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
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)
**## 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)
**## 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).
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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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