by Leah Wang

Over 1 million people sit in U.S. state prisons on any given day. These individuals are overwhelmingly poor, disproportionately Black, Native, Hispanic, and/or LGBTQ, and often targeted by law enforcement from a young age, as we detailed recently in our report Beyond the Count. And all too often, they are also suffering from physical and mental illnesses, or navigating prison life with disabilities or even pregnancy. In this, the second installment of our analysis of a unique, large-scale survey of people in state prisons, we add to the existing research showing that state prisons fall far short of their constitutional duty to meet the essential health needs of people in their custody. As a result, people in state prison are kept in a constant state of illness and despair.

Instead of “rehabilitating” people in prison (physically, mentally or otherwise), or at the very least, serving as a de facto health system for people failed by other parts of the U.S. social safety net, data from the most recent national Survey of Prison Inmates show that state prisons are full of ill and neglected people. Paired with the fact that almost all of these individuals are eventually released, bad prison policy is an issue for all of us — not just those who are behind bars.

About the Unique Data Used in This Report

This report offers a detailed view of the people in state prisons nationwide, using the most recent self-reported, nationally representative data available, the Bureau of Justice Statistics’ 2016 Survey of Prison Inmates. Though correctional populations are in constant flux, the Survey data released just over a year ago are essential to understanding incarceration today.

While the Bureau of Justice Statistics, the federal agency that collected the data, has published its own series of reports based on its findings, we designed this report to include many details overlooked in the government’s reports. We surface important details about identity, life experiences, health, and more. Where we can, we compare the data to those collected in decades prior or to measures of the general U.S. population, to get a sense of how prison populations compare and how state policies have changed, or remained stagnant.

Readers may already be asking how the data look by state, or when we’ll have more current data. Unfortunately, these survey data are not available state-by-state, and we estimate it may be another several years before the survey is fielded again (this survey has not been on a regular publication schedule since 2004, with 12 years between the two most recent data collections). But the information presented here is a powerful supplement to other state-specific incarceration data, creating a strong foundation for advocacy and sound policymaking.

Physical Health Problems: Chronic Conditions and Infectious Disease 

 The 2016 Survey data show that huge proportions of people in state prisons are impacted by disease, disability, and/or mental illness. As we detail below, incarcerated people have higher rates of certain chronic conditions and infectious diseases compared to the general U.S. population in many, but not all, cases. In cases where rates of illness are not higher, we must consider that rates of undiagnosed conditions and disease among incarcerated people are likely to be higher due to inadequate screening before and during prison. In addition, people in prison rely on — and are burdened by — having to request medical appointments through correctional staff, and having to pay unaffordable fees (“co-pays”) for care.

It’s important to remember that these comparisons are not intended to show that prisons are “good” or “bad” at managing particular conditions, but rather to show the overall frequency of illness in prisons, and question the uniquely American policy of locking up so many infirm and high-need people. Instead of asking, “should cancer prevalence be higher or lower in prisons?” a better question is, “why should a 70-year-old with cancer and heart disease be locked up at all?”

While an incarcerated individual’s health issues may begin before arrest, incarceration often exacerbates problems or creates new ones. Being locked up in and of itself causes lasting damage to one’s health and to loved ones’ health, including children born to justice-involved parents. People in prison have a constitutional right to basic healthcare, but that care tends to be reactionary, designed to treat acute health care problems rather than to prevent or effectively treat chronic disease. When it comes to some of the major public health breakthroughs of recent history — like gold-standard substance use treatment — incarcerated people have largely been left behind.

Many basic health-related findings from the Survey have been reported by the Bureau of Justice Statistics, but here we offer further demographic breakdowns by gender, race and ethnicity, and age, wherever we find notable differences. In some cases, we find that people in state prisons have much higher rates of illness compared to the general public:

More than 1 in 6 (17%), and the same percentage of older people (here, defined as people 55 and older), reports being diagnosed with asthma, compared to just 8% of U.S. adults who currently have it. Asthma, like mass incarceration, is a burden that falls disproportionately upon particular communities; the highest rates in the Survey belong to Black (18%), Native (18%), and multiracial people (20%). And considering that asthma can be triggered by mold, dust mites, air pollution, and pests — all things found in poorly maintained, harmfully sited prisons — asthma is a serious problem for incarcerated people.

Half (49%) of people in state prisons (but 59% of women) met the criteria for a substance use disorder in the 12 months before entering prison. This represents a decrease from 59% in the previous (2004) survey, but 49% is still an enormous proportion, compared to the 7.5% of U.S. adults that struggled with substance use disorder in 2016. Native people have the highest rates (62%) of substance use disorder, but white and multiracial people also have rates over 50% each. Prisons have an opportunity to provide high-quality, effective drug treatment to those who opt in, yet few actually do this. Instead, drugs and substance use disorder are incredibly common in prisons, and the likelihood of overdose death skyrockets upon release.

One in 10 (9.5%) people in state prison — including 16% of women and 21% of people over 55 — has been diagnosed with hepatitis C at some point, which is more than five times the estimated rate of U.S. adults with the viral infection. This is no coincidence: Hepatitis C risk is elevated among people who use drugs, and drug use is a common thread for people leading up to, and sometimes during, their prison sentence. Modern treatment for hepatitis C has a high cure rate, yet 80% of people in state prison who had ever been diagnosed with it still have it — reflecting the unwillingness of state prison systems to provide appropriate treatment, even at the expense of public health.

Including those with hepatitis C, 17% of people in state prisons have contracted an infectious disease at some point, and like hepatitis C, rates tend to be higher as compared to the general U.S. population. About 1.2% of people report ever having hepatitis B, compared to less than 0.5% of the U.S. population who have a chronic case of the infection. And 1.1% have a history of HIV/AIDS, compared to less than 0.5% of people in the U.S. over age 13. Infectious diseases spread more easily throughout congregate settings like prisons and can then spread to other facilities and communities through staff and transfers; in this way, mass incarceration was a key contributor to the high COVID-19 caseloads in certain communities in 2020.

While the prevalence of infectious disease has come down significantly since the last version of the Survey in 2004 (again, the most recent Survey was conducted pre-COVID), rates of many current medical problems reported by people in prison have increased.

For some other medical conditions, rates are comparable between incarcerated and non-incarcerated people, as we discuss in the findings below. But this is not to say that these conditions are “not problems” in prisons. Because people in state prisons face challenges to their physical and mental health on a daily basis, they need at least the same level of care as they might on the outside, which we know is not their reality. Finally, rates of medical problems are always much higher for older people (again, here defined as those ages 55 and older), painting a bleak picture of what it’s like to age in prison.

Our analysis shows that, among people in state prisons:

About 7% (and 23% of older people, ages 55+) have been diagnosed with heart disease at some point in their life. While heart disease is a leading cause of death both inside and outside of prison, the carceral environment makes it difficult for people inside to pursue a lifestyle and diet that staves off these problems.

About 29% (and 62% of older people) have been diagnosed with hypertension (high blood pressure), rates similar to those seen in the general population in 2016. However, literature on undiagnosed hypertension in the “noninstitutionalized” U.S. population (a regrettable example of carceral exclusion from public health research) shows that over 1 in 6 people with hypertension are unaware of their condition. This suggests that actual rates are far higher than diagnosed rates of hypertension, even among non-incarcerated populations.

About 8% (and 23% of older people) have been diagnosed with diabetes, another common condition nationwide that prisons and other correctional facilities frequently fail to treat. Diabetes requires careful management of blood sugar levels, and several lawsuits show outright neglect of life-or-death situations when diabetic incarcerated people needed timely food, insulin, or medical equipment. Both diabetes and hypertension are known risk factors for heart disease and stroke.

About 18% (and 45% of older people) have been diagnosed with arthritis or other rheumatic diseases like rheumatoid arthritis, gout, fibromyalgia, or lupus, which cause pain and inflammation, among other symptoms. Some of these are autoimmune diseases which can be brought on by exposure to stress; we know stressful situations like violence occur in prison regularly, but people in prison often experience trauma well before incarceration, such as parental incarceration and early contact with law enforcement.

About one-fourth (26%) have a body mass index considered normal or underweight, as in the U.S. more broadly. Almost half (46%) are categorized as “overweight” and the remaining 28% are considered obese. This actually represents a slightly lower obesity rate than among all U.S. adults, but prison diets hardly promote public health: Incarcerated people are forced to eat what the public has been specifically “advised to avoid for decades,” but in insufficient quantities, forcing often unhealthy commissary purchases for those who can afford it. As a result, both weight gain and weight loss can happen in prison.

Access to Healthcare: People Who Go to State Prison Disproportionately Lack Health Insurance Before Incarceration

The number of health problems reported by incarcerated people may be partially explained by their difficulty accessing healthcare before incarceration: half (50%) of people in state prisons lacked health insurance at the time of their arrest. That’s a devastating rate of uninsured people compared to the overall population: Between 2008 and 2016, the highest rate of uninsured people in the U.S. was just 15.5%. Those in state prison with insurance before arrest generally received it from either an employer (39% of the insured) or through Medicaid (32%). This high level of participation in Medicaid, a program serving those who cannot afford healthcare premiums, tracks with our previous finding that people in prison are far poorer, on average, than their non-incarcerated peers.

For some people, then, prison actually improves access to healthcare: Over one-fourth (27%) of people in state and federal prisons who came to prison with a chronic condition were first diagnosed with it while incarcerated. This sounds like a victory in terms of prison healthcare, but it speaks more to the utter failure of the U.S. healthcare system to serve everyone, especially the most marginalized. Moreover, prison healthcare falls short of the constitutional duty to care for those in custody. While most (81%) people in state prison report having seen a healthcare provider at least once since admission, that leaves nearly 1 in 5 (19%) who have gone without a single health-related visit since entering prison.

And as a result of such inadequate healthcare, many people in prison end up worse off upon release, or dying prematurely, realities that aren’t covered in the Survey data. Cancer, for example, is more deadly in prison than on the outside, and people recently released from prison have a higher risk of hospitalization and death from heart disease than the average person. In the first two weeks after release from prison, individuals face a risk of death that is more than 12 times higher than for non-incarcerated individuals.

Rates of Mental Illness Are Exceptionally High Among Incarcerated People, But Prisons Fail to Meet the Demand for Help

The Survey data confirm that the long-standing mental health crisis in prisons is as serious as ever: Over half of people in state prisons reported some indication of a mental health problem. Women and Native people in prison are suffering from mental illness at even higher rates. The data reveal policy failures that begin in our communities: governments have chipped away at the social safety net and accessible community-based treatment for years, while spending on the carceral system has increased. As law enforcement and courts respond to mental illness like it’s a crime, prisons and jails fill up with people who have serious mental health needs — which these systems are not designed to accommodate. And the longer they are in prison, certain people are likely to develop worsening mental health symptoms, especially those who are sent to solitary confinement.

The mental health crisis in prisons is only partially captured by the Survey, but the data reveal that:

More than half (56%) of people in state prison had some indication of a mental health problem, whether recent (14% report serious psychological distress in the past month) or previously diagnosed (43% report any history of one or more mental health conditions). Yet only about one-fourth of the total population (26%) have received professional help for their mental health since entering prison. Less than 1 in 3 (30%) people experiencing serious psychological distress in the past 30 days reported currently receiving professional help.

The prevalence of every single mental health condition is higher for women: Rates of post-traumatic stress disorder are almost three times as high in women as in men (34% of women versus 13% of men). Rates of manic depression, bipolar disorder, and/or mania (reported by 44% of women), as well as depressive disorders (49% of women) are double the rate compared to men.

State prisons allow too many in their custody to remain in a constant state of distress: In the 30 days before the survey was administered, one-sixth (16%) of respondents felt “nervousness” all or most of the time; 12% felt hopeless all or most of the time; 11% said they felt depressed all or most of the time. Almost one-fourth (23%) felt like “everything was an effort.” Native incarcerated people report these concerning symptoms at the highest rates across the board.

Mental health diagnoses in state prisons are most prevalent among multiracial people (56% report one or more), white people (53%), and Native people (52%), compared to Hispanic (36%), Black (33%), or Asian (32%) people. These figures track closely with how people of different racial and ethnic groups utilize mental health services outside of prison.

A staggering half (50%) of people in state prisons who have a history of substance use disorder treatment also have a history of one or more mental health conditions. This is disproportionate overlap: According to the National Institute on Drug Abuse, 38% of U.S. adults with substance use disorder also had one or more mental health disorders.

Some mental health diagnoses reported by people in prison may have been brought on by incarceration, which is itself a traumatizing experience. Other data tell us that well before that, when someone is arrested, the odds of them having serious mental illness or psychological distress are even greater, reflecting the practice of sweeping people experiencing mental health crises into the criminal legal system instead of redirecting them to community-based services. Despite how ill-suited these facilities are for providing these services, prisons and jails have become some of our nation’s largest de facto mental health care providers since the deinstitutionalization of public psychiatric hospitals beginning in the 1950s. State policy decisions, then, led directly to the profound overlap of mental illness and mass incarceration that we see today.

Disabilities: Incarcerated People Report Disabilities at Much Higher Rates Than the Broader U.S. Population

Similar to those who need treatment, people with disabilities are failed by the criminal legal system time and time again. After disproportionate contact with law enforcement, unaccommodating courts, and unequipped jails, almost half a million people with disabilities end up locked up in state prisons on a given day — accounting for 40% of state prison populations nationwide, and 50% of women’s state prison populations.

From vision-related (12%) to hearing (10%) and ambulatory (12%) disabilities, incarcerated people have much higher rates of disability compared to the general U.S. adult population, where an estimated 15% have any disability. Furthermore, a higher percentage of people in state prison in every age group report having a disability compared to the general population. Along racial and ethnic lines, multiracial and Native people in state prisons had higher rates of nearly every type of disability, followed by white people. Black, Hispanic, and Asian incarcerated people reported lower-than-average rates of disabilities.

Unsurprisingly, older people are the most likely to report a disability, with almost 6 in 10 (57%) of those age 55 to 64, and 7 in 10 (70%) of those 65 or older, reporting at least one disability. Between disability, other chronic conditions and excessive security costs, it’s twice as expensive to incarcerate someone age 50 or older compared to a younger, healthier person. Considering the nationwide aging of the state prison population — a record 13% are age 55 or older at this point — turning prisons into “makeshift nursing homes” is one of the nation’s most wasteful, morally bankrupt experiments to date.

Cognitive disabilities, those that lead to serious difficulty concentrating, remembering, or making decisions, impact about one-fourth (24%) of people in state prisons. Similarly, one-fourth (26%) have been told that they have attention deficit or hyperactivity disorder, compared to just 9.4% of children under 18, and about 4.4% of U.S. adults. And while 25% of people across state prisons have a history of taking special education classes, only half (54%) of all adult correctional facilities in the U.S. offered special education classes as of 2019 — another example of the wide gap between what incarcerated people need and what state prisons provide.

People in prison who have disabilities are susceptible to bullying and worse: Deaf people, for example, may miss instructions or announcements for medication deliveries, and are sometimes placed in solitary confinement as a depraved substitute for providing hearing aids. In general, people with cognitive or other disabilities in prison are highly vulnerable to excessive use of force and abuse by both correctional staff and other incarcerated people.

Pregnancy and Reproductive Health: Expectant Mothers are Underserved in Prison

While not a health “problem,” pregnancypresents specific medical needs for many people entering the criminal legal system, and prisons and jails are among the worst places to be during such a high-need time. Excluding transgender women, about 4% of people (or 3,500) in women’s prisons — disproportionately women of color — report that they were pregnant at admission, and therefore had to navigate the challenges and impacts of carceral pregnancy.

In the 1991 equivalent of the Survey, a slightly higher percentage (6%) of women in state prisons reported being pregnant upon their admission, but the number of women in state prisons more than doubled by 2016, expanding the total scale of prison pregnancy. Most women who were pregnant at admission (68%) did not have health insurance at the time of their arrest, setting them up for possible undiscovered complications. Further, most of these women also spent time in jail before admission; one-fourth (26%) spent 6 months or more facing horrendous conditions in local jails before being transferred to prison.

Troublingly, 1 in 10 women (9%) who were pregnant at admission had not had an obstetric exam, an important check of both maternal and fetal well-being, and only half (50%) had received prenatal care in the form of special testing, dietary changes, or childcare instruction. As we found previously, pregnancy nutrition standards, in particular, are largely missing from most state department of corrections policies.

In a previous study, we found that state prisons lack many other formal policies that would ensure the health and safety of both the parent-to-be and their child. Besides meager progress in addressing the inhumane practice of shackling pregnant people, many states fail to screen for high-risk pregnancies, or to make hospital arrangements for delivery, forcing some to give birth in the horrid confines of their cell. Thanks to researchers focused on reproductive justice in correctional settings, we now have an idea of how this systematic neglect of pregnant people plays out: In some state prison systems, miscarriages, premature births, and C-section births are much higher than national rates. Meanwhile, some of the same states make breastfeeding (or lactation) difficult or impossible, and keep opioid use disorder treatment out of reach for expecting or new parents, showing a clear disregard for their lives.

How Do We Begin to Address the Unmet Needs of People in State Prisons?

To be clear, findings from the 2016 Survey of Prison Inmates only confirm what research has shown for years: that incarcerated people face enormous obstacles to achieving and maintaining good health. The ongoing lack of care and compassion (as well as years of deeply problematic, non-consensual medical experimentation) behind bars has led to a deep sense of distrust in correctional healthcare to keep people in good health, or even to “do no harm.”

And while it’s easy to blame “the prison system” or private healthcare companies for these dangerous conditions, each of these trying aspects of prison life is the result of state policy: harsh policy that was implemented and remains unchanged, or — in the case of more humane standards — policy that exists on paper, but is often not enforced at the facility level. As we’ve asserted time and time again, state policy drives mass incarceration and defines day-to-day life for most people directly impacted by incarceration, including over 1 million people in state prisons, over half a million more in local jails, their children, and countless other loved ones.

State lawmakers must be aware of forces before incarceration that may lead to poor or declining health: Namely, the concentration of poverty, trauma, and disadvantage among people before they enter state prison, including the clear gap in health insurance coverage for those who can’t afford market-rate premiums or obtain a job offering health benefits. State policy must also reflect the reality that releasing someone from prison with no plan for continuing their healthcare regimen is a public health failure, considering the disproportionate nature of illness and disability behind bars. As organizations like Community Oriented Correctional Health Services have been saying for years, there must be coordination between correctional facilities and community providers to minimize disruptions in treatment and insurance coverage.

For those currently behind bars, there are myriad ways to begin addressing the egregious conditions of state prison confinement. Below, we offer further exploration of the topics discussed in this report and a non-exhaustive list of policy solutions.

Improve Access to Health Services Inside Prisons and Upon Release

Eliminate fees for medical care (often misleadingly called “co-pays” in policy), which would reduce financial barriers to needed health visits and limit the spread of disease;

Hold private healthcare contractors accountable for cost-avoiding, negligent practices that leave incarcerated people without necessary care;

Ensure that medical and mental health providers — whether they are state-managed or privately run — take a trauma-informed approach to care, which can be achieved through policy review, training, or hiring trained staff;

Counteract the federal “exclusion” policy of terminating Medicaid upon incarceration by expanding Medicaid coverage, which results in suspension instead; assist individuals in custody in pre-enrolling months before release to ensure coverage immediately upon returning to their community; and

Require prisons to coordinate follow-up appointments and ensure that people leave custody with several weeks’ worth of prescription medication.

Acknowledge Specific
Areas of Health Need and Types of Chronic Disease:

Improve reproductive care in prisons: Offer pregnancy testing, comprehensive prenatal care, and offer voluntary, cost-free reversible contraception and abortion services;

Require testing and modern treatment for conditions like hepatitis B, hepatitis C, heart disease risk factors, and traumatic brain injury;

Ensure that people who were on treatment regimens pre-incarceration do not experience disruption in (or denial of) treatment, which greatly increases the chance of relapse and/or overdose death;

Accommodate all people with disabilities with appropriate equipment and modifications in built environment, communications, daily routines, and programming; and

When people with mental health issues, substance use disorders, and co-occurring disorders cannot be released right away, increase the availability of
counselors and clinicians.

Ensure That Prisons Are Habitable Spaces:

Improve failing (or nonexistent) infrastructure in prisons that makes people sicker, like undrinkable water and lack of air conditioning;

Overhaul prison food such that it provides nourishing and filling meals, which will decrease physical and mental health problems and reduce reliance on expensive commissary items;

Require emergency response plans for state prisons to respond to various situations, including outbreaks of infectious diseases;

Immediately reduce, and eventually eliminate, the use of solitary confinement, euphemistically known in some states as “restrictive housing” or “segregation,” which can cause permanent psychological damage and increase risk of premature death after release; and

Create robust, external oversight mechanisms for conditions of confinement, such as an ombudsperson’s office.

Move Older and Ailing People Out of Prisons Permanently:

Expand and accelerate medical parole(also known as compassionate release), allowing very ill people to receive care at home among loved ones; and

Expand and accelerate parole eligibility for those who are above a certain age, otherwise known as geriatric parole, and ensure that no parole processes are subject to “carveouts” (such as excluding those incarcerated for violent or sexual offenses).

Of course, many people in state prisons should not be behind bars at all, much less for the excessively long sentences they are often serving. The above reforms should go hand-in-hand with meaningful decarceration efforts guided by state policy: greasing the wheels of discretionary and presumptive parole, expanding earned good time, retroactive sentencing reform, and others.

And finally, while this should be obvious, addressing bad policy and creating better prison policies must not come at the expense of non-carceral, community-based solutions. States must curtail their reliance on police, jails, courts, and prisons as solutions to social and public health problems.

This article was originally published by Prison Policy Initiative in June 2022. It is reprinted here with permission. View the original article, including graphs and charts, at https://www.prisonpolicy.org/reports/chronicpunishment.html.

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