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  • [Solved] English homework

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    help with homework – [\ \ IMG_7725.png](https://www.sweetstudy.com/files/img-7725-png-10200053 "IMG_7725.png") – [\ \ IMG_7726.png](https://www.sweetstudy.com/files/img-7726-png-10200055 "IMG_7726.png") – 2 years ago

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  • [Solved] AR DB

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    DUE TODAY DB – 2 years ago **files (1)** – ## ARTDB.docx **## ARTDB.docx** As discussed in Unit 1, art is a uniquely human endeavor, so I must say that “people” make art. But art takes many forms, including painting, drawing, sculpture, dance, photography, graphic design, cooking, embroidery, potter…

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    DUE TODAY DB

    – 2 years ago

    **files (1)**

    – ## ARTDB.docx

    **## ARTDB.docx**

    As discussed in Unit 1, art is a uniquely human endeavor, so I must say that “people” make art. But art takes many forms, including painting, drawing, sculpture, dance, photography, graphic design, cooking, embroidery, pottery, etc. As humans, we are born with an innate ability to create art, which is manifested early in the child who draws on the wall with crayons, colors in a coloring book, sculpts figures with Play-Doh, or makes finger paintings for art class in school. A little girl who dresses up in her mother’s clothes and plays tea party is an example of a child exercising her creative imagination to express her experiences and view of the world through acting. Art starts to become acquired when the person grows from childhood into older childhood and adolescence; if he wants to pursue an artistic outlet, he must do something more “serious” or “meaningful” to be taken seriously as an artist. At this point, art becomes “hard” in the sense that it’s not something that just anyone can do.

    In African cultures, the artisans who made masks (figure 1), bowls, or pottery were valued for their practical skills in meeting society's needs. In Western societies during the Middle Ages, artists were valued for their ability to paint murals, for example, that adorned cathedrals (decorative) and taught lessons from scripture (figure 2). In the modern world, artists are still valued for their ability to create decorative works of art. Still, the notion of art for art’s sake also seeks to exalt art and set it apart from any practical or didactic function (figure 3).

    _Figure 1_

    ![A close-up of a mask AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/ar-db)

    _Figure 2_

    ![A painting of a person and person AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/ar-db)

    _Figure 3_

    ![A group of images of soup cans AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/ar-db)

    Who makes art? Do you think artists have innate ability or acquired skill (or both)? How do artist’s roles change with different cultural considerations? Support your answers with examples, and provide any links or images that help in your explanations.

    PART 2

    Visual information is the key to social networking's popularity. From digital cameras to Blackberries and iPhones, taking pictures has become an everyday experience for most of us. Respond to the following questions.

    · How often do you take pictures?

    · What device do you usually use to take them?

    · How much attention do you devote to the composition, lighting, or arrangement of your pictures?

    · How do you use the images?

    · How can you improve your photos?

    ## image1.jpeg

    ## image2.jpeg

    ## image3.jpeg

    **## ARTDB.docx**

    As discussed in Unit 1, art is a uniquely human endeavor, so I must say that “people” make art. But art takes many forms, including painting, drawing, sculpture, dance, photography, graphic design, cooking, embroidery, pottery, etc. As humans, we are born with an innate ability to create art, which is manifested early in the child who draws on the wall with crayons, colors in a coloring book, sculpts figures with Play-Doh, or makes finger paintings for art class in school. A little girl who dresses up in her mother’s clothes and plays tea party is an example of a child exercising her creative imagination to express her experiences and view of the world through acting. Art starts to become acquired when the person grows from childhood into older childhood and adolescence; if he wants to pursue an artistic outlet, he must do something more “serious” or “meaningful” to be taken seriously as an artist. At this point, art becomes “hard” in the sense that it’s not something that just anyone can do.

    In African cultures, the artisans who made masks (figure 1), bowls, or pottery were valued for their practical skills in meeting society's needs. In Western societies during the Middle Ages, artists were valued for their ability to paint murals, for example, that adorned cathedrals (decorative) and taught lessons from scripture (figure 2). In the modern world, artists are still valued for their ability to create decorative works of art. Still, the notion of art for art’s sake also seeks to exalt art and set it apart from any practical or didactic function (figure 3).

    _Figure 1_

    ![A close-up of a mask AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/ar-db)

    _Figure 2_

    ![A painting of a person and person AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/ar-db)

    _Figure 3_

    ![A group of images of soup cans AI-generated content may be incorrect.](https://www.sweetstudy.com/questions/ar-db)

    Who makes art? Do you think artists have innate ability or acquired skill (or both)? How do artist’s roles change with different cultural considerations? Support your answers with examples, and provide any links or images that help in your explanations.

    PART 2

    Visual information is the key to social networking's popularity. From digital cameras to Blackberries and iPhones, taking pictures has become an everyday experience for most of us. Respond to the following questions.

    · How often do you take pictures?

    · What device do you usually use to take them?

    · How much attention do you devote to the composition, lighting, or arrangement of your pictures?

    · How do you use the images?

    · How can you improve your photos?

    ## image1.jpeg

    ## image2.jpeg

    ## image3.jpeg

  • [Solved] English assignmnet

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  • [Solved] Public health

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    – 2 years ago **files (1)** – ## PH528-PolicyAnalysis-FinalDraft.docx **## PH528-PolicyAnalysis-FinalDraft.docx** **Policy Analysis** **_Section 4- Final Draft (100 points)_** _PH 528_ **Introduction:** State Senator Hob Bryan (Mississippi District 7) is the chairman of the Mississippi State Senate …

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    – 2 years ago

    **files (1)**

    – ## PH528-PolicyAnalysis-FinalDraft.docx

    **## PH528-PolicyAnalysis-FinalDraft.docx**

    **Policy Analysis**

    **_Section 4- Final Draft (100 points)_**

    _PH 528_

    **Introduction:** State Senator Hob Bryan (Mississippi District 7) is the chairman of the Mississippi State Senate Public Health and Welfare Committee. Now that the state legislature has passed a bill legalizing medical marijuana use in the state, members of the committee are debating whether to draft legislation to legalize
    **recreational use** of marijuana in Mississippi. Senator Bryan has asked you to write a policy analysis on this issue.

    **A policy analysis contains five sections:** problem identification, background, landscape, options, and recommendation. For this assignment, you will revise your completed sections based on feedback and put them together to form a full policy analysis.

    **Sections: Must be 5 pages minimum- section page amounts are suggestions**

    1.
    **Problem Identification (1 sentence)**

    2.
    **Background (~1 page)**

    3.
    **Landscape (~3 pages)**

    4.
    **Options (~1.5 pages)**

    5.
    **Recommendation (~0.5 pages)**

    **Format:**

    · No title, heading, or title page needed- just begin with your problem question

    · Bolded section titles

    · Use in-text citations and include a reference page in APA citation style

    · 5 pages of content (minimum, can be more) + reference page

    · Double-spaced, one-inch margins, 12 pt. Times New Roman font

    · Can include tables if that helps to organize your thoughts

    **Other Notes:**

    · Read and use Ch. 14 in your textbook, which outlines how to write a policy analysis

    ·
    **All information** should include an in-text citation and a mention on your reference page in APA

    · Can reference scholarly articles, news articles, and reputable government, health, or non-profit agencies

    · Avoid direct quotations from references- paraphrase and cite

    ·
    **_Your policy analysis will be run through SafeAssign to check for plagiarism- a SafeAssign score of more than 20% will receive an automatic zero_**

    **Due Date:** Submit through Blackboard as a .doc or .docx file by
    **11:59 PM on Sunday 2/23.**

    **## PH528-PolicyAnalysis-FinalDraft.docx**

    **Policy Analysis**

    **_Section 4- Final Draft (100 points)_**

    _PH 528_

    **Introduction:** State Senator Hob Bryan (Mississippi District 7) is the chairman of the Mississippi State Senate Public Health and Welfare Committee. Now that the state legislature has passed a bill legalizing medical marijuana use in the state, members of the committee are debating whether to draft legislation to legalize
    **recreational use** of marijuana in Mississippi. Senator Bryan has asked you to write a policy analysis on this issue.

    **A policy analysis contains five sections:** problem identification, background, landscape, options, and recommendation. For this assignment, you will revise your completed sections based on feedback and put them together to form a full policy analysis.

    **Sections: Must be 5 pages minimum- section page amounts are suggestions**

    1.
    **Problem Identification (1 sentence)**

    2.
    **Background (~1 page)**

    3.
    **Landscape (~3 pages)**

    4.
    **Options (~1.5 pages)**

    5.
    **Recommendation (~0.5 pages)**

    **Format:**

    · No title, heading, or title page needed- just begin with your problem question

    · Bolded section titles

    · Use in-text citations and include a reference page in APA citation style

    · 5 pages of content (minimum, can be more) + reference page

    · Double-spaced, one-inch margins, 12 pt. Times New Roman font

    · Can include tables if that helps to organize your thoughts

    **Other Notes:**

    · Read and use Ch. 14 in your textbook, which outlines how to write a policy analysis

    ·
    **All information** should include an in-text citation and a mention on your reference page in APA

    · Can reference scholarly articles, news articles, and reputable government, health, or non-profit agencies

    · Avoid direct quotations from references- paraphrase and cite

    ·
    **_Your policy analysis will be run through SafeAssign to check for plagiarism- a SafeAssign score of more than 20% will receive an automatic zero_**

    **Due Date:** Submit through Blackboard as a .doc or .docx file by
    **11:59 PM on Sunday 2/23.**

  • [Solved] Public health

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    – 2 years ago **files (2)** – ## Assignment5.docx – ## IncarcerationCaseStudy.pdf **## Assignment5.docx** **Assignment #5** _PH 528_ **Directions:** Read the “Incarceration Case Study”, which outlines policy efforts to address public health in prisons and among incarcerated populations. Respond to t…

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    Assignment Prompt & Instructions

    – 2 years ago

    **files (2)**

    – ## Assignment5.docx

    – ## IncarcerationCaseStudy.pdf

    **## Assignment5.docx**

    **Assignment #5**

    _PH 528_

    **Directions:** Read the “Incarceration Case Study”, which outlines policy efforts to address public health in prisons and among incarcerated populations. Respond to the following questions, with each response a
    **minimum of 150 words.**

    **Due Date:** Upload your assignment to Blackboard as a .doc or .docx file by
    **11:59 PM on Sunday 2/26.**

    **Questions:**

    1. Is mass incarceration a public health issue? Does it contribute to/exacerbate health inequity in the U.S.? Provide reasoning for your responses.

    2. Discuss the implications of compassionate release, which is a policy that allows people with terminal illnesses to be released from prison before their sentences are served.

    3. The article discusses the role of clinicians, correctional health systems, and community health systems in improving public health in this vulnerable population. Which action discussed do you think will make the biggest public health impact?

    4. When Medicare or Medicaid beneficiaries are incarcerated, they are ineligible for benefits because of their incarceration status. What policies could be enacted to address this gap in coverage? You may discuss your personal opinions or the suggestions by the article authors.

    5. How can we use lessons learned from the COVID-19 pandemic to better the health of individuals who are currently incarcerated or recently released?

    **Case Study Source:** Wang, E.A., Western, B., & Berwick, D.M. (2020). COVID-19, decarceration, and the role of clinicians, health systems, and payers: A report from the National Academy of Sciences, Engineering, and Medicine.
    _JAMA_,
    _324_(22), 2257-2258.

    **## IncarcerationCaseStudy.pdf**

    COVID-19, Decarceration, and the Role of Clinicians,
    Health Systems, and Payers
    A Report From the National Academy of Sciences,
    Engineering, and Medicine

    The nation’s correctional facilities are deeply en-
    tangled with the coronavirus disease 2019 (COVID-19)
    pandemic.1 The criminal justice policies that drove
    mass incarceration have created fertile ground for
    the pandemic. According to the COVID Prison Project,
    by August 2020, 90 of the largest 100 cluster out-
    breaks in the United States have occurred in prisons and
    jails.2 Many correctional facilities are overcrowded and
    understaffed, and the high rates of incarceration among
    Black, Latino, and Native communities map closely with
    the demographic pattern of severe acute respiratory syn-
    drome coronavirus 2 (SARS-CoV-2) infections and
    COVID-19–related death.

    Despite being a focal point of the pandemic and past
    respiratory outbreaks, correctional facilities have not
    consistently been included in pandemic planning or guid-
    ance. Unlike in nursing homes and other long-term care
    facilities, which were also sources of outbreaks, health
    care in prisons and jails has no mandatory independent
    quality oversight nor is it integrated with the commu-
    nity health systems. The consequences include variabil-
    ity and failures in pandemic management.

    The health risks that converge in the US penal sys-
    tem make reducing the incarcerated population, other-
    wise labeled decarceration, an important and urgent
    strategy for mitigating virus transmission in prisons and
    jails. A new report from a consensus panel of the Na-
    tional Academy of Sciences, Engineering, and Medi-
    cine provides recommendations on decarceration.3 The
    committee recognized that the current public health re-
    sponse in corrections is insufficient and that reducing the
    size of the incarcerated population could help increase
    the penetration and effectiveness of standard preven-
    tion measures in jails and prisons, such as testing, quar-
    antining, and medical isolation for those who remain.

    Since the pandemic began, prison and jail popula-
    tions have declined, which helped to limit the spread of
    the SARS-CoV-2 virus somewhat. Between January and
    August 2020, jail populations decreased by 22% (from
    738 400 to 575 952), state prison populations de-
    creased by only 4% (from 1 260 393 to 1 207 710), and
    federal Bureau of Prisons by only 10% (from 175 315 to
    156 968).4 Prisonshavebeendifficulttodecarcerategiven
    legal barriers to “compassionate release,” which is a legal
    provision that varies by state but typically allows people
    with terminal illnesses, such as metastatic cancer and end-
    stage heart failure, to be released before their sentences
    have been served. A condition of release often includes
    a documentation of prognosis by a licensed physician for
    a person who has 6 months or less to live. Rarely used be-

    fore the pandemic, compassionate release has been in-
    effective for distancing the most medically vulnerable in-
    dividuals in prison from the risks of COVID-19. In the
    Bureau of Prisons, where compassionate release was used
    most widely, only 156 prisoners were released among the
    10 940 who applied from March through May 2020.5

    Clinicians, the health care system, and payers each
    have roles in helping to reduce the prison and jail popu-
    lation and to support formerly incarcerated people
    after release.

    Clinicians
    Compassionate release could be a lever for protecting
    many high-risk patients from harm, but compassionate
    release policies are not aligned with current medical and
    geriatric science about care at the end of life or vulner-
    abilities based on medical risk. Licensed clinicians can ad-
    vocate to reform existing policies to include “life-limiting
    illness” or “debilitating” conditions rather than relying on
    prognostic certainty. Clinicians also can directly assist by
    providing medical attestations to the need for compas-
    sionate release of individual patients during COVID-19.

    Correctional and Community Health Systems
    Health systems should do more to meet the needs of re-
    leased individuals and their families. A person leaving in-
    carceration faces higher risks of hospitalization and death
    than does the general population. In a 2013 study in-
    volving 76 208 individuals released from Washington
    state prison and followed up for 10 years (1999-2009),
    the mortality rate was 737 deaths from all causes per
    100 000 person-years, which was significantly higher
    than was the rate for the noninstitutionalized popula-
    tion after adjusting for age, sex, and race (standard mor-
    tality ratio, 3.61; 95% CI, 3.48-3.73).6 Before the pan-
    demic, these elevated risks were related to overdose and
    other chronic conditions, including hepatitis C, cardio-
    vascular disease, and cancer, conditions for which mor-
    bidity and mortality may be preventable by primary care.

    Effective discharge planning by the correctional
    health system must consider both the baseline risk for hos-
    pitalizations and also how to prevent SARS-CoV-2 trans-
    mission. This involves COVID-19 testing prior to release
    and planning for access to community health care, non-
    congregate housing, food security, and basic material well-
    being. Discharge from corrections should include a 90-
    day supply of medications, appointments with primary
    care physicians, an internet-enabled phone (because en-
    gagement in primary care now requires telemedicine ac-
    cess), and a place to safely quarantine in the community.

    VIEWPOINT

    Emily A. Wang, MD,
    MAS
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    New Haven,
    Connecticut; and
    Department of
    Medicine, Yale School
    of Medicine,
    New Haven,
    Connecticut.

    Bruce Western, PhD
    Justice Lab and
    Department of
    Sociology, Columbia
    University, New York,
    New York.

    Donald M. Berwick,
    MD, MPP
    Institute for Healthcare
    Improvement, Boston,
    Massachusetts.

    Corresponding
    Author: Emily
    Wang, MD, MAS,
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    367 Cedar St, Harkness
    Bldg A, Ste 410A,
    New Haven, CT 06511
    (emily.wang@yale.
    edu).

    Opinion

    jama.com (Reprinted) JAMA December 8, 2020 Volume 324, Number 22 2257

    © 2020 American Medical Association. All rights reserved.© 2020 American Medical Association. All rights reserved.

    Downloaded From: https://jamanetwork.com/ on 04/03/2022

    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

    [http://www.jama.com?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    People released from incarceration need reliable assistance to
    connect into the community health care system. For those navi-
    gating the extreme uncertainties and insecurity of prison and jail
    release, community health systems should accept new patients
    without government identification and soften restrictions for the
    need to connect first to an electronic health record portal to con-
    nect by video. Health systems can rely on proven strategies to
    maximize participation in health care after release, such as by hir-
    ing community health workers to work within the health system.7

    Evidence shows that addressing the needs of newly released indi-
    viduals can improve their engagement in primary care and reduce
    preventable hospitalizations and later contact with the criminal
    justice system.8

    Medicaid or Medicare and Payment
    Central to health care access is insurance. On any given day, the jail
    population includes more than 700 000 individuals, but more than
    10 million people a year pass through jails.9 Approximately 6% of
    the jail population is 65 years or older. When Medicare or Medicaid
    beneficiaries are incarcerated, they are ineligible for the benefits be-
    cause of their incarceration status. The Medicaid Inmate Exclusion
    Policy prohibits use of federal funds and services for medical care
    provided to “inmates of a public institution.” About two-thirds of the
    jail population are held before trial and most are unable to post bail
    to get released. Perversely, the law denies these health insurance
    benefits to those who are too poor to pay bail but for defendants
    with more resources who can pay for their release, their Medicaid
    or Medicare continues.

    Under the Centers for Medicare & Medicaid Services (CMS)
    administrative rules, states can initiate programs or policies to sup-
    port safe decarceration, including covering the costs of SARS-CoV-2
    testing and related health needs prior to release and facilitating
    access to medications, primary care, substance use, and mental

    health treatment. Importantly, states can follow Social Security
    Administration rules and suspend (as opposed to fully terminate)
    Medicaid or Medicare benefits when a person is incarcerated, which
    ensures activation of coverage upon release. Suspension of these
    benefits also has financial benefits. States that have suspended Med-
    icaid have been reimbursed for inpatient medical services for incar-
    cerated individuals enrolled in Medicaid and have reported cost sav-
    ings ranging from $3 million to $19 million per year.10

    Medicaid coverage also could be expanded with waivers under
    Sections 1115 and 1135 of the Social Security Act. Some states are seek-
    ing waivers to expand the scope of services to incarcerated people
    during the COVID-19 emergency to cover testing or outpatient treat-
    ment, although CMS has not yet approved any waivers. In addition,
    wholesale expansion of Medicaid in the first 30 days prior to re-
    lease could cover COVID-19 testing and also create a smoother tran-
    sition to the community by covering medications and enabling re-
    ferrals to community care.

    Even in the 12 states that have not yet expanded Medicaid un-
    der the Affordable Care Act, coverage is available for COVID-19 test-
    ing and related services if the state takes up the optional eligibility
    group provided in the Families First Coronavirus Response Act of
    2020. This pathway allows low-income adults in nonexpansion
    states, including incarcerated adults, to enroll in Medicaid. While the
    Inmate Exclusion Policy would continue to apply, this pathway could
    assist access to health care immediately upon release.

    Conclusions
    Decarceration in service of both public health and safer communi-
    ties will require sustained engagement from clinicians, health sys-
    tems, and Medicaid authorities. The actions the country takes now
    against COVID-19 are opportunities to put in motion longer-term im-
    provements to correctional and community health and to advance
    health equity at large.

    ARTICLE INFORMATION

    Published Online: November 16, 2020.
    doi:10.1001/jama.2020.22109

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: The members of the
    consensus committee that authored the National
    Academies of Sciences, Engineering, and Medicine
    report Decarcerating Correctional Facilities During
    COVID-19: Advancing Health, Equity, and Safety
    were Emily Wang (cochair, Department of
    Medicine, Yale University School of Medicine);
    Bruce Western (cochair, Department of Sociology,
    Columbia University); Donald Berwick (Institute for
    Healthcare Improvement); Sharon Dolovich
    (University of California, Los Angeles Law School);
    Deanna Hoskins (JustLeadershipUSA); Margot
    Kushel (Center for Vulnerable Populations,
    Department of Medicine, University of California,
    San Francisco); Hedwig Lee (Department of
    Sociology, Washington University in St Louis);
    Stephen Rafael (University of California, Berkley);
    Josiah Rich (Department of Medicine, Brown
    University); John Wetzel (Department of
    Corrections, Pennsylvania); and Emily Backes
    (study director) and Julie Schuck (program officer,
    National Academies of Sciences, Engineering, and
    Medicine).

    REFERENCES

    1. Saloner B, Parish K, Ward JA, DiLaura G,
    Dolovich S. COVID-19 cases and deaths in federal
    and state prisons. JAMA. 2020;324(6):602-603.
    doi:10.1001/jama.2020.12528

    2. COVID Prison Project. Accessed October 20,
    2020. https://covidprisonproject.com/

    3. National Academies of Science, Engineering, and
    Medicine. Decarcerating Correctional Facilities
    During COVID-19: Advancing Health, Equity, and
    Safety. National Academies Press. Accessed
    November 10, 2020. https://www.nap.edu/catalog/
    25945/decarcerating-correctional-facilities-during-
    covid-19-advancing-health-equity-and

    4. Franco-Paredes C, Ghandnoosh N, Latif H, et al.
    Decarceration and community re-entry in the
    COVID-19 era. Lancet Infect Dis. Published online
    September 29, 2020. doi:10.1016/S1473-3099(20)
    30730-1

    5. Blakinger K, Neff J. Thousands of sick federal
    prisoners sought release as COVID-19 spread: nearly
    all were denied. NBC News blog. October 7, 2020.
    Accessed November 10, 2020. https://www.
    nbcnews.com/news/us-news/thousands-sick-
    federal-prisoners-sought-release-covid-19-spread-
    nearly-n1242193

    6. Binswanger IA, Blatchford PJ, Mueller SR,
    Stern MF. Mortality after prison release: opioid
    overdose and other causes of death, risk factors,
    and time trends from 1999 to 2009. Ann Intern Med.
    2013;159(9):592-600. doi:10.7326/0003-4819-159-
    9-201311050-00005

    7. Kouyoumdjian FG, McIsaac KE, Liauw J, et al.
    A systematic review of randomized controlled trials
    of interventions to improve the health of persons
    during imprisonment and in the year after release.
    Am J Public Health. 2015;105(4):e13-e33. doi:10.
    2105/AJPH.2014.302498

    8. Wang EA, Lin HJ, Aminawung JA, et al.
    Propensity-matched study of enhanced primary
    care on contact with the criminal justice system
    among individuals recently released from prison to
    New Haven. BMJ Open. 2019;9(5):e028097. doi:10.
    1136/bmjopen-2018-028097

    9. Zhen Z. Jail Inmates in 2018. Bureau of Justice
    Statistics; 2020. Accessed November 10, 2020.
    https://www.bjs.gov/index.cfm?ty=pbdetail&iid=
    6826

    10. Beck A. Medicaid enrollment programs offer
    hope to formerly incarcerated individuals and
    savings for states. Health Affairs blog. February 20,
    2020. Accessed November 10, 2020. https://
    www.healthaffairs.org/do/10.1377/hblog20200218.
    910350/full/

    Opinion Viewpoint

    2258 JAMA December 8, 2020 Volume 324, Number 22 (Reprinted) jama.com

    © 2020 American Medical Association. All rights reserved.

    Downloaded From: https://jamanetwork.com/ on 04/03/2022

    [https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.22109?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.22109?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    [https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.12528?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.12528?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    [https://covidprisonproject.com/](https://covidprisonproject.com/)

    [https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and](https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and)

    [https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and](https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and)

    [https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and](https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and)

    [https://dx.doi.org/10.1016/S1473-3099(20)30730-1](https://dx.doi.org/10.1016/S1473-3099(20)30730-1)

    [https://dx.doi.org/10.1016/S1473-3099(20)30730-1](https://dx.doi.org/10.1016/S1473-3099(20)30730-1)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005](https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005)

    [https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005](https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005)

    [https://dx.doi.org/10.2105/AJPH.2014.302498](https://dx.doi.org/10.2105/AJPH.2014.302498)

    [https://dx.doi.org/10.2105/AJPH.2014.302498](https://dx.doi.org/10.2105/AJPH.2014.302498)

    [https://dx.doi.org/10.1136/bmjopen-2018-028097](https://dx.doi.org/10.1136/bmjopen-2018-028097)

    [https://dx.doi.org/10.1136/bmjopen-2018-028097](https://dx.doi.org/10.1136/bmjopen-2018-028097)

    [https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826](https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826)

    [https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826](https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826)

    [https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/](https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/)

    [https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/](https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/)

    [https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/](https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/)

    [http://www.jama.com?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    **## IncarcerationCaseStudy.pdf**

    COVID-19, Decarceration, and the Role of Clinicians,
    Health Systems, and Payers
    A Report From the National Academy of Sciences,
    Engineering, and Medicine

    The nation’s correctional facilities are deeply en-
    tangled with the coronavirus disease 2019 (COVID-19)
    pandemic.1 The criminal justice policies that drove
    mass incarceration have created fertile ground for
    the pandemic. According to the COVID Prison Project,
    by August 2020, 90 of the largest 100 cluster out-
    breaks in the United States have occurred in prisons and
    jails.2 Many correctional facilities are overcrowded and
    understaffed, and the high rates of incarceration among
    Black, Latino, and Native communities map closely with
    the demographic pattern of severe acute respiratory syn-
    drome coronavirus 2 (SARS-CoV-2) infections and
    COVID-19–related death.

    Despite being a focal point of the pandemic and past
    respiratory outbreaks, correctional facilities have not
    consistently been included in pandemic planning or guid-
    ance. Unlike in nursing homes and other long-term care
    facilities, which were also sources of outbreaks, health
    care in prisons and jails has no mandatory independent
    quality oversight nor is it integrated with the commu-
    nity health systems. The consequences include variabil-
    ity and failures in pandemic management.

    The health risks that converge in the US penal sys-
    tem make reducing the incarcerated population, other-
    wise labeled decarceration, an important and urgent
    strategy for mitigating virus transmission in prisons and
    jails. A new report from a consensus panel of the Na-
    tional Academy of Sciences, Engineering, and Medi-
    cine provides recommendations on decarceration.3 The
    committee recognized that the current public health re-
    sponse in corrections is insufficient and that reducing the
    size of the incarcerated population could help increase
    the penetration and effectiveness of standard preven-
    tion measures in jails and prisons, such as testing, quar-
    antining, and medical isolation for those who remain.

    Since the pandemic began, prison and jail popula-
    tions have declined, which helped to limit the spread of
    the SARS-CoV-2 virus somewhat. Between January and
    August 2020, jail populations decreased by 22% (from
    738 400 to 575 952), state prison populations de-
    creased by only 4% (from 1 260 393 to 1 207 710), and
    federal Bureau of Prisons by only 10% (from 175 315 to
    156 968).4 Prisonshavebeendifficulttodecarcerategiven
    legal barriers to “compassionate release,” which is a legal
    provision that varies by state but typically allows people
    with terminal illnesses, such as metastatic cancer and end-
    stage heart failure, to be released before their sentences
    have been served. A condition of release often includes
    a documentation of prognosis by a licensed physician for
    a person who has 6 months or less to live. Rarely used be-

    fore the pandemic, compassionate release has been in-
    effective for distancing the most medically vulnerable in-
    dividuals in prison from the risks of COVID-19. In the
    Bureau of Prisons, where compassionate release was used
    most widely, only 156 prisoners were released among the
    10 940 who applied from March through May 2020.5

    Clinicians, the health care system, and payers each
    have roles in helping to reduce the prison and jail popu-
    lation and to support formerly incarcerated people
    after release.

    Clinicians
    Compassionate release could be a lever for protecting
    many high-risk patients from harm, but compassionate
    release policies are not aligned with current medical and
    geriatric science about care at the end of life or vulner-
    abilities based on medical risk. Licensed clinicians can ad-
    vocate to reform existing policies to include “life-limiting
    illness” or “debilitating” conditions rather than relying on
    prognostic certainty. Clinicians also can directly assist by
    providing medical attestations to the need for compas-
    sionate release of individual patients during COVID-19.

    Correctional and Community Health Systems
    Health systems should do more to meet the needs of re-
    leased individuals and their families. A person leaving in-
    carceration faces higher risks of hospitalization and death
    than does the general population. In a 2013 study in-
    volving 76 208 individuals released from Washington
    state prison and followed up for 10 years (1999-2009),
    the mortality rate was 737 deaths from all causes per
    100 000 person-years, which was significantly higher
    than was the rate for the noninstitutionalized popula-
    tion after adjusting for age, sex, and race (standard mor-
    tality ratio, 3.61; 95% CI, 3.48-3.73).6 Before the pan-
    demic, these elevated risks were related to overdose and
    other chronic conditions, including hepatitis C, cardio-
    vascular disease, and cancer, conditions for which mor-
    bidity and mortality may be preventable by primary care.

    Effective discharge planning by the correctional
    health system must consider both the baseline risk for hos-
    pitalizations and also how to prevent SARS-CoV-2 trans-
    mission. This involves COVID-19 testing prior to release
    and planning for access to community health care, non-
    congregate housing, food security, and basic material well-
    being. Discharge from corrections should include a 90-
    day supply of medications, appointments with primary
    care physicians, an internet-enabled phone (because en-
    gagement in primary care now requires telemedicine ac-
    cess), and a place to safely quarantine in the community.

    VIEWPOINT

    Emily A. Wang, MD,
    MAS
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    New Haven,
    Connecticut; and
    Department of
    Medicine, Yale School
    of Medicine,
    New Haven,
    Connecticut.

    Bruce Western, PhD
    Justice Lab and
    Department of
    Sociology, Columbia
    University, New York,
    New York.

    Donald M. Berwick,
    MD, MPP
    Institute for Healthcare
    Improvement, Boston,
    Massachusetts.

    Corresponding
    Author: Emily
    Wang, MD, MAS,
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    367 Cedar St, Harkness
    Bldg A, Ste 410A,
    New Haven, CT 06511
    (emily.wang@yale.
    edu).

    Opinion

    jama.com (Reprinted) JAMA December 8, 2020 Volume 324, Number 22 2257

    © 2020 American Medical Association. All rights reserved.© 2020 American Medical Association. All rights reserved.

    Downloaded From: https://jamanetwork.com/ on 04/03/2022

    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

    [http://www.jama.com?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    People released from incarceration need reliable assistance to
    connect into the community health care system. For those navi-
    gating the extreme uncertainties and insecurity of prison and jail
    release, community health systems should accept new patients
    without government identification and soften restrictions for the
    need to connect first to an electronic health record portal to con-
    nect by video. Health systems can rely on proven strategies to
    maximize participation in health care after release, such as by hir-
    ing community health workers to work within the health system.7

    Evidence shows that addressing the needs of newly released indi-
    viduals can improve their engagement in primary care and reduce
    preventable hospitalizations and later contact with the criminal
    justice system.8

    Medicaid or Medicare and Payment
    Central to health care access is insurance. On any given day, the jail
    population includes more than 700 000 individuals, but more than
    10 million people a year pass through jails.9 Approximately 6% of
    the jail population is 65 years or older. When Medicare or Medicaid
    beneficiaries are incarcerated, they are ineligible for the benefits be-
    cause of their incarceration status. The Medicaid Inmate Exclusion
    Policy prohibits use of federal funds and services for medical care
    provided to “inmates of a public institution.” About two-thirds of the
    jail population are held before trial and most are unable to post bail
    to get released. Perversely, the law denies these health insurance
    benefits to those who are too poor to pay bail but for defendants
    with more resources who can pay for their release, their Medicaid
    or Medicare continues.

    Under the Centers for Medicare & Medicaid Services (CMS)
    administrative rules, states can initiate programs or policies to sup-
    port safe decarceration, including covering the costs of SARS-CoV-2
    testing and related health needs prior to release and facilitating
    access to medications, primary care, substance use, and mental

    health treatment. Importantly, states can follow Social Security
    Administration rules and suspend (as opposed to fully terminate)
    Medicaid or Medicare benefits when a person is incarcerated, which
    ensures activation of coverage upon release. Suspension of these
    benefits also has financial benefits. States that have suspended Med-
    icaid have been reimbursed for inpatient medical services for incar-
    cerated individuals enrolled in Medicaid and have reported cost sav-
    ings ranging from $3 million to $19 million per year.10

    Medicaid coverage also could be expanded with waivers under
    Sections 1115 and 1135 of the Social Security Act. Some states are seek-
    ing waivers to expand the scope of services to incarcerated people
    during the COVID-19 emergency to cover testing or outpatient treat-
    ment, although CMS has not yet approved any waivers. In addition,
    wholesale expansion of Medicaid in the first 30 days prior to re-
    lease could cover COVID-19 testing and also create a smoother tran-
    sition to the community by covering medications and enabling re-
    ferrals to community care.

    Even in the 12 states that have not yet expanded Medicaid un-
    der the Affordable Care Act, coverage is available for COVID-19 test-
    ing and related services if the state takes up the optional eligibility
    group provided in the Families First Coronavirus Response Act of
    2020. This pathway allows low-income adults in nonexpansion
    states, including incarcerated adults, to enroll in Medicaid. While the
    Inmate Exclusion Policy would continue to apply, this pathway could
    assist access to health care immediately upon release.

    Conclusions
    Decarceration in service of both public health and safer communi-
    ties will require sustained engagement from clinicians, health sys-
    tems, and Medicaid authorities. The actions the country takes now
    against COVID-19 are opportunities to put in motion longer-term im-
    provements to correctional and community health and to advance
    health equity at large.

    ARTICLE INFORMATION

    Published Online: November 16, 2020.
    doi:10.1001/jama.2020.22109

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: The members of the
    consensus committee that authored the National
    Academies of Sciences, Engineering, and Medicine
    report Decarcerating Correctional Facilities During
    COVID-19: Advancing Health, Equity, and Safety
    were Emily Wang (cochair, Department of
    Medicine, Yale University School of Medicine);
    Bruce Western (cochair, Department of Sociology,
    Columbia University); Donald Berwick (Institute for
    Healthcare Improvement); Sharon Dolovich
    (University of California, Los Angeles Law School);
    Deanna Hoskins (JustLeadershipUSA); Margot
    Kushel (Center for Vulnerable Populations,
    Department of Medicine, University of California,
    San Francisco); Hedwig Lee (Department of
    Sociology, Washington University in St Louis);
    Stephen Rafael (University of California, Berkley);
    Josiah Rich (Department of Medicine, Brown
    University); John Wetzel (Department of
    Corrections, Pennsylvania); and Emily Backes
    (study director) and Julie Schuck (program officer,
    National Academies of Sciences, Engineering, and
    Medicine).

    REFERENCES

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    9. Zhen Z. Jail Inmates in 2018. Bureau of Justice
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    10. Beck A. Medicaid enrollment programs offer
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    Opinion Viewpoint

    2258 JAMA December 8, 2020 Volume 324, Number 22 (Reprinted) jama.com

    © 2020 American Medical Association. All rights reserved.

    Downloaded From: https://jamanetwork.com/ on 04/03/2022

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    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005](https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005)

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    **## Assignment5.docx**

    **Assignment #5**

    _PH 528_

    **Directions:** Read the “Incarceration Case Study”, which outlines policy efforts to address public health in prisons and among incarcerated populations. Respond to the following questions, with each response a
    **minimum of 150 words.**

    **Due Date:** Upload your assignment to Blackboard as a .doc or .docx file by
    **11:59 PM on Sunday 2/26.**

    **Questions:**

    1. Is mass incarceration a public health issue? Does it contribute to/exacerbate health inequity in the U.S.? Provide reasoning for your responses.

    2. Discuss the implications of compassionate release, which is a policy that allows people with terminal illnesses to be released from prison before their sentences are served.

    3. The article discusses the role of clinicians, correctional health systems, and community health systems in improving public health in this vulnerable population. Which action discussed do you think will make the biggest public health impact?

    4. When Medicare or Medicaid beneficiaries are incarcerated, they are ineligible for benefits because of their incarceration status. What policies could be enacted to address this gap in coverage? You may discuss your personal opinions or the suggestions by the article authors.

    5. How can we use lessons learned from the COVID-19 pandemic to better the health of individuals who are currently incarcerated or recently released?

    **Case Study Source:** Wang, E.A., Western, B., & Berwick, D.M. (2020). COVID-19, decarceration, and the role of clinicians, health systems, and payers: A report from the National Academy of Sciences, Engineering, and Medicine.
    _JAMA_,
    _324_(22), 2257-2258.

    **## IncarcerationCaseStudy.pdf**

    COVID-19, Decarceration, and the Role of Clinicians,
    Health Systems, and Payers
    A Report From the National Academy of Sciences,
    Engineering, and Medicine

    The nation’s correctional facilities are deeply en-
    tangled with the coronavirus disease 2019 (COVID-19)
    pandemic.1 The criminal justice policies that drove
    mass incarceration have created fertile ground for
    the pandemic. According to the COVID Prison Project,
    by August 2020, 90 of the largest 100 cluster out-
    breaks in the United States have occurred in prisons and
    jails.2 Many correctional facilities are overcrowded and
    understaffed, and the high rates of incarceration among
    Black, Latino, and Native communities map closely with
    the demographic pattern of severe acute respiratory syn-
    drome coronavirus 2 (SARS-CoV-2) infections and
    COVID-19–related death.

    Despite being a focal point of the pandemic and past
    respiratory outbreaks, correctional facilities have not
    consistently been included in pandemic planning or guid-
    ance. Unlike in nursing homes and other long-term care
    facilities, which were also sources of outbreaks, health
    care in prisons and jails has no mandatory independent
    quality oversight nor is it integrated with the commu-
    nity health systems. The consequences include variabil-
    ity and failures in pandemic management.

    The health risks that converge in the US penal sys-
    tem make reducing the incarcerated population, other-
    wise labeled decarceration, an important and urgent
    strategy for mitigating virus transmission in prisons and
    jails. A new report from a consensus panel of the Na-
    tional Academy of Sciences, Engineering, and Medi-
    cine provides recommendations on decarceration.3 The
    committee recognized that the current public health re-
    sponse in corrections is insufficient and that reducing the
    size of the incarcerated population could help increase
    the penetration and effectiveness of standard preven-
    tion measures in jails and prisons, such as testing, quar-
    antining, and medical isolation for those who remain.

    Since the pandemic began, prison and jail popula-
    tions have declined, which helped to limit the spread of
    the SARS-CoV-2 virus somewhat. Between January and
    August 2020, jail populations decreased by 22% (from
    738 400 to 575 952), state prison populations de-
    creased by only 4% (from 1 260 393 to 1 207 710), and
    federal Bureau of Prisons by only 10% (from 175 315 to
    156 968).4 Prisonshavebeendifficulttodecarcerategiven
    legal barriers to “compassionate release,” which is a legal
    provision that varies by state but typically allows people
    with terminal illnesses, such as metastatic cancer and end-
    stage heart failure, to be released before their sentences
    have been served. A condition of release often includes
    a documentation of prognosis by a licensed physician for
    a person who has 6 months or less to live. Rarely used be-

    fore the pandemic, compassionate release has been in-
    effective for distancing the most medically vulnerable in-
    dividuals in prison from the risks of COVID-19. In the
    Bureau of Prisons, where compassionate release was used
    most widely, only 156 prisoners were released among the
    10 940 who applied from March through May 2020.5

    Clinicians, the health care system, and payers each
    have roles in helping to reduce the prison and jail popu-
    lation and to support formerly incarcerated people
    after release.

    Clinicians
    Compassionate release could be a lever for protecting
    many high-risk patients from harm, but compassionate
    release policies are not aligned with current medical and
    geriatric science about care at the end of life or vulner-
    abilities based on medical risk. Licensed clinicians can ad-
    vocate to reform existing policies to include “life-limiting
    illness” or “debilitating” conditions rather than relying on
    prognostic certainty. Clinicians also can directly assist by
    providing medical attestations to the need for compas-
    sionate release of individual patients during COVID-19.

    Correctional and Community Health Systems
    Health systems should do more to meet the needs of re-
    leased individuals and their families. A person leaving in-
    carceration faces higher risks of hospitalization and death
    than does the general population. In a 2013 study in-
    volving 76 208 individuals released from Washington
    state prison and followed up for 10 years (1999-2009),
    the mortality rate was 737 deaths from all causes per
    100 000 person-years, which was significantly higher
    than was the rate for the noninstitutionalized popula-
    tion after adjusting for age, sex, and race (standard mor-
    tality ratio, 3.61; 95% CI, 3.48-3.73).6 Before the pan-
    demic, these elevated risks were related to overdose and
    other chronic conditions, including hepatitis C, cardio-
    vascular disease, and cancer, conditions for which mor-
    bidity and mortality may be preventable by primary care.

    Effective discharge planning by the correctional
    health system must consider both the baseline risk for hos-
    pitalizations and also how to prevent SARS-CoV-2 trans-
    mission. This involves COVID-19 testing prior to release
    and planning for access to community health care, non-
    congregate housing, food security, and basic material well-
    being. Discharge from corrections should include a 90-
    day supply of medications, appointments with primary
    care physicians, an internet-enabled phone (because en-
    gagement in primary care now requires telemedicine ac-
    cess), and a place to safely quarantine in the community.

    VIEWPOINT

    Emily A. Wang, MD,
    MAS
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    New Haven,
    Connecticut; and
    Department of
    Medicine, Yale School
    of Medicine,
    New Haven,
    Connecticut.

    Bruce Western, PhD
    Justice Lab and
    Department of
    Sociology, Columbia
    University, New York,
    New York.

    Donald M. Berwick,
    MD, MPP
    Institute for Healthcare
    Improvement, Boston,
    Massachusetts.

    Corresponding
    Author: Emily
    Wang, MD, MAS,
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    367 Cedar St, Harkness
    Bldg A, Ste 410A,
    New Haven, CT 06511
    (emily.wang@yale.
    edu).

    Opinion

    jama.com (Reprinted) JAMA December 8, 2020 Volume 324, Number 22 2257

    © 2020 American Medical Association. All rights reserved.© 2020 American Medical Association. All rights reserved.

    Downloaded From: https://jamanetwork.com/ on 04/03/2022

    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

    [http://www.jama.com?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    People released from incarceration need reliable assistance to
    connect into the community health care system. For those navi-
    gating the extreme uncertainties and insecurity of prison and jail
    release, community health systems should accept new patients
    without government identification and soften restrictions for the
    need to connect first to an electronic health record portal to con-
    nect by video. Health systems can rely on proven strategies to
    maximize participation in health care after release, such as by hir-
    ing community health workers to work within the health system.7

    Evidence shows that addressing the needs of newly released indi-
    viduals can improve their engagement in primary care and reduce
    preventable hospitalizations and later contact with the criminal
    justice system.8

    Medicaid or Medicare and Payment
    Central to health care access is insurance. On any given day, the jail
    population includes more than 700 000 individuals, but more than
    10 million people a year pass through jails.9 Approximately 6% of
    the jail population is 65 years or older. When Medicare or Medicaid
    beneficiaries are incarcerated, they are ineligible for the benefits be-
    cause of their incarceration status. The Medicaid Inmate Exclusion
    Policy prohibits use of federal funds and services for medical care
    provided to “inmates of a public institution.” About two-thirds of the
    jail population are held before trial and most are unable to post bail
    to get released. Perversely, the law denies these health insurance
    benefits to those who are too poor to pay bail but for defendants
    with more resources who can pay for their release, their Medicaid
    or Medicare continues.

    Under the Centers for Medicare & Medicaid Services (CMS)
    administrative rules, states can initiate programs or policies to sup-
    port safe decarceration, including covering the costs of SARS-CoV-2
    testing and related health needs prior to release and facilitating
    access to medications, primary care, substance use, and mental

    health treatment. Importantly, states can follow Social Security
    Administration rules and suspend (as opposed to fully terminate)
    Medicaid or Medicare benefits when a person is incarcerated, which
    ensures activation of coverage upon release. Suspension of these
    benefits also has financial benefits. States that have suspended Med-
    icaid have been reimbursed for inpatient medical services for incar-
    cerated individuals enrolled in Medicaid and have reported cost sav-
    ings ranging from $3 million to $19 million per year.10

    Medicaid coverage also could be expanded with waivers under
    Sections 1115 and 1135 of the Social Security Act. Some states are seek-
    ing waivers to expand the scope of services to incarcerated people
    during the COVID-19 emergency to cover testing or outpatient treat-
    ment, although CMS has not yet approved any waivers. In addition,
    wholesale expansion of Medicaid in the first 30 days prior to re-
    lease could cover COVID-19 testing and also create a smoother tran-
    sition to the community by covering medications and enabling re-
    ferrals to community care.

    Even in the 12 states that have not yet expanded Medicaid un-
    der the Affordable Care Act, coverage is available for COVID-19 test-
    ing and related services if the state takes up the optional eligibility
    group provided in the Families First Coronavirus Response Act of
    2020. This pathway allows low-income adults in nonexpansion
    states, including incarcerated adults, to enroll in Medicaid. While the
    Inmate Exclusion Policy would continue to apply, this pathway could
    assist access to health care immediately upon release.

    Conclusions
    Decarceration in service of both public health and safer communi-
    ties will require sustained engagement from clinicians, health sys-
    tems, and Medicaid authorities. The actions the country takes now
    against COVID-19 are opportunities to put in motion longer-term im-
    provements to correctional and community health and to advance
    health equity at large.

    ARTICLE INFORMATION

    Published Online: November 16, 2020.
    doi:10.1001/jama.2020.22109

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: The members of the
    consensus committee that authored the National
    Academies of Sciences, Engineering, and Medicine
    report Decarcerating Correctional Facilities During
    COVID-19: Advancing Health, Equity, and Safety
    were Emily Wang (cochair, Department of
    Medicine, Yale University School of Medicine);
    Bruce Western (cochair, Department of Sociology,
    Columbia University); Donald Berwick (Institute for
    Healthcare Improvement); Sharon Dolovich
    (University of California, Los Angeles Law School);
    Deanna Hoskins (JustLeadershipUSA); Margot
    Kushel (Center for Vulnerable Populations,
    Department of Medicine, University of California,
    San Francisco); Hedwig Lee (Department of
    Sociology, Washington University in St Louis);
    Stephen Rafael (University of California, Berkley);
    Josiah Rich (Department of Medicine, Brown
    University); John Wetzel (Department of
    Corrections, Pennsylvania); and Emily Backes
    (study director) and Julie Schuck (program officer,
    National Academies of Sciences, Engineering, and
    Medicine).

    REFERENCES

    1. Saloner B, Parish K, Ward JA, DiLaura G,
    Dolovich S. COVID-19 cases and deaths in federal
    and state prisons. JAMA. 2020;324(6):602-603.
    doi:10.1001/jama.2020.12528

    2. COVID Prison Project. Accessed October 20,
    2020. https://covidprisonproject.com/

    3. National Academies of Science, Engineering, and
    Medicine. Decarcerating Correctional Facilities
    During COVID-19: Advancing Health, Equity, and
    Safety. National Academies Press. Accessed
    November 10, 2020. https://www.nap.edu/catalog/
    25945/decarcerating-correctional-facilities-during-
    covid-19-advancing-health-equity-and

    4. Franco-Paredes C, Ghandnoosh N, Latif H, et al.
    Decarceration and community re-entry in the
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    September 29, 2020. doi:10.1016/S1473-3099(20)
    30730-1

    5. Blakinger K, Neff J. Thousands of sick federal
    prisoners sought release as COVID-19 spread: nearly
    all were denied. NBC News blog. October 7, 2020.
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    nbcnews.com/news/us-news/thousands-sick-
    federal-prisoners-sought-release-covid-19-spread-
    nearly-n1242193

    6. Binswanger IA, Blatchford PJ, Mueller SR,
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    and time trends from 1999 to 2009. Ann Intern Med.
    2013;159(9):592-600. doi:10.7326/0003-4819-159-
    9-201311050-00005

    7. Kouyoumdjian FG, McIsaac KE, Liauw J, et al.
    A systematic review of randomized controlled trials
    of interventions to improve the health of persons
    during imprisonment and in the year after release.
    Am J Public Health. 2015;105(4):e13-e33. doi:10.
    2105/AJPH.2014.302498

    8. Wang EA, Lin HJ, Aminawung JA, et al.
    Propensity-matched study of enhanced primary
    care on contact with the criminal justice system
    among individuals recently released from prison to
    New Haven. BMJ Open. 2019;9(5):e028097. doi:10.
    1136/bmjopen-2018-028097

    9. Zhen Z. Jail Inmates in 2018. Bureau of Justice
    Statistics; 2020. Accessed November 10, 2020.
    https://www.bjs.gov/index.cfm?ty=pbdetail&iid=
    6826

    10. Beck A. Medicaid enrollment programs offer
    hope to formerly incarcerated individuals and
    savings for states. Health Affairs blog. February 20,
    2020. Accessed November 10, 2020. https://
    www.healthaffairs.org/do/10.1377/hblog20200218.
    910350/full/

    Opinion Viewpoint

    2258 JAMA December 8, 2020 Volume 324, Number 22 (Reprinted) jama.com

    © 2020 American Medical Association. All rights reserved.

    Downloaded From: https://jamanetwork.com/ on 04/03/2022

    [https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.22109?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.22109?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    [https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.12528?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.12528?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    [https://covidprisonproject.com/](https://covidprisonproject.com/)

    [https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and](https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and)

    [https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and](https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and)

    [https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and](https://www.nap.edu/catalog/25945/decarcerating-correctional-facilities-during-covid-19-advancing-health-equity-and)

    [https://dx.doi.org/10.1016/S1473-3099(20)30730-1](https://dx.doi.org/10.1016/S1473-3099(20)30730-1)

    [https://dx.doi.org/10.1016/S1473-3099(20)30730-1](https://dx.doi.org/10.1016/S1473-3099(20)30730-1)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193](https://www.nbcnews.com/news/us-news/thousands-sick-federal-prisoners-sought-release-covid-19-spread-nearly-n1242193)

    [https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005](https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005)

    [https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005](https://dx.doi.org/10.7326/0003-4819-159-9-201311050-00005)

    [https://dx.doi.org/10.2105/AJPH.2014.302498](https://dx.doi.org/10.2105/AJPH.2014.302498)

    [https://dx.doi.org/10.2105/AJPH.2014.302498](https://dx.doi.org/10.2105/AJPH.2014.302498)

    [https://dx.doi.org/10.1136/bmjopen-2018-028097](https://dx.doi.org/10.1136/bmjopen-2018-028097)

    [https://dx.doi.org/10.1136/bmjopen-2018-028097](https://dx.doi.org/10.1136/bmjopen-2018-028097)

    [https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826](https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826)

    [https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826](https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6826)

    [https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/](https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/)

    [https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/](https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/)

    [https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/](https://www.healthaffairs.org/do/10.1377/hblog20200218.910350/full/)

    [http://www.jama.com?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109](http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.22109)

    **## Assignment5.docx**

    **Assignment #5**

    _PH 528_

    **Directions:** Read the “Incarceration Case Study”, which outlines policy efforts to address public health in prisons and among incarcerated populations. Respond to the following questions, with each response a
    **minimum of 150 words.**

    **Due Date:** Upload your assignment to Blackboard as a .doc or .docx file by
    **11:59 PM on Sunday 2/26.**

    **Questions:**

    1. Is mass incarceration a public health issue? Does it contribute to/exacerbate health inequity in the U.S.? Provide reasoning for your responses.

    2. Discuss the implications of compassionate release, which is a policy that allows people with terminal illnesses to be released from prison before their sentences are served.

    3. The article discusses the role of clinicians, correctional health systems, and community health systems in improving public health in this vulnerable population. Which action discussed do you think will make the biggest public health impact?

    4. When Medicare or Medicaid beneficiaries are incarcerated, they are ineligible for benefits because of their incarceration status. What policies could be enacted to address this gap in coverage? You may discuss your personal opinions or the suggestions by the article authors.

    5. How can we use lessons learned from the COVID-19 pandemic to better the health of individuals who are currently incarcerated or recently released?

    **Case Study Source:** Wang, E.A., Western, B., & Berwick, D.M. (2020). COVID-19, decarceration, and the role of clinicians, health systems, and payers: A report from the National Academy of Sciences, Engineering, and Medicine.
    _JAMA_,
    _324_(22), 2257-2258.

    **## IncarcerationCaseStudy.pdf**

    COVID-19, Decarceration, and the Role of Clinicians,
    Health Systems, and Payers
    A Report From the National Academy of Sciences,
    Engineering, and Medicine

    The nation’s correctional facilities are deeply en-
    tangled with the coronavirus disease 2019 (COVID-19)
    pandemic.1 The criminal justice policies that drove
    mass incarceration have created fertile ground for
    the pandemic. According to the COVID Prison Project,
    by August 2020, 90 of the largest 100 cluster out-
    breaks in the United States have occurred in prisons and
    jails.2 Many correctional facilities are overcrowded and
    understaffed, and the high rates of incarceration among
    Black, Latino, and Native communities map closely with
    the demographic pattern of severe acute respiratory syn-
    drome coronavirus 2 (SARS-CoV-2) infections and
    COVID-19–related death.

    Despite being a focal point of the pandemic and past
    respiratory outbreaks, correctional facilities have not
    consistently been included in pandemic planning or guid-
    ance. Unlike in nursing homes and other long-term care
    facilities, which were also sources of outbreaks, health
    care in prisons and jails has no mandatory independent
    quality oversight nor is it integrated with the commu-
    nity health systems. The consequences include variabil-
    ity and failures in pandemic management.

    The health risks that converge in the US penal sys-
    tem make reducing the incarcerated population, other-
    wise labeled decarceration, an important and urgent
    strategy for mitigating virus transmission in prisons and
    jails. A new report from a consensus panel of the Na-
    tional Academy of Sciences, Engineering, and Medi-
    cine provides recommendations on decarceration.3 The
    committee recognized that the current public health re-
    sponse in corrections is insufficient and that reducing the
    size of the incarcerated population could help increase
    the penetration and effectiveness of standard preven-
    tion measures in jails and prisons, such as testing, quar-
    antining, and medical isolation for those who remain.

    Since the pandemic began, prison and jail popula-
    tions have declined, which helped to limit the spread of
    the SARS-CoV-2 virus somewhat. Between January and
    August 2020, jail populations decreased by 22% (from
    738 400 to 575 952), state prison populations de-
    creased by only 4% (from 1 260 393 to 1 207 710), and
    federal Bureau of Prisons by only 10% (from 175 315 to
    156 968).4 Prisonshavebeendifficulttodecarcerategiven
    legal barriers to “compassionate release,” which is a legal
    provision that varies by state but typically allows people
    with terminal illnesses, such as metastatic cancer and end-
    stage heart failure, to be released before their sentences
    have been served. A condition of release often includes
    a documentation of prognosis by a licensed physician for
    a person who has 6 months or less to live. Rarely used be-

    fore the pandemic, compassionate release has been in-
    effective for distancing the most medically vulnerable in-
    dividuals in prison from the risks of COVID-19. In the
    Bureau of Prisons, where compassionate release was used
    most widely, only 156 prisoners were released among the
    10 940 who applied from March through May 2020.5

    Clinicians, the health care system, and payers each
    have roles in helping to reduce the prison and jail popu-
    lation and to support formerly incarcerated people
    after release.

    Clinicians
    Compassionate release could be a lever for protecting
    many high-risk patients from harm, but compassionate
    release policies are not aligned with current medical and
    geriatric science about care at the end of life or vulner-
    abilities based on medical risk. Licensed clinicians can ad-
    vocate to reform existing policies to include “life-limiting
    illness” or “debilitating” conditions rather than relying on
    prognostic certainty. Clinicians also can directly assist by
    providing medical attestations to the need for compas-
    sionate release of individual patients during COVID-19.

    Correctional and Community Health Systems
    Health systems should do more to meet the needs of re-
    leased individuals and their families. A person leaving in-
    carceration faces higher risks of hospitalization and death
    than does the general population. In a 2013 study in-
    volving 76 208 individuals released from Washington
    state prison and followed up for 10 years (1999-2009),
    the mortality rate was 737 deaths from all causes per
    100 000 person-years, which was significantly higher
    than was the rate for the noninstitutionalized popula-
    tion after adjusting for age, sex, and race (standard mor-
    tality ratio, 3.61; 95% CI, 3.48-3.73).6 Before the pan-
    demic, these elevated risks were related to overdose and
    other chronic conditions, including hepatitis C, cardio-
    vascular disease, and cancer, conditions for which mor-
    bidity and mortality may be preventable by primary care.

    Effective discharge planning by the correctional
    health system must consider both the baseline risk for hos-
    pitalizations and also how to prevent SARS-CoV-2 trans-
    mission. This involves COVID-19 testing prior to release
    and planning for access to community health care, non-
    congregate housing, food security, and basic material well-
    being. Discharge from corrections should include a 90-
    day supply of medications, appointments with primary
    care physicians, an internet-enabled phone (because en-
    gagement in primary care now requires telemedicine ac-
    cess), and a place to safely quarantine in the community.

    VIEWPOINT

    Emily A. Wang, MD,
    MAS
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    New Haven,
    Connecticut; and
    Department of
    Medicine, Yale School
    of Medicine,
    New Haven,
    Connecticut.

    Bruce Western, PhD
    Justice Lab and
    Department of
    Sociology, Columbia
    University, New York,
    New York.

    Donald M. Berwick,
    MD, MPP
    Institute for Healthcare
    Improvement, Boston,
    Massachusetts.

    Corresponding
    Author: Emily
    Wang, MD, MAS,
    SEICHE Center for
    Health and Justice, Yale
    School of Medicine,
    367 Cedar St, Harkness
    Bldg A, Ste 410A,
    New Haven, CT 06511
    (emily.wang@yale.
    edu).

    Opinion

    jama.com (Reprinted) JAMA December 8, 2020 Volume 324, Number 22 2257

    © 2020 American Medical Association. All rights reserved.© 2020 American Medical Association. All rights reserved.

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    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

    [mailto:emily.wang@yale.edu](mailto:emily.wang@yale.edu)

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    People released from incarceration need reliable assistance to
    connect into the community health care system. For those navi-
    gating the extreme uncertainties and insecurity of prison and jail
    release, community health systems should accept new patients
    without government identification and soften restrictions for the
    need to connect first to an electronic health record portal to con-
    nect by video. Health systems can rely on proven strategies to
    maximize participation in health care after release, such as by hir-
    ing community health workers to work within the health system.7

    Evidence shows that addressing the needs of newly released indi-
    viduals can improve their engagement in primary care and reduce
    preventable hospitalizations and later contact with the criminal
    justice system.8

    Medicaid or Medicare and Payment
    Central to health care access is insurance. On any given day, the jail
    population includes more than 700 000 individuals, but more than
    10 million people a year pass through jails.9 Approximately 6% of
    the jail population is 65 years or older. When Medicare or Medicaid
    beneficiaries are incarcerated, they are ineligible for the benefits be-
    cause of their incarceration status. The Medicaid Inmate Exclusion
    Policy prohibits use of federal funds and services for medical care
    provided to “inmates of a public institution.” About two-thirds of the
    jail population are held before trial and most are unable to post bail
    to get released. Perversely, the law denies these health insurance
    benefits to those who are too poor to pay bail but for defendants
    with more resources who can pay for their release, their Medicaid
    or Medicare continues.

    Under the Centers for Medicare & Medicaid Services (CMS)
    administrative rules, states can initiate programs or policies to sup-
    port safe decarceration, including covering the costs of SARS-CoV-2
    testing and related health needs prior to release and facilitating
    access to medications, primary care, substance use, and mental

    health treatment. Importantly, states can follow Social Security
    Administration rules and suspend (as opposed to fully terminate)
    Medicaid or Medicare benefits when a person is incarcerated, which
    ensures activation of coverage upon release. Suspension of these
    benefits also has financial benefits. States that have suspended Med-
    icaid have been reimbursed for inpatient medical services for incar-
    cerated individuals enrolled in Medicaid and have reported cost sav-
    ings ranging from $3 million to $19 million per year.10

    Medicaid coverage also could be expanded with waivers under
    Sections 1115 and 1135 of the Social Security Act. Some states are seek-
    ing waivers to expand the scope of services to incarcerated people
    during the COVID-19 emergency to cover testing or outpatient treat-
    ment, although CMS has not yet approved any waivers. In addition,
    wholesale expansion of Medicaid in the first 30 days prior to re-
    lease could cover COVID-19 testing and also create a smoother tran-
    sition to the community by covering medications and enabling re-
    ferrals to community care.

    Even in the 12 states that have not yet expanded Medicaid un-
    der the Affordable Care Act, coverage is available for COVID-19 test-
    ing and related services if the state takes up the optional eligibility
    group provided in the Families First Coronavirus Response Act of
    2020. This pathway allows low-income adults in nonexpansion
    states, including incarcerated adults, to enroll in Medicaid. While the
    Inmate Exclusion Policy would continue to apply, this pathway could
    assist access to health care immediately upon release.

    Conclusions
    Decarceration in service of both public health and safer communi-
    ties will require sustained engagement from clinicians, health sys-
    tems, and Medicaid authorities. The actions the country takes now
    against COVID-19 are opportunities to put in motion longer-term im-
    provements to correctional and community health and to advance
    health equity at large.

    ARTICLE INFORMATION

    Published Online: November 16, 2020.
    doi:10.1001/jama.2020.22109

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: The members of the
    consensus committee that authored the National
    Academies of Sciences, Engineering, and Medicine
    report Decarcerating Correctional Facilities During
    COVID-19: Advancing Health, Equity, and Safety
    were Emily Wang (cochair, Department of
    Medicine, Yale University School of Medicine);
    Bruce Western (cochair, Department of Sociology,
    Columbia University); Donald Berwick (Institute for
    Healthcare Improvement); Sharon Dolovich
    (University of California, Los Angeles Law School);
    Deanna Hoskins (JustLeadershipUSA); Margot
    Kushel (Center for Vulnerable Populations,
    Department of Medicine, University of California,
    San Francisco); Hedwig Lee (Department of
    Sociology, Washington University in St Louis);
    Stephen Rafael (University of California, Berkley);
    Josiah Rich (Department of Medicine, Brown
    University); John Wetzel (Department of
    Corrections, Pennsylvania); and Emily Backes
    (study director) and Julie Schuck (program officer,
    National Academies of Sciences, Engineering, and
    Medicine).

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    Opinion Viewpoint

    2258 JAMA December 8, 2020 Volume 324, Number 22 (Reprinted) jama.com

    © 2020 American Medical Association. All rights reserved.

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