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SICK IN COUNTY JAIL.
By Harold Pollack
I spent yesterday at Cook County Jail, a behemoth complex of buildings the size of a small neighborhood on Chicago’s west side. During a glacial wait for some Xerox copies, I stared out the window at the sidewalks marked off by high fences and ugly concertina wire. Young moms, kids in tow, tentatively pushed baby strollers along this maze of concrete walkways leading to the visiting area. Out of sight, out of mind, prisoners are a population we readily ignore when the cable TV shows are off. Yet these men and women are absolutely central to public health.
Theodore Hammett and his colleagues compiled some rather amazing statistics here. Here is some of their analysis: One-fifth of all Americans living with HIV, one-third of all Americans infected with hepatitis C, and forty percent of all Americans living with tuberculosis disease passed through correctional facilities in 1997. They did not consider substance use disorders or severe mental illness, whiere the proportions are presumably larger.
The motley population that passes through local jails is especially important. These inmates are especially hard to serve during their typically-brief incarcerations. Many have not seen a doctor in years. The same behaviors that land them in jail expose them to serious physical and mental health risks. When these issues go unaddressed in the correctional system, thousands of people quickly bring these problems back to their families and local communities. These physical and mental health problems frequently resurface when former inmates require emergency care—or when something worse happens.
Correctional care provides an especially telling example of an unglamorous but critical public health function that is now being undermined by the crushing financial burdens facing state and local governments.
For years, Cook County has implemented a strong public health model. (I wrote about this in the Chicago Sun Times last year.) At one point, media accounts indicated that jail-based STI screening accounted for 40 percent of known Chlamydia cases among Chicago men. Studies indicate that such screening is cheap and cost-effective when compared with other widely-accepted medical interventions. But Cook County is facing difficult budget times—ironically the increasing burden of corrections and safety-net medical care being two main sources of budget hemorrhage. The county made an $800,000 budget cut that curtailed the screening of perhaps 100,000 inmates every year. No one can say how many infections will go undetected or will be spread because of this policy—the answer is: many.
Correctional care illustrates how hard it is to accomplish basic public health tasks in the absence of adequate political commitment, and in the absence of universal health care. When people are released from jail or prison, they are generally uninsured. Many states officially dis-enroll prisoners from Medicaid when they go behind bars. Felons may become categorically ineligible for various benefits that finance health coverage. Key mental health and substance abuse services are often uncovered even when people are nominally insured.
So on the ground, injection drug users leave jail and arrive at a methadone treatment program to surmount their heroin dependent, only to encounter the waiting list for indigent patients. Increasing numbers of HIV+ prisoners receive good medical care in jail, only to be released with poor transitional planning to maintain their treatment and medication in the broader community. Ex-offenders with mental health difficulties face even larger barriers.
As a child, the radical Italian writer Ignazio Silone once joked to his father about a ragged prisoner they saw being led off to prison. His father angrily responded: “Never make fun of a man who has been arrested! He can’t defend himself. He may be innocent. In any case, he is unhappy.” His family is, too. Services a despised population of jail and prison inmates generate few political benefits, and so are always tempting targets for budget cuts. This does not serve us well.
COMMENTS (11)
So, Harold, what do you propose be done and, just as important, how much will it cost and who pays for it?
Posted by: El Viajero | August 12, 2008 3:46 PM
El Viajero's comment is typical of individuals who don't realize that the first step in dealing with a policy problem is to recognize that there is indeed a problem. As a public health professional, I'm glad that someone has taken the time and effort to unveil an unglamorous problem with potential health consequences for the mainstream population. Naming it as a problem is a first step; advocating for it as a policy priority (and seeking funding) is the next.
Posted by: Caitlin C | August 12, 2008 4:33 PM
Fair question. Here are two things I would do:
1. Universal care with SA/MH parity, so returning prisoners and everyone else has access to the services they need.
2. A few billion dollars in additional funding for SAMHSA and HRSA--two safety-net agencies few people have heard of--that fund drug treatment and safety-net services, including interventions for prisoners. This one should happen independently of #1.
Posted by: Harold Pollack | August 12, 2008 6:28 PM
In other words what you are proposing is a tripling or quadrupling of the dollars we spend on healthcare to cover all that crap.
Our healthcare system is already the most expensive in the world. Higher spending is not in the cards guy.
Posted by: joe blow | August 12, 2008 8:16 PM
A few billion dollars in additional coverage is a modest amount, considering the nation's health care expenditures is over $2 trillion. (Medicare & Medicaid at over $700 billion.) Let's get a little perspective here--Harold Pollack's recommendations are perfectly reasonable (and modest), especially considering the co-morbidities linked to substance abuse and mental health. The expenses of universal health care are balanced by costs savings else where in the system.
Posted by: Michelle | August 12, 2008 10:47 PM
El Viajero; a comprehensive program of public health that serves people in the custody of the corrections and justice system so that they get the health care they need so as to preserve the public's health. And the taxpayers will pay for it, of course. Since, again, of course, the taxpayers don't want people with TB walking around. Also, it'll be relatively inexpensive when regarded as a total social cost, since the dollars spent on health care for prisoners et al will be significantly refunded as dollars are saved providing those same people emergency care later, as well as dollars saved on the health issues of the non-prisoners they later encounter.
Seriously, is that the best you can do?
Posted by: NBarnes | August 13, 2008 2:19 AM
The Cook County as well as the City of Chicago and the State of Illinois are all one party regimes controlled by the Dems. We're waiting for Todd, Richie, and Rod as well as Mike and Emil to get off their fat asses and do something for the people of Illinois and especially its most vulnerable citizens. But nobody's holding his breath.
Posted by: Refugee from Crook County | August 13, 2008 4:07 AM
We're waiting for Todd, Richie, and Rod as well as Mike and Emil to get off their fat asses and do something for the people of Illinois and especially its most vulnerable citizens.
Oh, you didn't get the 'drift'. When they say "let's do something", they mean federal money, not their money.
Posted by: El Viajero | August 13, 2008 10:32 AM
Oh, you didn't get the 'drift'. When they say "let's do something", they mean federal money, not their money.
Well, if we were using our municipal dollars, it would be tempting to dump the sick and contageous prisoners in some other city. You could be like Gulliani and have the police just pick them up and let them free outside of town. Hey, it's a lot cheaper and our constitutents don't get sick. It only sucks for those people in the other town, until they ship their sick prisoners back to us.
One of the problems with complete localism is that it leaves too much room for externalities - for one locality to dump its problems on another - in ways that don't actually increase aggregate well-being. This is not to say that some problems aren't better managed at a more localised level. It only means that some problems may not be efficiently solved without looking at the interests of all concerned.
Posted by: GrandArch | August 13, 2008 11:26 AM
It only means that some problems may not be efficiently solved without looking at the interests of all concerned.
The phrase 'collective action problem' doesn't exist to Republicans. I think all El Viajero saw in your post was a string of fnords that caused him to go squeeze his Milton Freidman plushie in terror.
Posted by: NBarnes | August 13, 2008 2:30 PM
So is this a federal jail we're talking about? Of course not. Did these prisoners break federal laws? Does the federal government pay to keep them incarcerated?
So why pick out this one issue to federalize?
Posted by: El Viajero | August 13, 2008 4:03 PM