Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons | Health Care Economics, Insurance, Payment | JAMA Internal Medicine

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Among People Incarcerated in US Prisons" /> <meta property="og:type" content="Article" /> <meta property="og:url" content="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2821730" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/939476/ioi240046t1_1727970862.85926.png?Expires=2147483647&Signature=W0VneQ2TJQMHKdHGFS8d2F8D7s2h~OFhm3DzoQrrDoW3FDvodBU1VQo5qOpgrPC31vvrGRSNc53PCFpJ5bG2R3SV~7UjJpugreWt~hLBtFJZlVNdI4BJsmWrty9QYLyCQ2laiGOd~M-v9I3kVMw74ae~74KBHh1vg4mFPh6mFjWfvXFdmQJWt7Td44OfL8EmGSYZWdTuWAcmSuF0QZpuroPr5IBeZ-56gr6PkqSV1R0~Wr5mqfi7aA8SOuoHEWDYqVLymblepHGfLRQBgLwyUmaRijsb-3ONHjv4e7hbhprWM58JvQHuZdGIkFrs0kQvtyM-X6TEd~MveGoPffwZyA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" 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content="https://cdn.jamanetwork.com/ama/content_public/journal/intemed/939476/ioi240046t1_1727970862.85926.png?Expires=2147483647&Signature=W0VneQ2TJQMHKdHGFS8d2F8D7s2h~OFhm3DzoQrrDoW3FDvodBU1VQo5qOpgrPC31vvrGRSNc53PCFpJ5bG2R3SV~7UjJpugreWt~hLBtFJZlVNdI4BJsmWrty9QYLyCQ2laiGOd~M-v9I3kVMw74ae~74KBHh1vg4mFPh6mFjWfvXFdmQJWt7Td44OfL8EmGSYZWdTuWAcmSuF0QZpuroPr5IBeZ-56gr6PkqSV1R0~Wr5mqfi7aA8SOuoHEWDYqVLymblepHGfLRQBgLwyUmaRijsb-3ONHjv4e7hbhprWM58JvQHuZdGIkFrs0kQvtyM-X6TEd~MveGoPffwZyA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta name="citation_author" content="Emily Lupton Lupez" /><meta name="citation_author_institution" content="Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts" /><meta name="citation_author_institution" content="Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author" content="Steffie Woolhandler" /><meta name="citation_author_institution" content="Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author_institution" content="City University of New York at Hunter College, New York" /><meta name="citation_author" content="David U. Himmelstein" /><meta name="citation_author_institution" content="Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author_institution" content="City University of New York at Hunter College, New York" /><meta name="citation_author" content="Laura Hawks" /><meta name="citation_author_institution" content="Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee" /><meta name="citation_author_institution" content="Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee" /><meta name="citation_author" content="Samuel Dickman" /><meta name="citation_author_institution" content="Planned Parenthood of Montana, Kalispell" /><meta name="citation_author" content="Adam Gaffney" /><meta name="citation_author_institution" content="Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts" /><meta name="citation_author_institution" content="Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author" content="David Bor" /><meta name="citation_author_institution" content="Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts" /><meta name="citation_author_institution" content="Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author" content="Elizabeth Schrier" /><meta name="citation_author_institution" content="University of California–San Francisco School of Medicine" /><meta name="citation_author" content="Chris Cai" /><meta name="citation_author_institution" content="Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts" /><meta name="citation_author" content="Lenore S. Azaroff" /><meta name="citation_author_institution" content="Edward M. Kennedy Community Health Center, Worcester, Massachusetts" /><meta name="citation_author" content="Danny McCormick" /><meta name="citation_author_institution" content="Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts" /><meta name="citation_author_institution" content="Harvard Medical School, Boston, Massachusetts" /><meta name="citation_title" content="Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons" /><meta name="citation_firstpage" content="1176" /><meta name="citation_lastpage" content="1184" /><meta name="citation_doi" content="10.1001/jamainternmed.2024.3567" /><meta name="citation_keyword" content="pregnancy" /><meta name="citation_keyword" content="health services" /><meta name="citation_keyword" content="health services accessibility" /><meta name="citation_keyword" content="mental health" /><meta name="citation_keyword" content="copayment" /><meta name="citation_keyword" content="correctional facilities" /><meta name="citation_keyword" content="incarceration" /><meta name="citation_keyword" content="psychological distress" /><meta name="citation_keyword" content="medical residencies" /><meta name="citation_keyword" content="internship and residency" /><meta name="citation_abstract" content="<h3>Importance</h3><p>Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access.</p><h3>Objective</h3><p>To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state’s standard prison co-payment and care receipt in 2016.</p><h3>Design, Setting, and Participants</h3><p>This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics’ 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey.</p><h3>Exposures</h3><p>The state’s standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison’s minimum wage.</p><h3>Main Outcomes and Measures</h3><p>Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level.</p><h3>Results</h3><p>Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week’s prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay ≤1 week’s wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay &gt;1 week’s wage: aOR, 2.17; 95% CI, 1.61-2.93).</p><h3>Conclusions and Relevance</h3><p>This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.</p>" /><meta name="citation_journal_title" content="JAMA Internal Medicine" /><meta name="citation_journal_abbrev" content="JAMA Intern Med" /><meta name="citation_volume" content="184" /><meta name="citation_issue" content="10" /><meta name="citation_publication_date" content="2024/10/01" /><meta name="citation_issn" content="2168-6106" /><meta name="citation_publisher" content="American Medical Association" /><meta name="citation_reference" content="Fair H,Walmsley R. World prison population list, 2021. Accessed March 17, 2024. https://www.prisonstudies.org/sites/default/files/resources/downloads/world_prison_population_list_13th_edition.pdf " /><meta name="citation_reference" content="Carson EA. Prisoners in 2021 —statistical tables. Accessed March 17, 2024. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf " /><meta name="citation_reference" content="citation_title=The health and health care of US prisoners: results of a nationwide survey.; citation_author=Wilper AP; citation_author=Woolhandler S; citation_author=Boyd JW; citation_journal_title=Am J Public Health; citation_year=2009; citation_volume=99; citation_issue=4; citation_pages=666-672; " /><meta name="citation_reference" content="citation_title=Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population.; citation_author=Binswanger IA; citation_author=Krueger PM; citation_author=Steiner JF; citation_journal_title=J Epidemiol Community Health; citation_year=2009; citation_volume=63; citation_issue=11; citation_pages=912-919; " /><meta name="citation_reference" content="Maruschak LM. Medical problems of prisoners. Accessed March 17, 2024. https://bjs.ojp.gov/library/publications/medical-problems-prisoners " /><meta name="citation_reference" content="Maruschak LM,Bronson J,Alper M. Medical problems reported by prisoners: survey of prison inmates, 2016. Accessed March 17, 2024. https://bjs.ojp.gov/library/publications/medical-problems-reported-prisoners-survey-prison-inmates-2016 " /><meta name="citation_reference" content="Maruschak LM,Bronson J,Alper M. Indicators of mental health problems reported by prisoners: survey of prison inmates, 2016. Accessed March 17, 2024. https://bjs.ojp.gov/library/publications/indicators-mental-health-problems-reported-prisoners-survey-prison-inmates " /><meta name="citation_reference" content="Maruschak LM,Bronson J,Alper M. Alcohol and drug use and treatment reported by prisoners. Accessed March 17, 2024. https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/adutrpspi16st.pdf " /><meta name="citation_reference" content="citation_title=Chronic medical conditions in criminal justice involved populations.; citation_author=Harzke AJ; citation_author=Pruitt SL; citation_journal_title=J Health Hum Serv Adm; citation_year=2018; citation_volume=41; citation_issue=3; citation_pages=306-347; " /><meta name="citation_reference" content="James DJ,Beattie LG. Mental health problems of prison and jail inmates. Accessed March 17, 2024. https://bjs.ojp.gov/library/publications/mental-health-problems-prison-and-jail-inmates " /><meta name="citation_reference" content="citation_title=Pregnancy, systemic disregard and degradation, and carceral institutions.; citation_author=Kuhlik L; citation_author=Sufrin C; citation_journal_title=Harv Law Policy Rev; citation_year=2020; citation_volume=14; citation_pages=417-466; " /><meta name="citation_reference" content="citation_title=The links between disability, incarceration, and social exclusion.; citation_author=Bixby L; citation_author=Bevan S; citation_author=Boen C; citation_journal_title=Health Aff (Millwood); citation_year=2022; citation_volume=41; citation_issue=10; citation_pages=1460-1469; " /><meta name="citation_reference" content="Bronson J,Berzofsky M. Indicators of mental health problems reported by prisoners and jail inmates, 2011-12. Accessed March 17, 2024. https://bjs.ojp.gov/content/pub/pdf/imhprpji1112.pdf " /><meta name="citation_reference" content="Maruschak LM,Berzofsky M. Medical problems of state and federal prisoners and jail inmates, 2011–12. Accessed March 17, 2024. https://bjs.ojp.gov/content/pub/pdf/mpsfpji1112.pdf#:~:text=%C2%84In%202011%E2%80%9312%2C%20an%20estimated%2040%25%20of%20state%20and,C%2C%20or%20other%20STDs%20%28excluding%20HIV%20or%20AIDS%29 " /><meta name="citation_reference" content="US Supreme Court. Estelle v. Gamble, 429 U.S. 97, (1976). Accessed July 2, 2024. https://tile.loc.gov/storage-services/service/ll/usrep/usrep429/usrep429097/usrep429097.pdf " /><meta name="citation_reference" content="US Government. U.S. Code § 4048: fees for health care services for prisoners. https://www.govinfo.gov/content/pkg/USCODE-2011-title18/pdf/USCODE-2011-title18-partIII-chap303-sec4048.pdf " /><meta name="citation_reference" content="citation_title=The effect of office visit copayments on preventive care services in an HMO.; citation_author=Cherkin DC; citation_author=Grothaus L; citation_author=Wagner EH; citation_journal_title=Inquiry; citation_year=1990; citation_volume=27; citation_issue=1; citation_pages=24-38; " /><meta name="citation_reference" content="citation_title=How does copayment for health care services affect demand, health and redistribution? a systematic review of the empirical evidence from 1990 to 2011.; citation_author=Kiil A; citation_author=Houlberg K; citation_journal_title=Eur J Health Econ; citation_year=2014; citation_volume=15; citation_issue=8; citation_pages=813-828; " /><meta name="citation_reference" content="citation_title=Effects of cost sharing on use of medical services and health.; citation_author=Keeler EB; citation_journal_title=J Med Pract Manage; citation_year=1992; citation_issue=8; citation_pages=317-321; " /><meta name="citation_reference" content="Ku L,Wachino V. The effect of increased cost sharing in Medicaid: a summary of research findings. Accessed March 17, 2024. https://cbpp.org/sites/default/files/archive/5-31-05health2.pdf " /><meta name="citation_reference" content="Sawyer W. How much do incarcerated people earn in each state. Accessed April 10, 2017. https://www.prisonpolicy.org/blog/2017/04/10/wages/ " /><meta name="citation_reference" content="citation_title=A study of women prisoners’ use of co-payments for health care: issues of access.; citation_author=Fisher AA; citation_author=Hatton DC; citation_journal_title=Womens Health Issues; citation_year=2010; citation_volume=20; citation_issue=3; citation_pages=185-192; " /><meta name="citation_reference" content="citation_title=Effect of co-payment on the use of medical services by male and female prisoners.; citation_author=Hyde R; citation_author=Brumfield B; citation_journal_title=J Correctional Health Care; citation_year=2003; citation_volume=9; citation_issue=4; citation_pages=371-380; " /><meta name="citation_reference" content="citation_title=Methicillin-resistant Staphylococcus aureus infections in correctional facilities—Georgia, California, and Texas, 2001-2003.; citation_author=US Centers for Disease Control and Prevention; citation_author=Tobin-D’Angelo M; citation_author=Arnold K; citation_author=Lance-Parker S; citation_author=LaMarre M; citation_journal_title=MMWR Morb Mortal Wkly Rep; citation_year=2003; citation_volume=52; citation_issue=41; citation_pages=992-996; " /><meta name="citation_reference" content="citation_title=Financial barriers and utilization of medical services in prison: an examination of copayments, personal assets, and individual characteristics.; citation_author=Wyant BR; citation_journal_title=J Evidence-based Practice in Correctional Health; citation_year=2018; citation_volume=2; citation_issue=1; " /><meta name="citation_reference" content="citation_title=Gender differences and the effect of copayments on the utilization of health care in prison.; citation_author=Wyant BR; citation_author=Harner H; citation_author=Lockwood B; citation_journal_title=J Correct Health Care; citation_year=2021; citation_volume=27; citation_issue=1; citation_pages=30-35; " /><meta name="citation_reference" content="Glaze L. Methodology: survey of prison inmates, 2016. Accessed March 17, 2024. https://bjs.ojp.gov/library/publications/methodology-survey-prison-inmates-2016 " /><meta name="citation_reference" content="Sawyer W. The steep cost of medical co-pays in prison puts health at risk. Accessed April 19, 2017. https://www.prisonpolicy.org/blog/2017/04/19/copays/ " /><meta name="citation_reference" content="citation_title=Short screening scales to monitor population prevalences and trends in non-specific psychological distress.; citation_author=Kessler RC; citation_author=Andrews G; citation_author=Colpe LJ; citation_journal_title=Psychol Med; citation_year=2002; citation_volume=32; citation_issue=6; citation_pages=959-976; " /><meta name="citation_reference" content="citation_title=Screening for serious mental illness in the general population.; citation_author=Kessler RC; citation_author=Barker PR; citation_author=Colpe LJ; citation_journal_title=Arch Gen Psychiatry; citation_year=2003; citation_volume=60; citation_issue=2; citation_pages=184-189; " /><meta name="citation_reference" content="Survey of Prison Inmates. United States, 2016. Accessed March 14, 2024. https://www.icpsr.umich.edu/web/NACJD/studies/37692/datadocumentation " /><meta name="citation_reference" content="citation_title=The need for higher standards in correctional healthcare to improve public health.; citation_author=Rich JD; citation_author=Allen SA; citation_author=Williams BA; citation_journal_title=J Gen Intern Med; citation_year=2015; citation_volume=30; citation_issue=4; citation_pages=503-507; " /><meta name="citation_reference" content="citation_title=Deliberate indifference: inadequate health care in U.S. prisons.; citation_author=Hurst A; citation_author=Castañeda B; citation_author=Ramsdale E; citation_journal_title=Ann Intern Med; citation_year=2019; citation_volume=170; citation_issue=8; citation_pages=563-564; " /><meta name="citation_reference" content="citation_title=Health care for people who are incarcerated.; citation_author=Puglisi LB; citation_author=Wang EA; citation_journal_title=Nat Rev Dis Primers; citation_year=2021; citation_volume=7; citation_issue=1; citation_pages=50-50; " /><meta name="citation_reference" content="citation_title=A three-dimensional action plan to raise the quality of care of US correctional health and promote alternatives to incarceration.; citation_author=Venters H; citation_journal_title=Am J Public Health; citation_year=2016; citation_volume=106; citation_issue=4; citation_pages=613-614; " /><meta name="citation_reference" content="citation_title=Can there be acceptable prison health care? looking back on the 1970s.; citation_author=Reverby SM; citation_journal_title=Public Health Rep; citation_year=2019; citation_volume=134; citation_issue=1; citation_pages=89-93; " /><meta name="citation_reference" content="National Commission on Correctional Health Care. Eliminating financial assessments for health care services during incarceration. Accessed March 17, 2024. https://www.ncchc.org/position-statements/eliminating-financial-assessments-for-health-care-services-during-incarceration-2/ " /><meta name="citation_reference" content="citation_title=Health care during incarceration: a policy position paper from the American College of Physicians.; citation_author=Health and Public Policy Committee of the American College of Physicians; citation_author=Kendig NE; citation_author=Butkus R; citation_author=Mathew S; citation_author=Hilden D; citation_journal_title=Ann Intern Med; citation_year=2022; citation_volume=175; citation_issue=12; citation_pages=1742-1745; " /><meta name="citation_reference" content="citation_title=Health care in U.S. correctional facilities—a limited and threatened constitutional right.; citation_author=Alsan M; citation_author=Yang CS; citation_author=Jolin JR; citation_author=Tu L; citation_author=Rich JD; citation_journal_title=N Engl J Med; citation_year=2023; citation_volume=388; citation_issue=9; citation_pages=847-852; " /><meta name="citation_reference" content="citation_title=The shift of psychiatric inpatient care from hospitals to jails and prisons.; citation_author=Lamb HR; citation_author=Weinberger LE; citation_journal_title=J Am Acad Psychiatry Law; citation_year=2005; citation_volume=33; citation_issue=4; citation_pages=529-534; " /><meta name="citation_reference" content="citation_title=Mentally ill persons in the criminal justice system: some perspectives.; citation_author=Lamb HR; citation_author=Weinberger LE; citation_author=Gross BH; citation_journal_title=Psychiatr Q; citation_year=2004; citation_volume=75; citation_issue=2; citation_pages=107-126; " /><meta name="citation_reference" content="citation_title=Horizons of context: understanding the police decision to arrest people with mental illness.; citation_author=Morabito MS; citation_journal_title=Psychiatr Serv; citation_year=2007; citation_volume=58; citation_issue=12; citation_pages=1582-1587; " /><meta name="citation_reference" content="citation_title=Effect of increased private share of inpatient psychiatric resources on jail population growth: evidence from the United States.; citation_author=Yoon J; citation_journal_title=Soc Sci Med; citation_year=2011; citation_volume=72; citation_issue=4; citation_pages=447-455; " /><meta name="citation_reference" content="Fuller D,Sinclair E,Geller J,Quanbeck C,Snook J. Going, going, gone: trends and consequences of eliminating state psychiatric beds. Accessed March 17, 2024. https://www.treatmentadvocacycenter.org/reports_publications/going-going-gone-trends-and-consequences-of-eliminating-state-psychiatric-beds/ " /><meta name="citation_reference" content="American Psychiatric Association. The psychiatric bed crisis in the US: understanding the problem and moving toward solutions. Accessed March 17, 2024. https://www.psychiatry.org/getmedia/81f685f1-036e-4311-8dfc-e13ac425380f/APA-Psychiatric-Bed-Crisis-Report-Full.pdf " /><meta name="citation_reference" content="citation_title=Losing years doing time: incarceration exposure and accelerated biological aging among African American adults.; citation_author=Berg MT; citation_author=Rogers EM; citation_author=Lei MK; citation_author=Simons RL; citation_journal_title=J Health Soc Behav; citation_year=2021; citation_volume=62; citation_issue=4; citation_pages=460-476; " /><meta name="citation_reference" content="citation_title=Incarceration as a key variable in racial disparities of asthma prevalence.; citation_author=Wang EA; citation_author=Green J; citation_journal_title=BMC Public Health; citation_year=2010; citation_volume=10; citation_pages=290" /><meta name="citation_reference" content="citation_title=Tobacco use by male prisoners under an indoor smoking ban.; citation_author=Kauffman RM; citation_author=Ferketich AK; citation_author=Murray DM; citation_author=Bellair PE; citation_author=Wewers ME; citation_journal_title=Nicotine Tob Res; citation_year=2011; citation_volume=13; citation_issue=6; citation_pages=449-456; " /><meta name="citation_reference" content="citation_title=Heat-related mortality in U.S. state and private prisons: a case-crossover analysis.; citation_author=Skarha J; citation_author=Spangler K; citation_author=Dosa D; citation_author=Rich JD; citation_author=Savitz DA; citation_author=Zanobetti A; citation_journal_title=PLoS One; citation_year=2023; citation_volume=18; citation_issue=3; " /><meta name="citation_reference" content="James N. Federal prison population buildup: overview, policy changes, issues, and options. Accessed March 17, 2024. https://www.ojp.gov/ncjrs/virtual-library/abstracts/federal-prison-population-buildup-overview-policy-changes-issues " /><meta name="citation_reference" content="citation_title=Ten urgent priorities based on lessons learned from more than a half million known COVID-19 cases in US prisons.; citation_author=Barnert E; citation_author=Kwan A; citation_author=Williams B; citation_journal_title=Am J Public Health; citation_year=2021; citation_volume=111; citation_issue=6; citation_pages=1099-1105; " /><meta name="citation_reference" content="Soble L,Stroud K,Weinstein M. Eating behind bars: ending the hidden punishment of food in prison. Accessed March 17, 2024. https://impactjustice.org/wp-content/uploads/IJ-Eating-Behind-Bars.pdf " /><meta name="citation_reference" content="citation_title=Psychological distress in solitary confinement: symptoms, severity, and prevalence in the United States, 2017–2018.; citation_author=Reiter K; citation_author=Ventura J; citation_author=Lovell D; citation_journal_title=Am J Public Health; citation_year=2020; citation_volume=110; citation_issue=S1; citation_pages=S56-S62; " /><meta name="citation_reference" content="citation_title=Mental health issues in long-term solitary and “Supermax” confinement.; citation_author=Haney C; citation_journal_title=Crime Delinq; citation_year=2003; citation_volume=49; citation_issue=1; citation_pages=124-156; " /><meta name="citation_reference" content="citation_title=The body in isolation: the physical health impacts of incarceration in solitary confinement.; citation_author=Strong JD; citation_author=Reiter K; citation_author=Gonzalez G; citation_journal_title=PLoS One; citation_year=2020; citation_volume=15; citation_issue=10; " /><meta name="citation_reference" content="citation_title=Solitary confinement and health.; citation_author=Brinkley-Rubinstein L; citation_author=Johnson T; citation_journal_title=N C Med J; citation_year=2019; citation_volume=80; citation_issue=6; citation_pages=359-360; " /><meta name="citation_reference" content="citation_title=Current trends in state inmate user fee programs for health services.; citation_author=Gipson FT; citation_author=Pierce EA; citation_journal_title=J Correct Health Care; citation_year=1996; citation_volume=3; citation_issue=2; citation_pages=159-178; " /><meta name="citation_reference" content="US Congress. Federal Prisoner Health Care Copayment Act of 2000. Accessed March 17, 2024. https://www.congress.gov/106/plaws/publ294/PLAW-106publ294.pdf " /><meta name="citation_reference" content="citation_title=A pound of flesh: how medical copayments in prison cost inmates their health and set them up for reoffense.; citation_author=Wiggins R; citation_journal_title=Univ Colo Law Rev; citation_year=2021; citation_volume=92; citation_pages=256-259; " /><meta name="citation_reference" content="Lockwood B,Lewis N. The hidden cost of incarceration. Accessed March 17, 2024. https://www.themarshallproject.org/2019/12/17/the-hidden-cost-of-incarceration " /><meta name="citation_reference" content="citation_title=Monetary sanctions: legal financial obligations in US systems of justice.; citation_author=Martin KD; citation_author=Sykes BL; citation_author=Shannon S; citation_author=Edwards F; citation_author=Harris A; citation_journal_title=Annu Rev Criminol; citation_year=2018; citation_volume=1; citation_issue=1; citation_pages=471-495; " /><meta name="citation_reference" content="citation_title=Discretionary disenfranchisement: the case of legal financial obligations.; citation_author=Meredith M; citation_author=Morse M; citation_journal_title=J Legal Stud; citation_year=2017; citation_volume=46; citation_issue=2; citation_pages=309-338; " /><meta name="citation_reference" content="Salas M,Ciolfi A. Driven by dollars: a state-by-state analysis of drivers license suspension laws for failure to pay court debt. Accessed March 17, 2024. https://finesandfeesjusticecenter.org/articles/driven-by-dollars-a-state-by-state-analysis-of-drivers-license-suspension-laws-for-failure-to-pay-court-debt/ " /><meta name="citation_reference" content="Rhode K,Ross T,Kim C. Reforming health care for patients in prison. Accessed March 17, 2024. https://www.theregreview.org/2022/02/12/saturday-seminar-reforming-health-care-patients-prison/ " /><meta name="citation_reference" content="Huh K,Boucher A,McGaffey F,McKillop M,Schiff M. Prison health care: costs and quality. Accessed March 17, 2024. https://www.pewtrusts.org/~/media/assets/2017/10/sfh_prison_health_care_costs_and_quality_final.pdf " /><meta name="citation_reference" content="citation_title=Paying the price: the pressing need for quality, cost, and outcomes data to improve correctional health care for older prisoners.; citation_author=Ahalt C; citation_author=Trestman RL; citation_author=Rich JD; citation_author=Greifinger RB; citation_author=Williams BA; citation_journal_title=J Am Geriatr Soc; citation_year=2013; citation_volume=61; citation_issue=11; citation_pages=2013-2019; " /><meta name="citation_reference" content="Herring T. COVID looks like it may stay—that means prison medical copays must go. Accessed March 17, 2024. https://www.prisonpolicy.org/blog/2022/02/01/pandemic_copays/ " /><meta name="citation_reference" content="Federal Bureau of Prisons. An overview of the First Step Act. Accessed March 17, 2024. https://www.bop.gov/inmates/fsa/overview.jsp " /><meta name="citation_reference" content="citation_title=Community investment interventions as a means for decarceration: a scoping review.; citation_author=Hawks L; citation_author=Lopoo E; citation_author=Puglisi L; citation_journal_title=Lancet Reg Health Am; citation_year=2021; citation_volume=8; " /><meta name="citation_reference" content="US Congress. S.1248—Safer Detention Act of 2023. Accessed March 17, 2024. https://www.congress.gov/bill/118th-congress/senate-bill/1248#:~:text=%2F20%2F2023)-,Safer%20Detention%20Act%20of%202023,final%20portion%20of%20their%20sentences.&text=creates%20a%20judicial%20review%20process%20for%20prisoners. " /><meta name="citation_reference" content="US Congress. S.1165—Reentry Act of 2023. Accessed March 17, 2024. https://www.congress.gov/bill/118th-congress/senate-bill/1165#:~:text=This%20bill%20allows%20for%20Medicaid,period%20preceding%20the%20individual's%20release. 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class="hide tagmanagervalue" data-attribute="articleDOI" data-value="10.1001/jamainternmed.2024.3567" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="articleTitle" data-value="Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="type" data-value="Original Investigation" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="issueVolume" data-value="184" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="issueNo" data-value="10" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="publishDate" data-value="October 1, 2024" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="topics" data-value="Health Care Economics, Insurance, Payment" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="topicCode" data-value="42114" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="category" data-value="Research" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="journalClub" data-value="No" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentStatus" data-value="Locked" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="articlePubState" data-value="Final" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentMedium" data-value="Article" data-type="string"></span> <div class="meta-article-type-wrap"> <div class="meta-article-type thm-col">Original Investigation </div> </div> <div class="meta-date">August 5, 2024</div> <div class="meta-article-title-wrap"> <h1 class="meta-article-title ">Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons</h1> </div> <div class="meta-authors"> <span class="meta-authors--limited"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Emily+Lupton+Lupez&q=Emily+Lupton+Lupez" rel=nofollow target="_blank">Emily Lupton Lupez, MD, MPH<sup>1,2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Steffie+Woolhandler&q=Steffie+Woolhandler" rel=nofollow target="_blank">Steffie Woolhandler, MD, MPH<sup>2,3</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=David+U.+Himmelstein&q=David+U.+Himmelstein" rel=nofollow target="_blank">David U. Himmelstein, MD<sup>2,3</sup></a></span>; <a class="meta-authors--etal td-u stats-meta-authors--etal">et al</a></span> <span class="meta-authors--remaining"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Laura+Hawks&q=Laura+Hawks" rel=nofollow target="_blank">Laura Hawks, MD, MPH<sup>4,5</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Samuel+Dickman&q=Samuel+Dickman" rel=nofollow target="_blank">Samuel Dickman, MD<sup>6</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Adam+Gaffney&q=Adam+Gaffney" rel=nofollow target="_blank">Adam Gaffney, MD, MPH<sup>1,2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=David+Bor&q=David+Bor" rel=nofollow target="_blank">David Bor, MD<sup>1,2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Elizabeth+Schrier&q=Elizabeth+Schrier" rel=nofollow target="_blank">Elizabeth Schrier, MD<sup>7</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Chris+Cai&q=Chris+Cai" rel=nofollow target="_blank">Chris Cai, MD<sup>8</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Lenore+S.+Azaroff&q=Lenore+S.+Azaroff" rel=nofollow target="_blank">Lenore S. Azaroff, MD, ScD<sup>9</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Danny+McCormick&q=Danny+McCormick" rel=nofollow target="_blank">Danny McCormick, MD, MPH<sup>1,2</sup></a></span></span> </div> <div class="meta-author"> <a class="meta-author-title is-b stats-meta-author-toggle" data-tog-target=".meta-author-content">Author Affiliations</a> <a class="meta-articleinfo-jumplink section-jump-link scroll-to stats-scroll-to-articleinfo" data-tab-toggle=".tab-nav-full-text" href="#249943361">Article Information</a> <div class="meta-author-content"> <ul class="meta-author-affiliations"> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>1</sup>Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>2</sup>Harvard Medical School, Boston, Massachusetts</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>3</sup>City University of New York at Hunter College, New York</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>4</sup>Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>5</sup>Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>6</sup>Planned Parenthood of Montana, Kalispell</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>7</sup>University of California–San Francisco School of Medicine</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>8</sup>Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>9</sup>Edward M. Kennedy Community Health Center, Worcester, Massachusetts</div> </li> </ul> </div> </div> <div class="meta-citation-wrap"> <span class="meta-citation-journal-name">JAMA Intern Med. </span><span class="meta-citation"> 2024;184(10):1176-1184. doi:10.1001/jamainternmed.2024.3567</span> </div> </div> <div class="widget-EditorsChoice widget-instance-AMA_EditorsChoice_Links"> </div> <div class="widget-LinkedContentToolbar widget-instance-AMA_LinkedContentToolbar"> <div class="linked-content-toolbar"> <div class="hidden js-search-open-multimedia-by-default" showContentByDefault="False"></div> <div class="linked-content-controls"> <a class="linked-content-trigger td-n stats-graphical-abstract" href="#graphical-abstract-tab"> <i class="icon-visual-abstract"><span class="sr-t">visual abstract icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Visual <div>Abstract</div></div> </a> <a class="linked-content-trigger td-n stats-editorial-comment" href="#editorial-comment-tab"> <i class="icon-document"><span class="sr-t">editorial comment icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Editorial <div>Comment</div></div> </a> <a class="linked-content-trigger td-n stats-related-articles" href="#related-articles-tab"> <i class="icon-related"><span class="sr-t">related articles icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Related <div>Articles</div></div> </a> <a class="linked-content-trigger td-n stats-author-interviews" href="#author-interviews-tab"> <i class="icon-author_interview"><span class="sr-t">author interview icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Interviews</div> </a> <a class="linked-content-trigger td-n stats-more-multimedia" href="#more-multimedia-tab"> <i class="icon-multimedia"><span class="sr-t">multimedia icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Multimedia</div> </a> <a class="linked-content-trigger td-n stats-listen-to-this-article" href="#listen-to-this-article-tab"> <i class="icon-audio"><span class="sr-t">audio icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Listen to <div>this article</div></div> </a> </div> <div class="linked-content-tabs"> <div id="graphical-abstract-tab" class="linked-content-tab graphical-abstract-tab"> <div class="widget-SectionDisplay widget-instance-AMA_GraphicalAbstract_Tab"> </div> </div> <div id="editorial-comment-tab" class="linked-content-tab editorial-comment-tab"> <div class="widget-ArticleLinks widget-instance-AMA_LinkedContentToolbar_EditorialComments"> <ul class="article-abstract-links related-abstract-content"> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2821733"> <div class="related-article-type">Invited Commentary</div> <div class="related-article-title sb-tc">Harming Health by Imposing In-Prison Co-Payments</div> </a> <div class="related-article-authors">Benjamin A. 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widget-instance-AMA_LinkedContentToolbar_MoreMultimedia"> </div> </div> </div> </div> </div> <a class="full-text-link is-b" data-url="" data-article-id="2821730"> <div class="full-text-link--text"><span class="full-text-link--text-top">Full </span>Text</div> </a> <div class="abstract-content"> <div class="widget-ArticleFulltext widget-instance-AMA_Article_Abstract_Widget"> <div class="article-full-text" data-userHasAccess="False"> <a class="article-section-id-anchor" id="249943306"></a> <span class="heading-text thm-col h3 cb section-type-keyPoints decorated-hed sb-sc ">Key Points</span><p><strong>Questions</strong> <span>What are the health status and health care access of people residing in US prisons, and are co-payments associated with reduced access to care?</span></p><p><strong>Findings</strong> <span>In this repeated cross-sectional study representing 1 421 700 people in US prisons, there was high, and possibly increasing, prevalence of mental health and chronic physical conditions, as well as poor access to care. Co-payments were associated with worse access, especially when the prison’s standard co-payment for a medical visit exceeded 1 week’s prison wage.</span></p><p><strong>Meaning</strong> <span>The results of this study suggest that incarcerated individuals, especially those in prisons that usually require co-payments for visits, often receive inadequate care despite their substantial health needs.</span></p> <a class="article-section-id-anchor" id="249943307"></a> <div class="h3 cb section-type-abstract decorated-hed "> <div class="heading-text thm-col sb-sc"> Abstract </div> </div> <p><strong>Importance</strong> <span>Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access.</span></p><p><strong>Objective</strong> <span>To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state’s standard prison co-payment and care receipt in 2016.</span></p><p><strong>Design, Setting, and Participants</strong> <span>This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics’ 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey.</span></p><p><strong>Exposures</strong> <span>The state’s standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison’s minimum wage.</span></p><p><strong>Main Outcomes and Measures</strong> <span>Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level.</span></p><p><strong>Results</strong> <span>Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week’s prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay ≤1 week’s wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay >1 week’s wage: aOR, 2.17; 95% CI, 1.61-2.93).</span></p><p><strong>Conclusions and Relevance</strong> <span>This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.</span></p> <div class="movable-ad-target bta"> </div> </div> </div> <div class="widget-ArticleLinks widget-instance-AMA_Abstract_EditorialComments"> <ul class="article-abstract-links related-abstract-content"> <li class="article-link related-abstract-article"> <a class="related-article-abstract-link" href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2821733"> <div class="related-article-abstract-type">Invited Commentary</div> <div class="related-article-abstract-title sb-tc">Harming Health by Imposing In-Prison Co-Payments</div> </a> <div class="related-article-journal-name">JAMA Internal Medicine</div> </li> </ul> </div> <a class="full-text-link is-b d-b bd-none ta-c fl-n radius mt1 mb1 m-auto" data-url="" data-article-id="2821730"> <div class="full-text-link--text fw-b"><span class="full-text-link--text-top">Full </span>Text</div> </a> <div class="seamless-access-button--mobile-only"> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_AdvancedSeamlessAccessButton_Mobile"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> </div> <div class="widget-UserComment widget-instance-AMA_Abstract_UserComment"> <div id="comment-wrapper"> <div class="comment-btn"> <a id="modal-opener" class="btn d-b mb1 sb-background-sc js-modal-opener" href="javascript:;">Comment</a> </div> </div> </div> <div class="widget-UserCommentBody widget-instance-AMA_UserCommentBody_Abstract"> </div> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_abstract_bta_dual"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_abstract_bta_dual" data-params="{"parameters":{"siteName":"jamainternalmedicine","siteId":15,"journalId":71,"adDisplay":8,"adSection":"abstract","adPosition":"bta","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <div class="widget-RelatedTopics widget-instance-AMA_Related_Topics_Abstract"> <div class="related-topics-block"> <h4 class="related-topics-heading topic-suggestions-heading sb-sc"> Read More About </h4> <div class="related-topics topic-suggestions"> <a href="https://jamanetwork.com/collections/42114/health-care-economics-insurance-payment" id="item_Link" class="related-topic topic-suggestion no-wrap sb-anchor-light">Health Care Economics, Insurance, Payment</a> </div> </div> </div> </div> <div class="sidebar"> <div class="branded-bar"></div> <div class="abstract-toolbar"> <a id="pdf-link" href="/journals/jamainternalmedicine/articlepdf/2821730/jamainternal_lupez_2024_oi_240046_1727970862.70355.pdf" class="toolbar-tool toolbar-pdf al-link pdfaccess js-pdfaccess" data-article-id="2821730" data-article-url="/journals/jamainternalmedicine/articlepdf/2821730/jamainternal_lupez_2024_oi_240046_1727970862.70355.pdf" data-ajax-url="/Content/CheckPdfAccess"><span class="toolbar-pdf-text"><span class="toolbar-link-text-extra">Download </span><span class="toolbar-link-text">PDF</span></span> </a> <a class="toolbar-tool toolbar-full-text is-b" data-url="" data-article-id="2821730"><span class="toolbar-link-text-extra">Full</span> Text</a> <div class="widget-ToolboxGetCitation widget-instance-AMA_Get_Citation_Abstract"> <a class="toolbar-tool toolbar-citation is-b stats-citation" rel="nofollow" data-reveal-id="get-citation" data-reveal> <span class="toolbar-link-text">Cite</span> <span class="toolbar-link-text-extra">This</span> </a> <div id="get-citation" class="reveal-modal get-citation" data-reveal> <h3 class="get-citation-title">Citation</h3> <p class="get-citation-citation">Lupez EL<span class='al-author-delim'>, </span>Woolhandler S<span class='al-author-delim'>, </span>Himmelstein DU, et al. 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