CRIMINAL JUSTICE

WHY ARE WE (STILL) DISCUSSING CORRECTIONAL HEALTH AND THE COMMUNITY ? ROBERTO HUGH POTTER University of Central Florida

ABSTRACT This article provides a brief overview of some of the issues in the relationships among correctional health issues and community health that lead to the original draft Surgeon General’s Call to Action on Corrections and Community Health. Unfortunately, more than a decade later, we continue to see the health disparities observed in the early 2000s persist. A systemic approach to problems presented by correctional populations is provided. This is followed by an intervention approach that might assist public administrators and non-profit mangers to improve the health of communities by targeting health and disabilities observed in those who process through our criminal justice system.

INTRODUCTION

In the introductory comments to this issue it was noted that the original Surgeon General’s Call to Action on Corrections and Community Health (CTA) was developed in the 2003-2005 time-frame. One of the first questions some will ask is why are we still discussing this topic? After all, it would seem that developments in the 12-15 years since have addressed the problem. Since then, we have seen the passage of the Affordable Care Act and Medicaid expansion in at least half of the states. We could probably do a whole special issue on the impact of these policy and practice changes alone.

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Unfortunately, as the contribution from analysts at the Bureau of Justice Statistics (BJS) and Research Triangle Institute (RTI) will demonstrate, we started from a situation of high burden, much of which has not been addressed systematically. Exactly how much of a “sentinel” population for physical and behavioral health disorders criminal justice populations represent remains an open question (Akers, Potter, and Hill, 2013). In this symposium issue, we hope to explore a range of diseases, disorders, and disabilities to assist public administrators in their understanding of the relationships among these “maladies” that come from our community, enter our correctional and court systems, and return to the community in a mostly rapid fashion.

To do this, we will begin by examining the processes of the criminal justice system, the scope of individuals who are processed through the system, and the organizational characteristics of the system itself. The articles contained it this issue span the entire process, including an analysis of deaths within and after release from correctional facilities and control. It is our hope that this information will reinforce the connections between corrections and community health in a way that assists public administrators to better harness the tools of governance to reduce disease and disability burden in both the community and the criminal justice process.

Debunking Some Harmful Notions First, however, I will ask the reader to indulge an old Sociologist in what we call some “debunking” activities. One of the first questions we have to address when discussing the importance of correctional health care is why only incarcerated individuals are “entitled” to health care? The simple answer is because the Supreme Court has said they do. The longer answer has to do with the lack of control over their own movement and access to services that typify

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the life of an individual in a jail or prison. That is, they cannot decide to schedule an appointment with their physician or go to the local urgent care or emergency room facility when they wish to. While we do not have time to outline the various ways in which medical or dental health care is sought and delivered in correctional facilities, suffice it to say that it is a controlled process that is not as easy as some would like you to believe. Care must be provided, but the way in which it is provided varies widely (Anno, 2001; Chari, Simon, DeFrances & Maruschak, 2016).

A related false perception among many in the community is that once someone is incarcerated, they have an open door to any health care they desire. Few things are further from fact. As has been outlined by both popular and academic writers, the care provided in correctional facilities needs meet only a “community standard” of health care. Many facilities provide inmates with a list of the commonly provided services available while one is incarcerated, along with a description of the “sick call” process. Of course, if a medical professional recommends that a higher level of care is required, correctional administrators are obliged to follow- up on that recommendation. There are avenues of appeal on both sides, naturally. Care that is ordered must be given; unless there is a second medical opinion (Anno, 2001).

Health care in correctional facilities is not “free.” Whether a “co-pay” is required of the inmate or prisoner is another area where processes vary widely. In the end, someone must pay for the care of the individual. It is likely to be those who pay the range of property and sales taxes in the community. For that reason alone, members of the community should be interested in correctional health care. We have seen that such concerns have helped motivate some of the “Smart on Justice” movements around the nation over the past decade. Several years ago, Potter (2010b) wrote an opinion piece to suggest that the jails and prisons of the United States

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offered a model for thinking about universal health care. Since at least the late 1970s, correctional facilities have managed a universal health care system – but only to those incarcerated (not for their employees). Once state and local prisoners and inmates leave confinement, they are on their own (see the Matz article). With the advent of the Affordable Care Act and Medicaid expansion in around half of the States, we have seen attempts to utilize Medicaid for those receiving Medicaid when they were detained, and to enroll qualified others in Medicaid when they were being released back into the community. Because these linkage systems are relatively new, it is still too early to assess how effective they are in getting correctional populations accessing and utilizing community-based health care (see the Butler article). And, as we will point out below, these would still likely impact only a small proportion of the total number of individuals who process through the criminal justice system annually.

In many ways, this is what we were told stopped the original CTA from being published. We had pointed out that, before confinement and upon release, an adequate public health treatment structure was absent from much of the nation. While we had avoided the “unfunded mandate” of requiring correctional health to do more, we had identified the lack of a public health medical system. This, we were told, created an “unfunded mandate” to the health care system to develop a national public health care infrastructure. This raised the specter of something like the British National Health Service (NHS) in the minds of some. As an aside, it has been a relatively recent development that the NHS started to deliver health services inside Her Majesty’s Prisons. In most Australian states, on the other hand, the state-level public health care provider is likely to operate in-facility health services for the combined remand and prison system.

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In the end, much of the mythology surrounding correctional health care and the health burden of inmates and prisoners is less about the burden than it is about the presumed advantage given to inmates and prisoners relative to the general community. In the next section, we examine briefly how the entry and return of community members into the correctional system reflects the community need, rather than just the needs of those incarcerated on any given day.

Stock, Flow, and Churn – The Nature of Criminal Justice Populations and Associated Problems

Many individuals are familiar with the “system” model of the decision-points in the criminal justice system (CJS) popularized by the 1967 President’s Commission on Law Enforcement and Administration of Justice (see Figure 1). While instructive, this model does not provide a clear picture of how populations move through the CJS, and how those cases are “disposed of” at various points. To address this processing information, we have provided a “funnel model” (see Figure 2) that uses 2015 data as an exemplar. We do need to caution that using one year as an exemplar is not ideal, as the process elements of the CJS do not fit neatly into an annual framework. However, as a way of explaining how populations leave the community for correctional facilities and return to the community from corrections, it will be illustrative.

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Figure 1

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Sequence of Decisions in the United States Criminal Justice System

For our purposes, the advantage of the funnel model is that it demonstrates that the bulk of criminal justice activity occurs at the local level, certainly at the county level. Most of the approximately 10.8 million arrests in 2015 were likely processed through county or regional jail facilities (some may have gone directly to Federal Detention Centers). The data on jail entries (“bookings”) for 2015 shows more cases entering jails (10.9 million) than arrests made. This may be due to two factors. First, not all of those processed into a jail were arrested in 2014, but perhaps earlier. Likewise, not all persons arrested in 2015 might have been admitted to a jail, but had their cases dealt with through diversion or automatic bond programs. Second, some individuals may be admitted to a jail multiple times based on the same arrest charge, and certainly those who violate terms of their probation from a sentence issued prior to 2015.

If we overlay the data in Table 1 on the funnel model, we also see that local law enforcement agencies (municipal and county policing agencies) are the most numerous criminal justice agencies (CJAs) in the environment. Their range of employees is also great, from a handful of officers and support personnel to the very large policing agencies encountered in major metropolitan areas. It is important to remember that sworn officers and some administrative personnel are likely to come into contact with the health issues presented by those with whom they interact, and especially those they arrest and detain.

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Figure 2 A “funnel” model of criminal justice processing 2015 Arrests1 10,797,088 Jail Admissions2 10,900,000 Jail Releases 10,900,000 Average Daily Population 721,300 Weekly Turnover Rate 57% Community Corrections Populations3 4,650,900 Prison Admissions4 608,300 Prison Discharges 641,100 Total Population 1,526,800 State 1,338,292 Federal 187,618 Sources: 1Arrest data: https://ucr.fbi.gov/crime-in-the-u.s/2015/crime-in-the- u.s.-2015/tables/table-29 2 Minton, T.D. & Zeng, Z. (2016). Jail Inmates in 2015. Washington, DC: Bureau of Justice Statistics. 3 Kaeble, D. & Bonczar, T.P. (2016). Probation and Parole in the United States, 2015. Washington, DC: Bureau of Justice Statistics. 4Carson, E.A. & Anderson, E. (2016). Prisoners in 2015. Washington, DC: Bureau of Justice Statistics.

Interestingly, while there are many more jails than

prisons, the number of individuals employed in jails is smaller than the number employed in prisons. Partly this is due to the “flow” or “turnover” issue we will discuss in this section. It is important to note is that almost as many people leave jails as enter them in any given year. In most states this is due, in part, to the fact that jails generally incarcerate individuals with sentences up to 365 days; prisons take those with sentences longer than one year. There are enough variations in how county jails are defined in state laws that our caution of “local results may vary” needs to be invoked.

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Massachusetts provides a good exemplar of a state where jails may hold certain individuals for periods of longer than one year. In 2005, just over half (57%; n = 1850) of all jails held fewer than 100 individuals daily; with just over 5 percent holding five or fewer inmates. It is important for administrators to be familiar with the respective roles of jails, probation, and prisons in their jurisdiction to assist in health interventions with correctional populations (Potter and Akers, 2010).

Analyses of data on individuals arrested for felony (indictable) crimes (Reeves, 2013) nationally indicates that more than half of individuals charged with such crimes are released from jail within 48 hours on some form of conditional release (e.g., bonded out, released on recognizance, etc.). In Florida, where there is a 24-hour first appearance rule for bond decision-making, it has been demonstrated that up to 60 percent of those booked into jail are released within 24 hours (Potter, Lin, Maze & Bjoring, 2012). Issues of how bond release decisions are made and funded have become policy topics in the past several years. Forty-four of fifty states in the United States utilize a combination of bonding mechanisms that include commercial bonding. Internationally, among those nations with a bail/bonding process, only the United States and the Philippines employ commercial bonding. In most parts of the world this way of promoting appearance at court hearings is handled by civil authorities. We mention this because of the potential impact on using jails for public health surveillance and/or interventions when they have rapid turnover (Akers, 2013).

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Table 1 Organizational Entities Involved at Each Segment of the US Criminal Justice System

Agency Type Total Agencies (LE) or Facilities (Corrections)

Total Employees

Full-time Sworn

Part- time Sworn

Total Civilian Employees

Non-Federal Law Enforcement*

Local Police 12,501 593,013 461,063 27,810 162,269 Sheriffs 3,063 353,461 182,979 11,334 181,816 State Police 50 93,148 60,772 54 33,269 Special Jurisdiction**

1,733 90,262 56,968 4,451 43,524

LE Totals 17,347 1,129,884 761,782 43,649 420,878 Non-Federal Corrections

Corrections Officers

Other Staff

Jails*** 2,851 213,200 169,200 NA 44,000 Prisons**** 1,719a 389,882 264,233 NA 125,649 Totals 603,082 433,433 169,649

*2008 data; Reaves, B.A. (2011). Census of State and Local Law Enforcement Agencies, 2008. Washington, DC: Bureau of Justice Statistics. ** Excludes “County Constable Offices in Texas” *** 2015 data; Minton, T.D. & Zeng, Z. (2016). Jail Inmates in 2015. Washington, DC: Bureau of Justice Statistics. 2005 data; Stephan, J.J. (2008). Census of State and Federal Correctional Facilities, 2005. Washington, DC: Bureau of Justice Statistics. aCombines public and private prisons operating at the State level. Note: Probation agencies are not included in this Table because of the variations across States and Counties with regard to how probation supervision is delivered. For more explanation, please see the methodology notes (p.8) in Kaeble, D. & Bonczar, T.P. (2016). Probation and Parole in the United States, 2015. Washington, DC: Bureau of Justice Statistics.

While this symposium issue is focused on the

populations who process through the criminal justice

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system, public administrators must also be concerned with the health of the employees in the CJAs. The writers’ first experience with such concerns among public administrators came during the early days of the severe acute respiratory syndrome (SARS) outbreak in 2002-2003. Individual jail and prison administrators had been worried about issues such as tuberculosis (TB) for several years, but it was the broader concerns with pandemics such as SARS and variants of the influenza virus that seemed to have made CJA employee health an area of critical concern (Blackmore, Potter, Schwartz, & May, 2010). The concerns were focused on those who had to occupy closed space with potentially infected clientele, such as in jails and police vehicles.

Around 95 percent of all criminal cases are resolved by a plea (BJS), regardless of whether felony (indictable) or misdemeanor (summary) charges are involved. This varies by states, so some are slightly lower and some slightly higher. Most of the convictions result in some form of sentence to supervision by a probation agency. Probation generally includes some form of restriction on behavior, often involving restrictions on substance use. Our funnel model notes that, during 2015, at least 4.6 million individuals were placed on probation, generally within the county (or counties) where they were arrested.

Probation is carried out in perhaps the most diversified manner of any CJS component. In some states and the federal government, probation is overseen by an agency within the court system. In other states, probation is operated by the state correctional agency or a separate agency under the Executive Branch. The role of felony and misdemeanor conviction(s) may also play a role in whether probation is handled at the state or county level. In some states, misdemeanor probation may be contracted-out to local governments and non-government organizations (NGOs). This is another area where knowledge of organizational control is of vital importance to planning

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health-related interventions. And, as will be detailed in the Matz contribution to this volume, it is one where we know very little about health-related issues or interventions. It is difficult to quantify exactly how many probation agencies and employees there are, which is why that information is missing from Table 1. If we were to modify our funnel, it would be to have the widening at probation level more evident.

Prisons, our most extreme form of punishment short of execution, absorb most of the public and NGO attention. The prison population in 2015 decreased to the lowest level since 2005. Using our funnel model, we can see that the number of entrants to the combined state and federal prison systems represented less than 10 percent of those who entered the county and regional jails. Again, because there is no actual count of unique individuals entering jails (one estimate was nine [9] million out of a year with approximately 13 million arrests; Spaulding, et al. 2009), it is difficult to say what proportion of unique individuals, progress from a local jail to a state or federal prison system.

The prison population decreased in 2015 with more individuals returning to the community than coming in from the community. The majority of prisoners were held in state prisons, with the federal system accounting for 13 percent of the total population. Among those sentenced to prison in 2006, the average sentence length was four years and 11 months (Rosenmerkel, Durose, and Farole, 2009), with about one percent of all sentences being for life. The length of the sentence to be served was reported to be about 87 percent of the original sentence as more states moved to “truth in sentencing” laws requiring substantial service before possible release back into the community. Thus, there are fewer prisons than jails (see Table 1), but prisons hold individuals for longer periods of time than do jails.

Partly due to the more serious crimes committed by those sentenced to prisons, requiring closer supervision, the

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number of employees in prisons is also larger than those found in jails (see Table 1). Given that prisons traditionally have been located in more rural areas of states, there may be limited health resources for the correctional employees to access than in more urban areas. Again, the concern with the health status of correctional personnel is a relatively new phenomenon. However, as many of these individuals are covered by state pensions and health care, developing knowledge about how their interactions with those they process and house impact the employees’ physical and behavioral health may be an area where new research will be of value to public administrators.

Corrections professionals have turned to the retail grocery sector to find terms to explain how individuals are processed through the system. As the funnel model suggests, the “flow” dimension of the total CJS is quite substantial and rapid, especially at the county level. This rapid turnover is referred to as “churn.” The churn within jails is estimated to be 57 percent of admissions (“bookings”) monthly. That is, more than half of those admitted to a jail were discharged within one month (most within 48 hours!). This churn effect means we have relatively little time to intervene with those who are arrested while we have them in custody. The “stock” population of interest is generally going to be found in prisons because of longer sentences. Yet, if our interest is in the health of the communities from which most of our churning population enters our correctional facilities, we need to be able to better understand the health issues that enter our jails and return to the community in relatively short order. As pointed out in just about every contribution to this symposium, these problems will return to the community.

Modeling Interventions The Substance Abuse and Mental Health Services Administration (SAMHSA) GAINS (Gather, Assess,

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Integrate, Network, and Stimulate) Center has developed an intervention model that fits nicely the funnel model of criminal justice processing. It is presented here as a way of thinking about planning health interventions at the multiple intersections of the CJS and the community. The quoted material here is taken from the SAMSHA website (https://www.samhsa.gov/criminal-juvenile- justice/samhsas-efforts). The “sequential intercept model” consists of five points of intervention: Intercept 1 – Community and Law Enforcement. These programs are efforts to divert persons with “mental health, substance use, or co-occurring disorders from the criminal justice system and into community services without the leverage of the court. The program focuses on the role of law enforcement officials working collaboratively with community behavioral health providers to prevent arrest and adjudication. Through this partnership law enforcement and behavioral health agencies design, implement, and oversee comprehensive strategies for diversion and engagement practices.” Intercept 2 – Arrest and Initial Detention/Court Hearings. Examples of programs at this stage of the process aim “to allow local courts more flexibility to collaborate with multiple criminal justice system components and local community treatment and recovery providers to address the behavioral health needs of adults who are involved with the criminal justice system and provide the opportunity to divert them from the criminal justice system.” Intercept 3 – Jails and Specialty Courts. Many readers will be familiar with the variety of specialty/problem- solving courts that have developed in the criminal courts. According to SAMHSA, the “focus of these courts is to address the underlying mental health and substance use

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issues and related needs of offenders by using the sanctioning power of the court to connect with treatment and other alternatives to incarceration.” Intercept 4 – Re-entry from Jails and Prisons to the Community. The focus of programs at this intercept is to expand and enhance “substance use treatment and related recovery and reentry services for adult offenders who are returning to their families and community after incarceration in state and local facilities including prisons, jails, or detention centers. The program encourages stakeholders to work together to give adult offenders with co-occurring substance use and mental health disorders the opportunity to improve their lives through recovery.” We would add that the two re-entry points outlined here present very different challenges for health planners. As noted earlier, the “churn” element of local corrections is especially challenging. Intercept 5 – Community Corrections. At this time, SAMHSA has no formal programs with probation agencies. Almost all states have some requirement for medical screening of new detainees in jails and prisons within specific time frames. Many of these reflect the standards set by the American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC). Both of those professional organizations require an initial medical screening within 48 hours of admission. Using Florida as an example again, some states require an “immediate” medical screening at intake/booking. This may be a simple set of questions and a quick blood pressure, heart rate, and respiration observation. Even such a requirement in facilities with multiple first appearance hearings during the day may result in missed detainees, and detainees whose medical situation is known, but are released before any action can be taken by jail medical staff.

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Because the process by which people come into a jail varies around the nation, making generalizations about physical and mental health, as well as substance use information that can be utilized for interventions is risky (Potter, 2010a). The availability of the information gathered in jails for new or continued interventions in the community is also problematic, as detailed in the Butler contribution to this issue. While most of those processed through the early stages of the criminal justice process will spend their supervised time on probation in the community, we know little about their health status (see the Matz contribution). There appears to be an almost unbridgeable gap between what health information might have been collected in a jail and intervention planning in the community (see Butler). It is not too strong to say that a great deal of revenue and talent is spent annually gathering information and beginning treatments squandered when detainees return to the community with little or no follow-through.

CONCLUSION

Because the issues that will be covered in this

symposium tend to be siloed, and because they are often phenomena with which people just don’t want to deal, we hope that this system-wide, community-integrated information will assist you in getting a better grasp on the situation. As public administrators, you deal with developing more effective and accountable programs to address community issues. We believe that correctional health care is one of those keystone program areas where we can begin to intervene with effectiveness to address physical and behavioral health issues in the community.

The multi-disciplinary, publicly- and privately- employed contributors to this symposium illustrate the need for an integrated and system-wide approach to reducing the health problems observed among those who enter and

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process through our correctional facilities and probation offices. In the final analysis, the health burden of incarcerated individuals will be reduced only when overall community health is improved. This is a common good to which we hope this symposium makes a positive contribution.

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Figure 1 Sequence of Decisions in the United States Criminal Justice System

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REFERENCES

Akers, T.A., Potter, RH, and Hill, C. (2013). Epidemiological Criminology: A Public Health Approach to Crime and Violence. San Francisco: Jossey-Bass/Wiley and Sons.

Akers, T.A. (2013). Criminological Epidemiological or

Epidemiological Criminology: Integrating National Surveillance Systems. In Waltermaurer, E. and Akers, T.A. (Eds.). Epidemiological Criminology: Theory to Practice. London: Routledge/Taylor and Francis.

Anno, B. (2001). Prison Health Care: Guidelines for the

Management of an Adequate Delivery System. Chicago: National Commission on Correctional Health Care.

Blackmore, J., Potter, R.H., Schwartz, R. D. & May, R.L.

(2010). Corrections Response to Pandemic Influenza. Hagerstown, MD: Association of State Correctional Administrators.

Carson, E.A. & Anderson, E. (2016). Prisoners in 2015.

Washington, DC: Bureau of Justice Statistics. Chari, K.A., Simon, A.E., DeFrances, C.J. & Maruschak, L.

(2016). National Survey of Prison Health Care: Selected Findings. Hyattsville, MD: National Center for Health Statistics.

Kaeble, D. & Bonczar, T.P. (2016). Probation and Parole in

the United States, 2015. Washington, DC: Bureau of Justice Statistics.

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Minton, T.D. & Zeng, Z. (2016). Jail Inmates in 2015. Washington, DC: Bureau of Justice Statistics.

Potter, R.H. (2010a). “Jails, Public Health and

Generalizability.” Journal of Correctional Health Care, 16(4): 263-272.

Potter, R.H. (2010b). “Lessons Learned from 25+ Years of

Universal Health Care Provision: Where Is the Voice of Correctional Health Care?” Journal of Correctional Health Care 15(2):160-161.

Potter, R. and Akers, T.A. (2010). Improving the Health of

Minority Communities through Probation-Public Health Collaborations: An Application of the Epidemiological Criminology Framework. Journal of Offender Rehabilitation, 49(8), 595-609.

Potter, R.H., Lin, H., Maze, A., and Bjoring, D. (2012).

Jails, Public Health Service Delivery and Empirical Knowledge: The Impact of Jail Population ‘Flow.’ American Journal of Criminal Justice, 37(2): 200- 208.

Reaves, B.A. (2013). Felony Defendants in Large Urban

Counties, 2009 – Statistical Tables. Washington, DC: Bureau of Justice Statistics.

Rosenmerkel, S., Durose, M. & Farole, D. (2009). Felony

Sentences in State Courts, 2006 – Statistical Tables. Washington, DC: Bureau of Justice Statistics.

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Spaulding, A.C., Seals, R.M., Page, M.J., Brzozowski, A.K., Rhodes, W. & Hammett, T.M. (2009) HIV/AIDS among Inmates of and Releasees from US Correctional Facilities, 2006: Declining Share of Epidemic but Persistent Public Health Opportunity. PLoS ONE 4(11): e7558. https://doi.org/10.1371/journal.pone.0007558

Stephan, J.J. (2008). Census of State and Federal

Correctional Facilities, 2005. Washington, DC: Bureau of Justice Statistics.

Websites: Anno, B. (2001). Prison Health Care: Guidelines for the

Management of an Adequate Delivery System. Available at: https://nicic.gov/library/017521).

Arrest data: https://ucr.fbi.gov/crime-in-the-

u.s/2015/crime-in-the-u.s.-2015/tables/table-29 Sequential Intercept Model:

https://www.samhsa.gov/criminal-juvenile- justice/samhsas-efforts

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