a Midwestern Sample. Race and Justice, 6(4), 325–349. https://doi.org/10.1177/2153368715619656 (Original work published 2016)

39.

Steinmetz

K. F.

Henderson

(2015). Inequality on probation: An examination of differential probation outcomes. Journal of Ethnicity in Criminal Justice, 14(1), 1–20. https://doi.org/10.1080/15377938.2015.1030527

40.

Testa

Porter

L. C.

(2023). Previous incarceration, health insurance, and the Affordable Care Act in the U.S. American Journal of Preventive Medicine, 65(6), 1034–1041. https://doi.org/10.1016/j.amepre.2023.06.014

41.

Tuttle

Jacobson

Rydberg

Henning-Smith

(2024). Understanding the impact of medical debt in rural communities: Perspectives from rural hospital administrators. UMN Rural Health Research Center. https://rhrc.umn.edu/wp-content/uploads/2025/04/Understanding-the-Impact-of-Medical-Debt-in-Rural-Communities.2025-Revised.pdf

42.

United States Department of Health and Human Services. (n.d.). Healthy People 2030: Incarceration. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/incarceration

43.

Wagner

(2003). County of conviction and prisoner residence. Prison Policy Initiative. https://www.prisonersofthecensus.org/news/2003/10/20/conviction/

44.

Weller

C. E.

Amaning

Vallas

(2022). America’s broken criminal legal system contributes to wealth inequality. Center for American Progress. https://www.americanprogress.org/article/americas-broken-criminal-legal-system-contributes-to-wealth-inequality/

45.

Western

Pettit

(2010). Incarceration and social inequality. Deadalus, 139(3), 8–19. https://scholar.harvard.edu/files/brucewestern/files/westernpettit10.pdf

46.

Widra

(2024). State of Incarceration: The Global Context 2024. Prison Policy Initiative. https://www.prisonpolicy.org/global/2024.html

47.

Wilper

A. P.

Woolhandler

Boyd

J. W.

Lasser

K. E.

McCormick

Bor

D. H.

Himmelstein

D. U.

(2009). The health and health care of US prisoners: Results of a nationwide survey. American Journal of Public Health, 99(4), 666–672. https://doi.org/10.2105/ajph.2008.144279

48.

Zhao

Han

Zheng

Fan

Shi

Fedewa

Yabroff

K. R.

Nogueira

(2023). Incarceration history and health insurance and coverage changes in the U.S. American Journal of Preventive Medicine, 64(3), 334–342. https://doi.org/10.1016/j.amepre.2022.09.023