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Source: CDC
Health
A method to preserve lives in correctional facilities
Researchers analyzing healthcare across numerous institutions associate accreditation with enhanced cooperation and treatment, leading to fewer fatalities
A landmark 1976 Supreme Court ruling stated that while the Constitution mandates healthcare for incarcerated individuals, the standard of care required does not have to be exceptional, merely “adequate.”
However, it often falls short, as indicated by Marcella Alsan and Crystal Yang, who research medical services in U.S. correctional settings.
In a groundbreaking study, the researchers discovered that prisons that achieve accreditation, similar to most hospitals, experienced significant enhancements in healthcare provision and quality, a notable reduction in fatalities, alongside substantial financial savings.
To understand the potential impact of accreditation, the investigators conducted a randomized trial involving 44 jails over four years. Half (termed treatment facilities) received generous subsidies for accreditation expenses, while the other half (control facilities) were offered a lesser subsidy after the study concluded. Jails detain individuals awaiting trial on a temporary basis and are typically managed by local law enforcement. The demographics here often face higher incidences of hepatitis, sexually transmitted infections, and various mental health hurdles.
In this adapted dialogue with the Gazette, Alsan, Angelopoulos Professor of Public Policy at Harvard Kennedy School, and Yang, Bennett Boskey Professor of Law at Harvard Law School, share insights from their research.
What initiated this research and how do you assess the quality of healthcare available to incarcerated individuals?
ALSAN: Our examination centered on the intersection between health and corrections, and we recognized significant disparities between the healthcare afforded to civilians and that provided to incarcerated individuals. Incarcerated persons possess a constitutional right to healthcare, the exclusive group that does. Over 90 percent of hospitals hold accreditation, but a comparable standard is absent in the corrections system.
YANG: The overall quality of medical care is typically quite poor and shows considerable variance. Our investigation concentrated on county jails; there may be greater consistency and oversight within state or federal prisons. In July, President Biden endorsed a Federal Prison Oversight Act, establishing an inspector general responsible for conducting independent evaluations of all federal Bureau of Prisons properties. Such a framework is lacking for the nation’s more than 3,000 county jails, and it’s estimated that only around 17 percent of all correctional facilities have actively pursued accreditation.
Several unique challenges are inherent to the correctional context. A significant issue is the retention and recruitment of staffing. This situation can create hurdles in sourcing qualified personnel and their training. Accreditation could help alleviate these challenges by establishing standards governing personnel practices and training.
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Crystal Yang.
Courtesy photo
What were the study’s most impactful revelations?
YANG: Effective collaboration between custody personnel and medical staff is essential for delivering healthcare in correctional facilities. We conducted anonymous staff surveys at both the commencement and conclusion of the study. One notable outcome was the marked enhancement in cooperation and coordination among medical and custody personnel, indicating that accreditation fosters better teamwork.
We identified two primary categories of quality standards where compliance significantly increased in treatment facilities compared to control facilities. These categories included personnel training and patient care improvements, particularly in the promptness of initial screenings for incoming individuals. If county jails are analogous to an emergency room, it’s imperative to engage a qualified healthcare provider immediately upon entry to determine the best treatment approach.
Perhaps the most significant discovery is the observed 90 percent decline in mortality rates in treatment facilities compared to controls, translating into an estimated 20 lives saved throughout the study. This is substantial and demonstrates that accreditation is highly cost-effective. Furthermore, we observed suggestive reductions in six-month recidivism rates among individuals processed in the treatment facilities, hinting at potential enhancements in community safety. Conducting a rough cost-benefit assessment shows that the net gains from accreditation can exceed $60 million annually per jail in terms of lives saved and likely decreases in recidivism.
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Marcella Alsan.
Niles Singer/Harvard Staff Photographer
What reasons contribute to the observed beneficial effects of accreditation?
ALSAN: Our findings indicate that there are remarkably few occasions…
where individuals are aiming to inflict damage. Frequently, individuals lack the knowledge they require regarding how to effectively carry out their training protocols and provide their medical services. Sheriffs often express that they didn’t choose to be the mental health caretakers for the nation. However, due to the rise in mental health issues — the opioid crisis and other factors — they have inadvertently assumed the role of primary mental healthcare providers. Clearly, there is a necessity for reducing incarceration rates and enhancing mental wellness within communities.
Moreover, there is an essential need to extend assistance to sheriffs. The accreditation procedure serves as a strategic outline: This is what ought to be done; this is what quality care resembles. And here’s how to convert these inputs into outcomes. We provided financial support for the accreditation process for these institutions. We initially did not believe the funding would be so vital for receiving accreditation. The cost ranges from $5,000 to $10,000 for these small and medium-sized correctional facilities, which constitute the majority of jails across the U.S. However, even this sum can be quite difficult to reallocate and plan within budgets. We are dealing with county finances, which often lack flexibility. Therefore, this financial support was indeed a key enabler for them to achieve accreditation.
What insights should policymakers and law enforcement derive from this study?
YANG: The primary message is that securing accreditation from the National Commission on Correctional Health Care is remarkably economical. It preserves lives and may also enhance community safety, considering we observe potential decreases in recidivism. These insights could prove significant for a sheriff or local government official who may be unaware of accreditation but wishes to reduce fatalities, which will consequently lessen their legal and liability risks—a concern that sheriffs prioritize. Moreover, sheriffs value community safety, so if accreditation leads to a decline in recidivism, this can present an additional appealing advantage.
ALSAN: From a public policy viewpoint, the federal government can influence the budget limitations of states. It can provide financing support; it can offer incentives for jails to undertake specific initiatives. Staffing remains a challenge — some correctional facilities lack the personnel to complete the necessary forms for accreditation.
Numerous systems have failed the individuals who find themselves incarcerated. A significant number of those arrested have never visited a dentist. Consequently, there exists a degree of dissatisfaction. Between ninety to ninety-five percent of these individuals will reintegrate into their communities. Why are we not seizing this chance for rehabilitation, treatment, or assessment? This consideration isn’t even factored into our cost-benefit analysis; we’re merely assessing the value of a statistical life. We aren’t even accounting for the possible prevention of community-wide dissemination of various habits, diseases, or simply emotional distress. These are individuals. Furthermore, they are your community members.