Chronic Disease and Treatment Access Burden Among Incarcerated Persons

Among those who are incarcerated, a recent study identified the use of medications for chronic conditions in jails and state prisons was substantially lower compared with the nonincarcerated population.

The incarcerated population bears disproportionately more of the most common chronic diseases than the general population while receiving substantially lower access to prescribed medications, according to a study published in JAMA Health Forum.¹

In the cross-sectional analysis of national data from the National Survey on Drug Use and Health (NSDUH) from 2018-2020, investigators found that the relative disparity between disease burden and pharmacologic prescribing ranged from 1.9-fold for hepatitis B or C to 5.5-fold for asthma among incarcerated persons.¹

“To our knowledge, our study is the first to use national data to document the substantial disparities in receipt of medications for chronic conditions in jails and prisons,” said lead author of the study, Jill Curran, MS, a research data analyst at Johns Hopkins Bloomberg School of Public Health.¹

Although incarcerated people have a constitutional right to health care while incarcerated, in practice, access to that care is often insufficient particularly for chronic diseases that require ongoing, outpatient care. Ms Curran and colleagues undertook the study to fill a gap in understanding the degree of differences between the rates of treatment for chronic diseases in incarcerated people compared with nonincarcerated people based on prescription drug use.

Chronic Conditions Among Incarcerated People

The main outcome of the study was the distribution of medications to treat 7 common chronic diseases: type 2 diabetes, asthma, hypertension, hepatitis B or C, HIV, depression, and severe mental illness.¹ Ms Curran and colleagues used data from the NSDUH, a nationally representative household survey of persons aged 12 years and older, to estimate the prevalence of each of these conditions among incarcerated people—specifically in jails and state prisons—and nonincarcerated people between 2018 and 2020. These data were combined with data from the IQVIA’s National Sales Perspective (NSP), which provides national dollar and unit sales of prescription medications, to quantify the distributions of drugs to incarcerated and nonincarcerated populations during this time.¹

For diabetes, investigators also examined the type of medications prescribed among incarcerated persons vs nonincarcerated, from the oldest drugs including, human insulins, sulfonylureas, and biguanides, to newer drugs like alpha-glucosidase inhibitors, analogues of human insulins, glinides, glitazones, and finally to the newest drugs such as antidiabetic-hormone analogues, dopamine receptor agonists, dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors.¹

Across all 7 chronic diseases, prescription drug use was consistently lower among incarcerated people compared with nonincarcerated people despite consistently higher prevalence of these diseases among the incarcerated.¹

The table shows the disparity between disease burden and volume of drug prescribed for each disease among the incarcerated.¹

When looking at the types of drugs distributed for type 2 diabetes, the oldest class of drugs were used in 87.1% vs 76.5% of incarcerated persons and nonincarcerated persons, respectively, with the newest class of drugs used in 1.8% and 12.3%, respectively.¹

Ms Curran noted that the large discordance in the use of type 2 diabetes drugs is consistent with the economics of these drugs, and could contribute to their underuse in the incarcerated, but that further investigation is needed given the inability to determine whether more new diagnoses are made among incarcerated people that would require a higher use of first-line treatment with newer therapies.¹

Overall, Ms Curran said that she and her colleagues were surprised by the extent of potential undertreatment of these common chronic diseases among the incarcerated, particularly by the 4-fold relative disparities in treatment for asthma, depression, and severe mental illness.¹

“Our study highlights the importance of improving care during incarceration, including diagnosis and pharmaceutical treatment for individuals who need it, which may mitigate some of the disparities faced among recently incarcerated individuals once released from correctional facilities,” she said.1 “Target initiatives, such as additional oversight from health care agencies, to further characterize and abate any undertreatment of individuals in the incarcerated populations would be beneficial.”

Efforts to Improve Health Care for the Incarcerated

Sterling Ransone, MD, American Academy of Family Physicians (AAFP) Board Chair, underscored the disproportionate number of incarcerated persons with chronic health conditions and noted that correctional facilities are often ill equipped to provide care for these persons. He noted, that like nonincarcerated persons, not providing quality care for chronic diseases can and will lead to more costly problems later.²

One specific measure the AAFP advocates for, he said, is a review and change to the cash bail system given the increased incarcerated time for many individuals awaiting trial that place many of these people at risk of short- and long-term negative health outcomes.²

“The AAFP has stressed to policymakers that delivering improved health care services in correctional and detention facilities and improving coordination of services following release could improve the health of incarcerated and post-incarcerated individuals,” Dr Ransone said.²

At the policy level, several efforts are underway to improve access to health care for incarcerated persons. One is for better reimbursement through Medicaid dollars. Currently, in States with expanded Medicaid, eligible inmates receive partial coverage but only for inpatient care for 24 hours or longer in a medical institution.³

For incarcerated people with chronic diseases who require ongoing outpatient management, Medicaid dollars are currently not available based on the 1965 Medicaid Inmate Exclusion Policy (MIEP) that prohibits Medicaid from covering incarcerated persons. Efforts in Congress are underway to repeal MIEP as part of the Human Correction Health Care Act (HR 3514) introduced in Congress in 2021.³

Furthermore, several Medicaid managed care organizations in various States⁴ are implementing programs to help incarcerated people access physical and behavioral health services upon release and reentry into the community.

A program in Ohio,⁵ for example, provides education and enrollment assistance to Medicaid beneficiaries and care management for people with significant health needs prior to their release from incarceration. Since 2018, the program has served 22,000 people with demonstrated success in connecting people to needed physical and behavioral health services, decreased the likelihood of recidivism, promoted participants physical and mental health needs, and helped participants care for family members after release. The program has led to a reduction in the state’s correction budget by $20 million.

On the Federal level, the Biden Administration announced in April 2023 a new Medicaid Reentry Section III5 Demonstration
Opportunity⁶ that will allow state Medicaid programs cover services for chronic
health conditions. 

References:

1. Curran J, Saloner B, Winkelman TYN, Alexander C. Estimated use of prescription medications among individuals incarcerated in jails and state prisons in the US. JAMA Health Forum 2023;4(4):e230482. doi:10.1001/jamahealthforum.2023.0482

2. American Academy of Family Physicians. Incarceration
and health: A family medicine perspective (Position Paper). Published online April 2017. Updated
June 2021. https://www.aafp.org/about/policies/all/incarceration.html

3. Medicaid and Incarcerated Individuals. Congressional Research Service. May 21, 2021. https://crsreports.congress.gov/product/pdf/IF/IF11830

4. Medicaid Managed Care Organizations and Reentry. California Health Policy Strategies, LLC. Policy Brief.
January 2019. https://calhps.com/wp-content/uploads/2019/01/Policy-Brief-MC-Managed-Care-model-Final.pdf

5. How strengthening health care at reentry can address behavioral health and public safety: Ohio’s reentry program. Community Oriented Correctional
Health Services. https://cochs.org/files/medicaid/ohio-reentry.pdf

6. HHS releases new guidance to encourage states to apply for new medicaid reentry section 1115 demonstration opportunity to increase health care for people leaving carceral facilities. Press Release. April 17, 2023.  https://www.cms.gov/newsroom/press-releases/hhs-releases-new-guidance-encourage-states-apply-new-medicaid-reentry-section-1115-demonstration