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When you think of public health, you probably don’t think of prisons.

Prisoners as a group represent one of the sickest segments of the population. According to a study by the RAND corporation, prisoners are four times more likely to have tuberculosis than the general population. Rates of Hepatitis C and HIV infection are nine times higher than that of the general public. Almost 52% reported drug abuse, while 35% of prisoners are dependent on one or more substances. 1 in 4 inmates is diagnosed with a mental health disorder in their lifetime.

When inmates are released, they bring their health problems back to their communities. Most don’t have health insurance or access to health services and treatment. Several of them will return to prison, still sick upon re-entry, putting staff and other inmates at risk. Therefore, prisoner health becomes a public health concern.

America has both the highest incarceration rate and the most prisoners in the world. There were 2.2 million US prisoners in 2011, with 716 prisoners per 100,000 residents. This large number of inmates makes jails a significant healthcare provider to a very sick population. In California’s county jails alone there were almost 2.3 million sickcalls (requests for medical attention that are answered by onsite medical staff,) according to data from 2012. About 500 thousand of these sickcalls resulted in a more advanced onsite medical appointment with a physician or practitioner.

Policy Changes

According to the National Institute of Corrections, California’s 2013 incarceration rate was about 11% lower than the national average, yet costs per inmate were 48% higher than the national average. Healthcare costs is one of several factors that contribute to California spending more taxpayer money on fewer prisoners than other states. However, a recent expansion of Medicaid eligibility may defray some of these costs.

Under the Affordable Care Act (ACA), Medicaid was expanded to single and childless adults through a new system to determine eligibility. Previously, eligibility was based on criteria that included having a disability, being pregnant, or having a child. In 2014, Medicaid allowed states to switch to income based criteria, extending coverage to non-disabled, non-elderly, low-income adults. This allows inmates to sign up for Medicaid, which shifts outpatient healthcare costs from the state government to the federal government. Medicaid only covers prisoners’ outpatient hospitalization costs, not general health services.

Another key change implemented through the ACA affects inmates’ health insurance by suspending rather than terminating coverage while they are incarcerated. When they are released, their insurance plan resumes. Prisoners cannot purchase health insurance on the exchange while they are in jail, but are able to do so upon their release.

The changes in prison healthcare mirror a gradual shift towards preventive healthcare and health maintenance. By treating people early and often, rates of lifestyle diseases are expected to decrease while overall health improves, ultimately reducing healthcare expenditures.

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